Grandma before and after
After initially improving the first few days once she was admitted to hospital, Winnie Ho's grandmother started acting out of character. Winnie learned her grandmother was suffering from delirium (L) a condition that causes acute confusion. Once home, her grandmother's symptoms resolved. (Photos: Courtesy Winnie Ho)

On the third day that her grandmother was in the hospital, Winnie Ho knew something was wrong.

Admitted to Toronto Western Hospital's (TWH) General Internal Medicine (GIM) unit, her grandmother's condition had been steadily improving, but now something wasn't right.

"Those first days in GIM, she was responsive again and more like herself, but then suddenly something seemed off," Winnie recalled. "I shared my concern with her care team but couldn't articulate what was happening.

"I just knew something was wrong by the look on her face."

That night, Winnie received an unsettling text from her brother who'd stayed overnight at the hospital with their grandmother.

"He told me that she'd tried climbing over the guard rails, saying that the hospital bed was a prison and she would die if she stayed in it," Winnie said. "She insisted her own bed was upstairs and begged my brother for help finding the staircase leading to her bedroom."

Delirium occurs in at least 20 per cent of hospitalized older adults

A nurse kindly walked their grandmother around the floor in an attempt to tire her out, and a doctor was paged to see if she could be given melatonin. Nothing helped, and for the next six hours, Winnie's grandmother was agitated and remained awake.

Though her grandmother was much calmer by morning, she still refused to sleep. Her grandmother's care team was certain their patient was suffering from delirium, a condition that causes a person to experience an acute, changing state of confusion as result of a physical problem (a change in the body) or a change in environment.

"It was a confusing and unpredictable day," Winnie recounted. "One hour she was bubbling with friendly conversation, the next she was screaming to go home.

"I was worried it meant her health would stop improving and that she'd need to remain in hospital."

It's an experience familiar to Tina Cheung, Clinical Nurse Specialist, GIM, Toronto General Hospital (TGH) who also works with UHN's Collaborative Academic Practice (CAP) to educate health professionals across the organization about delirium and the resources available to support patients and families.

"It can be quite distressful for a family to see their loved one suffer from delirium because this behaviour is not at all normal for them," Tina explains. "Despite delirium being quite common in hospitals, it's important to recognize it as the medical emergency it is, treat it accordingly and provide the proper support and education to the family."

It's estimated that hospitalized patients have a six per cent to 56 per cent chance of experiencing delirium, while the condition occurs in at least one-in-five hospitalized older adults such as Winnie's grandmother. Hospital environments can contribute to delirium due to the loud unfamiliar sounds, and the lack of access to windows and natural light.

"It can be an unfortunate side effect of being in a hospital," Tina says. "Patients are admitted to treat one condition and, in some cases, develop delirium, which makes early screening and implementing preventative strategies key in hospital settings."

Though healthcare teams would prefer to avoid delirium altogether, the good news is that, once identified, symptoms can get better with treatment, and there are several existing interventions that do not involve medications – such as making sure patients are engaged during the day to promote wakefulness and normal sleep patterns, minimizing disruptions by avoiding room changes, and clustering care to reduce the number of times staff members go in and out of their room.

"We also encourage family members to be present to surround the patient with familiar faces," Tina says. "Engaging family members in these strategies gives them a sense of what's being done to support their loved one."

Eventually, Winnie's grandmother improved enough for her to be discharged, and her delirium symptoms resolved completely when she returned home.

Though grateful for the care and kindness TWH's care team showed her grandmother, Winnie's unexpected experience with delirium has left an impression.

"Delirium may be common in hospitals, but I had no idea it was something I needed to worry about," Winnie says. "I'm just thankful we were able to address it and get my grandmother's recovery back on track."

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