REASONS FOR SUDDEN DEMENTIA – DELIRIUM AND DEMENTIA Part II

The Center for Medicare requires healthcare professionals to investigate causes and reasons for sudden dementia including these changes:

SIGNS OF POSSIBLE DEHYDRATION

  • recent decrease in volume of urine, more concentrated urine or a darker color
  • recent decrease in eating habits, skipping meals, leaving food uneaten, weight loss
  • nausea, vomiting, diarrhea, or blood loss
  • receiving IV drugs
  • receiving diuretics or drugs that might cause electrolyte imbalance

FUNCTIONAL DECLINE

  • falls or increased risk for falls
  • recent decline in the ability for self-care in hygiene, dressing, walking, eating, etc.

MEDICATION REVIEW

This area requires the services of the pharmacist. A medication review would first focus on new or recent medications and possible interactions with other medications the patient is taking. All narcotics need to be investigated, the elderly may become unreasonable, angry, or argumentative on narcotic medications. All behaviors that are different for the patient since beginning a new medication must be explored. Especially so for any drugs used to change or modify  behaviors such as anti-anxiety, antidepressants, sleep medications and of course anti-psychotic medications.

SOCIAL CHANGES

  • social withdrawal – recent loss of a family member or friend
  • recent changes in mood – crying or anxious\
  • a recent move – out of state or from home to facility

UNUSUAL BEHAVIORS

  • recent change in sleep habits, sleeplessness at night and sleeping during the day – nightmares
  • unusual, inappropriate or unsafe movements
  • hyper-active or hypo-active, a recent change to the extreme in a person’s level of activity

 

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

REASONS FOR SUDDEN DEMENTIA – DELIRIUM AND DEMENTIA – Part I

The increase number of people experiencing sudden dementia has caused delirium to be a focus of Medicare. As with everything else the way to capture attention is to create a monetary connection. In this case, Medicare reimbursement for sudden dementia is tied to identifying the cause of the patient’s delirium. The list of possible reasons, is to be a guide for consideration for every patient on Medicare with sudden dementia or delirium. Or any person admitted to a nursing facility who has sudden dementia as a diagnosis.

The basic physical changes that can cause a person to become delirious:

CHANGES IN VITAL SIGNS – COMPARED TO BASELINE (baseline, you always want to compare with what is usual)

  •  elevated temperature – 2.4 degrees higher than baseline
  • pulse rate less than 60 or higher than 100 beats per minute
  • breathing slower than 16 breaths a minute or higher than 25
  • a significant drop in blood pressure compared to baseline
  • a significant increase in blood pressure compared to baseline

ABNORMAL LABORATORY VALUES

  • electrolytes
  • kidney function
  • liver function
  • blood sugar
  • thyroid function
  • arterial blood gases (this is blood tested from an artery instead of a vein to check the ph of the blood as well as to see how well the lungs are moving oxygen into the blood and removing carbon dioxide out of the blood)

PAIN

  • how often is the pain, how intense, how long does it last, what is the quality of the pain?
  • how is the pain affecting the patient’s ability to function?

A complete pain assessment must be conducted at this time.

SIGNS OF INFECTION

  • fever
  • cloudy or foul smelling urine
  • congested lungs or cough
  • shortness of breath – or painful breathing
  • diarrhea
  • abdominal pain
  • wound draining pus
  • any redness around an incision or wound

Some of these symptoms may be present but if there isn’t a good reason for something such as a slow pulse –  that is related to a medication the patient is on, then this symptom must be considered as a cause for the sudden dementia, and investigated further.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

 

WHEN THE ELDERLY HAVE HALLUCINATIONS AND SEE BUGS – IT CAN BE DELIRIUM

One of the signs and symptoms of delirium can be hallucinating. Hallucinating does not mean that you have dementia but most likely a form of delirium.

Signs of delirium are:

  • Sudden confusion /acute change in mental condition
  • inattention
  • hallucinations
  • disorganized thinking
  • altered level of consciousness

I very well remember sitting with my Dad in the hospital every time he had surgery, because for him it was a given he would have delirium. Delirium with hallucinations. Every time Dad had anesthesia I knew he would come out of it talking about bugs.

As Dad was talking about the bugs he saw crawling up and down the walls of his hospital room, he was certainly concerned. Because he didn’t have  Alzheimer’s disease he could rationalize that what he saw was impossible. Yet, these bugs were very real to Dad at that moment. Seeing those bugs were a huge distraction, requiring me to sit directly in front of Dad. all the while making eye contact. Reminding and reassuring Dad that he was going to be fine, that this wasn’t real. Saying repeatedly “Look at me Dad,” all the while smiling into his concerned face.

