Photo: Waikato DHB nurse educators (l to r) Paula von Holzen, Christine Marra and Mark Reynolds
A new e-learning package for health staff is shining light into the frightening experience of delirium.
Delirium is a state that can quite suddenly affect people and can cause them to act in unusual ways and have delusions and hallucinations. Their “movie” is very real to them, and often one that conjures up feelings of confusion, fear or anxiety.
It is surprisingly common among people in or being admitted into hospital and other healthcare settings – for example, up to 30 per cent of hip fracture patients develop delirium and 10 to 15 percent of older patients can have some degree of delirium on admission to hospital.
Delirium is a frightening experience for the person, their family and friends, and carers, particularly because it can come on so suddenly.
Signs can range from confusion and restlessness, to being agitated or aggressive, or perhaps withdrawn and slow to respond. They can experience hallucinations of objects or people that are not there but are incredibly real to them. They can believe they are somewhere else or in a different time of their lives.
It is common for families to fear their loved one has “lost their mind” or got dementia.
The good news is that delirium is often preventable, manageable, and short-term. It is not dementia (which is long term and progressive), and the person is not “going mad”.
Delirium can be overlooked or misdiagnosed, which is why Waikato DHB nurse educators Mark Reynolds, Chris Marra and Paula von Holzen have put so much effort into developing educational packages for healthcare staff, and information for families and friends of patients.
“Nurses and caregivers have an essential role in the prevention and detection of delirium. The condition remains under-recognised and poorly managed, and yet it is potentially preventable in more than a third of older people with risk factors,” Marra explains.
Already Marra, von Holzen and Reynolds have worked with Wintec to develop graduate and post-graduate online teaching modules about delirium, and a foundation level printed pack for all health staff.
In recent months, they have updated the foundation information, made it more engaging and interactive, and posted it as an interactive online package on the e-learning platform shared across the five Midland district health boards – Waikato, Lakes, Tairawhiti, Taranaki and Bay of Plenty.
Marra explains that delirium is usually triggered by some other underlying stress or acute health condition – examples might be pain, or an event like surgery, or withdrawal from a drug.
An episode can last days, but it often fluctuates. A person might be coherent in the morning, but wandering, aggressive and hallucinating in the afternoon, which is hard to families to handle – until they understand more about delirium.
This is also challenging for staff because sometimes delirious patient will resist the very treatment that helps reduce their condition. They may believe pain-reducing pills are poison, or try to pull out IV treatment lines which are addressing dehydration or infection. They can even become abusive.
“The learning package shows you how to recognise the signs, assess for delirium, address the underlying issues, and manage the condition until it subsides,” Marra says.
“It’s also really important to involve the person’s family or close friends, because they can be quite upset and worried by the confused behaviour their loved one is displaying.
“We have some very practical advice such as giving the patient space, distracting them, and reminding them of familiar things about themselves and their lives that will help them feel more grounded again.”
One of the approaches is described as “going into their movie”, which means acknowledging how real the hallucinations and delusions can be for the patient.
“We don’t argue with them or try to convince them something is not real,” Chris Marra explains. “We might make a comment that fits in with what they are seeing or the environment they think they are in, but then we can also look for something that will distract them or something they can relate to that will help bring them back into the real world.”
In the package this is illustrated by a video about a patient, played by Marra, who comes to hospital and develops a delirium. The video provides a glimpse into some of the realities facing the patient with delirium, their family, and the health care professionals looking after them.
“What has motivated me in this work is that delirium is such a frightening and isolating experience for patients and I have heard many stories of horror from people recalling their experiences,” Marra says.
“By increasing awareness about delirium – who is at risk, how it can be prevented, what to do if it occurs – we can make a positive difference to the experience of patients and their families.”