Being sick feels like you’re wearing someone else’s glasses.”

Megan Boyle

What is delirium? Delirium is described as a “neurocognitive disorder,” which means that an individual who develops a delirium has increasing difficulty focusing their attention, becomes disoriented (often to place), and there may be memory problems and difficulty with speech. This disorder develops abruptly over a few hours or days and is related to a variety of medical conditions.

Some individuals may hallucinate and think they see bugs or animals around them or hear voices. Some patients become agitated or restless, and others may appear sleepy and remain quiet.  Delirium can develop at any age, but the risk increases as we get older.

A serious illness, overall frailty, poor nutrition, pain, hospitalization, surgery, and reactions to certain medications can all trigger an episode of delirium. The risk is especially high in the intensive care unit and during the last days and hours of life.

This disorder is not uncommon, and in one study 18-35% of adults over age 65 in a hospital medical unit had a delirium on admission. I would guess that many of you reading this have heard stories or been with a loved one who became delirious and understand how distressing it can be to the patient and family.        

Anna’s Story

Anna was 80 years old and living with her daughter. She was receiving radiation therapy along with chemotherapy for esophageal cancer and had several other medical conditions. After two weeks of daily radiation, Anna fell and was seen in the emergency room.

Her medications were adjusted, a pain medication was added for new back pain, and she was given fluids for dehydration. Two days later her daughter called the community health nurse to report that her mother was confused, insisting she had to “go home” and was refusing her medications.

During the follow-up home visit, the nurse practitioner observed that Anna could not maintain eye contact, follow any commands, was extremely restless, and did not know where she was. This was a sudden change from her previous mental status and it appeared that Anna had developed a delirium. Her daughter made the decision to transfer Anna to the hospital to be evaluated.

Although delirium and dementia can both affect memory and orientation, the key difference is how quickly delirium can develop. Dementia progresses slowly over years, not hours or days. Having dementia, however, does make a person more likely to experience a delirium should they become seriously ill or need surgery.  In Anna’s case, she did not have dementia, but she was not eating or drinking well, she had cancer along with other medical issues, and she was coping with daily radiation treatments. Her confusion and restlessness occurred overnight.

What is happening?

We do not completely understand what is going on in the brain during a delirium, and there are many theories about how the brain responds to stress during a serious illness. The levels of chemical substances that transmit impulses across brain cells are thought to play a role, but it is complicated and there is more than one mechanism involved that can result in a delirious patient.

What we do know is that there are risk factors some individuals have prior to getting sick that can make them more susceptible, and then when, for example, an infection or hospitalization occurs, this can tip the scale and the brain suffers.

Unfortunately, there is no simple test to diagnose a delirium nor is there a medication to prevent it. Once it develops, there are a few medications used to treat the symptoms. These tend to be avoided unless the delirium becomes severe, distressing or causes a significant safety risk to the patient. The concern is that adding yet another medication (usually a benzodiazepine or antipsychotic) may present more harm than benefit. Research is still ongoing to help guide the best treatment. 

The primary goal is to recognize delirium symptoms early and treat whatever medical conditions and environmental factors may be contributing. It is important to review all medications, look for infection, electrolyte imbalances, pain, low oxygen levels, kidney or liver disease, and the list goes on. Often it is the combination of a number of factors.

Although delirium can evolve quickly, the symptoms can vary throughout the day and can take days and sometimes weeks to improve. It can lead to a longer hospitalization stay and increase the risk of being discharged to a nursing home.       

The role of the family

Observing a loved one who is seriously ill, hospitalized, or at end of life become delirious can be alarming to family. The lack of recognition of a familiar face, problems with communicating or changes in personality can cause anxiety and fear in the family at the bedside. They may be further distressed by aggressive or angry behaviors and feel helpless to intervene and provide comfort.

Education and support from the healthcare team is needed to help them to better understand what is happening to their loved one and why, what to expect and how to be helpful.

As mentioned, there is no medication to prevent delirium, but there are ways for family and caregivers to assist their loved one. For example, if an older family member ends up hospitalized it can be so beneficial to make frequent visits and  bring in familiar objects to help keep them connected and oriented. This could include family photos, a favorite blanket, an article of clothing or their favorite music or food.

Family members can better identify early changes in mental status and behaviors and alert the healthcare team to a possible delirium. They can be invaluable in providing insight into how the patient seems to be responding to treatment. The environment can play a role in managing the symptoms of delirium as well.  Reducing the level of noise, avoiding over-stimulation, and dimming the lights at night can promote a normal sleep-wake cycle.

Make sure the patient has access to their glasses, hearing aids, and dentures if needed. A visible clock and/or orientation board with the day and schedule is another recommendation. Due to their confusion, these patients are unable to participate in making decisions about their medical care and must rely on family or healthcare proxies to advocate for them. 

Back to Anna

During her hospital stay, Anna was treated for a urinary tract infection. She again required fluids for dehydration, and her back pain was treated with a different medication. Her mental status began to improve, and she indicated that she did not want to continue her cancer treatments. Her daughter brought her home and after meeting with a hospice nurse, Anna chose to be admitted to hospice with the support of her daughter.

Bonnie Evans, RN, MS, GNP-BC, GC-C, lives in Bristol and is a geriatric nurse practitioner, End of Life Doula, and certified grief counselor. She can be reached at bonnie@bonnieevansdoula.com.