REVIEW ARTICLE

Pdf version

ACUTE GRIEF WITH DELIRIUM IN AN ELDERLY: HOLISTIC CARE

Table 4 lists down the possible reactions of Mr A as part of his way of handling the stress and anxiety of his loss.⁶ Grief experience impacts all aspects of the being of an individual. Manifestations listed are more intensified when there has been a sudden unanticipated death. There is no timetable for grieving; various emotional and behavioural grief reactions are presented in an unpredictable and haphazard manner, an experience that the patient would describe as an “emotional roller coaster”. Patient may feel sad and depressed at one moment, and peace and contentment at the next moment.⁶

Table 4: Personal impact of grief⁶

PERSONAL IMPACT OF GRIEF
Physical reactions	Change in appetite – overeating/under-eating Change in sleep pattern – insomnia/hypersomnolence Somatising symptoms – headache/dyspepsia/hyperpnoea/palpitation/exaggeration of skin allergy, diabetes, hypertension
Behavioural reactions	Passive and withdrawn Irritability and aggressive behaviour Hyperactivity Self-doubts
Cognitive reactions	Reduced attention span Loss of concentration Loss of self-esteem and confidence Indecisiveness
Emotional reactions	Self-blame/guilt/resentment Denial/anger/bargaining/depression/acceptance Fear/anxiety/paranoia/sadness Helplessness/hopelessness/frustrations/desperation
Spiritual/Philosophical reactions	Challenge to one’s religious belief Anger towards God

INVESTIGATIONS

Decisions on what laboratory and radiology tests to be done are based on the following critical analysis:

• Is the test necessary?
• What am I looking for?
• What is the likelihood of patient having this medical condition that we want to test for?
• The cost, convenience and availability of the test; is it a simple or complicated procedure, invasive or non-invasive, does it require hospitalisation?
• Is there any treatment or favourable outcome that can be achieved after obtaining a positive result?

At the first consultation, random blood sugar level can easily be assessed with a home glucometer as Mr A is diabetic and is currently on oral hypoglycaemic drug. Dipstick urine analysis is a quick way to screen for UTI. If there is positive finding coupled with presence of clinical signs and symptoms, urine sample could be sent to the laboratory for urine culture and sensitivity (C&S).

Daily observations and feedbacks from family members on clinical progress of Mr A are necessary for constant review of management plan. Further tests could be ordered if there is no clinical improvement, if these tests have not been done recently or if there are fresh cues to suggest the need to do them. Blood and urine samples could easily be taken at home (such as urine C&S, full blood count, calcium, electrolytes, thyroid profile, renal and liver function tests) and sent to a private laboratory.

Persistent or worsening fever, respiratory symptoms and development of lung crepitations may suggest presence of pneumonia, of which a chest X-ray would be necessary. Mr A will have to be mobilised to the hospital to have the chest X-ray done. Electrocardiogram (ECG) can be carried out in the clinic or at home if there is chest pain or arrhythmia to suggest cardiac problems.

Although many patients with delirium have an underlying dementia and structural brain lesions (previous stroke), brain imaging, using computered tomography (CT) scan or magnetic resonance imaging (MRI) has been shown to be unhelpful on a routine basis in identifying the cause of delirium and should only be reserved for those patients in whom an intracranial lesion is suspected. This might include patients with focal neurological signs, confusion after a fall or head injury, and evidence of raised intracranial pressure.⁷

Overall, the routine use of neuroimaging in delirium is not recommended, because the overall diagnostic yield is low, and the findings from neuroimaging change the management of patients in less than 10% of cases.⁸

MANAGEMENT

Non-pharmacological treatment

Mr A’s delirium requires a highly detailed and expert analysis of all the factors which might be disrupting the brain function. Ten steps in the management plan are listed in Table 5.

