Delirium shouldn't just be seen as 'dementia getting worse'

Many people assume delirium is part of dementia or that the two conditions are interchangeable. However, people without dementia can experience delirium and, conversely, not everyone with dementia experiences symptoms of delirium.

Delirium is an acutely disturbed state of mind characterized by restlessness, illusions and incoherence.

Emma Ouldred, a lead Dementia and Delirium (DAD) nurse at Kings College Hospital, London, believes there needs to be more awareness about the causes and symptoms of delirium. She says: “It doesn’t get the same platform as dementia and it should.”

She believes it is so important to know what can trigger delirum to avoid it developing in the first instance. This is especially the case for older people or those with dementia. She says: “People who have delirium have very poor outcomes, and of course people with dementia are much more likely to become delirious.

"We try and train and educate staff in best practice how to prevent the delirium from starting in the first place.”

‘People who have delirium have very poor outcomes’

Ms Ouldred believes her role as a DAD nurse is as much about education as it is clinical outcomes, and she helps carers understand the difference between delirium and dementia. She says: “Part of my job is picking up the phone. When a loved one calls and says, ‘do you know what Emma, Mum doesn’t seem quite right’, I will say ‘she needs to be checked out medically because she may be developing an infection or something’.”

Within the DAD team at Kings, Ms Ouldred is a registered general nurse (RGN) and she works within the inpatients' section of the hospital, the memory clinic and within the community. There are also two mental health nurses who job share and another RGN. She says: “DAD teams are now being set up everywhere”.

Ms Ouldred explains the team name was changed to include delirium as well as dementia as they are so interconnected, but to also raise the profile of delirium on its own. She says: “I think the problem is even now, people think the delirium is just the patient getting worse.

“One of the things I do in my memory clinic is that I try and get carers to think about delirium because if they have seen an acute change in their loved ones, it’s not that the dementia is getting worse; the chances are something is brewing.”

Delirium is such a debilitating condition that even after a week’s worth of antibiotics, acute confusion will often take much longer to settle. Ms Ouldred says: “Some people may not even get back to their baseline level of cognition.”

‘Physical ill health can have such an impact on mental wellbeing’

Delirium can happen with any illness after surgery, or after people take new medications. It happens quickly, over hours or days, and usually lasts for a short time. Sometimes an illness such as meningitis can trigger delirium.

Other reasons people are likely to develop delirium are linked to older age and quite often dementia.

It is also very common in patients at the end of their life.

According to the Alzheimer’s Society there are many signs that someone can be experiencing delirium, including:

• Being more confused than normal

• Changes in alertness – such as being either unusually sleepy or agitated.

• Having a lack of concentration or becoming easily distracted.

• Becoming disorientated – not knowing where they are or what day it is.

• Rambling speech.

• Showing changes in behaviour.

• Having disturbed patterns of sleeping and waking.

• Being prone to rapid swings in emotion.

• Experiencing hallucinations.

• Having abnormal or paranoid beliefs.

For many older people, and especially those with dementia, delirium can cause them to be abnormally withdrawn and sleepy. This is known as ‘hypoactive’ delirium and even health professionals can mistake it for depression.

The older a patient is, the more likely it is that very simple things can trigger delirium. Ms Ouldred explains: “It takes a more serious medical condition for younger people to develop delirium such as meningitis, but in the older population, if you’ve already got dementia it could be something as simple as constipation or a urine infection.”

She finishes by saying: “In the past it wasn’t recognised how physical ill health can have such an impact on mental wellbeing.”

Spotting delirium early ‘could avoid awful admission journey’

When NICE released guidelines in 2010, Ms Ouldred, “was really excited” and she thought, “this is it now!”

But the week the delirium guidelines came out, another NICE guideline came out too, and it took precedence over the delirium one. Ms Ouldred feels this was a missed opportunity to highlight the symptoms of delirium to a wider public, including to carers, domiciliary care workers and care home workers.

Spotting the signs of delirium and noticing behaviours that are different to how a resident or patient normally behaves is vital to avoid unnecessary hospital admissions. Ms Ouldred says: “We often get patients from care homes admitted to us that have perhaps been delirious for a couple of days, because it’s not been picked up that they are brewing something.”

The DAD nurse thinks that hospital admissions amongst the elderly, and especially those with dementia, could be drastically reduced if staff were trained to spot the signs of delirium early on.

She says: “If staff picked up the fact that residents were becoming unwell through recognising signs of delirium, then they may be treated at home, and wouldn’t have that awful admission journey that they might have otherwise.”

If you are concerned and would like to find out more, contact Alzheimer’s Society on 0300 222 11 22 or visit alzheimers.org.uk/getsupport.