November

Worried daughter is puzzled why mom became more confused in hospital

Sylvia's mother Mary is an 88-year-old lady who was admitted to hospital with a fall. She was diagnosed with bladder infection and was treated with antibiotics. However 2 days after the admission Sylvia noticed that her mother was becoming confused, asking after her husband who died 3 years previously and was not recognising her grandchildren. Sylvia requested to speak to me. Why was her mother becoming worse in hospital? Surely hospitals are there to make people better!

Worsening confusion before or during hospital admission is a very common problem in older people. In many patients there is a prior history of "confusion" or "little memory trouble" which relatives and patients frequently attribute to old age. Sylvia admitted that her mother was getting forgetful since the death of her husband but "nothing out of the ordinary". She was living alone but Sylvia had to take over her bills and other paperwork. Two years earlier Mary could not find her car in supermarket car park, she gave up driving since. Last year she got lost on her way home from the local church.

I explained to Sylvia that her mother most likely has dementia. Older age is not an excuse for "memory troubles". I had a 99 year old patient who scored 29 out of 30 on memory test called MMSE (Mini Mental State Examination), with anything over 28 out of 30 generally being considered as normal. There are some exceptions of course. Once I treated a 90 year old retired Professor of Physics who scored 30 out of 30 and yet he was complaining that he had lost his memory. He needed some more complex tests to diagnose dementia.

Dementia has received a lot of publicity lately and rightly so. It is important to get early diagnosis because there are treatments available which will not cure the disease but will make it better or slow down the deterioration. At times, medications may ease patient's anxiety, anger, outbursts and improve daily functioning. Some patients know that they have a problem but avoid talking about it because they feel they might get stigmatised. "Are you saying I am going doolally doctor?" - I hear frequently. I spent hours explaining that dementia is a medical condition, just like any other, which needs timely diagnosis to ensure the best chances of treatment.

Having the correct diagnosis also helps to prepare for the future.Getting a specialist evaluation and/or working with a trusted group of professionals can be priceless. With the right treatment people with dementia are likely to continue living independent lives for longer. However in some dementia will progress faster than in others and times will come when the person with dementia will not be able to make important decisions regarding their health, finances, wills, and preferences in care. Having the diagnosis and understanding of the trajectory or the speed of this medical condition can aid patients and caregivers to plan for the future.

But let's go back to Sylvia's question. Why Mary became confused? 25% of hospital beds are occupied by patients with dementia, many of them get diagnosis of dementia during the admission for other medical problems. That is because patients with dementia are more likely to develop condition called delirium, compared to patients without dementia, when they develop acute illnesses such as bladder infection, pneumonia, stroke, heart attack and many others. In fact, in some patients, just the change of environment and admission to a busy hospital ward is enough to precipitate delirium. Delirium is an acute confusion superimposed on the process of gradual intellectual deterioration. It is a sudden development of dramatic changes including confusion, hallucinations, fluctuating alterations in the degree of alertness. It is delirium which makes the background "little memory trouble" much worse and it becomes obvious to everyone that the problem is much bigger than previously thought. The degree of underlying, sometimes still undiagnosed dementia will determine the severity of delirium. The more severe dementia the worst the recovery from delirium.

So what Sylvia and doctors can do to help Mary? Unfortunately there is no treatment for delirium. The care for delirium is centred on preventing it or treating an underlying acute condition, ensuring patient is adequately hydrated and not in pain. But by far the most important part of care is creating a calm homely and familiar environment around the patient. I advise the friends and relatives to bring to hospital family photos, a large clock or a wrist watch to orientate patients, and spend time talking to them. Glasses, dentures, hearing aids are all important too. The chances of recovery are much better if patients are discharged to their own home sooner as it is difficult to find a "calm" place in an acute hospital setting, and early discharges should be facilitated if it is safe to do so.

Sylvia's mother was discharged home 10 days later after completing treatment for her bladder infection and a period of rehabilitation. Her MMSE was 18 out of 30 on the day of the discharge. We organised carers' support during the day and Sylvia stayed with her mother during the night and weekends. When I saw them in clinic 2 months later Mary's MMSE was 25 out of 30 - a great improvement in a calm and happy home. Mary was content with the new diagnosis of dementia. She is back to living an independent live with visits from her carers and her daughter and will come to see me in a year's time for a routine check up.

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