By: Alexandra Curkovic,  clinical nurse specialist, Hospital Elder Life Program 

Have you ever heard of delirium? This disorder isn’t commonly understood, but it is a common concern among older adults in the hospital (it can also affect kids).
It’s an acute disorder, which means it usually appears suddenly and doesn’t typically last too long. It can develop in as little as a few hours and symptoms tend to fluctuate in severity throughout the day. People with delirium have problems in attention and awareness. It is most common in older patients who are hospitalized, but the symptoms are not always easy to identify.

A patient with delirium may have difficulty following a conversation and may get confused about their environment to the point that they don’t recognize they are in the hospital. Changes to the patient’s physical environment—like moving a patient to a new room—may make symptoms worse.

What does hospital delirium look like?
People with delirium can act confused and may:• have trouble paying attention
• be forgetful
• be restless and upset
• have trouble concentrating
• startle easily to any sound or touch
• slur their speech
• ramble and jump from topic to topic
• not know where they are
• have trouble staying awake
• see and hear imaginary things
• mix up days and nights
• act confused for a short period of time during the day and then be suddenly okay
• drift into sleep during conversation

Delirium can have serious, negative effects on a person’s ability to function independently and can affect their quality of life long term. It can also increase a person’s likelihood of developing dementia.

A patient’s perspective on delirium:

John Vlainic, a former Hamilton Health Sciences employee, experienced delirium while he was in the hospital being treated for a serious infection. He describes the experience as completely disorienting. “I remember being adamant there were men on the roof outside my hospital room window,” he says, recalling one of the visions he imagined. “I also became convinced the machine warming my oxygen was dangerous. I decided I would unplug it in the middle of the night.”

John’s wife Ruth says it was concerning seeing her husband in this state. They were glad when his delirium started to lift after a couple days.

What’s the difference between dementia and delirium?

Dementia develops over months, with a slow progression of cognitive decline over years. On the other hand, delirium occurs abruptly over a few days or weeks, and symptoms can come and go during the day. A person with dementia is much more likely to develop delirium when hospitalized.
The main difference separating delirium from dementia is inattention and level of alertness. The individual with delirium simply cannot focus on one idea or task. This inattention is usually present in later stages of dementia.
Level of consciousness for patients with delirium may fluctuate from very tired to very easily startled state whereas patients with dementia are normally alert unless they are in the later stage. .

Risk factors for hospital delirium:

There are several risk factors that can make a person more likely to develop delirium. The tips below will help you to reduce these risk factors in the hospital:

1. Cognitive impairment: People with existing dementia or mild cognitive impairment are more likely to develop delirium. Look out for signs of changes in thinking like memory loss or difficulty with daily tasks.
How to help: If someone has cognitive impairment, keep their mind active while they’re in the hospital. Ask questions about current season, holidays, past hobbies and family members. Bring familiar items, like board games or books to their room to help occupy them.

2. Sensory impairment: Hearing or vision loss can make it more difficult for someone to assess their surroundings and can contribute to delirium.
How to help: Bring their sensory aids with you to the hospital and label them. If they typically wear hearing aids or glasses, make sure they wear them during their hospital stay.

3. Loss of mobility: Lack of movement can make someone more likely to develop delirium. A patient who walked independently before hospitalization may feel unsteady during their illness or after an operation, and need assistance with a walker or other mobility device.
How to help: Advocate for removal of tethers such as IVs and oxygen tubes, and urinary catheters. Encourage the patient to move throughout the day to keep their muscles strong. Family members can help!

4. Dehydration: When people get dehydrated, they are significantly more likely to develop delirium.
How to help: Watch out for physical indicators of dehydration like muscle weakness, speech difficulty, dry mouth and a pale lining inside of the mouth. Encourage drinking throughout the day. Talk to the care team to make sure your loved can safely drink.

5. Recently added medications: New medications can increase someone’s risk of delirium. The medications most often associated with delirium are benzodiazepines and anticholinergics.
How to help: Discuss alternative medications with the care team to reduce risk.


If delirium develops while your loved one is in hospital:

• Tell the staff right away if you see a change in thinking.
• Develop a plan of care with the staff to help with the confusion.
• Try to redirect to current season, date and place. Explain why they are in the hospital. You may need to repeat this many times. Do not argue if they see things differently.
• Continue to ensure glasses and hearing aids are worn if needed.
• Continue to ensure your loved one is eating and drinking well. Ask your nurse if it is okay to feed your love one.
• Continue to encourage walking.


Hamilton Health Sciences has a Hospital Elder Life Program (HELP) service available for patients over 75 who are in select clinical areas at Hamilton General or Juravinski hospitals. If your loved one develops delirium, ask if these services are available on their unit. Click here for more information about the HELP Program.
This helpful handout provides more information for patients and families can learn more about preventing delirium while in the hospital.

