Too little is still known about why patients suffer delirium. But nurses and doctors have to deal with the issue almost every day. Standardized delirium management was introduced at the USZ in 2013. However, experience reports are just as important for day-to-day work. We spoke to one of the patients affected.
Anja B., 48 years old at the time, fell into delirium for three days following a liver transplant at the USZ. “Unfortunately, I can still remember the delirium very clearly.” She remembers “I remember exactly how I felt at the time: not good at all.”
In order to prevent, recognize and treat delirium at an early stage, the Directorate of Nursing and MTTB carried out a pilot project in 2011/12 in interprofessional collaboration. A delirium management guideline was developed and tested in nine departments. The benefits of systematic delirium management were clearly demonstrated after the evaluation. It has been used in almost the entire hospital since 2013.
Between reality and nightmare
Anja B. remembers: “When I woke up, everything was dark and I was in a spaceship. I quickly realized that I was having a nightmare.” When she woke up the next time, it was dark around her again. This time she was supposedly in a research laboratory. That and the fact that she couldn’t move, even though she wasn’t fixed anywhere, seemed strange to her. “They told me I’d had an operation. But I was healthy and nothing hurt at all. Then it occurred to me that the people present wanted to kill me.”
“This is typical of delirious patients. They often have extreme anxiety and feel extremely threatened by the people around them,” explains Jutta Ernst. She is a research associate at the Center for Clinical Nursing Science and heads the interprofessional delirium specialist group at the USZ.
Recognize early and intervene quickly
The specialist group consists of a geriatrician, a psychiatrist, a neurologist, nursing staff from the various medical fields and an occupational therapist and implements delirium management at the USZ. This is based on the three pillars of prevention, early detection and early treatment. Competencies, decisions and diagnostics are clearly regulated and described. For example, patients at risk are systematically screened and preventive measures are introduced. Delirium management also includes a brochure that supports relatives in dealing with those affected.
“My relatives were immediately informed about my condition. Before each visit, they were informed about how my last night was, what was planned for the day, what they could expect when they saw me and what the next steps were,” says Anja B.
Little is known about its origins
Despite its frequent occurrence and many studies on the subject, little is still known about the pathophysiology or neurobiological basis of the development of delirium. Probably because many different factors lead to the occurrence of delirium. As a rule, it is the interplay between increased vulnerability (age, visual and hearing impairment, etc.) and simultaneous exposure to “delirogenic”, i.e. delirium-promoting factors. These include, for example, surgical interventions, infections, a strange, noisy environment, permanent catheters or delirogenic medication.
“In Anja B.’s case, the trigger was probably hepatic encephalopathy (liver-brain disorder) and the subsequent liver transplant,” explains assistant doctor Dilmurodjon Eshmuminov, who treated Anja B. at the time. Anja B. is just one of many patients affected: in 2018, 1443 patients were diagnosed with delirium at the USZ. These patients had an average length of stay of 19.9 days, whereas non-delirious patients stayed at the USZ for an average of 7.3 days. “Delirium is very cost-intensive and also relevant to DRGs. It leads to a longer hospital stay as well as increased morbidity and mortality,” explains Jutta Ernst. The mortality rate for delirious patients was 9.8% (2.8% for non-delirious patients).
Delirium treatment is staff-intensive and represents a stressful situation for patients, relatives and the treatment team. Many patients describe their condition during delirium as a never-ending nightmare. Anja B. was no exception: “Delirium was a really frightening experience, but thanks to my family and my sense of humor, I have come to terms with it well. The only thing that has remained is an aversion to orange curtains – it reminds me of the intensive care unit.”