“How should delirium be managed in the hospital?”
This question came up during a Q & A session, as we were discussing the Choosing Wisely recommendation to avoid tying down older adults who become confused during a hospitalization.
Delirium is a common and very important problem for all older adults in the hospital. It doesn’t just happen to people with Alzheimer’s or a dementia diagnosis. (And, it’s not the same thing.)
But many family caregivers have hardly heard of hospital delirium. This is too bad, since there’s a lot that family caregivers can do to prevent this serious complication, or at least prevent an older loved one from being physically restrained if delirium does occur.
In this post, I’ll review what older adults and families absolutely should know about hospital delirium. And, we’ll cover some of the things you can do if it happens to your loved one.
Why hospital delirium is so important to know about
Delirium is a state of worse-than-usual mental function, brought on by illness or some kind of stress on the body or mind.
It is sometimes referred to as “hospital confusion” or “hospital sundowning.” And if it happens in the intensive care unit (ICU), it is sometimes referred to as “ICU psychosis.”
Although people with dementia are especially prone to develop delirium, delirium can and does affect many aging adults who don’t have Alzheimer’s or another dementia diagnosis. Here are some facts that all older adults and family caregivers should know:
- Delirium is very common during hospitalization. Delirium can affect up to half of older patients in a hospital. Risk factors include having pre-existing dementia and undergoing surgery. Having had delirium in the past is also a strong risk factor.
- Delirium is strongly associated with worse health outcomes. Short-term problems linked to delirium include falls and longer hospital stays. Longer-term consequences can include speeding up cognitive decline, and a higher chance of dying within the following year.
- Delirium is often missed by hospital staff. Busy hospital staff may not realize that an older person is more confused than usual, especially if the delirium is of the “quiet” type. (Although many people are restless when delirious, it’s also common for people to become quiet and “spaced out.”)
- Delirium is multifactorial. There often isn’t a single cause for delirium. Instead, it tends to happen due to a combination of triggers (illness, pain, medication side-effects) and risk factors (dementia, or pre-dementia). This means that treatment — and prevention — often require a multi-pronged approach.
To summarize, delirium is common, serious, and often missed by hospital staff.
Fortunately, there’s a lot that you can do as a family caregiver. In particular, you can help your loved one more safely get through a hospitalization by:
- Taking steps to prevent delirium;
- Keeping an eye out for any new or worse-than-usual mental states that might signal delirium;
- Making sure hospital staff address the problem if it does happen;
- Questioning things if the hospital resorts to tying a person down, before all other options have been tried. (This last one is a Choosing Wisely recommendation.)
How to prevent hospital delirium
Now, not all hospital delirium can be prevented. Some people are very sick, or very prone to delirium, and it’s certainly possible to develop delirium even when all triggers and risk factors have been addressed. Furthermore, many older adults are already delirious when they first get hospitalized.
Still, there are steps that can be taken to reduce the chance of a bad delirium. Experts estimate that about 40% of delirium cases are preventable.
The ideal is to be hospitalized in a facility that has already set up a multi-disciplinary delirium prevention approach, such as the Hospital Elder Life Program. Other hospitals have Acute Care for Elders units (also called “ACE” units) which also provide a special environment meant to minimize the hospital stressors that can tip an older person into delirium.
For elective surgeries, such as joint replacements, look for a hospital that has set up a geriatric co-management program for orthopedics, such as this one.
Here are some specific interventions that help reduce delirium, and how you can help as a caregiver:
- Minimize sleep deprivation. Consider asking the nurses if it’s possible to avoid blood pressure checks in the middle of the night. A quieter room can help. Do NOT ask for sleeping pills, however! Even a mild sedative, such as diphenhydramine (brand name Benadryl) increases the risk of developing delirium. Sleeping pills can also make delirium worse in someone who is already affected.
- Minimize vision and hearing impairments. Make sure the older person has glasses and hearing aids available, if they usually need them.
- Provide familiar objects and reassuring companionship. A few family photos can bring some soothing cheer to an older person’s hospital stay. Family or friends at bedside are also often very helpful, especially since they can help gently reorient an older person to where he is, and what’s been going on.
- Avoid overwhelming or overstimulating the person. Try to minimize mental strain or emotional stress for the person. A calm reassuring presence is ideal. If you need to give instructions or discuss something, try to keep things simple.
