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Delirium: Follow-up questions with Dr. Christina Reppas-Rindlisbacher

Dr. Christina Reppas-Rindlisbacher, geriatrician and PhD candidate from Women’s Age Lab at Women’s College Hospital, presented a webinar in February 2023 about delirium. Delirium is a serious but common condition affecting older adults, resulting in a sudden change in thinking. These effects are most seen in changes to a person’s memory, reasoning, ability to stay alert and understanding of time and place.

In the webinar, Dr. Reppas-Rindlisbacher presented an overview of delirium including its causes, treatments and long-term impacts. She also discussed what families and care partners can do to help when loved ones are hospitalized or need surgery.

Webinar attendees, as always, had plenty of questions. Here are some of the questions and answers we didn’t have time to address during the session.

To watch the full webinar, please visit RTOERO Learning.

Delirium Q&As

Q: On average, how long does delirium last?

A: On average, delirium typically lasts for days and will start to improve as soon as the underlying precipitants are reversed. The most severe symptoms of delirium often go away within days but in some cases, there can be a “brain fog” that persists for weeks to months. Twenty per cent of people with a severe delirium will still have cognitive impairment at 6 months’ time. 

Q: If you once had delirium, are you more susceptible to it again?

A: Yes, one of the main risk factors for getting delirium again is past history of delirium.

Q: If you develop delirium in an acute hospital setting, does this increase the risk of developing some form of dementia at a later date?

A: Yes, it does. Some people will argue that this is a chicken-and-egg scenario and that the people who get delirium already had dementia (it just wasn’t obvious yet). It’s hard to say for sure if delirium is causative or just a marker for dementia. However, we have good long-term data that shows that people who experience delirium have an increased risk of getting new dementia in the future and that those who already have dementia have faster dementia progression if they experience a delirium.

Q: How common is delirium at the end of life?

A: Delirium at the end of life is very common. Sometimes the onset of delirium, while a person is very sick, can be a sign that a person is nearing end of life. Not everyone reaching the end of life has these experiences, but it is fairly common, and it can be very distressing to families. Many of the same strategies that I covered in the presentation that families can employ to help relieve distress also apply to delirium at the end of life.

Q: Have you seen delirium in cancer patients?

A: Yes, I certainly have. It happens most commonly after surgery or after radiation (especially whole-brain radiation). Usually, these patients were already frail or had some level of cognitive impairment going into these treatments. “Brain fog” from chemotherapy or “chemo brain” has also been described. This is not the same as delirium but can still cause distress or anxiety.

Q: If an older person has a hip replacement for example, do surgeries done with spinals cause delirium as much as a general anaesthetic? Are spinals safer?

A: This is a very good question. You would think that spinals cause less delirium, but in many studies of hip fractures done with spinal vs general anesthetic, the rate of delirium was the same with either approach. This suggests that there are other things going on during the surgery (blood loss, pain, inflammation) which cause the delirium rather than exposure to the anesthetic itself. You can read about one of these studies, “Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults,” in the New England Journal of Medicine.

Q: Is there anything that can be done for people who are mostly at a non-verbal state?

A: This is certainly a challenge, and in these cases, I usually ask for the expertise of my speech and language colleagues. It depends on the state of the person and why they are non-verbal. Sometimes personalized communication boards with pictures describing needs can be helpful, and the presence of family members or loved ones will always be helpful.

Q: How do we stop the delirium when a person sees things that don’t exist?

A: This can be challenging because we have nothing that takes away the hallucinations apart from antipsychotics and sedatives, which carry their own risk of side effects.  Whether or not to do anything about the hallucinations depends on how distressing they are. For example, some people who report seeing bugs will be calmer if a trusted presence provides comfort and reassurance. Others will remain scared despite reassurance. If the doctor is worried about psychological distress or the distress is causing a person to behave in a way that is harmful to themselves or others, then sometimes an antipsychotic medication will be used. Careful counselling about the side effects should always occur, and they should always be stopped as soon as possible.

Q: How should one respond to someone who is delirious if redirecting doesn’t work? Is it possible to “snap one out ” of their delusions?

A: Unfortunately, there is no way to “snap” someone out of delirium. Gentle redirection, reassurance and orientation to place, time and circumstances are suggested. Sometimes people need time for the underlying cause of delirium to be addressed, and then the brain can start to heal.

Q: What can be done during an extreme paranoia episode?

A: The answer to this is similar to the answer above. When paranoia occurs in the setting of delirium, we always try using communication, reassurance and family presence first. If these strategies do not work and the person is paranoid to the point of exhibiting behaviours that put themselves or others at risk of harm, then sometimes antipsychotic medications are used at low doses and for the shortest time possible. 

Q: Does the Women’s Age Lab have a newsletter or some other means of communication which we could access?

A: Yes! The Women’s Age Lab’s most recent newsletter was just published, and you can access it here.