Information for Carers of Patients with Delirium

Delirium is when someone becomes acutely confused because of a physical problem or a change in environment. Delirium is commonly known as “an acute confused state”. Delirium may affect patients of all ages having major surgery but some groups are more common than others.

Delirium can last a few days, weeks, or even months from when the first symptoms developed, these can include nightmares. Delirium gets better when the cause is treated. You may recover very quickly but it can take several days.

• Disorientation - where the person becomes unsure of the time, person or place.
• A sudden change in the person’s mental state or behaviour over a short period of time.
• Memory problems - usually affecting their short term memory, e.g. forgetting they are in hospital or forgetting they have taken their tablets or eaten their breakfast.
• Disturbed level of consciousness - this may be restless and agitated behaviour, or sleepy and lethargic behaviour, or the person may switch between the two.
• A disturbance to the person’s sleep / wake cycle.
• Someone with delirium may not recognise their family or friends.
• They may become paranoid and develop an extreme and irrational fear or distrust of others.
• It is common for those with delirium to experience hallucinations, where they hear or see things that are not really there.

There are a number of risk factors for developing delirium, and often an individual has more than one.

Examples are:

• Over the age of 65 - the risk increases with age
• Those living with a chronic infection e.g. long term infected joint
• Those who are dehydrated and/or constipated • Living with dementia
• Physically frail and/or malnourished
• Who have experienced a stroke, a head injury or brain surgery
• Any condition affecting the central nervous system e.g. Parkinson disease.
• Have undergone major surgery
• Taking many different medications including opiate pain killers and sleeping tablets
• Patients with severe pain
• Those with hearing difficulties, eyesight problems or those experiencing problems in an unfamiliar environment.
• Individuals who consume excessive amounts of alcohol/or who take illegal drugs or who stop them suddenly before surgery
• Present as severely unwell
• Serious underlying medical conditions e.g. cancer spread throughout the body
• Patients with urinary retention or with a urinary catheter in place

Up to 30% of cases can be prevented and prior to surgery the RNOH works to identify these high risk patients. Other cases of delirium may be less predictable and unique to that individual e.g. those particularly sensitive to a certain drug.

If you are experiencing some of the symptoms described above or as a carer you notice them please inform a member of staff.

• We will investigate the medical causes of delirium and treat infection, uncontrolled pain, constipation or inability to pass urine, and the side effects caused by different medicines.

• We will try to avoid using any medical equipment that may disturb patients, such as urinary catheters (small tubes inserted into the bladder to help patients pass urine without leaving their bed) or intravenous cannulas (drips), unless they are necessary for their treatment.
• We will make sure that the patient has enough fluids so they do not become dehydrated or constipated.
• We will make sure that the patient has easy access to their glasses, hearing aids or any other aids they need.
• We will try to get the patient up and moving about as quickly as possible. If necessary they will be given physiotherapy to help them get mobile again.
• We will avoid moving patients around the ward or to another ward where possible. However, some moves, for example to comply with infection control requirements, may be unavoidable.
• We will ensure that the patient has enough food. We will check that they can feed themselves, and also find out if they have any favourite foods in order to encourage them to eat. At RNOH we use a red tray system at mealtimes to identify those patients who require assistance with their meals.
• We will help the patient to restore and maintain their normal sleep pattern. For example, we will help them to avoid taking naps during the day, keep noise to a minimum and ensure that there is low lighting at night.

It is normal to experience some pain or discomfort after surgery. The RNOH staff will work towards reducing pain to a minimum so that a patient does not suffer uncontrollable pain but is able to recover steadily as pain reduces. Major orthopaedic surgery often requires strong pain killers in the immediate period after surgery with the possible side effects of delirium. Every patients requirements are different.

When required the specialist pain team are available to assist - every patients’ requirements are different and the staff will work with the acute pain team to help ease this.

Use of Sedatives
Sedatives can make deliriun worse so should only be used in a few situations e.g. when someone who drinks a lot of alcohol stops suddenly or if a patient is at risk of serious harm.

Any sedative medication will be given in the lowest possible dose for the shortest time possible and will be regularly reviewed by the medical team.

If you recognise any of the signs and symptoms described above in your relative whilst they are in hospital, please inform one of the doctors or nurses on the ward.

Whilst your relative with delirium is on the ward, we encourage you to visit regularly. This is because patients often become distressed or frightened when they are in an unfamiliar environment. Some patients find that familiar things help; e.g. favourite TV programmes, sport, music.

The RNOH recognises that delirium can be alarming for both patients and their carers.

This may be particularly important if your relative does not speak English. We do have access to an Interpreter service during working hours.

You can also help by doing the following:

• Use of an ipod to allow them to listen to their favourite music,familiar songs or prayers.
• Use of an ipad, with headphones to watch favourite TV shows.
• Bringing in daily newspapers, telling the patient what day and time it is, or reassuring them that they are being cared for in hospital.
• Bringing in their favourite snacks. A member of staff will be available to support patients with eating and drinking requirements.
• Talk to your relative or friend about their past experiences and memories, as this may be calming and reassuring for them. You may even want to bring some photographs or other mementos.
• Letting staff know if you think your relative is constipated or in pain.
• Assisting with caring for the individual - this may include carrying out practical tasks such as personal care, help with eating and drinking, or staying with the individual to provide support and reassurance when these tasks are being carried out by nursing staff. This may also involve support and company during the day/ night. If you would like to assist the individual whilst they are on the ward please discuss this with the nurse in charge.
• Ensuring that the individual you care for has their glasses, hearing aids and dentures close to hand. Where possible, ensure that they are in working order, labelled and are being used.

• The Alzheimer’s Society The Alzheimer’s Society have produced a number of factsheets on delirium. www.alzheimers.org.uk
• www.dementiauk.org
• www.rcpsych.ac.uk/healthadvice/problemsdisorders/ delirium