Hospital delirium: Signs, causes and how caregivers can help

What is delirium?

Hospital delirium, or acute confusional state, is a temporary change of a person’s mental state. According to the Diagnostic and Statistical Manual of the American Psychiatric Association, delirium is defined as “a disturbance in attention… and awareness” that “develops over a short period of time”.

It is common in older persons who are hospitalised or in long-term care facilities and can happen without warning. It may start within hours or a few days, and some can last for more than a month.

Delirium can be a stressful, confusing situation to face, as your loved one may exhibit signs of cognitive impairment, experience vivid hallucinations or go through other symptoms. You may find yourself unsure as to how to comfort or reassure them.

The onset of delirium is usually a sign that there may be an underlying medical issue. Of concern is that delirium is under-recognized and underdiagnosed, which can negatively impact your loved one if not treated immediately. Though it shares similarities with dementia symptoms, both delirium and dementia are not the same things.

This condition is more prevalent in older persons recovering in a caring environment (such as hospitals) after surgery or treatment. Risk factors besides age may include pre-existing dementia, having survived a stroke, and the person’s overall state of health.

There are three types of delirium:

• Hyperactive delirium: characterised by restlessness, agitation, confusion or a sudden change of mood; they may also have vivid hallucinations and cannot distinguish what is real and what isn’t
• Hypoactive delirium: the polar opposite of hyperactive delirium, characterised by inactivity or reduced motor activity, sluggishness, abnormal drowsiness, and constant sleepiness
• Mixed delirium: a combination of hyperactive and hypoactive delirium, where either state may take precedence over the other

Delirium and dementia

As mentioned earlier, delirium tends to be poorly recognized by medical providers or is wrongly diagnosed as dementia or another similar impairment. Of particular note is that hypoactive delirium tends to be poorly recognized or detected due to an overlap of similar symptoms as dementia.

This can be exacerbated by factors such as an inability to tell delirium apart from dementia, which leads to an inaccurate medical diagnosis that can be detrimental to the care recipient’s health.

Medical professionals have noted that delirium can be an indicator of potential health complications, which can be prevented if the proper steps are taken to address the underlying issue(s).

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Persons who have dementia are at higher risk of delirium as well, which could complicate treatment. This, however, does not mean that a person will have both.

While there are similarities, both delirium and dementia are still vastly different. For one, delirium is triggered almost immediately, between a few hours to a few days, while dementia sets in slowly and worsens over a long time.

Another key difference is that delirium affects attention and recognition, while dementia affects memory and cognitive functions due to a loss or impairment of brain cells.

Nonetheless, delirium is still commonly misdiagnosed, especially when the overlap between delirium and dementia symptoms are interchangeably mistaken.

The medical team will need to frequently monitor your loved one for any changes to their behaviour, and identify any signs that may indicate delirium. It is recommended that your loved one sees a psychiatrist to establish a baseline for their mental state. This is a useful preventive measure for the medical team to determine if delirium is affecting your loved one.

Signs of delirium

Take note of the following signs and symptoms of delirium. These may also differ depending on the type of delirium.

• Inattentiveness
• Inability to follow conversations
• Disorientation, e.g. not knowing where they are or what time it is
• Rambling, or incoherent speech
• Difficulty understanding what is being said to them
• Lethargy, heightened sleepiness
• Hallucinations
• Restlessness or agitation
• Rapidly changing moods

Causes of delirium

Hospital delirium has a number of risk factors, including (but not limited to):

• Recovery from surgery
• Infection or a terminal illness
• Side effects from medications
• Medical drug toxicity (caused by improper dosage)
• Dehydration
• Anemia
• Malnutrition
• Pain or significant discomfort
• Sleep deprivation
• Emotional distress
• Alcohol withdrawal
• Previous history of delirium

Note that having a risk factor does not mean your loved one will have delirium.

Caring for someone with delirium

Delirium episodes can be disquieting for you when you do not know what to expect or how to best manage it. How it manifests and at what frequency can determine the impact of the delirium on their physical and mental well being.

Even if you are not currently caring for anyone with delirium, knowing about its signs, symptoms and treatment methods early on can be helpful to equip you for care responsibilities in the future.

This is especially true if your loved one needs to undergo treatment at a health or nursing care facility. Being able to take necessary action when it occurs can be the difference between positive and negative outcomes in their recovery.

In a formal care setting

While in the hospital, the medical team will conduct a thorough assessment to determine if your loved one has delirium. The assessment given will be tailored to identify symptoms of delirium; one such assessment is the 4AT test.

Once it is identified, the medical team will structure a care plan to help with their recovery. You should listen carefully to the doctor’s recommendations and ask what you can do to help with the process.

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Treatment for delirium while your loved one is warded usually comes down to ensuring that any underlying conditions your loved one may have are detected and treated. Delays in providing adequate treatment, or any mistreatment due to misdiagnosis, can be detrimental to their long term well being.

The medical team will aim to provide both support and medication care to your loved one to treat delirium.

The goal is to address any underlying causes or triggers that might exacerbate the delirium, as well as to provide the best environment for a holistic recovery. This might include any of the following criteria. Note that this is not an exhaustive list.

