“During the day he’s completely calm, but at night he gets very agitated.”
“Tonight she hasn’t stopped calling out for her mother, who passed away many years ago. But she’s been asleep all day, and it was almost impossible to wake her up.”
These testimonies will be relatable to many relatives and caregivers of an elderly person who has to spend time in hospital.
They attest to a situation that is all too common: an elderly person is hospitalised, and experiences a sudden deterioration in their health, mainly characterised by spatial and temporal disorientation and agitation.
It looks like dementia, but could it be something else?
Dementia or delirium?
Dementia is not one specific disease, but a general term used to describe the progressive loss of cognitive functions: attention, concentration, orientation, problem-solving ability, and so on. Eventually, it impedes an individual’s autonomy and their ability to perform daily activities.
While many of these symptoms overlap with those of an unexpectedly agitated elderly patient, dementia develops progressively, over a long period of time.
In the case of the testimonies above, the patients may be experiencing an acute confusional state, also known as delirium.
This complex and prevalent complication of hospitalisation can have a direct impact on patients’ illness and mortality rates. It is therefore extremely important to prevent it, or, failing that, to establish an early diagnosis in order to treat it correctly.
According to several studies, it can affect 20% to 30% of elderly hospitalised patients.
A patient suffering from delirium might experience the following symptoms:
- Changes in levels of attention and alertness, which may vary over the course of the day. Often, an affected individual is hyper-alert at night, but very sleepy during the day.
- Changes in cognitive function, including memory loss (not remembering what happened during the night), disorientation (thinking they are actually at home), disordered or disjointed speech, and so on.
- Other symptoms can include changes in perception or hallucinations, agitation, or sudden, unpredictable mood swings.
Various factors at work
There are many factors that converge in an elderly patient and give rise to these symptoms. Some of them are intrinsic to the ageing process, such as polypharmacy (simultaneous use of several drugs) or sensory impairment.
Many others are related to the process of hospitalisation itself, such as stress caused by acute illness, the administration of certain drugs, or surgery. Environmental factors also play a part, such as constant interruptions from nursing staff and other patients making it hard to get a good night’s sleep.
Despite sharing some characteristics, dementia and delirium are clinically quite distinct. However, they can, and often do, occur together – in fact, a patient diagnosed with dementia is more likely to present with delirium during a period of hospitalisation.
This may be due to a decrease in cognitive reserve, meaning a person has fewer available brain resources to help them cope with stressful situations.
Can it be treated?
The good news is that delirium can indeed be treated – the sooner, the better. We must bear in mind that one of the main risks is that it goes unnoticed and no action is taken. This is compounded in patients with dementia, since dementia is associated with alterations in levels of alertness.
If delirium is a reaction to a particular medicine, the solution is simply to withdraw it. If the cause is an infection, treating the infection may alleviate symptoms.
On other occasions, specific pharmacological treatment will help to control behavioural disorders. All of these options should, of course, only be considered after thorough assessment by a specialist.
There are also measures to help prevent delirium from occurring in the first place. Initiatives such as HELP (Hospital Elder Life Program) in the US include non-pharmacological measures like reorientation, sleep management, early mobilisation, use of sensory devices (such as glasses or hearing aids), hydration and digestive health.
The implementation of such programmes and the continuous training of health professionals are essential in preventing and promptly diagnosing a problem that is fast becoming a silent epidemic.
How caregivers can manage or prevent delirium
There are some essential steps to helping an elderly hospitalised patient avoid or manage the onset of delirium:
- Maintain a regular day and night schedule. Open the curtains to let in sunlight during the day and help them sleep at night by reducing noise and turning off lights.
- Keep the room quiet, so the patient can be as comfortable as possible.
- Keep up basic conversation, using short, simple phrases and giving the patient ample time to respond.
- If the patient becomes confused or frightened, remind them where they are and what is happening.
- If the patient becomes agitated or irritated by something in particular, keep calm and avoid arguing. A change of subject, or scenery, can help a lot.
- If the patient is hallucinating, do not dismiss or challenge them. You have to recognise their feelings and try to gently calm them down.
In conclusion, prevention and early detection are essential for optimal treatment of delirium, a disorder that can have a major impact on a person’s physical and mental health, not to mention severe consequences for public healthcare systems.
Laura Zaurín Paniagua, Docente e investigadora Grado en Enfermería Universidad San Jorge, Universidad San Jorge
