clinical focus
What can happen to someone experiencing delirium
if it is left untreated?
At the time that a person is delirious, their thinking and their
physical function declines. They often become quite drowsy.
They’re often quite frightened, because they don’t know what’s
going on with their thinking. People will often know that there’s
something wrong, but they can’t necessarily express it well
verbally, or they feel that they’re going crazy. A lot of people
wonder if they’re getting dementia.
It comes on quite suddenly and they’re often frightened as
well because of the delusional thinking or the hallucinations that
frequently happen.
Patients may often be seeing things or thinking things that make
them very frightened … but they’re unable to express that clearly,
so it often is expressed in fear or anxiety, agitation, aggression.
So in the delirium itself, it’s just incredibly distressing. And even
the patient who seems quite quiet, can be very distressed without
us realising it because they’re keeping all of this to themselves –
either because they can’t communicate it, or they are frightened
of communicating it to others.
A patient who has delirium does a lot worse in the shorter term
and in the longer term, than a patient with the same condition,
same age, same sort of baseline, who doesn’t have delirium. So if
you have the delirium in hospital, you’re more likely to fall. You’re
more likely to stay in hospital longer; more likely to be admitted to
a nursing home, not be able to go home. And it increases the risk
of mortality in patients and there’s also some evidence coming
out that there’s an association or link between having a delirium
in older age and then later developing a longer-term cognitive
impairment. It’s a dementia-like illness, not quite the same but it
has a lot of the same features as dementia.
With patients who’ve had delirium in hospital, say for example in
an intensive-care setting, there’s a lot of understanding now that
those patients don’t return to their prior level of function [so there
is increased interest in looking at] what we can maybe be doing
about this so that this doesn’t happen to people when they are
discharged from hospital.
What are some signs health professionals can look out for?
It’s understanding what the diagnostic criteria are. The first, the
cardinal, feature of delirium is a disturbance to [the person’s]
attention and awareness. Attention, to me, is when you go into
a patient’s room and the person looks at you in the eye and
recognises your presence, and can maintain conversation, can
maintain attention to what it is you’re doing and saying. That is my
way of telling if someone is attending to their surroundings.
So if someone doesn’t open their eyes when you come into the
room, if they open their eyes, and then close them again very quickly,
if they drift off halfway through a conversation, or if they change topic
of conversation halfway through, those are the first things to watch.
The second thing is a change from baseline. We have to know
what people’s usual level of function is and thinking is. And the
changes happen quite quickly and the changes tend to fluctuate.
Then the third criteria is that there’s a change in thinking
or cognition that manifests as changes to speech, behaviour
and ability to physically coordinate your movements. Memory,
orientation, things like that [also being affected]. The perceptual
disturbances like hallucinations and delusions and illusions, are
categorised as cognitive changes.
The fourth criteria, is [establishing] that it’s not related to
dementia or coma.
And the fifth criteria is that there’s a physiological cause
explaining the changes. Usually people with delirium will have
several things going on physiologically. So we have to work out
what’s going on physically for the person and then correct those
imbalances. This means recognising the delirium, finding the
cause and rectifying the imbalance are important treatments …
and then continuing all those prevention strategies, which every
person needs regardless of their state of illness or health.
Talking [to patients is also vital]. It’s great if we know the person,
and often in residential aged care, we will know that person well …
but in hospitals, it’ll be a bit different because often we don’t know
our patients very well. The major way of recognising a change to
someone’s behaviour, or thinking, or awareness or attention, is to
communicate with the patient, but also with the family – so all the
people who know the person much better than we do.
How can health professionals best treat or prevent delirium?
The most effective intervention is prevention. Of all the studies that
have been done into delirium, that’s coming through as the most
effective thing to do. The most effective prevention is through caring
for a person so that they get enough sleep, so that they get enough
to eat and drink, so they get to move around as much as possible, so
that they get to exercise their thinking – in terms of conversation, or
reading, or board games – and it’s important that they can see and
hear as well as possible, so if someone needs to wear their glasses or
wear a hearing aid, that those things are available to people.
So this is really quite amazing because of all the drug trials and
all the anaesthetic techniques, and all of the other interventions,
these strategies are the ones that actually keep patients safest.
And it is actually fundamental care. It makes sense because every
human being needs those things on a daily basis. We need to be
able to eat enough, drink enough, sleep enough, walk around,
converse and communicate and see and hear.
So if someone is sick, you really need those things even more.
But I think we tend to think that the more technical aspects of
our care are the things that really make a difference to people.
And often they do, but if those other fundamental aspects
of maintaining the person in as good a state as possible are
overlooked, then it’s hard for them to get better.
What needs to be done on a broader scale to improve delirium
detection and the outcomes for those who experience it?
There are some great things happening in Australia in terms of
hospital care. A delirium care standard will be coming out as part
of hospital accreditation in the next few years. This means there
are a number of elements to that standard. The first one is that
we assess every person who comes in, particularly older people,
for cognition on admission, that we screen daily for delirium in
patients at risk. There are a number of tools that we can use that
are quite quick and simple and they don’t take too long. And the
other thing is to avoid the use of psychotropic indication. There’s
increasing evidence that anti-psychotics actually make delirium
worse, whereas for many years, they have been the first line
medication treatment for delirium.
The other thing is to plan for discharge, getting the person back
to where they usually live as soon as possible.
But the main thing is for everyone to be aware of how common
delirium is and how serious it is. We shouldn’t be using terms like
“pleasantly confused” because it’s not pleasant to be confused
at all. It’s not funny from the perspective of the person who is
confused. We really need to be aware of delirium, understand
what it is, and that it’s a really significant issue. ■
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