• Providing the right medication to address your loved one’s deficiencies/impairment
• Assisting with mobility and speech
• Helping cope with changes
• Help keep them calm and feeling safe
• Providing comfort

There is concern among medical professionals that the use of antipsychotic medications could lead to prolonging delirium or making it worse.

Some observations have found that high doses of these medications can affect your loved one’s memory, leading to confusion and disorientation that can lead to delirium.

Thus, these medications should only be considered in cases of serious behavioural or emotional disturbances. In place of these, non-drug interventions have led to better recovery outcomes with little to no side effects.

Physical restraints are another no-no to treating delirium. Studies have found that restraining a person with delirium can worsen their outcomes and present a variety of complications, including heightened anxiety, asphyxiation, or even heart attack.

A multidisciplinary approach is often the best course of action to holistically treat your loved one’s delirium. An emphasis on your loved one’s comfort should also be prioritised to help minimise and address confusion.

Accompanying them can give them some level of comfort since there is someone they know and trust to be with them in an unfamiliar environment.

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Helping them with activities can also be beneficial, but it is important to give them enough room that they can feel comfortable doing it independently. Encouragement at all times can do wonders to their recovery progress.

You can also bring items from the home to the ward to help serve as comfort items since they know what these items are and what significance they have to them. Simple reminders like these can be very helpful to manage their delirium.

Ensure your loved one also gets enough nutrients from food and drink. Sufficient nutrition will help stave off the worst of delirium’s effects, especially in hypoactive delirium where your loved one may be a lot less active. If they use any hearing or visual aids, make sure they have it on them at all times, where possible.

Be alert for any changes that may occur over time while your loved one recuperates. Stay in touch with the medical team from time to time for updates to your loved one’s condition. If you notice anything different, be sure to notify them immediately.

Care at home

In the event your loved one is recovering from another medical condition, chances are they may be discharged early if their recovery is making good progress. In some cases, you might find that delirium presents itself in your loved one sometime after the discharge.

Quickly notify the medical team so that they can conduct an assessment to confirm if it is delirium, and then come up with a care plan to can help address it.

The primary importance should be to keep their environment safe and quiet. Being at home surrounded by familiar faces and objects can be beneficial to their recovery, but you should always be prepared for instances when they might go through a bout of confusion or experience vivid hallucinations.

Ensure other family members are aware of this, too; family support will be important to help speed up the recovery process. Their assistance with caregiving responsibilities can also allow you time to settle other things that you need to attend to, or give yourself some room to rest and recuperate.

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If they have trouble understanding your speech, be sure to talk to them slowly and simply so that they understand you. Use visual cues to help, and regularly identify yourself or others so they remember.

Reassure them if they feel stressed or confused, and be sure not to dismiss them entirely if they do not know what is going on. Always approach them calmly, and avoid surprising them so as to not trigger a delirious episode.

During the day, keep them awake with leisurely activities, and expose them to sunlight as much as possible. Short walks around the park are a good activity you can accompany them on.

Avoid taking naps, as it can potentially exacerbate symptoms. Help them to sleep soundly at night by reducing sources of noise and other distractions that could interrupt their sleep. All of these steps can help to reduce confusion and maybe even episodes of hallucinations.

Stimulate their minds with some fun brain teasers to help with their cognitive functions. Suggestions include board games, simple quizzes, reading a book, or even crossword puzzles.

Doing these together can make them feel at ease to have someone they know with them. Try to encourage them to find solutions to these activities, and guide them only if they really need help. Encourage independence as often as possible.

Being at home, it is a lot easier to make sure they get the right amounts of nutrition during meals. Plan their meal times accordingly and at set intervals, including their medication doses, if any. Communicate with them and see if there might be anything that they’d like, or offer alternatives if it might not be recommended as part of their dietary plan.

Be sure to schedule follow up appointments and accompany your loved one for them. If all goes well, your loved one should make significant progress and be free of delirium in no time. Share your observations with the doctors and see what else can be done to improve their recovery.

Preventing delirium

Delirium affects people differently, especially concerning its duration. The important thing is to keep a close eye on your loved one’s condition to make sure the delirium has completely subsided and to make them comfortable in the meantime

Environment modification is generally the best way to help your loved one’s recovery. It helps to have them in a familiar setting and to be active for as often as possible. Even after the delirium has passed, make your loved one’s schedules a routine to keep them healthy and happy.

Getting help

With proper care, delirium can quickly be remedied. Be sure to have follow-up checks done until your loved one’s condition is given the green light. Convey any concerns that you may have with the medical team; if need be, further assessments can be done to determine how to improve your loved one’s condition.

Support groups can be an additional option to consider. Whether it is for you to find others going through a similar situation, or for your loved one to socialize with new people, support groups can be helpful channels to interact with others, share stories and experiences, and make new friends.

If you feel like you are having a difficult time caring for your loved one, it is perfectly fine to seek help. If your family is helping you out with chores and care responsibilities, there is nothing wrong with taking some time for yourself.

Whether to get professional help to sort out your emotions, or to have some personal time to unwind and recharge your batteries, you should prioritise your needs when you need them most.