You’re in the hospital. Gripped by confusion, though, you don’t realize where you are or why. You don’t recognize anyone. You don’t understand the forest of medical equipment surrounding you. And you just want to go home.
You’ve entered the sudden, unnerving state called delirium. And no one can say when you’ll be able to leave it behind, or how long its effects may last.
For hospitalist Christopher Pribula, M.D., and his Sanford Health colleagues, delirium has become a key focus in patient care. Risk factors for experiencing delirium can include surgery, serious illnesses and hospitalizations, especially in the intensive care unit, along with dementia and lower cognitive function, certain medications and older age, among others.
Delirium is common, but it isn’t always inevitable — and that’s why Dr. Pribula puts a lot of thought into how he might be able to help prevent it in the patients he admits to the hospital. It’s not an easy decision, though, when you know a medication that can help the patient feel better or less agitated also could increase their risk for or worsen their delirium.
“There’s a fine balance between making sure you’re not making things worse, but also making sure you keep people safe,” Dr. Pribula said.
While COVID-19 has been shown to cause neurological problems, right now, research can’t say conclusively whether the disease itself puts patients at higher risk for delirium, Dr. Pribula said. Many COVID-19 patients already have significant risk factors for it. So prevention measures are key for those patients — even if they require some adaptations.
Delirium prevention measures
Delirium, Dr. Pribula said, is “a lot more common than people realize.” An increasing older population means dementia has become more common.
Developing delirium can lead to a variety of challenges, from longer hospital stays to the need for prolonged rehabilitation to discussions about feeding tubes. Agitation could lead to additional injuries.
“It makes it a lot easier if you can prevent those things from happening,” Dr. Pribula said.
Some of the techniques health care workers can use to prevent delirium involve normalizing days and nights in a setting where people are coming and going at all hours and hallway lights never turn off.
“If you’re sitting in a hospital room, 5 o’clock in the morning and 5 o’clock at night look exactly the same,” Dr. Pribula said.
So they try to continually orient patients. During the day, they keep lights and TV on, open window treatments and mention the time. At night, they turn everything off and close the door to the hallway.
Some patients, especially older adults, might take melatonin supplements to help encourage sleep at a normal time.
Medications ranging from opiates and muscle relaxants to proton pump inhibitors and H2 blockers can be associated with delirium as well. But so can uncontrolled pain. So doctors consider how much the patient should receive, or whether there might be an alternative to medication.
Dr. Pribula describes a scenario of being proactive in helping a patient with the potential for delirium:
A woman in her 80s, functioning well otherwise, falls and breaks a hip. She needs to have anesthesia and pain medication. Immediately, delirium prevention measures are started. He tries to keep her pain under control with non-opiates and gives her melatonin to try to keep her days and nights straight.
Delirium and COVID-19 patients
Dr. Pribula has spent significant time caring for patients in the COVID-19 unit at Sanford Broadway Medical Center in Fargo, North Dakota. He worked the first 18 days when the unit was set up, crafting protocols and calming fears, and he has worked there since as well.
Right now, he said, questions about COVID-19’s influence on delirium don’t have definitive answers.
“That being said, especially severely ill coronavirus patients, they’re set up for critical illness delirium in the first place,” Dr. Pribula said.
They have acute respiratory distress syndrome with long intubation times under heavy sedation — all high-risk factors. In the ICU, the amount of sedatives are limited if possible, Dr. Pribula said.
For less severely ill COVID-19 patients, delirium prevention measures are similar to those for non-COVID-19 patients, he added. However, isolation from families can be more of a challenge. So the nursing staff tries to interact more frequently with the patients “and give them that human touch that we all need, especially when we’re fighting a severe illness,” Dr. Pribula said. “It’s hard to fight that by yourself.”
Bewildering for families, too
Dr. Pribula sympathizes with families bewildered by the fact that their loved one could go from healthy and functioning — driving and balancing their checkbook — to suddenly debilitated by delirium.
Delirium can look agitated, where a person fidgets and may even pull out medical lines, or lethargic, where a person doesn’t seem to be awake or paying attention. Either can distress families.
But family members also can be key to orienting their loved ones by sitting with them.
“Families can become a useful partner in dealing with delirium by being that reassuring presence there for their loved one, when they’re able to,” Dr. Pribula said. “’Hey, Mom, you’re in the hospital at Sanford. They’re taking good care of you. Do you need something? Do you need to use the bathroom? Are you hungry? Are you having pain?’”
It’s hard, amid the fear and frustration, to not be able to tell families how long it will take for their loved one to “get back to themselves,” Dr. Pribula said.
But he’s grateful for the compassion his Sanford Health colleagues show to their patients. As one example, he recalls an older patient with dementia hospitalized with COVID-19. She was delirious and confused about where she was and about people covered in protective equipment surrounding her.
“She was writing, ‘Help me,’ on the window with a marker,” Dr. Pribula said.
When a nurse saw that her agitation was escalating, instead of reaching for a medication, she instead saw an opportunity to calm the patient by praying her rosary with her and playing cards.
Delirium can take a lot away from a patient — recognition, clarity, understanding — and leave fear in its wake. That’s why Dr. Pribula and other health care providers try so hard to help prevent it.
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