October 17, 2023
Delirium in the Elderly
Dr. Thomas Mouser, MD, is chief medical director with EveryStep. He is dually board certified in internal medicine and palliative care, having completed his residency at University of Iowa – Des Moines and a fellowship at Stanford University. Dr. Mouser has spent countless hours at the bedside of those with serious illness and chronic disease. In his role, he helps hospice, home care and palliative care patients and their families navigate complex medical decisions as guided by the patient’s goals of care. Dr. Mouser’s fellowship training provided for an expertise in advanced symptom management and communication when working with those with high burdens of suffering. He is passionate about helping his patients reach their best quality of life so they can live life to the fullest.
Q: What is delirium?
Dr. Mouser: Delirium is complicated because we don't fully understand why it happens in one person and not in another, and it's also something that can easily get missed or misdiagnosed. When someone comes into the hospital and they're acutely confused, a lot of people assume they have dementia. But the reality is delirium is very different than dementia because it comes on suddenly.
"When somebody's delirious, we first and foremost just recognize this is not them; this is the disease process taking over their ability to think and process clearly. We work with them where they're at."
Dementia occurs slowly, over many years. It also fluctuates between having symptoms and going back to normal. Delirium is caused by global dysfunction of the entire brain and delirium can be reversed. While people with dementia may have good days and bad days, they never go back to normal like in delirium.
Q: What causes delirium?
Dr. Mouser: Delirium is caused by anything that can assault the brain or throw off its normal function. We know those people most prone to delirium are elderly, whose brains are more vulnerable to stress. So anytime there's an infection in the body, it can throw chemicals into the blood that throw the processes of the brain out of kilter. It's very common for people who are elderly to have acute delirium come on when they have something like a simple urinary tract infection. Another thing that is super common is literally just changing their normal environment or structure, sleep deprivation or any organ dysfunction. Delirium is extremely common during illnesses. We see it a lot in the hospital, but at end of life, we almost always anticipate we're going to see it at some point.
Q: What kinds of drugs can cause delirium?
Dr. Mouser: Common offenders would be sedative hypnotics and anti-anxiety medications like Xanax, Ativan or Valium, as well as sleep aids like Benadryl. Any medication that causes the potential for sedation has a high risk of delirium. Other classes would be medications that typically are aimed at trying to help chemical processes in the brain, like antidepressants. They affect brain function by affecting neurochemistry. But when the brain is vulnerable and encountering a lot of stress, affecting the neurochemistry can sometimes cause the brain to go into a tailspin.
Q: What can you do as the caregiver or if you are present when someone experiences delirium?
Dr. Mouser: Probably the biggest mistake that I see is people trying to argue with them or fight with them or convince them that they're behaving badly. Ultimately all that does is fuel the intensity of the situation, fuel the distrust, and cause them to get more distressed. When somebody's delirious, we first and foremost just recognize this is not them; this is the disease process taking over their ability to think and process clearly. We work with them where they're at. I've gotten down on my knees before when somebody thinks children are under their bed making noise and just ask the children, who you know aren't there, to leave the room because they need to sleep. It's amazing sometimes to see how the patient will respond, calming down and going to sleep because you escorted the children out. I typically don't try to correct their false belief, but I work within it. I stay calm, I talk to them softly. If they're really distressed and it's just causing more agitation for me to be talking to them, I may exit. It can be really challenging, but the most important thing is to recognize that they are not acting from their own intention or volition.
Q: What about when my loved one acts or does things out of character?
Dr. Mouser: Families don't need to feel the shame and embarrassment of them doing things that are not characteristic, and there are behaviors associated with delirium that you may find embarrassing. They decide they don't want to wear clothes; they decide to fix the television remote and take it apart; or they eat things that aren't edible. They are not themselves when they are delirious, and we need to protect them and not judge them because of their behavior. If somebody has a fixed illusion that something is going on, and we work within that rather than trying to just tell them they're wrong, they're more likely to trust us and let us help them than if we're constantly going toe to toe with them and trying to change their perception, even though it might be a bit distorted.
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