- Encourage physical activity and mobilization. Although many older people are sick or weak while in the hospital, it’s important to encourage safe activity as soon as possible. Physical therapy and minimizing bladder catheters (which can tether an older person to the bed) can help.
- Avoid sedatives and tranquilizers. Especially if the older person is restless or having difficulty sleeping, it’s not uncommon for sedatives such as diphenhydramine (brand name Benadryl) to be prescribed. But these can increase the risk of delirium, and should be avoided. So instead, try non-drug relaxation therapies such as soothing music, massage, a cup of tea, and familiar companionship.
- Minimize pain and discomforts. Ask the older person if he or she feels bothered by pain or constipation. If so, bring it up to the doctors. It’s not uncommon for pain to go inadequately treated unless family caregivers help an older patient bring it to the doctors’ attention.
If you think your loved one has developed delirium, make sure the doctors and nurses know about it. You may want to ask them what their plan is for evaluating and managing it. This will help you stay up-to-speed on the hospital course.
Some hospitals may even interview families to help diagnose delirium, using something called the FAM-CAM (short for Family Confusion Assessment Method) tool. The Confusion Assessment Method is generally considered the gold standard for diagnosing delirium.
Common causes of hospital delirium
Here are some common causes and triggers of hospital delirium and of “sundowning” symptoms when an older person is in the hospital. (Remember: in most older adults, multiple underlying causes and triggers are present.)
- Blood electrolyte imbalances (e.g. blood sodium being too high or too low)
- Infections, such as pneumonia, sepsis (bacteria in the bloodstream), and urinary tract infections
- General anesthesia and/or surgery
- Dehydration
- Drug toxicities and medication side-effects
- Withdrawal from alcohol, sedatives, or other drugs
- Blood glucose being too high or too low
- Sleep deprivation
- Kidney or liver problems
- Untreated pain or constipation
In people who have Alzheimer’s or another form of dementia, just the stress and unfamiliarity of the hospital setting can be enough to tip them into increased confusion.
Sensory impairments, such as uncorrected vision or hearing, can also help tip a vulnerable older person into delirium.
How hospital delirium is treated
To treat delirium, here’s what the doctors and nurses usually do:
- Identify and reverse as many triggers as possible. Remember, delirium is often multi-factorial. So even if there is a urinary tract infection that seems to have brought it on, the hospital team should try to spot any other factors that could be contributing (such as a medication side-effect, or a lack of glasses).
- Provide supportive care. It’s especially important to provide a calm restorative environment when a person is suffering from delirium. People may do better if they can avoid frequent room changes, and if they have a window allowing orientation to daylight.
- Prevent injury and manage difficult behaviors. This can be very challenging in those patients who become restless when delirious. Some hospitals have special “delirium rooms,” in which trained staff provide non-drug management of disoriented patients. As a last resort, the doctors do sometimes use low doses of medication. Research suggests that a small dose of antipsychotic, such as Haldol, is generally better than using a benzodiazepine (such as Ativan) which is more likely to make an older person’s confusion worse.
What you can do if an older person becomes delirious in the hospital
It can be scary to see an older person confused in the hospital, especially if you know that delirium can have serious consequences.
First and foremost, try not to panic. It’s time to hope for the best. Focus on doing what you can to help the delirium resolve.
As a family caregiver, you can play a very important role in providing a supportive and reassuring presence during an older person’s delirium. You can also:
- Advocate for minimum disruptions, and a quieter more pleasant room if possible.
- Make sure glasses and hearing aids are available, if needed.
- Help your loved one speak up if you think pain or constipation may be a problem.
- Question things if the hospital staff want to physically restrain the older person in bed. (This is a Choosing Wisely recommendation.) In many cases, if a person is dangerously restless, it’s better to start by trying a low dose of anti-psychotic, as mentioned above. Physically restraining a person often increases agitation and can lead to injury.
If you are of the really vigilant and proactive type, you may want to double-check that your loved one isn’t getting any sedatives or anticholinergic medications that make confusion worse. Even though these medications are risky for hospitalized older adults, it’s not uncommon for them to be prescribed!
What to expect after delirium: Even when all the right things are done — including getting the person home to a restful familiar environment — it often still takes a while for delirium to get better. In fact, it’s pretty common for it to take weeks — or even months — for delirium to completely resolve in an older adult. In some cases, the person never recovers back to their prior normal.