Each year, approximately 1,300 individuals in Ontario are admitted to long-term care (LTC) within 180 days of an acute care hospitalization for stroke or transient ischemic attack (TIA).  To better understand the sociodemographic characteristics and burden of care for stroke survivors admitted to LTC, a new provincial report was released by CorHealth Ontario and the Institute for Clinical Evaluative Sciences, entitled:  Ontario Stroke Evaluation Report 2018: Stroke Care and Outcomes in Complex Continuing Care and Long-Term Care. This report provides a review of data between 2010 and 2015, and delves into the nature and extent of rehabilitation therapy and stroke best practices available to stroke survivors in these settings.

The intent of this report is to inform system planning, facilitate and advocate for system change, and identify opportunities for quality initiatives and research.
Of stroke survivors residing in LTC, key findings for 2014/15 include the following:

• 2% were women
• 3% required extensive assistance with activities of daily living
• 8% were at high risk for depression
• 4% experienced bowel incontinence and or 61.3% were reported to have bladder incontinence
• 3% had severe cognitive impairment
• 6% were considered to be socially engaged
• 9% were admitted to inpatient rehabilitation prior to admission to LTC (an increase from 21.5% in 2010/11)
• 4% did not receive any core therapies (i.e. physiotherapy, occupational therapy and speech-language pathology) and no stroke survivors received all three core rehabilitation therapies. Given that time spent in therapist-supervised core rehabilitation is calculated over a 7-day period, the median number of minutes of physiotherapy received per day was 6.4.  Only negligible amounts of occupational therapy and speech-language therapy services were provided.
• 4% received nursing restorative care programming (a decrease from 28.5% in 2010/11)
• 5% experienced a fall
• 3% diagnosed with atrial fibrillation received anticoagulant medication within 90-days of discharge from acute care
• 1% died within 6 months of admission to LTC following their acute stroke or TIA.

Also of note were the low health-related quality of life scores (mean = 0.37 out of 1) and the proportion of stroke survivors in LTC over 85 years of age, which increased from 36.1 to 40.8 per cent over the five-year period.
Conclusions from the report specific to LTC are outlined below:

1. Stroke survivors in LTC settings have high care needs requiring extensive assistance with activities of daily living. Their low degree of social engagement and poor health-related quality of life are concerning.
2. Rehabilitation for stroke survivors in LTC is almost exclusively physiotherapy. The time spent in rehabilitation therapy and recreation therapy per day is minimal, and access to physiotherapy and nursing restorative care in LTC has declined over time. The low health-related quality of life scores may be attributed to the limited rehabilitation, nursing restorative care and recreation therapy, and the prevalence of depression and pain.
3. Defining the role of LTC in the stroke recovery trajectory will become more imperative as the shifting demographic is predicted to result in an increasing number of LTC admissions and increased stress on the overall health care system.

MORE: PUTTING A STROKE COACH IN EVERY PATIENT’S CORNER

This report also outlines the following recommendations specific to LTC which address changes at the system, regional and facility level:

1. Limited provision of rehabilitation to stroke survivors in LTC warrants review of resource allocation/care models for rehabilitation therapy and nursing restorative care programming to inform an appropriate model for this setting.
2. Regional Stroke Network Community and LTC Coordinators should advance stroke best practices and LTC staff education by:
   • Leveraging existing stroke care resources (e.g. Taking Action for Optimal Community and Long-Term Stroke Care©, Stroke Care Plans for LTC, etc.), existing technology (learning management systems, software solutions) and partnering with stakeholders such as the RNAO LTC Best Practice Coordinators.
   • Supporting specialized training of LTC staff in secondary stroke prevention and highly prevalent post stroke complications such as urinary incontinence, fall prevention, pain management, and post stroke depression.
   • Supporting LTC facilities in modifying care planning libraries to include best practice care interventions as outlined in the Stroke Care Plans for LTC (e.g., integrate the Stroke Care Plans into care planning libraries where gaps are identified).
   • Collaborating with LTC facilities to sustain current efforts and explore further innovations in fall prevention strategies and programs to promote safe mobility.

The LTC representative from your Regional Stroke Network is available to provide further information and to support quality initiatives aimed at enhancing  best practice stroke care provided to residents of Ontario LTC Homes. To access this representative within your area, please email CorHealth Ontario at info@corhealthontario.ca.

Direct Link: hospitalnews.com/ontario-stroke-evaluation-report-2018-stroke-care-and-outcomes-in-complex-continuing-care-and-long-term-care/

Submitted by Community & LTC Coordinators of the Ontario Regional Stroke Networks.