Table 5: 10 steps management plan for delirium

10 STEP MANAGEMENT PLAN FOR DELIRIUM
1.	Risk assessments for injury to self, family members and carers
2.	Reassurance, explanation and education for patient and family
3.	General physiological requirements – adequate oxygenation, hydration, nutrition, sleep
4.	Provide a conducive and unambiguous environment
5.	Provide support and orientation for patient
6.	Maintain competence of patient with good communication skills
7.	Identification and correction of underlying causes/precipitating factors – adverse drug effects, fever, constipation, urinary obstruction, bereavement, psychosocial problems, cultural and religious issues
8.	Further investigations to exclude more serious medical problems
9.	Pharmacological treatment
10.	Referrals

Mr A does not seem to be highly aggressive or pose a danger to others or to self, as to require immediate emergency treatment or hospitalisation. Reassurance and educating Mr A and his family members on delirium and its associated underlying medical and psychosocial conditions are important. Unless there is reason to believe that Mr A has experienced permanent loss of cognitive function, the patient and family members should be reassured that the symptoms are temporary and should resolve.⁹

While the underlying causes and precipitating factors are identified and treated, top priority must be given to general measures to ensure optimal physiological requirements, to provide a conducive environment, support and orientation for Mr A and good communication skills to maintain Mr A’s competence. Table 6 summarizes the various ways and means of achieving this essential non-pharmacological supportive care.

Table 6: Tips for carers at home^4,13,14

TIPS FOR CARERS AT HOME4,13,14
General physiological requirements
1.	Monitor his food and fluid intake and help to maintain his normal elimination patterns.
2.	Maintenance and restoration of normal sleep patterns.
3.	Adequate ventilation and oxygenation (if there is presence of difficulty in breathing and cyanosis).
Providing support and orientation
4.	Repeated orientation (place clocks, calendars, newspapers, familiar objects in the room).
5.	Provide familiarity. Encourage patient to keep meaningful possessions as anchors to reality.
6.	Repeated reassurance, ideally by the same person.
7.	Good communication skills with appropriate verbal and body language. Avoid using medical jargon in patient's presence because it may encourage paranoia. Invite him to talk about his background to maintain links with his past.
8.	Strategies in dealing with confused speech of patient. Tactfully disagree if topic is not sensitive/change the subject/acknowledge the feelings expressed but ignore the contents.
9.	Gentle approach from the front. Explain whatever is going to be done for him and ask for feedback to gauge his comprehension.
10.	Sensory aids where necessary (glasses, hearing aids).
11.	Comforting rituals such as maintaining his daily evening walk, a glass of milk before going to bed, etc.
12.	Use television or radio for relaxation and to help the patient maintain contact with the outside world.
13.	Involve family and caregivers to encourage feelings of security and orientation.
Providing conducive environment
14.	Consider using single rooms to aid rest and avoid extremes of sensory experience.
15.	Calm environment with good lighting to reduce misperceptions; minimal distractions with controlled sources of excess noise.
16.	Keep room temperature to a comfortable level between 22°C to 26°C.
17.	Assess safety of environment. Reduce risk of falling by providing commodes at bedside. Remove floor wiring that may cause him to trip. Remove glare of TV screen.
Maintaining competence
18.	Avoidance of physical, emotional or chemical restraints that may frighten him, erode his sense of control and heighten his confusion.
19.	Keep things simple. Don't ask him to make difficult decisions and avoid repetitive questioning. This can be frightening and humiliating and may increase his confusion.
20.	Wrist restraints are doubly frightening for patient. Having his hands tied represents the ultimate loss of control. Devise alternative measures such as placing mattress on the floor to avoid falls.
21.	Maintain activity levels and encourage self-care.
22.	By asking the right questions and finding out what one can do, one can develop appropriate assessments and interventions to help patient break through the clouds of his confusion.

