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Mismanagement of Delirium
Commentary by Jennifer Merrilees, RN, PhD, and Kirby Lee, PharmD, MA, MAS
[Free full-text AHRQ Patient Safety Network article online]
[EXCERPTS]
The Case
An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional hospital, the patient was not able to walk independently. He was given crutches and instructions for no weight-bearing on the injured leg. He was admitted to a skilled nursing facility for physical therapy to establish mobility and for assistance with bathing and dressing. His wife stayed with him most of the day during [the] first 2 days.
Prior to this event, the patient lived at home and was independent in activities of daily living. He used distance and reading glasses, eye drops 3 times daily, and had hearing aids. Over the previous year, he experienced nondisturbing visual hallucinations (e.g., bird in the tree, squirrel on the lawn, bug on the floor). He had disturbed nighttime sleep and occasionally got up at night, showered, and dressed, before asking his wife the time. He experienced frequent daytime sleepiness with varying levels of concentration. He had a shuffling and sometimes propulsive gait, and he fell easily.
On day 3 in the skilled nursing facility, prior to arrival of his wife, the patient became delirious and agitated. He waved his crutch to keep staff at a distance, threatened to kill them if they approached, and knocked over furniture. The sheriff was called. The patient was taken to the hospital emergency department (ED). The patient spent his first night in the ED hallway with his wife and daughter alternately by his side. On day 2 of hospitalization, he was transferred to a hospital room and was visited by a psychiatrist. That night, the patient became delirious and threw a cup of water at a sitter. On day 3, the patient was lucid and explained he thought he [had] been captured and was trying to escape. He expressed remorse. The psychiatrist recommended transfer to the geriatric-psychiatry ward for better patient management, and the patient’s wife accepted the recommendation without understanding the implications. At the time of the transfer, the patient had been immobile for 3 days, and he had constipation, mild dehydration, and pain.
Over the next 2 days, the wife and daughter became concerned about their loved one’s care and requested alternate ward placement that allowed a 24-hour family caregiver at the bedside. They further requested that the staff address the patient’s mobility needs and work to eliminate some of the delirium triggers. The psychiatric intern was called and explained to the patient’s family that the patient has been involuntarily committed, and no change in placement or treatment would be considered. The intern further explained that the primary medical concern was the patient’s behavior, not his mobility. The family requested to see the intern’s supervisor, who spoke to the family by telephone and confirmed the intern’s statement. The family then called the patient’s primary care physician, who deferred to the specialists on the overall plan, but requested that the patient’s daughter be allowed to stay with the patient overnight. The ward nurse refused the request and the wife and daughter were escorted from the locked ward at 9:30 PM.
The patient continued to experience nighttime agitation and was aggressive toward staff during nights 3–5, which led to the use of restraints. Ward staff extended the daytime visiting hours for the family, 8 AM–10 PM, but continued to refuse the family’s requests to stay at night to provide comfort and reassurance. Medical students rounded on days 5 and 6 and administered mini-mental status exams, but no in-depth medical history or dementia evaluation was administered. The patient continued to have constipation, mild dehydration, increased leg pain, and ingrown toenail pain. Risperidone was administered to control agitation and hallucinations on day 5. On day 6, the patient became aphasic, exhibited slurred speech, moaned with discomfort, occasionally cried “spinning,” and exhibited breakdown on the skin of his heels and buttocks. On day 8, the patient’s wife called the hospital legal department to file a complaint. At that point, the hospital allowed the patient’s daughter to spend the night. The patient continued to act out dreams, but having a family caregiver at the bedside prevented escalation to aggression.
The patient was released back to the skilled nursing facility on day 9, with a diagnosis of Lewy body dementia. The risperidone was discontinued several months later by a new geriatrician in the skilled nursing facility. Since the precipitating incident, the patient has lost 40 lbs. He now has limited speech, limited mobility, and tardive dyskinesia, and he is dependent for all activities of daily living.
The Commentary
by Jennifer Merrilees, RN, PhD, and Kirby Lee, PharmD, MA, MAS
This case highlights the challenges and pitfalls of managing delirium in patients with dementia. Delirium, an acute state of confusion, is a significant problem among hospitalized patients with dementia. Delirium affects as many as 50% of hospitalized older adults and is associated with substantial health care costs. Patients with dementia are especially vulnerable to delirium. Such patients are at high risk for negative outcomes including accelerated and permanent cognitive decline, prolonged hospitalization, re-hospitalization, nursing home placement, and death. Although clinical guidelines and evidence-based reviews are available, managing delirium continues to be challenging.
Timely and accurate evaluation is critical in caring for patients with dementia. By history, this patient exhibited features of parkinsonism (shuffling gait and falls), disturbed nighttime sleep, daytime sleepiness, fluctuating cognition, and visual hallucinations. These symptoms suggest primarily Lewy body dementia (LBD) with additional vascular factors. Throughout this case, the patient experienced significant delays in being evaluated. Early review of the patient’s medical history and symptoms should have been conducted. If soon after the patient was admitted with the leg fracture it was also known he had LBD, the clinical team may have realized that antipsychotics, particularly risperidone and olanzapine, might not be well tolerated.
An important first step in managing delirium is to recognize it. Hallmark signs include an abrupt change in cognition, variability in level of consciousness, and disrupted sleep–wake cycle. In this case, the patient’s sudden and abrupt behavioral changes were an indicator of delirium: on his third day at the SNF, he became agitated and combative. At this point, care should have focused on identifying potentially modifiable risk factors for delirium (Table 1 ). For example, given his visual and auditory impairments, without his glasses and hearing aids he was likely misinterpreting the staff’s actions and his surroundings. Similarly, he had leg and toenail pain, and it is not clear if his pain was adequately managed. Furthermore, he was constipated and dehydrated, additional risk factors for delirium that were not addressed. Instead, the patient was transferred to the hospital emergency department, spending an entire night in the ED hallway before being admitted to a hospital room. On his third day of hospitalization, he continued to show evidence of delirium (fluctuating cognition and behavior) and the psychiatrist recommended that he be transferred to a geriatric-psychiatry unit.
Unfortunately, the staff response was in direct contrast to delirium guidelines. Treatable risk factors for delirium were not addressed, and the patient was denied critical interventions to appropriately manage and treat delirium. At the time of his transfer to the geriatric-psychiatry unit, the patient had been immobile for 3 days. Physical activity was further inhibited by the use of restraints and antipsychotic medications. He was denied orientation and reassurance when staff prevented his family from staying with him, even though the presence of his daughter clearly calmed him down.
The outcomes in this case might have been dramatically improved if clinical guidelines for delirium management had been followed, nonpharmacological interventions were implemented, and family had been allowed more active participation in the patient’s care.
Table 1. Risk Factors for Delirium.
[Free full-text AHRQ Patient Safety Network article online]
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