Caring about delirium in people with dementia

 

Lorraine Haining’s background is in nursing and she has specialised in dementia care for the past twenty years. She’s one of the 41 community nurses in Scotland who hold the title of Queens Nurse.  Lorraine enjoys the education arm of her work and knows acquiring knowledge and skills can be really empowering for family carers.

 

 

 

The UK has an increasing population of older people and many will be at risk of developing multiple health conditions. The combination of multiple health conditions, frailty and dementia or cognitive decline, can put the person at very high risk of developing Delirium, a common and serious condition which if not addressed early, can have very adverse outcomes for the person with dementia.

As well as the person living with dementia, delirium can have a major impact on carers. Therefore, it is really important to ensure carers are empowered by making them aware of what to look for, how to respond and importantly, to prevent it from happening or recurring. Acknowledgement of the vital role carers play in this condition from recognition to treatment and prevention, has only been recognised in the last few years.

 

So what is delirium?

Delirium or Acute Confusion is a state of rapid, intense mental confusion that can happen to anyone if they become severely unwell. Onset is very sudden, within hours or days, and it can be very frightening for both the person and carers who are supporting them.

There are various types of delirium and they can present very differently:

Types of Delirium  

Features

 

Hyperactive  
This type is more obvious with very clear sudden and major changes in the person’s presentation The person may present with agitated and hyper-alert behaviours. These may include hyper vigilance, restlessness, rambling speech, loud vocalisations, hallucinations, increased motor activity, wandering, distractibility, irritability and low tolerance for frustrations. Due to confusion and fear they may become defensive and can respond by verbally or physically threatening those trying to help
Hypoactive
Clinical features are much less obvious than in hyperactive delirium.

Hypoactive can often be mistaken for depression or dementia or a decline in a person who already has an existing dementia.

It has poorer outcomes for the person if not treated swiftly.

The person will present as predominantly drowsy and inactive. There will be decreased speed of activity and speech, reduced awareness of surroundings.
Mixed
There are alternating features between the hyper and hypoactive types. In this instance the patient may switch between both hyper and hypo delirium features

 

What are the common risk factors and triggers?

  • Older Person (age over 65)
  • Multiple health conditions
  • Infections
  • High temperature
  • Pain
  • Side-effects or interactions of drugs
  • Suddenly stopping drugs or alcohol
  • Dehydration or low salt levels.
  • Liver or kidney problems.
  • Major surgery, particularly hip and vascular surgery
  • Dementia: People with dementia are 5 times more likely to develop delirium.
  • Constipation
  • Unfamiliar surroundings

 

 

So how do you know the difference between delirium and dementia?

This is not always straightforward even for professionals, as you may be seeing a delirium superimposed on dementia. Below are some comparisons that may be helpful to differentiate them from each other.

Delirium Dementia
Starts Suddenly Gradual changes over time
Reversible Irreversible
Level of Consciousness:

Fluctuates form being overactive to being hard to rouse/waken

Level of Consciousness:

Rarely alters

Perceptions:

Hallucinations/illusions are common

Perceptions:

Not common unless the person has parkinson’s/Lewybody dementia

Speech:

Slow and incoherent

Speech:

Repetitive, difficulty finding words

Disorientation:

With time, place and person but may fluctuate over short periods

Disorientation:

Time place and person less likely to fluctuate

Processing of Information:

Unable to concentrate and pay attention, distractible, disorganised thinking, loss of intellectual and reasoning capabilities and short term/fluctuating memory impairment

Processing of information: 

Short and long term memory Impairment

Physical:

Illness, multiple medications, toxicity: Often

Physical:

Illness, multiple medications, toxicity: Rarely

Disruption of sleep cycle:

Arousal often increases at night

Disruption of sleep cycle:

Often due to disorientation to time and unable to read cues from environment

Outcomes: 

Excellent if treated early

Outcomes:

Progressive and life limiting

 

How will delirium be treated and managed?

If you suspect delirium, then assessment and appropriate tests should be carried out as soon as possible. There can be multiple triggers/causes which can make diagnosis and treatment complex, and this may take some time, so the earlier you seek help the better the outcome for the person. Once the cause is identified and treated the delirium will usually resolve, however recovery time is different for each person and in some cases the symptoms may persist for up to six months.

A person with dementia has more challenges as the disease process may already be compromising brain function therefore, they may take more time to recover.

If delirium is diagnosed in hospital it is really important to ensure the persons GP is informed of the diagnosis as they may need to provide community follow up and monitor the situation. After an initial episode of delirium, it is very beneficial to initiate a Prevention Plan to ensure you identify any early warning signs, treat quickly and prevent escalation. Speak with the hospital staff, your local GP or Community Mental Health Team who may have specific Care Plans in place already

As a carer, delirium can have a major impact on you also and you may need to enlist other members of the family or friends for support. Knowledge is power and in this instance it can be the case! So, ensure you are given appropriate information, you are kept informed, ask questions, make your needs known by asking for a carers assessment and don’t be afraid raise your concerns, your loved one may not be able to!

We provide a one-day course for partners, family members and friends caring for someone with dementia to explore the topic of delirium in more detail.

If you would like to attend this one-day courses in the future, please register your interest on our waiting list.

 


References

National Institute for Clinical Care Excellence (NICE) – Delirium prevention diagnosis and management (updated 2019) 

Royal College of Nursing (RCN)

Scottish Intercollegiate: Guidelines Network (SIGN): Risk Reduction and Management of Delirium (2019)

Scottish Delirium Association (SDA) (2014). Delirium Toolkit

Health Improvement Scotland