Oh my gosh, life is so crazy that I haven’t even had time above and beyond my studies to sit and actually blog about my studies. Whether it was my child’s mental health challenges, my family being all-hands-on-deck just getting stuff done, our time in the city managing our work and parenting commitments, attending to the needs of my friends, or just plain family time at home keeping me away, it’s just been impossible to keep blogging every time I study.
That said, I’m pleased to report that my studies have remained on track and ahead, despite my lack of actually writing about it. My home and family life continues to be a joy, and my newfound freedom in just being able to explore my academic and creative potential just keeps on being there for me to be amazed by, or even shocked. I have never felt so liberated and free to be me. I’m even designing and building new garden for my house this week, and I have no barriers to doing that. Well, none except a quite bad spinal injury. But she’ll be right. I’ll take lots of breaks.
I love my two classes. They are actually drawing to a close soon, sadly. I have really learned a lot about how to deliver responsible, sensitive, authoritative clinical care to culturally and linguistically diverse communities as well as informed care for older persons, whether they’re coming into clinic or in a hospital.
Today I’ve been doing a lecture for COU1212, which is a gerontological psychology class, basically. The responsible and educated and caring delivery of counselling for older adults. We’re going into some fairly meaty assessment and diagnosis stuff which is always exciting, and we’re really looking at a cross-disciplinary approach. With the client who is older, so much of what makes life good is going to be related to how their health’s going that week. For this to be something we hear and understand in the most compassionate way, we really have to do some work on understanding the illness and risk for older adults in more detail than just “What is dementia?”
I have been feeling pretty disappointed in fellow students for dropping off in their online participation. I have realised over the last week or two that the majority of them aren’t in the class to actually get as much as they can out of it; it’s about achieving a “pass” for themselves. So, once they’ve written their idea of a “compulsory” forum post, they tend to bugger off and stop interacting. For the student who really wants to be the best possible therapist they can be, this is pretty disappointing. If there’s no class to interact with, you’re sorta left to your own devices.
So, today I have really jumped headlong into learning more nuts-and-bolts knowledge of delirium. I mean real diagnosable measurable delirium.
I think the word is bandied-out a lot, like many other words, but it’s a medical and psychiatric reality for many individuals and their families. In fact, about half of the elderly patients you see in a hospital are going to experience delirium. It’s confusing and distressing and above all, exhausting.
The learning psychologist really does need to have a firm handle on the responsible identification and diagnosis of delirium, though. It’s different to dementia, and mainly distinguishable by its onset. It will come on with quite some speed and strength, whereas dementia is more of a slow thing that comes on over months or years and will – most unfortunately – hang around. Delirium, on the other hand, will come on over hours or days, then can be done in just as quick a time. In some cases, it will not fully resolve for months.
I’ve witness delirium firsthand and I have also had delirium myself when I was in ICU for pneumonia. I remembered things very differently to the reality, and I also have “recollections” of things that weren’t really a thing. I was only told of the true sequence and nature of events by my husband once I had recovered. It was only when he told me of how things REALLY unfolded that I realised I had some sort of other version of it; a version my brain had fabricated. There are entire days missing in my recollections of that critical week, too. I also had a strange experience of being able to view the television in my room; a quite trippy perspective of the Black Panther movie and a news item about Morris dancers, of all things!
The causes of delirium are not that well understood, but we do know who the high-risk patients usually are. They’re the ones with recent surgery who might have been treated for pneumonia, UTIs, constipation, or dementia. They are also possibly going to be quite sleep-deprived. This sleep-deprivation can become a cyclical problem, when they delirium itself has kept the patient awake overnight, they are also not resting properly because they’re in a hospital with lots of noise and a chaotic schedule and many unknowns… and this fatigue can then further increase the risk of continued delirium.
When experiencing hyperactive delirium, the patient may:
become agitated or aggressive
have incoherent speech
have disorganised thoughts
have delusions or hallucinations
With hypoactive delirium, the patient may:
present as generally sluggish and drowsy
be less reactive to environmental stimuli
In a mixed state, the patient will be fluctuating between both hyperactive and hypoactive delirium types.
The shortcut for provisional and registered psychologists is this:
60% of cases of delirium are suspected to be missed by clinicians despite the symptoms being so obviously delirium! Be aware, be educated. Remember that many sufferers of delirium will have recently had surgery or otherwise been hospitalised for pneumonia, urinary tract infections, constipation, and dementia. By the time the episode YOU witness comes along, they are already one very tired cookie. Do all you can to advocate for their comfort and rest. Refer to other experts if you have reached the outer limits of the capacity of your own expertise.
50% of older people in hospital are going to be experiencing delirium. It’s a serious neuropsychiatric condition that we need to be knowledgeable about and prepared for, not just for that client but for the information and reassurance of their families. They can also access medications such as antipsychotics or Haloperidol to deal with it so definitely work across disciplines with other healthcare professionals to ensure this individual accesses the treatment they deserve (N.B. we definitely wanna avoid opiates).
People experiencing a delirious episode are statistically much more likely to have a fall, leading to injuries, further compications, an average 10 days longer in hospital, and ultimately, a higher mortality rate.
Our prime responsibility as psychologists is to provide a calm, reassuring presence as well as assisting to identify environmental factors that can be adjusted to make it more quiet and serene. For example, turning off televisions or anything else making too much noise, dulling the light in the room, keeping voices calm and low, and so on. It’s really important that the individual gets enough sleep, too.
Find out when the episode started and ask this of a loved one. Don’t necessarily take the word of your client in this case. Why? Because they have delirium and they mightn’t actually know, or they might have an inaccurate or totally wrong answer.
Establish the baseline. Is their behaviour usually cognitively intact or do they live with dementia or memory problems?
Does this state fluctuate and has it been changing at various points in the day? How have they been overnight?
Is this the first time they have experienced it?
Can they pay attention and sustain that attention? Try asking them to count backwards from twenty, by twos. How well do they maintain their focus?
Examine for altered levels of consciousness.
Try to stand back and observe any other abnormalities. Don’t just use interviewing to verify this stuff… do it objectively.
Bernadette Brady, ECU
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