Sunday, September 2, 2012

Dementia: When a Hospital Visit Becomes a Medical Emergency

We return to the story of Peter and Susan,* a typical couple facing Alzheimer's.

When Peter, now aged 78, needed to be hospitalized for a hip replacement, both he and his wife, Susan, sailed into the hospital room with daughters in tow. Everything was going well until a complication landed him in the intensive care unit (ICU), where he began behaving oddly. He thought he was in a hotel room, swore that rats were living under the bed, struggled at night against invisible intruders, and complained that the “hotel” staff were trying to poison him. After a psychiatric consult, Peter was given medication to calm him and help him sleep. Mystified, the family stayed with him day and night until he was back in a regular room. Here, with more normal routines, the delirium cleared.

Susan soon learned that during illness, hospitalization or recovery from surgery or stroke, many people experience delirium, a rapidly developing and severe confusion accompanied by altered consciousness and an inability to focus. It’s the most common complication of hospitalization among older people, and almost 80 percent of those treated in ICU’s develop it. When this malady isn’t recognized, it can hinder recovery. Prolonged delirium is associated with poor long-term outcomes, both mental and physical, and may even lead to death.

Among older people, delirium can be induced by a wide range of conditions: infection, insufficient food and drink, a trauma, such as surgery or injury, uncontrolled pain, medications, or simply the unfamiliar surroundings of a hospital. Susan now understands that people who have dementia are more likely to develop delirium when hospitalized. She does not confuse these two conditions. Delirium usually arises rapidly, fluctuates in severity, involves changes in consciousness and attention. It also clears up within days or weeks. By now she is very familiar with dementia, which comes on slowly, is progressive and usually permanent. Until it is severe, consciousness and attention are still possible.

Susan has a list of her own from the Harvard Women’s Health Watch she subscribes to, and plans to share it with her Alzheimer’s support group: essential how-to’s for preventing delirium when the patient is hospitalized.

Families. An engaged and attentive family member can help prevent delirum and advocate for the patient so they receive optimal care. Because family members see their loved one through the entire journey from primary care to hospitalization to rehabilitation, they are the logical advocates for their patient.

Consult with a geriatric specialist. Not all surgeons are familiar with delirium. When an older person plans a hip replacement or any other surgery requiring anesthesia or sedation, advice from a geriatric physician can facilitate planning for medication, pain control, post-operative mobility and sleep support.

Bring a full medication list to any new health professional. Many drugs that act on the brain can cause delirium, including narcotic painkillers, sedatives, stimulants, sleeping pills, antidepressants, Parkinson’s disease medication and antipsychotics. Even antihistamines and some drugs for digestive problems, allergies and severe asthma can contribute to delirium. Additionally, all medications should be reported because they could interact with drugs given in the hospital.

Make things familiar. Take along a few family photos or comforting objects—a relaxing music CD, a rosary, a favorite blanket—to the hospital. Calm conversations about current events or family activities can be comforting.

Staying close. Family members provide the greatest comfort and reassurance, and are the first to recognize when their family member is behaving inappropriately. Plan to have a family member there night and day while the patient is in a state of delirium.

Don’t forget sensory aids. Eyeglasses, hearing aids and dentures are often put away during a hospital stay, but that could leave the patient disoriented and less able to function. Be assertive to hospital staff about their use.  If concerned about loss, leave an expensive hearing aid at home, and pick up an inexpensive hearing amplifier at an electronics store.

Promote activity. Help your loved one get up and walk two or three times a day. Exercise their brain with conversation, crosswords, card games or other pastimes, depending on their mental ability.

Be there for meals. With companionship and assistance, the patient is far more likely to eat and drink an adequate amount. Be prepared to bring in some special goodies that you know will help to cheer up the patient.

Participate in discharge planning. Patients are sometimes sent home or to a rehabilitation facility while still delirious. A patient with delirium cannot fully understand discharge instructions, so family members will need to be there to help—and learn about signs that he or she needs if the loved one must return to the hospital. Make certain that nursing staff know your loved one’s pre-hospitalization level of functioning, so they won’t assume that the current behavior is typical. Ask for a complete medication review. It might be useful to discontinue some drugs (such as sedatives) that were added during hospitalization.

(Excerpt from Chapter 8 of Caregiving Our Loved Ones: Stories and Strategies That Will Change Your Life)

*Susan and Peter are a composite, based on numerous in-depth interviews I conducted as part of my research study of caregivers. You can read more about these brave women here.

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