Prolonged delirium

1
Prolonged delirium - experiences from a
specialized delirium treatment and rehabilitation
ward in a health center hospital Stocholm
20.-21.11.2008 Temamöte NAD
Katriina Hospital, a primary care hospital, in
Vantaa, Finland
Pirjo Juhela, MD, geropsychiatrist
(presenter) Laura Häggblom, MD (collection of
data) Lea Annanmäki, MD geriatrician Leena
Niinistö, MD, PhD, GP
2
Vantaa, Finland - population ca 190 000
(growing quite fast) - mainly suburban
relatively "young" population, but changing fast
Older population of Vantaa (2005)
3
Delirium A sudden state of severe confusion and
rapid changes in brain function (symptoms
inability to concentrate, disorganized thinking,
hallucinations, sensory misperceptions and
illusions, disturbances of sleep, drowsiness,
disorientation to time, place, or person,
problems with memory, hyperactivity/hypoactivity)
Delirium can be due to a number of conditions
that derange brain (predisposing factors old
age, dementia, etiology metabolic disturbance,
somatic illnesses, toxic conditions,
withdrawal of drugs/alcohol - delirium
tremens) Usually reversible condition lasting
few days - but can be prolonged and also chronic
in its course
4

• Why a specialized delirium ward??
• Need to develop acute/post acute geriatric
• care
• Penalty fees from secondary and tertiary
• specialist care

5

• But also because...
• delirium patients seemed to be "wrong" patients
• everywhere
• at Katriina Hospital (primary care)
• ("too" restless, "too" wandering,
• "too" psychiatric, "too" complicated)
• at geropsychiatric unit
• ("too" somatic)
• at specialist care units
• ("just too much", and "nothing to treat!")

6
Program started August 2006 in old facilities,
but with new staff and training
7

• 20 beds - few long term (1-4)
• 1 junior doctor
• consultants
• geriatrician, geropsychiatrist
• 1/2 nursing administrator
• 5 RN
• 8 vocational nurses
• 1 physiotherapist, 1/4 social worker,
• 1/4 recreational therapist
• possibility to consult
• occupational therapist and psychologist

8

• Patient flow 8/2006 - 8/2008
• total 148 patients - referred because of
  delirium, mainly from secondary or
• tertiary care
• males 74 50 Age distribution
• females 74 50
• Background
• Dementing processes 64 43
• Alcohol related problems 40 27
• Dementia alcohol 4 3
• Other 40 27 (for instance acute neurological
  or psychiatric disorders)

9

• 81 patients with reversible delirium
• abrupt cognitive decline relative to prior
• level
• recovery or substantial recovery from cognitive
  symptoms
• before discharge
• - 26 (32.1) had dementia
• - 31 (38,8) had alcohol problems
• - 4 (4,9) had alcohol problems and dementia
• - 20 (24,7) had other neurological or
  psychiatric
• disorders

35 patients (alcohol related delirium ARD) -
alcoholproblems present at risk drinking or
serious alcohol dependency previously
10
Age distribution
D males 46 females 54 ARD males
66 females 34
Delirium - no alcohol (D) (n 46) Alcohol related
delirium (ARD) (n 35)
11
Placement after hospital stay
Living arrengements before hospitalization
D home or similar 98 ARD home or
similar 98 (one homeless) Mean hospital stay
D 71 days delirium ward, total 82 days
ARD 38 days delirium ward, total 55 days
12
Alcohol related brain damage - what is it??
acute alcohol related delirium?? prolonged
delirium /reversible alcohol dementia?? chronic
alcohol related brain damage? How big issue is
age?? Is treatment of alcohol related brain
damage possible? is it cost effective?
Alcohol interventions - when and how?? Are we
too nihilistic?? Prevention??
13

• What have we learned?
• Complexity - there is always
• something more
• You need to be a detective -
• information is not easy to find
• It takes time to recover -
• you need patience

14
We need to understand delirium experience
" Delirium Everyone's psychosis" Malcolm
Bowker, 1995, BMJ "While being ventilated in the
intensive care unit (one week) I do not
remember sleeping or waking....." " Simple
psychotherapeutic measures...."
15

• What is important in the care environment??
• Have ears and eyes open, observe and notice
• even small clues
• - patient is often unable
• to communicate his/her needs,
• - find his/her narrative - story - reality -
• help to create meaning
• Mobilisation / rehabilitation of body and mind
• - physical
• - mental cognitive, behavioral
• and emotional

16
A special thanks is due to the capable staff of
Ward 1 at Katriina Hospital
17
But to reach the patient we need....... Safety,
security and trust!
Atmosphere must convey these by being calm,
comforting, soothing and avoiding all
unnecessary alarm!
18
What should we offer after discharge? -
rehabilitation in-patient/out-patient settings
within normal alcohol (addiction) programs? or
specialized for older adults? - follow up by
specialized addiction nurse? - follow up by
GP? - geropsychiatric out-patient care? -
something else? - nothing?
19
Audit-screening at Korso Health Center 2008
catchment area of ca 24 000, with population
over 60 ca 2000
Older adults - visits to addiction nurse 2008
_________________________________________________
__________________________________
Men Women
Total 96 62 152
20
(No Transcript)
21
First age - childhood, adolescence Second age
- adulthood, middle age Third age - after
middle age, before old age Fourth age -
old age Fifth
age?? - frailty - death
22
Childhood - "Changing period / being in
between" adolescence, youthhood, young
adulthood Adulthood - "Changing period/
being in between" third age, "young old
age" Old age - loss of autonomy, frailty
death
23
(No Transcript)
24
(No Transcript)
25
(No Transcript)
26
(No Transcript)