It happened eight years ago, but Jenna Cormier still remembers how difficult it was watching her grandfather’s personality change.
A registered nurse who hadn’t been in the profession for long, Cormier’s experience with delirium was limited at the time.
“I remember being quite frightened by it, that drastic change in personality that I wasn’t used to. It just didn’t seem like my grampy at the time,” Cormier said in an interview.
“It seems like their personality has temporarily changed, although when it is your family member it’s hard to remember that this is a temporary change. It’s something that is quite scary if you don’t understand what delirium actually is.”
Delirium is described as a common but often under-recognized medical emergency. It affects on average between one in four to one in five people in hospital on a given day.
On Wednesday, health care volunteers are raising awareness about delirium by conducting screenings at several inpatient units and sites across Halifax, Antigonish, and Cape Breton.
‘Anyone can get delirium’
“Delirium is really almost a brain injury or brain decompensation. It’s new confusion, cognitive problems that people develop because they’re unwell,” Dr. Samuel Searle, geriatric medicine physician, said in an interview at the Veteran’s Memorial Building in Halifax.
“I think the first and the most important thing to know is that delirium is not normal, right? It’s not a good thing that you’re confused…so delirium, first and foremost, is not a normal process to have and identifying it is the absolute appropriate thing because that’s the starting point.”
According to the Nova Scotia Health (NSH) ‘This Is Not My Mom’ campaign, delirium isn’t dementia, nor is it a mental illness. It’s a medical condition that causes a temporary problem with mental function. It usually begins suddenly and symptoms often come and go. They also typically increase at night.
“It is a medical emergency, and early diagnoses and treatment offer the best chance of recovery,” notes the campaign literature.
Technically, anyone can get delirium. But Searle said those most likely to be affected have other health issues or are starting to experience problems with their memory and thinking.
“But on the flip side of that, if someone is very healthy, doesn’t have any memory problems and they get delirium, which they can, that usually represents a very, very serious condition,” Searle said.
“They’re actually the most at risk for developing memory and thinking problems permanently in the future.”
Between 20% and 24% test positive in Nova Scotia
This is the third year in a row that World Delirium Awareness Day is being marked by delirium screenings at NSH sites. The first year, it was restricted to the Halifax Infirmary.
“There was some information sent from CIHI (the Canadian Institute for Health Information) basically saying that there’s something going on with our delirium (numbers), specifically in HRM,” Searle said.
“That kind of started the delving into it a little bit further, recognizing that maybe there’s an issue. So that year we just said, Hey, let’s just screen everyone.’”
They screened almost 400 patients at the Halifax Infirmary that first year. Searle said it was so well-received they decided to expand the initiative. He said the number of patients who screen positive tends to consistently hover between 20% to 24%.
“It doesn’t matter if you’re on a medical floor or on a surgical floor, on a hospitalist’s floor,” he said. “It’s about 20 to 24% of people who are delirious on a given day when we screen them.”
Searle said last year, almost all adult inpatients in NSH’s participating central and eastern zone hospital sites were screened. About 22% screened positive.
“That is consistent with the literature, which can be anywhere from 18 to 30% of people are delirious in hospital,” Searle said. “That’s for their whole hospital stay as opposed to on a given day, and that’s not unique to Nova Scotia.”
Passing the test
The standardized approach to screen for delirium requires little to no training. It takes about two minutes using a tool called a 4AT in reference to its four components.
Searle gives me a one-on-one demonstration.
He tells me that the first thing he needs to do is determine whether I’m appropriately alert.
“We identify two major forms. One is people are very confused and heightened, looking for a fight, agitated,” Searle explained. “And then there are other forms where people are very groggy and tired.”
After determining my level of alertness is appropriate, Searle formally introduces himself and asks me to share my age, date of birth, and to identify our current location. Then he asks what year it is.
So far so good.
Searle then requests that I cite the 12 months of the year, going backwards and starting from December. I don’t recall ever doing that in my life, but I get through it.