People experience and express grief in different ways, often shaped by culture⁶ but in all places and cultures, the grieving person benefits from the support of others.¹⁰ The experience of grief and mourning process involves many changes in the life of Mr A. It is a period of adaptation and transitions in all aspects of his life. It is his whole personhood that faces this forced change. Grief reconciliation depends on many other factors confronting the individual in his life. A bio-psychosocial spiritual model of care is essential to address and support Mr A in the management of his grief and delirium.⁶

John Welshons in his book entitled “Awakening from Grief” states the principles of grief counselling: “So there is no way to apply systems, rules or emotional maps. Our job is to be a presence, rather than a saviour; a companion, rather than a leader; a friend, rather than a teacher”.¹¹

The “Companioning Model of Bereavement” caregiving developed by Dr Alan D Wolfelt is one where bereavement carers help the bereaved to integrate life losses by being present to them and observing-companioning. The helper:¹²

• Listens in a supportive manner to their concern
• Help them to understand the wide range of reactions to trauma such as shock, disbelief, frustrations, anger, denial, confusion, sadness, etc.
• Reassurance that their emotional reactions are natural, normal and to be expected
• Assist them to prioritize and organise day to day and recovery tasks
• Assist them to draw on their own strengths and develop healthy coping mechanisms
• Sensitively and caringly support individuals to grieve their losses in their own unique ways

Family physician acts as a facilitator to encourage discussions between Mr A and his son’s family with regard to legal, religious and cultural issues. The strategic approach of going along with Mr A’s personal wish and preference will render him some peace of mind and comfort.

Pharmacological treatment

Poly-pharmacy and reactions to medications such as narcotics, benzodiazepines, cardiovascular agents and anticholinergic agents are major causes of confusion in elderly patients. Mr A’s recent prescription for cough mixture (anticholinergic) and midazolam (benzodiazepine) should be withheld. Drugs for his chronic illnesses that he has been taking for years without any problem could be continued. Without the anticholinergic side effects of drugs, Mr A’s difficulty in micturition and constipation could improve as well. On-the-spot catheterisation could provide immediate relief of urinary obstruction and at the same time to allow collection of urine sample for office dipstick examination. Dulcolax suppository may be preferred to oral laxative to clear the bowels. Fever can be controlled symptomatically with paracetamol. Use of antibiotics may be considered if there is underlying respiratory or UTI that requires one.

All sedatives can cause delirium and should be avoided if at all possible. Sedative compounds can improve agitation but may worsen cognitive impairment and is associated with a greater incidence of falls.¹³ Use of sedatives are indicated mainly for carrying out essential investigations (such as CT scan and MRI) and treatment, for preventing harm and injury to patient and carers and for relieving distress in highly agitated or hallucinating patients.¹⁴

Haloperidol is the drug of choice as it is the most widely used agent with documented efficacy to decrease agitation associated with delirium.^14,15 It is preferable to use one drug only, to start with the lowest possible dose and increase if necessary to a maximum of 2 mg daily orally or intramuscular (IM) injection of 2 mg every six hourly (oral and IM doses are not equivalent). Medication has to be reviewed daily and to be discontinued as soon as possible. If a second line treatment is needed for severe distress and agitation, a short acting benzodiazepines rather than diazepam is preferred.^7,15

There is evidence that Risperidone and Olanzapine increase risk of cerebrovascular events in elderly patients with history of dementia or previous history of stroke or transient ischaemic attack (TIA). These drugs should not be started as first line treatment for such patients. Use of Risperidone for acute psychotic conditions in elderly patients with dementia should be limited to short term and should be under specialist advice. Both drugs should not be used to treat behavioural symptoms of dementia.⁷

Mr A does not require any antipsychotic drug. Occasionally if agitation is worse and unmanageable at night, perhaps a small nocturnal dose of haloperidol may help to reduce the agitation and induce some sleep. Early identification and prompt treatment of the underlying causes may reduce the severity and duration of his delirium.⁷

When do we use medication to treat grief reaction?

Normal grief is neither an illness nor a pathological condition: it is a normal response to losing of a loved one. However, what is normal and how our grief is expressed can vary considerably from one griever to the next. Everyone grieves differently according to their age, gender personality, culture, value system, past experiences with loss, and available support.

