Managing delirium in hospital.

Delirium is not well recognised by health care professionals, though I believe this is improving, certainly in hospitals where there exists dedicated older persons specialist care.
If delirium is not well recognised then, it bodes that delirium may not be managed well either.

What does delirium look like?

Delirium can present as hyperactive or hypoactive or sometimes a mixture of both.
A person may be agitated and active (hyperactive delirium) or very quiet and tend to sleep more than usual (hypoactive delirium).
And the symptoms may fluctuate in severity throughout the day too.

People with a hypoactive delirium are more likely to be the patients who are not given the appropriate attention during a hospital admission, as they present as being ‘compliant’ patients, they are quiet, don’t call out and disrupt other patients and they don’t ‘wander’.

If your loved one who has a mild cognitive impairment or dementia is admitted to hospital and is unusually quiet and drowsy you need to discuss with the treating medical team about hypoactive delirium as a priority.
The underlying cause of the hypoactive delirium needs to be investigated and treated!

A patient with a hyperactive delirium presents as being agitated, ‘non compliant’ and may try to continually get out of bed and ‘wander’.
These are the patients who are likely to have a nurse ‘special’ attending them during their admission.
A ‘special’ is usually an assistant in nursing who is assigned to monitor and provide care for the person with dementia and/or delirium, specifically ensuring the patient doesn’t fall or ‘wander’ into other patient’s rooms or doesn’t ‘wander’ off the ward.

The ‘special’ may or may not be familiar with dementia and/or delirium.

The informed carer.

This is where you, as the informed carer and/or family are able to steer the day to day care of your loved one, to ensure the management of the delirium is appropriately implemented, to ensure the ‘special’ is actively administering an appropriate plan of care.

What do I mean by actively administering appropriate care?
I mean that the ‘special’ is encouraging and assisting the patient, your loved one, to maintain orientation within the hospital ward and to maintain regularity or normality of their daily routine.
That the ‘special’ is encouraging and assisting your loved one to get out of bed and sit in a chair for meals.
That the ‘special’ is offering your loved one sips of fluid throughout the day and assisting them with their meals, if they aren’t feeding themselves.
That the ‘special’ is taking your loved one to the shower rather than sponging them in bed.
And that the ‘special’ is talking to them, engaging with them, and actively re orientating them.
That they have their hearing aids in and their glasses on.
And most importantly, that the ‘special’ is not continually telling your loved one to ‘lie down’ or ‘go back to bed’.

You see, it’s easier for nursing staff to try to keep a confused older person in bed than get them up and get them engaged with their surroundings!
It hurts to say that because I’m proud to be a nurse and I think we do an amazing job…..we just don’t do delirium all that well.

I once walked into a 2 bed bay where both the elderly gentlemen were being specialled by a ‘nurse special’.
Both ‘nurse specials’ were sitting at the end of each bed, both preoccupied on their mobile phones and both elderly gentlemen were in bed with the sides up just looking at the ceiling.
Staying in bed looking at the ceiling all day does not promote resolution of a delirium…it will prolong the delirium.

Staying in bed is not helpful.

Immobility, which may result in someone sleeping the day away can cause disruptions in day/night, sleep/wake cycle.
It can cause reduced gut motility leading to constipation.
It often results in urinary incontinence, which in itself is distressing for the patient and the family but also causes skin irritations and potentiate incontinence lesions.
It can cause reduced clearing of lung secretions and may potentiate chest infections.
Immobility causes deconditioning in a person, prolonging their recovery and prolonging their hospital admission.

If your loved one is in hospital and they are experiencing delirium, talk to the treating medical team and check if there is no reason why your loved one cannot get out of bed (a broken hip/fractured neck of femur might be one reason).
If the treating medical team has no objection to your loved one getting up and getting moving, then please get the nursing staff to attend to this!
At the bare minimum, ask the nursing staff to help your loved one get into a chair, so they can look out the window, eat and drink their meals with reduced risk of choking and interact with you eye to eye, so to speak.

Resolution of delirium is not going to happen quickly.
It may take days or weeks for this acute confusional state to diminish.
The simple supportive measures I have described will assist in the delirium resolving and will give your loved one a better opportunity to heal and return home, which is the best environment for someone with a cognitive impairment.

Those controversial words.

A note on the words ‘non compliant’ and ‘wander’, I detest this language and it is inappropriate to use this kind of language when describing the actions of cognitively impaired older patients, but it is language you may encounter in the hospital.

It demonstrates a lack of understanding of the attending clinician on what is happening with the patient experiencing dementia and/or delirium.

I use this language here to inform and empower you as the carer and family of the person with dementia and/or delirium so that you’ll be able to generate appropriate and informed conversation on the management of your loved one, with our valued health care professionals.