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Dementia, Delirium, and When to Seek Medical Care (Ep #028)

Interview with Dr. Lisa Frank (Part 1)


Dr Regina Koepp:    Today. I am delighted, elated, over the moon to be here with my best friend, Dr. Lisa Frank, who is a board certified adult psychiatrist who was a medical director of an inpatient...two separate inpatient units for several years and is now in community practice.

Hello there I am Dr. Regina Koepp and this is the Caring for Aging Parents Show. I'm a board certified clinical psychologist and I specialize in older adults and families. I help you manage the most complicated situations with your aging parents so that you have peace of mind knowing that you are doing everything you can to help your parents live their best lives without giving up your own life in the process. So for the best tips on helping you to care for your aging parents, subscribe to my show and you'll get new tips every Wednesday. As we get started, I wanted to share with you an important freebie I made about dementia. It's called Dementia 101: A Beginner's Guide to Dementia Disorders. In it, I talk about what dementia is and isn't. I describe the phases of dementia and what to do if you're worried that your aging parent may have dementia. I'll link to it in my show notes. So take a minute and download it. It answers some of the most frequently asked questions I get about dementia. So this is the first of a three part interview with my best friend, Dr. Lisa Frank. Today I'll be interviewing Dr. Frank about what DELIRIUM is, what it looks like in people who have dementia and when to seek medical care, and then how to navigate the emergency room. So let's get started.


What are the signs that your loved one with dementia may need medical care?

Dr Regina Koepp:    So what are the signs that families should be looking out for to help them make a decision about... "I think it's time that I need to take my loved one with dementia to the ER to get checked out."

Dr Lisa Frank:      Okay. So the biggest the biggest thing to watch out for is a change in their mentation or a change in their behavior. So if a person has difficulty finding their way places or remembering names and that's their baseline and then all of a sudden they believe that their family member is trying to take their money or is trying to harm them and thas a sudden change, that happens within a few days, or they have a reversal in their sleep cycle. So they're up in the middle of the night instead of sleeping at night. And the important part is that this changes very quickly within a few days or maybe over a week's time. That's a sign that there is something going on in addition to the dementia that is likely leading to a delirium.


What is delirium?

Dr Lisa Frank:      And a delirium is an acute confusional episode that's caused by an underlying medical issue. Most commonly a urinary tract infection in older adults but can be something as simple as a cold or if they become dehydrated. So that would be a reason to take your loved one to the emergency room to be evaluated.

Dr Regina Koepp:    Okay. So just to summarize: If a person with dementia has, say at baseline they might get lost driving, they might wander on their own, they might rummage through drawers, that's their baseline. That's what they look like in their life with dementia. Right. Then all of a sudden they get delusional where they're like, "you're stealing my money" (and you go and you've been married for 60 years), right? Or "you're having an affair" I hear a lot. And that's like yesterday the person with dementia was at baseline and today, everything is going awry. Like " who is this person?" It's so unusual. Okay. So that, so there's a delusional component.

Dr Lisa Frank:      You can be a delusional component. Can be more agitation. So maybe they let their son or daughter help them get dressed at baseline. Okay. And then within a couple of days, suddenly they're very resistive and won't allow help. They're refusing medication. They're not eating or drinking well...

Dr Regina Koepp:    And, that's a departure from how they usually are.

Dr Lisa Frank:      Correct.

Dr Regina Koepp:    And they should bring them to the ER.

Dr Lisa Frank:      Yes.

Dr Regina Koepp:    Okay. And then you said another thing which was that, so one was a delusion, one was change in sleep cycle.

Dr Lisa Frank:      Yes.

Dr Regina Koepp:    And so why would that be a precursor to like a delirium?

Dr Lisa Frank:      So with delirium we typically see a reversal in sleep cycle and so that can be either the first change that's seen or it can be later, a several day later change that's seen, but typically that's part of what lets us know there's a delirium present.

Dr Regina Koepp:    Oh, interesting. I didn't even know that. And I work with families as all the time. Thank you for that it's going to help me!

Dr Lisa Frank:      Sure.

Dr Regina Koepp:    You said it could be something as a minor to major as a UTI, urinary tract infection, but then it can be as simple as a cold.

Dr Lisa Frank:      Right. So if someone has a cold, they may not feel like getting up out of bed. They may not feel like drinking as much fluid as they normally do or eating as much. And as we age we just become more susceptible to subtle changes. And that can trigger an episode of delirium...

Dr Regina Koepp:    On top of the dementia.

Dr Lisa Frank:      On top of the dementia.


How is delirium different from dementia?

Dr Regina Koepp:    Families hear this term all the time. And it's hard for them to differentiate... How is [delirium] different from dementia? Because what you're describing is sometimes what they're like with dementia.

Dr Lisa Frank:      Correct.

Dr Regina Koepp:    So what is the difference?