There is consensus belief that medication ought to be used sparingly and focused on giving relief from anxiety or insomnia as opposed to providing relief from depressive symptoms.¹⁶ As a general rule, normal grief does not warrant the use of antidepressants. While medication may relieve some of the symptoms of grief, it cannot treat the cause, which is the loss itself. Furthermore, by numbing the pain that must be worked through eventually, antidepressants delay the mourning process.¹⁷

However, if feelings of hopelessness blossom into irrational despair and are accompanied by other depressive features, a diagnosis of clinical depression may result along with the need for pharmacological intervention.¹⁶

The differences between grief and depression

Though grief and clinical depression share many symptoms, there are ways to tell the differences. Grief involves a wide variety of emotions and a mix of good and bad days. With depression, the feelings of emptiness and despair are constant, severe and persistent.¹⁷

Other symptoms indicative of depression includes intense guilt and feelings of hopelessness and worthlessness, suicidal thoughts, slow speech and body movements, inability to function at home or at work and seeing or hearing things that are not there.¹⁷

Referrals

Indications for referrals to hospitals are mainly for investigations and treatment of serious medical problems that could not be carried out at home and if there is severe agitation and potential danger of patient harming himself or his family members.

PROGNOSIS

The course of delirium can last from several hours to several months. Delirium due to certain specific conditions (such as hypoglycaemia, infection, drug toxicity) typically resolves rapidly with treatment. However, there may be increased risk of cognitive and functional decline in frail and sick patients who develop delirium during hospitalisation.¹⁸

Full recovery should not be ruled out for Mr A merely because he has had a stroke before, but it does require a consistent, supportive, stimulating environment and a coordinated approach between the family members and medical professionals.¹⁹

REFERENCES

1. Bond SM. Delirium at home: strategies for home health clinicians. Home Healthc Nurse. 2009;27(1):24-34; quiz 35-6. [PubMed]
2. Cole MG. Delirium in elderly patients. Am J Geriatr Psychiatry. 2004;12(1):7-21. [PubMed]
3. Lixouriotis C, Peritogiannis V. Delirium in the primary care setting. Psychiatry Clin Neurosci. 2011;65(1):102-4. [PubMed] [Full text]
4. Life & Health Library. Hall, Geri Richards. Acute confusion in the elderly; 1996. [Online] [Link]
5. Young J, Inouye SK. Delirium in older people. BMJ. 2007;334(7598):842-6. [PubMed] [Full text]
6. Wheeler-Roy S, Amyot BA. A field manual. Grief counselling resource guide. New York State Office of Mental Health. 2004. [Online] [Full text]
7. Clinical guidelines for the care and treatment of older patients with psychiatric co-morbidity in a general hospital setting (Revised 2005). Isle of Wight, NHS. [Online] [Link]
8. Hirao K, Ohnishi T, Matsuda H, et al. Functional interactions between entorhinal cortex and posterior cingulate cortex at the very early stage of Alzheimer's disease using brain perfusion single-photon emission computed tomography. Nucl Med Commun. 2006;27(2):151-6. [PubMed]
9. Gleason OC. Delirium. Am Fam Physician. 2003;67(5):1027-34. [PubMed]
10. Nadeau JW. Families making sense of death. Thousand Oaks, CA: Sage; 1998;10(4):289.
11. Welshons JE. Preparing for our own death. Awakening from grief. Finding the way back to joy. Manawao, Hawaii: Inner Ocean Publishing; 2003. p. 159.
12. Wolfet AD. “Companioning vs. treating: beyond the medical model of bereavement caregiving - Part 3”. The Forum Newsletter. Association of Death Education and Counselling; 1998.
13. Meagher DJ. Delirium: optimising management. BMJ. 2001;322(7279):144-9. [PubMed] [Full text]
14. Purchas M. Guidelines for the diagnosis and management of acute confusion (delirium) in the elderly. Royal Cornwall Hospitals, NHS Trust. 2005. [Online] [Full text]
15. Breitbart W, Marotta R, Platt MM, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry. 1996;153(2):231-7. [PubMed]
16. William JW. Grief counselling and grief therapy. A handbook for the mental health practitioner. 4th ed. New York: Springer Publishing; 2009. p. 108-42. Coping with grief and loss. helpguide.org [Online] [Link]
17. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):669-76. [PubMed] [Full text]
18. Bayne JR. Management of confusion in elderly persons. Can Med Assoc J. 1978;118(2):139-41. [PubMed] [Full text]
19. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-8. [PubMed]
20. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-98. [PubMed]