Delirium from a metabolic disorder, head injury, alcohol, drug use, and for the elderly many times an infection or as in my Dad’s case surgery may result in hallucinations.  With Dad, as long as the hospital health care professionals could be persuaded to not medicate him(and that was possible as long as I provided one-on-one) for his hallucinations, we could wait until the drugs were out of his system.

After he had recovered from the delirium, for some time he would refer back to that time. He couldn’t get over how real his hallucinations and how real those bugs were.

The answer for my Dad and the anesthesia was just giving him time, one-on-one care and attention.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

SUDDEN CONFUSION – GO TO EMERGENCY ROOM

While it is easily seen when a person has a dramatic change in consciousness and they are in a stupor or coma, delirium is not that easy to identify. The emergency department is usually the point of entry into the hospital for the confused elder. The ER runs at a high speed and it is necessary for an accurate diagnosis for the patient’s family or friends to give a good history.

Patients in a deep sleep or stupor, who can only be aroused with extreme physical stimulation are in a medical emergency. The emergency room personnel assume that the person is not always so difficult to arouse, and they recognize the emergency. However identifying changes in a patient with delirium is much more difficult because the hospital staff do not know how the patient usually is. This puts the burden of communicating the emergency situation on the accompanying family member.

It is estimated that ER physicians miss the diagnosis of delirium in 57 to 83% of cases. This wastes valuable time for the patient, time that they need for early intervention. This missed diagnosis can be due to the fact that the elder themselves do not know why they have come to the hospital. Or if the elderly person is agitated they may even be admitted to the psychiatric ward, without a good assessment.

Giving a good mental history:

  • when did you first notice a change in mental function?
  • do these changes seem to come and go – get worse or better over time
  • does the person have problems paying attention – give an example of what is normal for this person and how they are now not acting normally – having difficulty carrying on a conversation – getting distracted and changing the subject
  • patients who are inattentive may actually fall asleep when they are not engaged in conversation, this change in sleep/awake patterns needs to be stated
  • the patient now has rambling thoughts and disorganized thinking
  • if the patient has had any recent falls, this is a very important piece of information and will help the physician in their physical examination – looking for possible head trauma
  • maintain an accurate list of all of the elder’s medications as well as any over the counter medications they are taking – maintaining this list will make it much easier in an emergency situation
  • share with the emergency staff if the elder has a history of alcohol abuse or use of sedatives
  • has the elder ever experienced an episode like this in the past?

Being prepared and ready with this pertinent information is impressive and will more likely get the attention of the emergency personnel than saying “He is just not acting right.”

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

SUDDEN CONFUSION – CAN THE PERSON WITH DEMENTIA GET DELIRIUM?

Many people, including those in healthcare use the terms dementia and delirium interchangeably. Even tho they are not the same, patients can have both conditions at the same time. A person with dementia can certainly develop delirium, they are even more inclined under certain circumstances, to develop delirium.

The person with several disease processes as well as dementia, will be the person at most risk for developing delirium. Research has shown that the person with dementia has a lower mental reserve and less ability to adjust to a physical assault. That assault can come in the form of an infection such as a urinary infection or upper respiratory infection. Because the person is more vulnerable due to their dementia, they can under these circumstances develop delirium.

Other factors creating an increased likely hood of developing delirium are advanced age, history of alcohol abuse, poor nutrition, poor physical function, poor vision, hearing loss, dehydration, congestive heart failure, extreme pain (such as that related to a fracture), and many medications especially narcotics. Many times the cause of the delirium will not be found.

When the person is admitted to the hospital they are at increased risk to develop delirium if they have dementia. Due to the nature of the running of a hospital, the confused person may have physical restraints to keep them safe if they are trying to get out of bed unassisted. The elderly who are incontinent may now have a catheter for the purpose of obtaining urine specimens as well as easier care considerations. These possibilities as well as the likelihood of the elder now having an increased number of medications can result in an increased risk of developing delirium.

In the United States, hospital emergency rooms are currently seeing approximately 18 million patients 65 years and older. As the population ages, the number of visits to the emergency room by the elderly will increase dramatically as well. The potential for large numbers of the elderly population going to the emergency room for sudden confusion and developing confusion when admitted to the hospital is increasing. All of this adds up to an expectation of  not only the increase in elderly persons with dementia but also the increase in cases of delirium.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

SUDDEN INCREASE IN CONFUSION IN ALZHEIMER’S PATIENT – IS THAT EVEN POSSIBLE?