For more on delirium, see:
- 10 Things to Know About Delirium (includes information on delirium vs. dementia)
- Delirium: How Caregivers Can Protect People With Alzheimer’s (includes a list of helpful online resources that I’ve reviewed)
- A Common Problem That Speeds Alzheimer’s Decline, and How to Avoid It
You can also listen to our podcast episode, featuring leading delirium researcher Dr. Sharon Inouye, the founder of the Hospital Elder Life Program:
062 – Interview: Preventing Hospital Delirium & Maintaining Brain Health
This article was first published in 2014, and was last updated by Dr. K in March 2024.
Sandra says
Hi, my mother is 68, and underwent surhery for early stages pancreatic cancer on 11 dec 2018.(7 weeks ago). All went ok, just some fluid issues kept her in the hospital. 3 Jan she was moved to the ICU with septic shock, week later a stomach bleeding, cardiac arrest. They got her stabile but one day shy of 4 weeks ICU she still has no contact with the outside world, she is awake but does not move or communicate. The doctors assume it is a hypoactive delirium but are not sure. She was an active person and suddenly not even recognition, have you seen a delirium lasting this long before ? thank you
Leslie Kernisan, MD MPH says
So sorry to hear of your mother’s condition in the ICU. Delirium can indeed last a long time, especially if the person has been very seriously ill, which it sounds like she has been. That said, to be really immobile and uncommunicative sounds a bit unusual; usually with hypoactive delirium, the person is quiet and spaced out and inattentive, but would not appear to be asleep all the time or comatose.
I would recommend that you keep asking them to explain what they think might be going on. You could also ask if a specialty consultation could be considered, such as an inpatient neurology consultation. Good luck, I hope she gets better soon!
Dan Pollard says
My father is 3 weeks into alcohol withdrawal at the hospital and it’s not going well. He is 79 and not in the greatest health, although he has no major illness. He simply won’t snap out of his delirium slumber/sleepiness. He has had a few moments where he wakes up and is aware of us in the room, makes eye contact and tries to talk (but can’t really), but otherwise he is asleep all day. The doctors are suggesting we remove support – remove his IV and O2 nose piece – presumably to accelerate the dying process. They have seen this more than us obviously, and insist he is palliative. But it’s hard to give up on him as there isn’t anything REALLY wrong. His vitals are all ok. Don’t know what to do, but giving up on him seems cruel given that some people do spends weeks in delirium related to alcohol withdrawal, and then come out of it.
Leslie Kernisan, MD MPH says
Sorry to hear about your father’s situation. Hm. If the doctors are “insisting he is palliative” but you feel there isn’t anything “really wrong”, then it sounds to me like there’s been a communication breakdown somewhere.
It doesn’t happen all that often but I have seen doctors recommend a “comfort care because he’s dying” approach before it seemed really necessary. Alternatively, is it possible that you’ve interpreted their recommendations as meaning they think your father is dying, but in fact they might have some other idea in mind? Or perhaps the medical team is aware of other worrisome signs that indicate a poor prognosis, but this hasn’t been communicated to you?
I would recommend asking more questions of the team. Tell them you’d like to better understand what they think is going on with your father’s health and what to expect.
Another thing you can try would be to ask for a consultation with a palliative specialist. Many hospitals have them available. Please don’t assume this means you agree with a “comfort care” approach for your father; the purpose would be just to get more help discussing a difficult situation. Palliative care providers have more training than the average hospital doc in discussing difficult situations with families and clarifying what is going on. Good luck!
Becky says
My 79 year old mom fell at Thanksgiving and hurt her back. She was in rehab for a month with no problems delirium related.
This past Friday she was bending over to get books out of a drawer and she fell again and broke her wrist.
She was given two IV doses of morphine and something in pill form at hospital. While they were wheeling her in for surgery the next day, her heart started racing and her breathing became shallow. They cancelled surgery and set her arm manually. Her co2 level was 75 and they transferred her to ccu and gave her a mask.
Next they ran tons of tests on her. They diagnosed copd, a uti, which she is diagnosed with every time she goes to the doctor and a sinus infection.
Up until the mask on Saturday she was not delirious. She started the confusion while on the mask which she pulled off at 2 in the morning and would not allow back on. The next 48 hrs she was combative, confused and did not know anyone. It is Tuesday now and she has calmed down, but doesn’t respond much and is very tired. She will sometimes not know names.
