My book ‘Essentials of delirium’ will be published by Jessica Kingsley Publishers in 2020.
As I know from personal experience, watching a loved one flip in and out of ‘delirium’ is profoundly shocking.
Delirium is a cause of major emotional distress to those around. It could also lead your loved one never to return home after a hospital admission, but instead lead to a fast transfer to a nursing home.
It could perhaps lead to an accelerated decline in cognitive function.
It seems rather perplexing why all the doctors on a ward round might genuinely seem unperturbed by a patient in deep sleep, hard to rouse at 11 am in a busy noisy ward, with the curtains wide open. In response to a basic enquiry from a relative, who has fought hard to be on the ward during ‘visiting hours’, a doctor might not actually be able to explain what has caused this rapid change in personality and behaviour, or when this horror of the delirium experience will finally be over.
Delirium can happen in any care setting, including at home. We need anyone involved in care, especially of those at risk (including people with dementia), to be able to spot it (chapter 1). On suspecting it, we need delirium to be identified, diagnosed and managed appropriately (chapter 2). Some individuals are particularly at risk of dementia (chapter 3), and it’s worth knowing how one might minimise the chances of developing delirium.
For that period of time when a person is experiencing a delirium, that person takes a temporary diversion from his own life course, it’s as if his sense of personhood has been ‘suspended’. But it’s worth thinking about the significant effects of suspending a patient’s identity as a person. The full force of this argument would be to strip him of dignity and of an entitlement to other human rights. It is shocking that relatively little attention has been given to addressing how to optimise the conditions for person-centred care, but this should be a goal of high quality care (chapter 4).
Communication is not only essential between the person delivering delirium care and all those providing care, but is also essential between all members of an interprofessional team for effective teamwork (chapter 5). Even if a person with delirium himself is uncommunicative, the promotion of health and wellbeing, for example early mobilisation and good nutrition and hydration, are critical (chapter 6).
There is an impressive army of interventions in delirium, including non-pharmacological and pharmacological approaches (chapter 7). Given that we do not understand the precise neuroscience behind delirium, work in this space has been surprisingly successful. But there is now robust recognition that patients can have range of outcomes after delirium (chapter 8), which means that prompt recognition and management of delirium is a moral imperative as well as a legal one from the perspective of patient safety. A person with delirium might have long-lasting psychological effects of the delirium episode, and the power of stories of survivors of delirium cannot be underestimated (chapter 9).
Enabling and protecting a person while experiencing delirium must be achieved somehow, and all persons involved in high quality delirium care must understand the current legal and ethical issues. Only this way can one understand how decisions may be made in care, and also why objections are raised against restraints and inappropriate chemical medication (chapter 10).
Knowing when delirium is reversible, appreciating what to do when somebody in his last days with delirium, and understanding the scope of services is important for anyone with an interest in palliative and end-of-life care in delirium (chapter 11).
Beneficial improvements in providing high quality care through quality improvement are easier to achieve when interested parties are involved in, rather than the recipients of, change (chapter 12). Educational initiatives, whether developments in the undergraduate curriculum or innovations in service provision such as the use of simulations or e-learning, continue to ensure that a well trained workforce can recognise and do something about delirium (chapter 13).
Chapters
This book is divided into 13 chapters, but this separation of information is artificial as many topics cross these chapters.
Chapter 1. Delirium awareness
Chapter 2. Delirium identification, assessment and diagnosis
Chapter 3. Delirium risk reduction and prevention
Chapter 4. Person-centred delirium care
Chapter 5. Communication, interaction and behaviour in delirium care
Chapter 6. Health and wellbeing in delirium
Chapter 7. Interventions in delirium care
Chapter 8. Outcomes after delirium episodes
Chapter 9. The delirium experience
Chapter 10. Law, ethics and safeguarding in delirium care
Chapter 11. Palliative and end of life care, and delirium
Chapter 12. Evidence based medicine and quality improvement
Chapter 13. Educational initiatives
A word of thanks.
I am grateful to Prof Alasdair MacLullich (Edinburgh) and Prof Sharon Inouye (Harvard) for their introductions, and to Dr Daniel Davis (London) and Dr Amit Arora (Stoke-on-Trent) for their afterwords.
Finally, I’d like to thank my mum for teaching me all the really important stuff about delirium. I will always be eternally grateful.
Dr Shibley Rahman
London, July 2019
Dr Shibley Rahman blog 