By Carlos Thomas
When hospitalized, older patients are at risk of developing delirium, and those with dementia are even more susceptible.
Following publication of a STAT News column, Penn Memory Center Co-Director Dr. Jason Karlawish sat down with Deborah Kan, the founder of Being Patient, an independent news and community platform that aims to bring accurate information to people impacted by Alzheimer’s disease. Kan and Dr. Karlawish sought to define what delirium is, the reasoning behind why those with dementia are more susceptible to developing delirium, and what caregivers should do during this time to prepare themselves and the ones they care for.
Delirium “describes an acute confusional state,” said Dr. Karlawish. “Simply put, the person doesn’t seem like the way they used to be; there’s been some sort of change.”
This change can take two forms. The first form of delirium is the hyperactive form, where the patient may become physically agitated. “And in the hyperactive, agitated form of delirium, patients often develop elaborate and very frightening delusions. A common one will be that they think they’re in prison or in jail and will cry out for help to get them out.” Contrastingly, the second form of delirium is the hypoactive form, where the patient becomes withdrawn and fades in and out. However, both forms involve inattentiveness and waxing and waning qualities.
Although, one may develop delirium if they are ill and at home, the likelihood of occurrence increases during hospitalization, says Dr. Karlawish. “Delirium is sort of a product of many different factors coming together: an aging brain, one that’s acutely ill; going to a hospital, a changing environment; a host of other changes, a host of other noxious stimuli to the brain from some of the medications that are given.”
These factors can contribute to the development of delirium in patients who have not shown any signs of cognitive decline. However, as Dr. Karlawish explained, those with dementia are at an increased risk of developing delirium.
“The way I kind of think about it is that delirium is to Alzheimer’s and dementia like pain is to cancer. There are many different diseases that cause pain, but like we all know there’s something about cancer that has a unique pain experience, and cancer is also more likely to cause pain.” “And that’s the same sort of relationship between dementia caused by Alzheimer’s disease or illnesses like Parkinson’s disease, and delirium. You don’t have to have those diseases to get delirium, but if you do have those diseases, you’re at a greater risk of developing delirium.”
To mitigate the chances of developing delirium or reduce the severity and duration, Dr. Karlawish outlined the following steps of basic care: “getting good sleep, not being woken up repeatedly in the middle of the night; being adequately hydrated; avoiding medications that can precipitate confusion, particularly anticholinergic medications like Benadryl (diphenhydramine); and being reassured and reoriented by people who can communicate with you effectively.”
The last step outlined by Dr. Karalwish comes during a time where many hospitals and long-term care facilities have placed restrictions on visitors. As Dr. Karalwish explained, some hospitals have clear policies, while others may leave it to the discretion of the staff. Nonetheless, Dr. Karlawish stresses the importance of having caregivers present by opening up the conversation to say, “There are certain people that might need to come into the hospital who aren’t visitors, but they’re caregivers.”
This raises the question of how to manage caregiving in the context of today. Dr. Karlawish believes it is possible to arrive at a reasonable compromise that involves taking into perspective both sides.
“I think it’s going to be a negotiation,” he said. “I think one needs to tame one’s emotions and say, ‘How can we have a mature conversation about how we are going to care for my relative who has moderate stage dementia and is at a high likelihood of getting quite ill from delirium? Which is only going to extend their hospital stay.’”
Dr. Karlawish hopes that once the pandemic passes, there will be added respect for the role of the caregiver as an essential part of a patient’s healing process. That the caregiver is “not just a visitor.” To look back at this troubling time and acknowledge the necessity of the caregiver.