Is this the pain meds and hence co2 elevation, pain, lack of sleep, copd? We did not know she even had this.
I am furious because my mom finally fell asleep which she desperately needs and rehab people came to do exercises.
The doctor does not seem very concerned and wants to release her to the rehab facility tomorrow.
Only Tylenol and Tramedol, but also a pill for relaxation and anxiety is given to her along with an antibiotic.
Her co2 is down to 60 which is still very high from what I can tell.
Shouldn’t the doctor be more concerned at this point?
Thank You for reading this!
Leslie Kernisan, MD MPH says
Sorry to hear about all these recent health complications, it sounds like your mom has been through a lot over the past week.
I really can’t say whether the doctor should be more concerned or not, it’s impossible to know from a distance. I will say that even though she didn’t experience any delirium during her previous rehab stay, she may have experienced more illness and stressors this time around and that may be why she experienced delirium. Having a high CO2 level can also affect the brain.
Medications such as tramadol and also “pills for relaxation” (which are often benzodiazepines) are usually avoided if possible by geriatricians, because they can make confusion worse.
If you are concerned about her CO2 levels — or really any aspect of her healthcare — I would recommend asking more questions of her health providers and getting them to spell out what they are doing and thinking. Hope she gets better soon, good luck!
Jessica says
Thank you for this forum. I have been reading these comments all evening and they have calmed me greatly. My husband is a type 1 diabetic for the last 44 years, diagnosed at 4 years old. He has retinopathy and is legally blind. He can see but is definitely visually impaired. He has degenerative disc disease and a herniated disc, recently diagnosed with spinal stenosis. Two weeks ago he severely injured his back somehow at home, we suspect moving some heavy furniture. He was unable to move at all without screaming, laid on the couch for a week. I was trying to help him but didn’t have the strength to get him up and down very well. He actually hit his head on the wall in one instance of trying to get him back on the couch. So after four ER visits to one hospital, where they refused to admit him and just gave me cipro antibiotic and flexeril, dilaudid iv for pain, we noticed some hallucinations at home. Did some research and found flexeril can sometimes cause this, so we discontinued use. Symptoms only got worse so we took him to the other local hospital and they finally admitted him for the back problem. After one day in the hospital he developed delirium. Doctors discontinued all drugs as well as the steroids they had been giving him there. He improved greatly after a few days, so the gave him Zyprexa and sent us home with a 7 day regiment. Day 1 out of hospital he seemed himself again. Back pain is still severe but improving. Day two and three delirium symptoms have returned at home, to the point where he was livid that there were people in our house stealing his stuff. We have stopped the Zyprexa and are waiting to see if his symptoms resolve again. Any advice on how to care for him would be greatly appreciated. I dread taking him back to the hospital as I know it will cause him to rapidly slide back into delirium faster. He has been spiking a fever every once in awhile but they checked him for infection, cat scan, mri, and eec to check his brain before discharge. All other medications have been discontinued except Percocet which he has taken for pain twice a day for at least two years.
Thank you so much
Jess
Leslie Kernisan, MD MPH says
Sorry to hear of your situation, it sounds quite difficult.
Your husband is not an older adult, he is 48. I don’t have any experience with long-time type 1 diabetics of his age. Generally as people get older and more physically vulnerable, it’s easier for them to tip into delirium when ill or physically stressed by lack of sleep, medication side-effects, etc. Whereas for younger people, it takes a much more severe illness to cause delirium. I would recommend making sure he is carefully checked for infection or illness. Good luck!
Jessica says
So he spiked a fever at home. We were unable to get it to go down at all. After a few days we took him back to the ER, they sent him home with an antibiotic. Fever still wouldn’t subside so we took him back and they admitted him. Found out today he has bacteria in his blood. Still not sure what kind. Of course he is hospitalized and his delirium has returned today, as I had to return to work. I have used every available vacation hour and can not afford to miss anymore work. I am terrified and at a loss as to what to do. This is a terrible illness.