“Lovely. That was very well done. Nice and quick, no pauses,” Searle tells me. “Usually I’m looking for seven months at least. If you can’t get seven months, then that usually screens positive.”
The last thing he needs to check is whether there’s been any significant change or fluctuations in my cognition or overall alertness in the last 24 hours.
He tells me that I’ve passed the test.
‘Stick to your guns’
Raising awareness about delirium isn’t just about targeting the public. Searle said his first target audience was health care providers. Because it’s so commonplace in hospitals, he said delirium is often viewed as “almost a normal thing.”
The ‘This Is Not My Mother’ campaign notes that studies have shown up to 67% of delirium cases were not recognized by physicians, and 43% of cases were not recognized by the nurses caring for the patients.
“You can imagine if you’re seeing something every day, all the time, you normalize it and you think, ‘Oh, no, they’re just ‘pleasantly’ confused. And that’s not right. That confusion is something bad,” he said.
Searle said he often feels badly for family members who recognize there’s something wrong with a loved one, but can’t quite put a finger on it.
“It’s important for people in the community to know that you should stick to your guns,” he said. “If that person’s not their usual self, then they need to continue to advocate for them.”
While a patient experiencing delirium isn’t likely to recognize it themselves, friends and loved ones can be alert to the signs. Searle said a rapid change in someone’s level of consciousness as well as overall confusion can be indicators.
“Oftentimes as well it comes with other health things that we often see quite regularly in geriatric medicine. So new falls, not being able to do those things that they usually are able to do on a daily basis,” he said.
“It can range from having trouble getting up and moving, going to the bathroom, or they’re having trouble cooking their meal that they usually are cooking. It’s just different.”
Treating the underlying cause
Treatment of delirium involves treating its underlying cause. That could include, but isn’t limited to, heart failure, stroke, or infection.
Ensuring the person is getting adequate sleep and that they’re eating and drinking is also important.
“You can imagine when they’re confused, they may not appreciate that they’re hungry, that they’re thirsty, that they have to use the washroom, that they have a full bladder, and so it’s just those basic things sometimes,” he said.
“And those basic things sometimes we forget in such a busy, busy place, especially when we’re looking for other things to treat and manage. But those things are really important.”
Importance of having data
Searle said this year they’ll be able to compare Nova Scotia results with information going to CIHI.
“We’ll be able to compare our results with the information that goes to the Canadian Institute for Health Information, and so we’ll be able to start to put numbers on that in terms of are people having their delirium recognized more, and how are those outcomes,” he said.
‘Get my grampy back’
Being a nurse but also having witnessed a loved one with delirium, Cormier said it’s important for everyone to remember that delirium isn’t the person.
She said because they’ll sometimes say “not nice things,” it can be difficult to separate who they truly are from the delirium.
“I think there’s a lot of confusion with people when it comes to dementia and delirium, people assuming that they’re one in the same thing. Oftentimes you do see somebody who has dementia that has delirium on top and it makes it a lot harder to identify,” Cormier said.
“Sometimes that delirium diagnosis slips people’s mind, so bringing it to the forefront (is important). And we know that if we get to it quickly, that we have the ability to get that person back. Maybe not fully if it’s left longer, but the quicker we’re able to react, the more likely it is that that person’s going to be at their baseline.”
From a family perspective, Cormier said it’s important for health care professionals to also be mindful about how they speak to patients with delirium. She recalled how difficult it was to witness some of them treating her grandfather like a child.
“Sometimes we have a higher inflection in our voice, like we might be talking to somebody who doesn’t understand. And as a family member watching that, that can be hurtful when this isn’t who they are. I think that would be the one thing that I would want people to know. That this isn’t them,” she said.
“They’re not a child. They’re an adult. They deserve dignity and respect, and this is something that we’re able to medically manage and then, hopefully, we get my grampy back.”
In the end, Cormier did get her grampy back.