Harold came into the skilled nursing facility, admitted from the local hospital. Harold lives at Pleasant Meadows, an assisted living community where he has been independent. The problem arises when the nurse from the skilled facility  calls the nurse from Pleasant Meadows. The Harold that the nurse now describes in not the man the Pleasant Meadows nurse has know for the last 6 month, before he went to the hospital. Harold?  Uncooperative, disoriented, unsteady on his feet, falling, with generalized weakness? No, no the nurse from Pleasant Meadows insists that they (the skilled facility) don’t know what they are doing and don’t know how to take care of Harold.

Sadly this scenario is not unusual, for one healthcare facility to accuse another of not knowing what they are doing. Doesn’t the fact that because Harold already has the diagnosis of Alzheimer’s disease mean that it is understood that he is confused? Yes, Harold is always confused, but this new Harold is in an altered mental state. He was admitted to the hospital with pneumonia. Infections in the elderly many times can cause confusion. This infection caused Harold to experience a rapid decline in his mental functioning and an increase in his confusion.

Sudden increase in confusion can result in very vague symptoms. The family member might say he is “not acting right”, has different behavior, is either more sleepy or more agitated, is extremely distracted,  has recent inappropriate behavior. These sudden changes can come within days or even hours of onset. The great difficulty comes in diagnosing why the individual is suddenly more confused. As well as realizing that it is going to take much more time for the problem to resolve compared to the fast onset.

Harold will continue to have increased confusion even after he has recovered from his pneumonia. And Harold is likely not to return to his previous level of mental functioning.  This infection has tragically caused him to lose some mental clarity  and has resulted in progression of his dementia. Right now Harold needs one on one care, with people who explain the environment and what is going on, as well as protecting him from unsafe activities. All the while giving his mind the time to heal as well as his body.

Yes, it is not only possible for someone with Alzheimer’s disease to suddenly become more confused, it is more than likely when there is an infection involved. A sudden increase in confusion, or delirium continues to be misunderstood.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

DELIRIUM AND HIP FRACTURE – SUDDEN CONFUSION FOLLOWING SURGERY

Mr. Frank is a 76 year old man who has been admitted to the hospital for a hip fracture. Mr. Frank had fallen at home and when he was admitted he was very alert, friendly, quiet and pleasant. Yes, he was in some pain before his surgery, but it was well controlled with medication. Now that he has come out of anesthesia, after his successful surgery, he is yelling, throwing his bed sheets as well as everything on his bedside table, on the floor. He is very agitated, and keeps trying to climb out of bed, even though the staff instruct him to use the call light for assistance. Mr. Frank is suddenly a completely different patient. A very difficult patient.

The hospital staff are sure that Mr. Frank has delirium because of the suddenness of his change in mental status. Having delirium following a bone fracture and surgery isn’t all that uncommon for the older patient. Studies show that physical or mental illness affects 15-53% of older surgical patients. Delirium is more common in the older patient than younger patients. And the person with delirium is also more likely to have other complications as well. Actually 48% of patients older than 65 years are shown to have had acute confusion before and after surgery.

Delirium before surgery can be related to pain or sleep disturbances due to pain. Or an electrolyte imbalance, medications the patient has been taking, or possibly an infection that was related to the fall in the first place. All of the possibilities require extensive evaluation of current medications, lab work for complete blood count, urinalysis and serum electrolytes. After consulting with the physician, many other tests may be ordered to assess the source of the delirium and  create a treatment plan.

Care of this older, confused patient will include being very present for Mr. Frank. Making good eye contact when staff speak to him, as well as using soft reassuring words. If Mr. Frank is having hallucinations giving him one-on-one care to reassure him that what he is experiencing is not real. Making sure that if Mr. Frank uses glasses, that they are clean and on when he is awake. If Mr. Frank uses a hearing aid that the battery is working and that the hearing aid is in and turned on when he is awake.

Maintain a quiet and peaceful environment while decreasing noise as much as possible. This is the time to also reassure the family, while you educate them on the subject and course of delirium. While teaching them how to be involved with the patient, to assure a positive outcome. Watching a loved one struggling with anxiety and agitation is very difficult on the family as well as the patient.

It is reported that post operative delirium in the older patient, is costing 164 billion annually. While that is certainly an impressive number, it doesn’t even touch on the real cost to the elderly patient and his family.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

WHEN DEMENTIA AND CONFUSION AREN’T PERMANENT – SUDDEN DELIRIUM

I receive emails from families who can’t understand what has happened to Mom, Dad, Uncle Charlie and so on. You see this person was just fine a couple of weeks age, driving, shopping, living alone, balancing their check book, and now the doctor says Mom has Alzheimer’s disease and needs to live in a nursing home. What usually happened is that Mom had an infection, an accident, change in medication or surgery and this put Mom into a state of delirium

Synonyms for delirium are; irrational, raving, deranged, and yes even demented. Once the stress is over, the elder returns to their previous state of cognition. But what if Mom is in the hospital when she becomes delirious? The hospital personnel don’t know Mom and  don’t recognize her delirium. Mom will be labelled a confused, demented elder and medicated to keep her under control and “safe.” This will only lead to increased confusion making Mom appear even more confused.