Julie Meredith says
My mother had lung cancer removed on November 20, 2018. She did great came home 3 days later on the 23rd. Unfortunately on the 27th she woke up completely confused and I took her back to the hospital. She was diagnosed with pneumonia and a UTI and was kept in the hospital for 10 days. I kept telling the staff something was wrong with my mom I asked the doctors about her meds and could it be something they were giving her because she still wasn’t herself, One Dr told me she was just severely depressed and would be okay but this wasn’t ever how I knew depression to be my mom just wasn’t right. Another one of her doctor’s after I pressed them to figure out what was going on said he believed it to be hospital delirium, that it would get better once she left the hospital. So they released her on Dec. 8th. Took her home and she stayed confused. I took her to her PCP and they ignored the fact she wasn’t okay mentally. Until the last day of Dec they diagnosed her as having severe delirium. We are now almost 2 months into this and she has only had about 15 good somewhat clear days. She seems to get better for 5 days and then completely goes down hill back to total confusion. The Dr claims this is normal for delirium patients that its a rollercoaster ride, but how do you go from getting better to right back on the ground worse. Before all this my mom was completely independent and driving, cooking, traveling and all. Now she has to use a walker and falls every few days, no longer drives and no longer does anything she use to. She did a complete 360 after surgery. Can delirium last this long? Or should I be looking for another diagnosis? I feel so lost and desperately trying to help her. I am losing all trust in the medical field because of all of this.
Leslie Kernisan, MD MPH says
This does sound like a tough situation. At this point, she’s only been discharged for about a month (since Dec 8). It can take months for some older adults to improve, so she may just need more time to rest and recover. I’m not sure why she seems to get much worse every five days although there certainly can be some up and down with good days and bad days. Usually, if there is a sudden worsening, we check to make sure there isn’t a new infection or other medical stressor.
It sounds to me like you and the doctors are learning through some trial and error. If she gets evaluated a few times after suddenly getting worse, and nothing treatable turns up, then yes, they will probably attribute this to slowly resolving delirium, and they’ll stop thinking they need to check in detail when she has another day of being worse than usual. This could just be her pattern, or maybe she is responding to a poor night’s sleep or something else that is interrupting her slow recovery.
I’m sorry I don’t have anything more definitive or satisfying to share. It’s not clear to me that you should be looking for another diagnosis at this point, but if she seems sick or unwell, definitely get her re-evaluated.
It can be really hard to keep watching and waiting for things to improve. And of course, it can be hard to know when something new is wrong, with all this up and down. Get some extra help and support from other family members and friends if you can. Good luck, take care, and hang in there!
Lynne says
Thank you so much for you help. I have been so stressed and at a loss to know what to do to help her through this new medical situation.
Are there any suggestions that you can give me that can help to improve her now that she is home? Most of the articles that I’ve come across deal with currently hospitalized patients.
I have tried to recreate her environment pre-hospitalization as much as it is possible. Instead of taking her to my home, for example, I have taken her to her home although often she does not recognize it. I also try to rein in my impulse to do too much for her now that she is physically capable of doing things for herself. I am torn between fearing that I would hinder her progress if I do too much for her or if I am pushing her too hard in allowing her to get her own drinks. I am also trying to wait patiently for her to remember words for her sentences instead of supplying them. Also, does it help or harm my mother when I remind her that I’m her daughter instead of her sister or that she has two different people exchanged in her mind?
I’m so sorry for all of these worries at once. I feel as if I’ve dumped so much on you at once, but I feel as if I’ve been swimming in mud for weeks now with no real answers and I would certainly appreciate you help and guidance. Thank you so much!
Leslie Kernisan, MD MPH says
Sorry to hear of your situation, even though it’s great that she’s been able to leave the hospital, it can still be quite stressful to have an older parent remain confused for days or weeks.
It sounds to me like you are doing all the right things, in that you’ve brought her back to a familiar environment and you’re encouraging her to do things for herself.
Re whether or not to remind her that you’re her daughter, I would say try one approach and then the other, and continue with whichever one leads to LESS agitation or stress for her. If correcting her mistake seems to upset her, then stop. If she’s accepting of the information, then it’s probably ok to correct her.
You don’t say what she was like before. Is she slowly improving now, or has she stayed at the same level of confusion for weeks? Most older adults will slowly get better (but may not get quite back to how they were before). So it’s really a matter of time and patience. It IS a real strain to take care of someone who is confused, so if you are very stressed, see if there is any way for you to take some kind of break from the situation, or otherwise restore yourself. Older people often do pick up on the stress of their family caregivers, so taking care of yourself can help her recovery. Good luck and take care!