Dr Lisa Frank:      Yeah, and I'll say it's not just families who are confused by this. Often physicians miss delirium as well. And, it's very common in hospital settings. It's very common in skilled nursing facility settings. So a delirium is an acute confusional episode that comes on rapidly and is due to an underlying medical cause. So a dementia is an ongoing, chronically debilitating disease process that happens slowly over time. And by slowly, I mean years. A delirium is very quick. So a delirium develops within a few days to a week. And that's one of the distinguishing characteristics. And that's helpful when family members go to the emergency room, if they're able to or call the emergency room to convey to the provider. So that they're aware this is a sudden change from baseline, which should trigger the ER doctor to consider looking for a urinary tract infection or blood chemistry changes or another source of infection.

Dr Regina Koepp:    And to give history like did the individual with dementia have infections recently have delirium in the past year? Like how many times they've been to the ER in the past year? Things like that.

Dr Lisa Frank:      Absolutely.

Dr Regina Koepp:    Yeah, so that history is so important.

Dr Lisa Frank:      Always important for families to give history.


Going to the Emergency Room

Dr Regina Koepp:    The family gets to the ER and it's a nightmare and they're like thinking, do I need to take my loved one anyway? And they realize there are these acute changes and they do, but they're worried, "what's going to happen to my loved one when they get there? Because ERs are a nightmare.

Dr Lisa Frank:      Yes. ERs are a nightmare and they require long wait times and that's the nature of ERs. But it's CRITICAL that if there is a sudden change in baseline that the loved one go to the emergency room to be evaluated for the cause. Yeah. So take a deep breath, maybe.

New Speaker:        

Dr Regina Koepp:    Bring snacks and water.

Dr Lisa Frank:      And your phone.

Dr Regina Koepp:    Ha. And your phone. Yeah.

Dr Lisa Frank:      So, the staff will admit the person and hopefully draw labs while you're waiting and then the physician comes in. It's very important to convey to the physician the change in baseline and the sudden onset of symptoms, what the family has been seeing. And if there is anything on the labs that comes back requiring treatment such as antibiotics or IV fluids that will get started in the emergency room. The person may or may not require admission to a medical unit and they would go to a medical unit versus a psychiatric unit.

Dr Regina Koepp:    Okay. Well let me ask you, so say the family gets there and the person with dementia is agitated and they're being told you still have to wait. So what determines wait times in an ER? How do they even figure out who gets seen first?

Dr Lisa Frank:      So there's a triage nurse typically who evaluates patients and determines acuity. And it depends on the type of ER, it depends on if they're a trauma center, they are going to take trauma patients urgently. If the loved one is very agitated and is disruptive or hurting himself or you know, just difficult to manage, they may go ahead and have that patient go into a room if they have a room available.

Dr Regina Koepp:    Okay. So there has to be space to admit somebody or is it called admitting somebody when they bring them into the ER.

Dr Lisa Frank:      You get admitted to the ER?

Dr Regina Koepp:    So say that they are made to wait in the waiting room. They've met with the nurse who does the vitals and the nurse says, "go wait". And then the person with dementia takes off.

Dr Lisa Frank:      So, most ERs have security and so they would then, if the family said, "my loved one won't stay. Can you help me?" Security would help the person come back. There are many different reasons why an emergency room may not be able to manage that person in that moment. So it really depends on the day. It depends on who else is there. Um, in terms of other patients who are coming in for treatment.

Dr Regina Koepp:    Got it. So if there are a lot of people coming in for treatment with heart attacks and strokes and trauma, like from car accidents, like serious traumas.

Dr Lisa Frank:      You may have to wait longer.

Dr Regina Koepp:    So then they're brought back, their labs are started. They, um, get some, maybe some IV fluids. Maybe they start to feel better then what? They'll go home, sometimes, or they'll...

Dr Lisa Frank:      So it depends on what is causing the delirium. If there's a delirium present, then the physician's job is to determine what's causing the delirium. And again, that can be typically an infection, usually a urinary tract infection, but it could be a blood chemistry change. If someone is not been keeping up with their fluids at home, they could be dehydrated or there could be, they maybe have a chronic medical condition that has had a sudden change.

Dr Regina Koepp:    Right? Because people with dementia also have other medical problems. So you're going to have like a heart disease and Alzheimer's disease. You could have heart disease, diabetes and Alzheimer's disease. I mean you could have a sort of really complicated medical profile. So something could be activated somewhere else that's not dementia related.

Dr Lisa Frank:      Correct. And, people with dementia are not able to convey information as well as people who are cognitively intact. So another reason why it's important for family to be there to give that history.

Dr Regina Koepp:    Thank you. Because this just like a wealth of information and I'm learning a lot and I've been doing this for like 15 years, so thank you!

Dr Regina Koepp:    That's all for today. And in wrapping up, I wanted to remind you about the freebie that I made about dementia called Dementia 101: A Beginner's Guide to Dementia Disorders. Take a minute and download it. It will really help you out. Join Dr. Frank and myself next week to talk about hallucinations, delusions, and antipsychotic medications. If this video was helpful, be sure to subscribe and don't forget to share this video with your friends who are caring for their aging parents because nobody should have to do this caregiving thing alone. Lots of love to you and your family. Dr. Frank and I will see you next Wednesday.


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