We all hear stories of the difficulties people have when caring for their elderly family members. But once in a while I hear a story that I feel needs especially to be shared because even the most informed and well-intentioned caregivers may be unaware of the subtle signs that may indicate a very dangerous condition. Such is the case with delirium -- an acute mental disorder that presents as disorientation and can come on very quickly -- within hours or days. Delirium is quite common among people over the age of 65, and while it can be life-threatening, or lead to adverse events culminating in the loss of independence or an increased risk of chronic illness, delirium is often preventable. Recognizing and responding to the signs of delirium in its earliest stages is an important skill for the family caregiver to develop.
Clara is the 86-year-old mother of my close friend, Margie. An energetic woman who has lived on her own for many years, Clara has always been upbeat and optimistic, even in the face of the diabetes she's had to manage for the last several years. My friend Margie stops by to visit her mother every morning before work, but, other than dropping off a few of Clara's favorite magazines and showing her fascinating new uses for her new computer, there's not much she needs in the way of assistance. Getting Clara's coffee and breakfast ready each day is more of a comfort for Margie than a necessity for Clara.
Recently, Clara was scheduled for a home visit by a nurse from the Visiting Nurse Service of New York (VNSNY) to have a weekly diabetes coaching session and blood sugar monitoring. These were typically pleasant and uncomplicated visits in which the nurse would review the patient's self-checked blood sugar measurements and talk about healthier food choices if she found moderate spikes in blood sugar. The week before, Clara and the nurse had had a lively discussion, talking about the news of the day and the latest activities of President Obama.
However, when the nurse arrived last week, something was clearly wrong. Margie was still at Clara's house at 11:00 in the morning, and, upon entering the apartment, the nurse could see the stress in Margie's eyes. "I don't know what's wrong," said Margie, clearly distraught. "Mom is complaining about the breakfast I made, though she's not being very specific. She is extremely irritable, but I'm not exactly sure why. In fact, after complaining all morning, now she won't even talk to me." Margie felt bad that she had upset her mother, but didn't know what to do.
The home care nurse checked Clara's temperature, blood pressure and blood sugar, all of which were normal. However, the nurse agreed with Margie that the patient was markedly different on this day. The nurse started asking Clara pointed questions, and observed that Clara was not able to give the date or say what she had eaten for breakfast that morning. Hearing Margie's report that Clara had been in her usual cheerful state the day before, the nurse made a call to Aneil Shirke, M.D., Ph.D., a psychiatric consultant in the VNSNY Behavioral Health program.
Upon hearing the symptoms of sudden disorientation, irritability and non-communicativeness, as well as the nurse's report that Clara's daughter "has never seen her this way," Dr. Shirke recommended a call to 911. "Any physical or behavioral condition that comes on in just 24 hours is a true medical emergency and needs to be evaluated in an emergency room," stated Dr. Shirke. He went on to say that many family caregivers hesitate to call 911 because they don't want to be a bother, especially when symptoms are not specific. But he stressed that "a family caregiver's intuition is very important; they may fear they've done something to upset a person, when more commonly the patient is experiencing delirium."
In the emergency room, Clara received a standard blood workup, chest x-ray and brain scan, and within a short time, it was clear that she was suffering from dehydration. She was given intravenous fluids and released later in the day, with instructions on how to remain hydrated.
Dehydration is one of the most common causes of delirium in the elderly (other common causes are infections and medications). Dehydration is especially a problem in the summer, when many older people, in an attempt to save money, turn off their air conditioners, or, due to reduced sensations of thirst, forget to drink regularly. "Unfortunately, many of the body's checks and balance systems, which work so well in middle age, become less sensitive in the elderly," stated Dr. Shirke. "Someone may become dehydrated to a dangerous level without any real outward physical symptoms." An attentive family caregiver, taking seriously that a family member is "not herself" and seeking prompt medical attention, can truly save a life.
After a brief, re-hydrating stay in the hospital, and some extra attention at home, Margie's mother was back to her old self. Clara was fortunate that she had home care in place because experienced health professionals know to take signs of delirium seriously and coordinate prompt medical attention. Yet it is also important that caregivers educate themselves about the major factors that predispose an elder care patient to the onset of delirium. Your family member is especially at risk for delirium if he or she suffers from:
- Cognitive Impairment
- Immobility
- Visual Impairment
- Hearing Impairment
- Sleep Deprivation
- Dehydration
- Alcohol abuse
Since delirium can have such dire consequences, and is often hard to treat when it gets severe, it is best to try to prevent it whenever possible. As the caregiver, there are things you can do to help prevent delirium for your family member in the hospital or at home, including:
- Go for walks together: Even down the hall! Some physical exercise three times a day is optimal.
- Be careful with sleeping medications: Wean your family memberer off of them if possible (with the doctor's approval). Try good, old-fashioned remedies such as a warm glass of milk, back rubs and playing soothing music.
- Play games: Word games, bingo, guessing games -- anything that gets the brain actively engaged and orients a person to their surroundings.
- Discuss current events: Watch the news together and share current stories from the extended family's lives.
- Foster independence: Can your family member button his/her own shirt? Then encourage it, no matter how long it takes. Find ways to re-introduce your caregiving charge to the daily activities he/she has always enjoyed (cooking, mending, tinkering, etc).
Dr. Shirke gives the following mnemonic to remember the most common causes of delirium:
D Dehydration
E Electrolyte imbalance
L Liver failure
I Ischemia or hypoxia (insufficient blood flow and oxygenation)
R Renal failure
I Impaction of stool
U Urinary tract or other infection
M Medications, especially psychotropics