Lynne says
My 71 yr old mother has always been a very independent and healthy woman who has had no previous medical history, no previous surgeries, is not on any medication and doesn’t even have a GP. She has always been a very active and can-do person. She has lived alone since my father died almost 15 yrs ago.
Recently she experienced gall bladder pain and had to be scheduled for surgery.
The surgery ended up being a complicated open surgery and she was in the hospital for a week instead of the two hours that she’d planned. Since then she has been admitted 5 more times for complications arising from the surgery including kidney failure and dehydration from falling so ill afterwards. She has spent very few days in the past 5 weeks at home. I have stayed with her for every minute of those hospitalizations and with her at her home to help to care for her.
During her last hospitalization she suddenly became agitated and aggressive demanding to know who I was. When I told her my name and my relationship to her she called me a liar and began to argue with me. I tried to calm her down and reason with her but it was clear that something had changed. She became paranoid, aggressive and even violent and it became worse over the next few days at the hospital.
I researched what was taking place and believed that she had hospital delirium. A few of her nurses agreed and as soon as she was well enough I had her discharged. I didn’t think that subjecting her to rounds of needless tests when she was in such a frantic state demanding to go home would do her any good.
Thankfully she did begin to improve almost the second that we left the hospital. Her aggression lessened, although it will still appear with a bit of paranoia at times. But overall we were making some progress.
We returned to a follow up visit when I realized that she probably had a UTI. She has been on antibiotics for a few days now. By the next day her behavior changed dramatically. She is no longer as violent and aggressive. Her confusion has not fully gone away but she does not try to hit you when you say something that she doesn’t agree believe. (Which is, of course, something that she never did before.)
I’m concerned about her loss of skills and memories, though. It has been about a week since her discharge from the hospital and four days since she started her antibiotics. She seems to know who we are but she still talks about people who aren’t there and forgets things that were just said. She also doesn’t always remember that she owns the house that she’s in and has lived there for 40 yrs. She keeps wondering where she’s going to live and how she’s going to take care of herself. She’s forgotten how to use the remote control, the computer, and sometimes the cell phone. Are these skills that will likely come back to her in time or should I be worried that there may have been something else that happened to her (stroke).
Thank you so much!!
Leslie Kernisan, MD MPH says
Sorry to hear of your mother’s recent health challenges, it sounds like she has been through a lot! Great that she seems to be improving now, however.
It can indeed take weeks or even months for an older person’s brain and thinking to fully recover, after an episode of significant delirium. Stroke is not usually considered unless there are significant neurological signs, such as asymmetry in the face, slurred speech, or weakness on one side. (If she has high BP or other stroke risk factors, consider getting those medically optimized, but that is for her long-term health and not to improve her situation right now.)
Good luck!
Mary Bartlett says
My 81-year old husband has Parkinson’s and had a total knee replacement surgery 5 days ago. He became delirious the day after surgery, convinced I was having an affair in another city with a prominent leader and the scandal was on the cover of Time magazine. Now, he’s convinced he’s actually at the airport, not the hospital, restrained by armed guards who have broken his knee. He has to be watched around the clock because he keeps trying to get out of bed. Normally, he has a wonderful mind (he is an emeritus professor) with no signs of dementia. I try to spend as much time with him as I can, but can’t be with him more than 5 hours a day or so. His son lives far away. His surgeon wants to get him into transitional care at the same hospital ASAP to receive extensive PT, but this is not possible in his current state. He takes a number of meds for his Parkinson’s,s, including antidepressants, Sinemet, Simbalta, and Diloxitine. He used to take Clonazapam occasionally but isn’t doing so in the hospital. the dementia seems to be getting worse each day. He has good caring doctors, but I’m very concerned about his recovery and what things will eventually be like at home.
Leslie Kernisan, MD MPH says
Sorry to hear of your husband’s delirium. If he was mentally sharp before surgery, that improves his chances of eventual recovery. But as noted in the article and the comments, it can take a while for delirium to resolve.
Some hospitals do have special units designed for hospitalized older adults, and usually, they prioritize mobilizing people as early as possible. So even if he cannot participate in intensive PT, hopefully it will be possible to encourage him to move around safely.
Try to not argue or talk him out of any delusions; it’s better to be reassuring and non-confrontational.
Good luck!
