By Shelley Matthes, RN-BC, BSN, RAC-CT , Director of Quality Improvement at Ecumen
I recently had a close call with my mom, reminding me how easy it is to mistake delirium for dementia, and and how dangerous that is.
My nephew was visiting my relatively healthy 86-year-old mother, who had just had her hip replaced. He called me to say Mom was “acting weird” and using her cell phone to try to change the television channels. It was totally out of character for Mom to act this way. But it was not dementia. It was delirium, which is a medical emergency.
She had been taking a diuretic to control fluid retention as she was recuperating from the hip surgery, and her sodium levels had dropped drastically, triggering the delirium.
The story ends happily. I got her to her doctor and advocated for her with assurances that this was not normal. And the real problem was diagnosed.
But I think how scary this was and how easy it would be to dismiss “weird” behavior as dementia, while ignoring the life-threatening condition causing her delirium.
With this on my mind, I was reading an article in McKnight's Long-Term Care News with yet more evidence that antipsychotic drugs can mask dangerous underlying conditions that need immediate treatment. In the article, Yoanna Skrobik, M.D., critical care chairwoman at the University of Montreal posed this thought-provoking question for all of us in senior care care to ponder:
. . . “Are we treating the patients or our own discomfort?”
The article detailed a study showing that use of the commonly prescribed antipsychotic Haloperidol (Haldol) is no more effective than a placebo for treating delirium in critically ill patients. Short-term use of Haldol had once been claimed an appropriate treatment for the psychosis that can occur with delirium. Now this too is called into question as ineffective and inappropriate in the study published in The Lancet. The only clear result of Haldol administration is sedation.
Too Often Delirium is Passed Off as Dementia
Delirium is an acute and serious medical condition due to many diverse underlying causes, whereas dementia is a general term that describes a group of symptoms due to permanent damage or death of the brain’s neurons caused by several diseases, with Alzheimer’s being the most common.
As with my mom, the symptoms of delirium and dementia can easily be confused and often are. The Alzheimer’s Association explains the difference this way: “In dementia, changes in memory and intellect are slowly evident over months or years. Delirium is a more abrupt confusion, emerging over days or weeks, and represents a sudden change from the person’s previous course of dementia. Unlike the subtle decline of Alzheimer’s disease, the confusion of delirium fluctuates over the day, at times dramatically. Thinking becomes more disorganized, and maintaining a coherent conversation may not be possible. Alertness may vary from a “hyperalert” or easily startled state to drowsiness and lethargy. The hallmark separating delirium from underlying dementia is inattention. The individual simply cannot focus on one idea or task. “
According to the Mayo Clinic, causes of delirium include infection, electrolyte imbalance, dehydration, lung and other organ disorders, adverse reactions to pharmaceuticals or anesthesia, injury, stress, metabolic imbalance and unfamiliar environment.
Too often in U.S. acute-care (hospital) and sub-acute care (nursing home, assisted living, home care) settings, unaware caregivers, faced with a confused elderly patient, mistakenly attribute cognitive changes associated with delirium to dementia, which means the underlying causes of a person’s delirium, such as infection or an adverse drug reaction, are untreated. This can set off a chain of problems for the person, including increased risk for further injury due to falls, cognitive and physical decline, and even death. Untreated delirium can lead to permanent cognitive impairment.
Why The Confusion by Care Professionals?
Symptoms of delirium and dementia often look similar, including disorientation, incoherence and memory disturbance. Both are more common in seniors. Antipsychotics will sedate a patient and decrease the behavioral symptoms, and relief of symptoms is paramount to caregivers. Nurses want people to feel better, so it is not uncommon to call the doctor for pharmaceutical relief. However, oftentimes sudden cognitive changes, even in those with dementia could indicate potential delirium.
What Can We Do to Prevent Delirium From Being Mistreated?
This is where critical thinking is very important. Nurses and other long-term care team members, who spend a great deal of time with the person, are in a very good position to spot changes that can lead to a delirium diagnosis and the treatment of its underlying causes. Ways that care professionals can help ensure proper treatment include:
- Knowing differences between delirium and dementia and never automatically assuming that dementia is the cause of behavioral disturbances.
- Conducting a comprehensive assessment of a person’s medical and surgical history, medications prescribed, social supports, allergies, fluid and electrolyte balance, treatment of pain, nutritional status, bowel and bladder function, baseline cognitive and functional ability, and screening for depression.
- Being alert for changes in the person’s behavior, reporting them immediately to the nurse who can collaborate with the physician.
- Recording and communicating observations from shift to shift.
- Creating a good living environment by reducing noise, avoid waking a person at night, monitoring and providing good nutrition and hydration, orienting the person to where he or she is, and providing good hygiene and oral care.
- Collaborating closely with family members and Listen-- they can help you identify trends or changes in their loved one.
- Keeping yourself and team members educated on delirium.
Dr Steven Levinson, contributor to the Center for Medicare and Medicaid Services INTERACT II initiative (INTERventions to Reduce Acute Care Transfers) stated, “Behavior is an outward expression of an inward problem.”
Identifying delirium and addressing underlying causes is essential to transforming the dementia care culture. And at its core, it is treating people-- not our own discomfort.