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Alzheimer's, Delirium, and the Dreaded Urinary Tract Infection

Posted Nov 22 2011 8:51am
Delirium is a sudden alteration in mental status -- brain failure in a vulnerable individual, often an older adult with multiple health issues, caused by something else such as medications, urinary tract infection, lack of sleep, excessive light or noise or pain.

Delirium, which occurs suddenly, is not the same as dementia, although individuals with dementia are more susceptible to developing delirium during hospitalization than individuals without dementia.

By Bob DeMarco
Alzheimer's Reading Room

Bob DeMarco
Alzheimer's caregivers take note.

The dreaded urinary tract infection. Yikes.

One of the most frequently discussed topics by Alzheimer's caregivers in support groups is the urinary tract infection. This happens because most persons living with dementia cannot tell you they are sick; and as a result, they often suffer from urinary tract infections that result in a trip to the hospital emergency room.

I can't tell you how many "hair raising" emails I have received from caregivers describing hallucinations and delirium as a result of an infection, almost always a urinary tract infection.

One big issue with infection is memory loss on the part of the person living with Alzheimer's. In most cases I know of, the patients memory declines when they suffer from an infection that goes undetected for a while. The question? Will their memory come back to where it was prior to the infection?

Because these patients cannot tell us "they are sick", we have to be very vigilante when it comes to infection. This requires taking their temperature daily, establishing their core body temperature, and looking for spikes in their temperature. For example, Dotty's core body temperature is around 97.6 degrees. So, if I take her temperature and it is 98.6 degrees, she is sick.

You cannot rely on a doctor or a nurse to spot a urinary tract infection. When I take my mother to the doctor and say to the examining nurse, she has an infection they look at me like I am a nut job.

They ask Dotty, how are you? She says, "I'm fine". They take her temperature -- 98.4, they say she is fine. I respond, no she isn't, her core body temperature is 97.6. I had more than one nurse say, so what?

I ask for the urine culture. Bingo, one hundred percent of the time infection.

I don't want to mislead you. I had to learn this the hard way. I really don't know how many undetected urinary tract infections Dotty had before I learned to deal with the problem. I can tell you this.

There were times when she became dull, disoriented, and very difficult to deal with and I assumed it was the Alzheimer's and the stages of Alzheimer's. It took several years of heartache and confusion before I finally figured out what was happening to her and what I could do about it.

Did I say you can't rely on the nurses and doctors on this one? You cannot rely on the emergency room or hospital personnel either.

Fact: an estimated 80 percent of patients in intensive care units experience delirium during their hospital stay, however delirium is unrecognized in 60 percent of patients who experience it.

If they can't get it right in the ICU, why would anyone assume that a personal care doctor or a nurse can get it right?

We, the Alzheimer's caregivers are not doctors, for this reason we must become detectives.

Read the following closely.

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Protecting our brains: Tackling delirium

Malaz Boustani
"Having delirium prolongs the length of a hospital stay, increases the risk of post-hospitalization transfer to a nursing home, doubles the risk of death, and may lead to permanent brain damage," said Regenstrief Institute investigator Malaz Boustani, M.D., M.P.H., associate professor of medicine at the Indiana University School of Medicine and director of the Healthy Aging Brain Center at Wishard Health Services.

"Statistically having delirium is as serious as having a heart attack. Once delirium occurs, the same percentage of individuals die from it as die from a heart attack," said James Rudolph, M.D., president of the American Delirium Society .

Delirium, which occurs suddenly, is not the same as dementia, although individuals with dementia are more susceptible to developing delirium during hospitalization than individuals without dementia.

A new national plan of action provides a roadmap for improving the care of patients with delirium, a poorly understood and often unrecognized brain condition that affects approximately seven million hospitalized Americans each year.

"Delirium: A Strategic Plan to Bring an Ancient Disease into the 21st Century," written on behalf of the American Delirium Society, appears in the supplement to the Nov. 2011 issue of the Journal of the American Geriatrics Society. Publication of the supplement, "Advancing Delirium Science: Systems, Mechanisms and Management" was supported by the John A. Hartford Foundation.

Delirium is a sudden alteration in mental status -- brain failure in a vulnerable individual, often an older adult with multiple health issues, caused by something else such as medications, urinary tract infection, lack of sleep, excessive light or noise or pain. In the United States, an estimated 80 percent of patients in intensive care units experience delirium during their hospital stay, however delirium is unrecognized in 60 percent of patients who experience it.

Delirium has plagued the ill and vulnerable with increased risk of death for centuries, at least since Hippocrates described the condition in the fourth century B.C. Today, as much as $152 billion is spent annually in the U.S. on delirium related costs such as hospitalization, rehabilitation services, or nursing homes residency.

The new framework outlines four broad goals and details steps to achieve them
Goal 1: Improve clinical care related to delirium including screening patients for delirium risk and developing non-toxic treatments for delirium.

Goal 2: Improve delirium education especially improving public understanding that a change in mental status in an older patient is a medical emergency and correcting the misconception among health care providers that delirium is a 'normal' feature of hospitalization in older patients.

Goal 3: Invest in delirium science by funding research at levels comparable to diseases with similar outcomes. In 2009, NIH funding for delirium was only $12 million compared to $392 for pneumonia/influenza.

Goal 4: Develop a network of delirium professionals to advance the first three goals.

"Delirium may be averted or resolved but we are missing it because we are not focused on preventing, diagnosing or managing it. We need to improve inputs into the brain, create healing environments that do not overload their brains, and cautiously use medications tha act in the brain. Most importantly, we need to make sure we are alert to signs of delirium and address it as soon as possible," said Dr. Rudolph.

Ultimately the patient and his or her caregivers bear the burdens of delirium and the consequences thereafter. The focus of this call to action puts the patient at the forefront.

"Patients, family members, doctors, nurses, pharmacists and everyone involved in delivery of care need to be told about the short term and the long term impact of delirium in our society so we can have a delirium-free century," said Dr. Boustani.
_____________________________________________
Authors of the strategic plan, writing on behalf of the American Delirium Society, are James L. Rudolph, M.D., S.M.; Malaz Boustani, M.D., M.P.H.; Barbara Kamholz, M.D.; Marianne Shaughnessey, R.N., Ph.D., and Kenneth Shay, D.D.S., M.S.

Delirium: A Strategic Plan to Bring an Ancient Disease into the 21st Century. James L. Rudolph, Malaz Boustani, Barbara Kamholz, Marianne Shaughnessey, and Kenneth Shay, on behalf of the American Delirium Society. J Am Geriatr Soc 2011;59(Suppl. 2):S237-S240.


More Insight and Advice for Caregivers

Original content Bob DeMarco, the Alzheimer's Reading Room


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