Delirium is slow to fade

The rising elderly population could lead the requirement of hospitalisation to increase in cases of delirium. This condition occurs due to an underlying physical health problem. Delirium involves one or few of the following signs: Sudden onset or change in behaviour or loss of memory function, fluctuating in severity including occasional periods of normalcy, clouding of consciousness that may start close to the sun-set, which is why typically it is known as sun-downing and also worsened behaviour throughout the night with impaired sleep and either restlessness or under-activity. Quite often, a sudden behavioural change accompanied by forgetfulness is the initial symptom. Many times, hospitalisation is required unless there an experienced home nursing care or access to specialists. For family members, a common worry is whether it is Dementia or a psychiatric disorder, but it is neither.

There are a number of underlying physical conditions that can trigger delirium. Some of the common ones include infections in the urinary tract or in the lungs and either high or low levels of glucose or sodium in the blood. Constipation, pain, deafness and multiple medications also contribute to delirium. It can also be caused due to life-threatening problems like clots, leading to blockage or bleeding or infection in the brain that warrants urgent treatment under a Neurologist. Unfortunately, ICU stay can itself occasionally contribute to abnormal experiences and staff members call this as ICU psychosis. It does take time to detect the underlying cause. Even after the problem is detected and fixed, delirium takes its own course, and resolves slowly, so family members and other caregivers need to be patient.

Repeated episodes or prolonged course of delirium may be an early warning sign of dementia that needs assessment at a later stage. It is possible to reach their previous level of memory functioning after delirium resolves itself in most cases. The patients in hospital wards benefit from a side room, with optimal noise and light, minimal staff movement, by repeatedly being informed that they are in a confused state, being reminded of the date, day, and assisted in the identification of people around them.

Some patients may become aggressive due to fear. Changes in the level of consciousness can create confusion for the patient, they may try to escape from the place, remove intra-venous lines leading to injuries or even push staff members away. Physical restraints are in practice to ensure patient safety in some hospitals as medications do not have much evidence on their effectiveness. Sedation may not be appropriate and other common medications which are known to have anti-cholinergic properties are avoided wherever possible.

Delirium is a condition that requires regular reviews from specialists including physicians, neurologists, liaison psychiatrists and others depending on the underlying cause. Delirium, during the first week after a surgical procedure that involved general anaesthesia, is very common in elderly persons. Appropriate measures, preparedness, environmental modifications, repeated reassurances will help manage the condition better. Delirium is thought to occur because of various immunological mechanisms that assist during the recovery of the underlying condition. Some chemicals are released to which the elderly brain is sensitive, unlike the adult brain. The cause of this condition is still being researched. Once the underlying cause is treated and the severity of delirium comes down, it is possible to manage with home nursing care.

A sudden change in behaviour was the only complaint in a few patients with Covid-19 recently. Similarly in certain patients, urinary tract infections are detected without associated complaints such as fever, or problem in passing urine and even change in blood counts which is why urine tests are necessary. Delay in treating the underlying cause could be life-threatening. With a rising elderly population, there is a definite need for more geriatric experts.

(The writer is a consultant psychiatrist with geriatric psychiatry experience)