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Hospital Induced Dementia

Hoca

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Last week, sitting in a class on aging issues and care resources, my head popped up in surprise. A woman inquired about a term I had not heard before – “Hospital Induced Dementia.” Those of us who work in, around, write or even just read about health care are frequently alerted to ‘new’ terminology. I figured others might not be familiar with this risk either, and awareness is a helpful thing.

The phrase was new to me, but when I decided to do more reading on it, I realized that the experience was not new to me at all. I had encountered it three times with my mother, never having a name for it.

Indeed, the more accurate label is “Hospital Induced Delirium” (HID). Dementia is a mental condition that will get worse, advancing progressively over time (whether quickly or slowly). Conversely, delirium can be a reversible cognitive condition. If recognized and addressed early, it can possibly be fixed.​

Dementia vs. Delirium in Hospital


A seemingly-fine person can become delirious and present as if having full-blown dementia that existed for years. The confusion in terms may have developed since it is sometimes called “dementia-like syndrome” or “delirium-acquired dementia.” The good news is that this previously-fine person can be helped. Maybe. Sometimes medication adjustments or treatment with cognitive rehabilitation will be of aid, neither of which are necessarily quick-acting.

The determination of which situation exists is key.

I find these statistics shocking. About 33% of those over 70 years old who undergo surgery or enter the Intensive Care Unit are affected by HID. Not to the same degree of course. Further some studies have shown that 75% of people (particularly older) coming out of ICU demonstrate signs of dementia. Ouch. Often over-worked doctors don’t see it, but family members do. These signs of dementia can lead to permanent memory loss, poor communication skills or other mental disabilities.

The question is – will the relevant medical professional just diagnosis dementia or Alzheimer’s, and proceed from that determination? Or recognize the possibility of HID and a condition which may be reversed.​

HID Causes


The causes of this hospital (or critical care center) condition aren’t fully clear, and most literature says that there is “no conclusive evidence” that the hospital stay can lead to dementia. Still the coincidence is strong when it comes to delirious conditions.​

[Hospital-Induced Delirium is]
one of the largest health problems the public doesn’t know about.”
E. Wesley Ely, Md, MPH
(Vanderbilt Univ School of Medicine,
Associate Director of Aging Research, VA GRECC)​

Over-Medication or Medication Pile-on


The first suspect-cause of this type of delirium isn’t surprising. Drugs are invasive to our body and mind, even when their use is necessary.

Regarding the onset of HID, the most typical of these medication influencers are Sedatives, such as lorazepam (Ativan), diazepam (Valium) or multi-purpose benzodiazepines, which slow the brain and nervous system. They can actually CAUSE rather than ease the behaviors they are trying to suppress. Anticholinergic drugs (working with the peripheral nervous system) are frequently noted as well. Even OTC products like antihistamines, gastrointestinal meds or antidepressants are linked to delirium. Especially so if there is a predisposition (common in our later years). Diuretics are used to remove fluid from the body (especially legs, ankles, or feet) and frequently the drug of first choice with signs of congestive heart disease. Unfortunately, they are often accompanied by a change in behavior or cognitive function.

Careful use of medications like the sedatives, strong sleep aids and other drugs mentioned above may be obvious, but anesthesia can be a factor as well. This is important when considering surgery. Are less worrisome options available from your anesthesiologist?​

Settings


Physical surroundings that are totally unfamiliar to a person, especially with loud sounds, bright lights and other disruptions of normal life are considered strong factors in Hospital-Induced Delirium. Some experts recommend that the same kind of environment used for infant areas (low lighting, calm colors, quietness) are also best for elderly, and indeed all of us.

The post-hospital rehabilitation setting should be cognizant of patient care both physically and mentally. While artificial lighting should be soft, real lighting during the day is vital, with good darkening (like darkening curtains) at nighttime.

Aside from the physical environment mentioned above, the patient needs good sleep (again a reason for quietness) and needs to MOVE. James Rudolph, MD, (VA Boston Healthcare System) explains movement is “important because we think that mobility serves as a re-orienting stimulus.”​

My Mom


The story of my mother’s end-of-life stage is too long, and too painful, to recount here. Made worse for me as I lived 3,000 miles away and felt either out-of-touch or as if I lived in the airport. On several of the bad occasions, I realize now that she had some classic signs of HID – Hospital Induced Delirium (you can substitute ‘hospital’ with health care facility if you like). Being 91 years old at that period, she may have been developing dementia as well, meaning she was predisposed to HID.

I believe she experienced HID more than once. I say that because she also had the classic “bounce-back” circumstances. Her situation (and reaction) stemmed from infection, which is also very common. She had ankle and foot infections with skin ulcers. And indeed, antibiotics and diuretics (as explained above) may have been overly used.

On the two earlier occasions, the infection cleared up and she seemed to recover mentally to a significant degree. The final time, when she went to hospital, to long-term care, to hospital, to long-term care (no, not a typo), she wasn’t as lucky. She became more verbally offensive than was normally the case and sedatives were in store. The fact that she hated what was happening to her led to depression, and as such to more sedatives. The cognitive abilities reduced dramatically for this person who just a short time before was living alone.​

Common Signs & Remedies


Common signs of delirium can be confused with dementia. For my mom, they were classic. She became paranoid (they were “trying to keep her in these awful places” – both of which were true, of course). At the end, hallucinations came and went, when she periodically thought I was her life-long friend (long dead), Helen.

The longer sedatives were used to calm the anxieties of ‘never going home,’ communication skills decreased further. [Admittedly, I wouldn’t tell her she was never going home, but others may have tried to accustom her to her “new home.”] Who knows if she slipped from delirium to dementia, or if the HID helped her along?

Other common signs of delirium are:
* Confusion about where one is, what is the time, or day of the week
* Sudden changes in demeanor and mood
* Inappropriate outbursts
* Being unable to remember names and things, whether short or long term
* Difficulty concentrating. A “Brain Fog” that is like a bad dream.

There are a few preventive steps to keep in mind for yourself or a loved one. For instance, when painkillers are needed, talk to your doc about prescribing ones less likely to trigger delirium. Concentrate on rest and sleep without disruption. That also means encouraging natural sleep-wake cycles by using bright natural light (or outdoors) during the day, and dark lighting at night. Try to wean yourself (or another) off of a respiratory breathing machine as soon as is reasonably possible. KEEP moving.​

Final Thought​


This was not meant to be a thesis on Hospital Induced Delirium, but instead to make certain that readers understand that it’s a possible risk. Knowing what to look for makes a real difference. And knowing that it may NOT be Alzheimer’s or dementia can be reassuring.​



Resources:

Patient and Families overview. Critical Care recovery models from Vanderbilt University.

Improving Delirium Care. American Delirium Society. https://americandeliriumsociety.org/

Scientists isolate biomarkers that can identify delirium risk and severity. Science News/ Science Daily. https://www.sciencedaily.com/releases/2020/01/200122122059.htm

Hospitalized Elder Life Program (HELP). From Aging Brain Center at the Institute of Aging Research. Amercian Geriatric Society Co-care.



Title picture credit: Dementia or Alzheimer’s Man Image by Gerd Altmann from Pixabay 749618_640.jpg



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