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Delirium as a Cause of Behaviors

Delirium as a Cause of Behaviors
Back a hundred years ago . . .

OK, maybe it was 10 years ago—I attended a seminar on geriatric mental health assessment. As a company we were starting to gain better understanding of the diseases of dementia and Alzheimer’s, and personally I was just interested in learning more. As a bonus to the seminar, I received a book called Delirium: The Mistaken Confusion by Debra Cason-McNeeley.

In the DSM-5, delirium is now under “Neurocognitive Disorders” and has the following criteria: 
 
  • Disturbance in consciousness
  • Change in cognition
  • Develops over a short period of time (hours to days) and fluctuates
  • There is an identifiable general medical condition (or is substance-induced)

The etiologies of delirium are numerous and include, but are not limited to:
 
  • Infectious — UTIs, pneumonia, meningitis
  • Withdrawal — alcohol or benzodiazepines
  • Acute metabolic — liver or kidney failure
  • Trauma — post-op, or a head injury
  • CNS pathology — tumor, stroke, seizure
  • Vitamin deficiencies — thiamine or B12
  • Endocrine — glucose or thyroid
  • Acute vascular — shock
  • Toxins — alcohol, opioids, anesthetics, steroids, insulin, NSAIDs
  • Heavy metals — lead or mercury

Delirium is a medical emergency that is common, but not normal. As the title of the book would indicate, it's often mistaken for confusion or as a part of the normal aging process or for dementia.

As the individual experiences a change in his or her affect, behaviors, and/or cognition, I can see how it might be easily mistaken for anxiety or defensive behaviors. It would be easy to say, “Mrs. Jones is just super anxious—she’ll be fine if we just give her some space,” or “Mr. Jones doesn’t like what any of us has to say today! Tag, your turn”—instead of really looking for the Precipitating Factors of the behaviors we're seeing change. (Here's a short AMA article on differentiating among depression, delirium, and dementia in elderly patients, and a longer video from UC-Davis.)

I was out doing some work with a hospital and we had a lengthy conversation about this topic, as this particular hospital has taken a very intentional approach to screening and re-screening for delirium. In addition to delirium, they're also intentionally screening and re-screening for substance withdrawal and thoughts of harm to self or others.

Often I work in partnership with the security team within hospitals. Within the past few weeks, I’ve wondered more and more how often a Code Gray, or a Code “Strong” (I hate this term, by the way) gets called, and security rush to the scene to find someone really suffering from delirium. While someone experiencing delirium may respond to a supportive approach, or to a redirection of some kind, might they also be frightened by a uniformed officer arriving on the scene? Set aside the confusion the security may increase—what about a nurse who they no longer recognize now poking and prodding (in their perception) and asking personal questions? I can only imagine how scary or overwhelming that might be. And so, while not acceptable, it’s really no surprise that they may lash out in fear—verbally or physically.

Not long ago I was meeting with a security director who was talking about all the serious incidents that were occurring in the ED. I heard about the urban nature of the setting; of the gang activity outside the walls of the hospital that sometimes trickled in, but the most recent injury was to a nurse treating an elderly patient well into his 80s—not an individual with gang ties. I wonder—was this man suffering from delirium that had not been diagnosed? Was it alcohol withdrawal or psychosis that was causing the change in affect, behaviors, and cognition?

Maybe I’m preaching to the choir; maybe more hospitals than I realize do intentionally and diligently screen and re-screen for these debilitating conditions. It certainly reinforces my statement that the behavior in healthcare is clinical—not criminal, which is why I get a little confused when we think we’re actually preventing assaultive or disruptive behavior by creating laws that make it a felony to assault a healthcare worker. (No, I’m not saying in any way that a nurse should just suck it up and take the hit.) The behaviors are linked to clinical underpinnings—even a person who isn’t a patient is likely demonstrating an inability to cope with the stress of the situation, or maybe they're experiencing complications with their mental health or with withdrawal themselves—not planning and plotting an act of violence driven by criminal thinking. I’m not saying there shouldn’t be accountability, but how much better would things be if we caught it early, treated the clinical condition, and thereby prevented the symptoms from worsening?

Of course nothing is 100%, and I’m in no way saying that it’s easy to manage while providing care to individuals who because of their illness(es) are demonstrating behaviors that are high risk. But I wonder what would be different if we educated our staff a little differently? What if security was more informed about mental health issues, or delirium, or what happens to an individual as they're withdrawing from alcohol or drugs? What if security weren’t called only to be enforcers of rules and policies, but were seen as a part of the care team?

The sooner we treat the underlying etiology of the behavior, the sooner we are back to providing Care, Welfare, Safety, and SecuritySM for everyone.
 
 
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