Kara L McLaughlin says
Is this possible outside of hospital inpatient settings? Although my mother has not experienced inpatient medical care, she’s had unreasonable/out of character (original character, not our new norm) reactions to medical procedures and some loss of brain function never returned. The worst of it is usually after the fact, once away from the facility. After some skin biopsies she flew off the handle so badly in the car (they they not only overwhelmed but hurt her) that one of the cauterized sites on her face starting gushing blood. Now we face possible radiation treatment and I can’t get radiation oncologists to meet with me separately in advance to come up with a workable plan. I’m so tired of dealing with medical professionals who don’t have a clue about how a simple office visit can be terrifying for her since she can’t comprehend everything and is incapable of reasoning. The word radiation alone could trigger negative thoughts since my father died shortly after his last round of radiation. Someone told her afterwards that new evidence pointed to radiation could make prostate cancer spread vs arrest its progress. She felt complicit in his death for encouraging radiation, even though they were following Dr recommendation & my father had done extensive research. Her last physical, done by her NP who is in her facility at least once a week, caused her to want to move out. She couldn’t relate anything beyond they took her blood pressure again and won’t leave her alone and just needed to get out of there. Is there something I could put in a note for the physician to read in advance? I fear if they hurt her, or overwhelm her, I may never get her back to complete treatments. Suggestions?
Leslie Kernisan, MD MPH says
Hm. Yes, it is possible to develop delirium outside the hospital, it can be due to a new infection, a medication side-effect, an electrolyte imbalance, and other causes.
That said, it sounds like your mother is chronically cognitively impaired and also that she might be experiencing some type of anxiety or fear reaction, in response to procedures. Most people with dementia do get cognitively worse when they are anxious, and I have also seen some of them regularly fall into spirals of anxiety –> worse cognition –> even more anxiety & distress about what’s going on –> even worse cognition.
I think you are right to try to be proactive and reduce the anxiety and distress triggers as much as possible. I’m sorry but not surprised to hear that you are having difficulty getting the health providers to cooperate. Most of them are very busy and have limited capacity to make adaptations, even when those are clearly needed by the patient.
You can put your concerns in writing and if you do so, these often get scanned into the chart. But I also think that a health provider is most likely to listen if they speak to you (assuming you can get them on the phone). All of this takes effort and is tiring, as you rightly point out.
In terms of suggestions…first of all, if your mother has a habit of getting distressed by medical care, then this is a “burden” or downside that has to be considered. Every time you consider whether to proceed with a treatment or procedure, be sure to ask yourself whether the likely benefits outweigh the risks and burdens. Does your mom really need those skin biopsies? What would happen if she didn’t have them?
As people progress with dementia, a lot of routine care becomes more distressing for them. They also often become less likely to benefit, because their life expectancy becomes limited. So, it’s good to keep reviewing what is most important for your mother to get from her medical care, and what kinds of risks and burdens are worth tolerating.
Behavioral approaches are the safest and best way to manage anxiety spells or other difficult behaviors. We have an article on those here:
7 Steps to Managing Difficult Dementia Behaviors (Safely & Without Medications).
Otherwise, medications can sometimes help with anxiety. Be careful about the fast-acting ones (benzodiazepines such as lorazepam), they become habit-forming quickly and often make thinking and balance worse in older people. SSRI type antidepressants such as citalopram sometimes reduce anxiety, but they take 6-8 weeks to reach full effect.
Sorry once again that the medical system is making things harder instead of easier for you. Good luck and take care!
Dianne Bennett says
My husband is Stage 4 Parkinsons, 10 years dx. Two weeks ago he had double bypass heart surgery. He has been in C-ICU since. He suffered grave pulmonary issues two days following surgery and was reintubated for 7 days. Five of those days he was on propofol anesthesia. Then just fentanyl. After fentanyl was discontinued it took him 2 days to wake up. When he woke up he had delirium … and still does. They are working diligently on his coexisting pulmonary issues from surgery, his delirium and getting him stronger.
They are now giving him melatonin at night to help his night/day schedule.
Any thoughts?
Leslie Kernisan, MD MPH says
Well, you don’t say how old he is, but he’s been very sick and also at baseline he has a mind that has been damaged by Parkinson’s. It will take time for him to recover. Melatonin is a reasonable approach to try to correct the circadian rhythm. Sounds like they are doing reasonable things.
If you or other family members can be a reassuring presence, that can help. Be sure to take care of yourself and get support for your own caregiving journey too. Good luck!