The presence of delirium can indicate that the elder’s brain has a decrease in capacity and may indicate an increased risk of developing dementia. The healthcare community sees delirium frequently with the elderly and infrequently with the young. The same person can have had no history of delirium, even though they have experienced several hospitalizations, yet when they are old, they become confused and disoriented every time they are admitted.

Whenever there is a sudden change in an elder’s ability to think, focus, reason, and remember, look back to whatever stress could have caused the change. The longer the person suffers from delirium, the more chance it will not be resolved.

Remember Alzheimer’s Disease is slow, delirium is fast and doesn’t have to be permanent.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

DRUGS AND DELIRIUM

Anti-psychotic medications are routinely prescribed for delirium. However if the delirium is due to anesthesia, a drug, an electrolyte imbalance or infection and the effects will wear off relatively soon. It would be much wiser given the side effects, to just have someone stay with the individual. Non-drug support works much more effectively especially with the elderly than introducing yet another drug.

Side effects are far ranging such as; loss of balance, restlessness, trembling, difficulty urinating, weakness, dizziness, skin rash, and even unusual movements of the mouth, arms and legs. When these drugs are used, the family member should be given a complete list of the drugs side effects.

Delirium is a very frustrating condition for the patient. It causes misinterpretation of their environment. Keeping the patient informed of what day it is, what time of day it is, what has happened, where they are and what is going on right now is very important. Often if the patient is hallucinating they will tell you that they know what they are seeing, can’t be true, but they are seeing it anyway.

These drugs may be introduced just because it is difficult to care for someone who is delirious. However many elderly people being discharged from the hospital, are now leaving on powerful anti-psychotic medications due to delirium. The problem arises when the patient is no longer delirious due to the infection, surgery or medical condition that caused it in the first place. But now they are suffering from the side effects of the drug.

What does work for delirium? Studies now show that the quickest way to recover from delirium is to get moving. Having patients get out of bed and start walking it off, turns out to be the best and safest medicine yet. Make sure the patient is hydrated, there is a reason patients come out of surgery with IV solutions. Make sure the patient is exposed to sun light during the day and in a dark room at night so that they return to their normal sleep/awake cycle.

And most of all provide that one on one caregiver, who can explain the environment while reassuring the patient that all is well and they are safe.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing 

DEMENTIA AND DELIRIUM INCREASE CHANCE OF FALLS

Confusion due to dementia and delirium are known risk factors for falls in healthcare. Researches have noted that persons with confusion have a risk of falling 1.8 times that of the elderly without dementia. Falls in the elderly are predictable when the elder has; balance problems, problems with dizziness or fainting, cardiac problems, arthritis, osteoporosis, vision problems, is weak from immobility or a recent infection, is taking numerous medications or a medication for anxiety, or depression.

But the risk of a fall increases to almost double the risk when the elderly have dementia or delirium as well as the other known risk factors.

Behavioral problems – the person with dementia or delirium will have decreased safety awareness and make poor decisions. The person with dementia or delirium are more likely to forget to use assistive devices such as canes and walkers, or stop and put on good safe footwear. If the person also experiences angry outbursts of a physical nature, this also greatly increases their risk of falling.

Dietary deficiency –  the person with dementia or delirium can suffer from a poor nutritional status due to bad food choices. Adequate protein, essential vitamins, and water are needed for good health.  And especially vitamin D and calcium are necessary for strong bones.

Vision changes – a person with dementia can experience a decline in the ability to sense where they are in space. This often results in sitting down and missing a chair. Added to that a decrease in visual accommodation to light and dark, glare intolerance, altered depth perception and possibly physical changes in eyes due to aging, increase the risk of falls to an even greater degree.

Chronic illness – arthritis causing stiffening of joints, osteoporosis and bone deterioration increases risk of injury related to a fall, stroke and Parkinson’s disease increase the risk of falls. These are known issues with aging, and the elder with dementia who has painful swollen joints from arthritis is at even more risk.

Acute illness – has been shown to be a factor in 10% to 20% of falls in the elderly. An acute infection will cause weakness, fatigue, even dizziness. But the person with dementia or delirium will have an increase in their confusion.

Continuous monitoring of the elder with dementia or delirium is necessary as well as monitoring for these increased risk factors.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing