Saturday, December 25, 2010

The Ravaged Face of Delirium

Before delirium: a face of radiance, serenity and beauty.
(photo courtesy of Gina Kronstadt).

Even after four days of treatment, she remained tortured.
    (Dec/ 25. 2014) Delirium, if it's not happening to you or someone you love, is a fascinating phenomenon. It reminds me of "The Exorcist," in which the patient becomes taken over by a deranged and ominous being. My mother screamed, moaned, hallucinated, writhed, and spoke in tongues when she had delirium last month. Delirium increases mortality (about 35 to 40  percent of hospitalized patients with delirium die within 1 year), and expedites the process of dementia. It can take months to recover.
    My father had delirium twice  when he had dementia. We didn't dream that some mad thunderbolt could pierce his brain and propel him into a fury of storytelling, urgent confessions, scientific theorizing, twisted reminiscence and vivid hallucinations. If you live to be over 65, it is very likely to happen to you, whether you have dementia or not. 
    Delirium is a temporary, acute-onset condition that is rarely discussed, often misdiagnosed and poorly understood. In my father, it was disturbing to witness, but it was also a wonder to behold. A major new study has been launched to examine delirium's  neurological causes and effects. 

    My father had reached the point where he was little more than an inveterately courteous potted plant ("Thank you kindly, ma'am.) He was spending the day with Joe and me in the spring of 2010. He had been up all night at home, distressing my mother with strange rants, and making a ruckus upstairs and downstairs. 
    She had no idea what was happening to him. He was frantic about being late for his junior college basketball game. "They're counting on me! I have to hitchhike to Charlotte, but I can't find my uniform! Oh no! Oh no!" The game that he was referring to was the championship 70 years ago, which he won by making one last shot as the buzzer sounded.
     Mama finally realized that he was not going to calm down and go back to bed, so she stayed up and let him talk for hours. His brain was being flooded with memories that his dementia had appeared to erase years ago, she said, but the memories were all mixed up: Ninety years of life in a massive jumble. She was exhausted, but she said it had been fascinating to witness the reawakening of his mind..
     When we picked him up to bring him to our house, he seemed exhausted, too. He refused to eat any lunch and said he wanted to lie down, so we helped him into bed. When I tucked him in, he said, "You're an angel, honey."
    Within 30 minutes or so, we heard loud talking and noises from the bedroom. Daddy was rummaging through all of the bureau drawers, yanking things out and saying, "No! No!" He seemed to be on the verge of tears.
    "My thesis -- it's gone! They took it -- what will I do?" he cried. "I have to present it to the faculty committee in twenty minutes! Mitch will be so upset with me!"
    Mitch, who died in the 1980s,  had been one of my father's oldest friends and was his boss for a time. My father had forgotten years ago who Mitch was, but now the memory had been somehow revived.
Photoillustration by Diane Fenster.
   Daddy almost collapsed, and I helped him back onto the bed, sitting down next to him. I asked him what his thesis was about.
   "I compiled all the reference data on 34 rare metals, and described the latest methods of production, the chemical and physical properties......It seems to me I limited my emphasis to the metallic or elemental forms, with only a minor review about compounds."
    It had been at least 18 months since my father had been capable of speaking in complete sentences, much less delving into his scientific knowledge. I was exhilarated as well as baffled by this revivification of his intellect. He was even employing his long-lost professorial tone. And using words like "hitherto."
    "The war accelerated the development of new technologies, and materials hitherto unknown -- the rare metals -- were suddenly in demand. Barium, strontium, molybdenum, beryllium, germanium, gallium, chromium....." his voice trailed off, and then he began breathing hard and looking at the ceiling..
    "Oh no, not again," he exclaimed. He reached up and fluttered his fingers. "Don't you see them up there? Crawling, crawling. They are so big. Can't Joe take them away? Oh no -- look! Now they're on the floor, too." He put his face in his hands. "Honey, please do something."
    We took him to see his doctor. We had to virtually carry him to the car -- his legs were collapsing under him -- and he continued with his wild monologue on the drive to the clinic. "Please take me to the airport so I can talk to your mother," he said. "I think she is going back to Poland. I'm afraid I've done something to upset her."
    Then he took my arm and whispered, "Did you know she was the first Jewish Miss America?"
     It was his mother, not his wife, who was from Poland. And it was my first boss in New York -- Bess Meyerson -- who had been the first Jewish Miss America. She did look a lot like my mother, but she wasn't as beautiful. And my mother had been raised in a rollicking Southern Baptist church, not a synagogue.
     We had to get a wheelchair to take him into the clinic. Daddy was behaving in such an agitated manner that the nurse had us wait for the doctor in an examination room instead of the waiting room. We didn't have an appointment, so it might be awhile.
    He was very distressed -- shivering, scratching his arms, chest and thighs, and looking around the room nervously.
Delirium IV by blepharopsis
   "Don't tell anyone, honey, but those men have been coming back into my room at night."
    "What men?" I asked.
    "The ones in hats and suits. They told me I have to hide their suitcases full of money for them, and I told them I don't want to. They said they would kill you girls and your mother if I said no.
    He launched into an earnest, urgent communication with me that sounded as if he were speaking in tongues. My mother and sister had both described this to me, but I had no idea how chilling it would be to have your father looking deeply into your eyes and trying desperately to convey something while making no sense whatsoever. It was clear that he believed he was perfectly understandable.
    Dr. Maisa Morris, a beautiful and dedicated doctor, had been standing in the doorway for a few moments, listening to my father.
    "It's delirium," she said. "He probably has a urinary tract infection. Let's get a specimen, and we'll do a quick workup in the lab."
    Indeed, he did have a UTI. She prescribed antibiotics and said the delirium should subside within 24 hours. Actually, it took less than eight hours.
    If my mother's medical care had been competent, the same would have happened to her. Instead, and despite my pleadings from Day One that she be given a urinalysis, they ignored me, and she remained in agony for a week before being taken to the emergency room. By then, the delirium was so entrenched, that even after she was diagnosed with a urinary tract infection and put on IV antibiotics, the delirium persisted. 
    Now, weeks later, she is horrifically altered: Her mood is depressed, irritable, complacent. She is in a wheelchair, which has never happened before. She is so weak, she can't hold a coffee cup. She can't finish a coherent sentence. She is living in a total fantasy world, involving hot-air balloons, driving around trying to find a health-food store, having a wonderful visit with her grandmother (who died 80 years ago) and finding a bunch of Far Eastern people having a party in my sister's house. She is maddeningly resistant to physical therapy, which would restore her ability to walk and feed and clothe herself. She doesn't care anymore. That's what delirium can do to you. It destroys you much faster than dementia does. 
    We were so lucky to have a doctor who correctly diagnosed a frightening malady in my father that is more often than not misdiagnosed. If only Sunrise Senior Living had been so enlightened. Instead of getting her diagnosed and treated, they pumped her full of sedatives so her outbursts wouldn't be so loud.

     I was anxious to learn more about delirium when my dad had it. I had thought of it as a condition that might be brought on by a very high fever or by alcohol withdrawal, but I discovered that this "acute confusional state" is actually an expected phenomenon among hospitalized elderly people. I was astonished that it is so common, yet so poorly publicized and so poorly understood. The medical literature acknowledges that, "A firm understanding of the pathophysiologic mechanisms of delirium remains elusive.".
"The Machinations of Dementia" is a 2007 CD by Blotted Science.
    Delirium is arguably the single most common acute disorder affecting adults in general hospitals. It affects 10-20 percent of all hospitalized adults, and 30-40 percent of  hospitalized patients over 65, and up to 80 percent of ICU patients, particularly those who are mechanically ventilated. Up to 80 percent of those over 65 who undergo surgery will emerge from anesthesia with a case of delirium. ICU delirium predicts a 3- to 11-fold increased risk of death at six months.The reason is unknown.
    Delirium is coming to be recognized as a "sixth vital sign," and it is recommended that delirium assessment be a part of routine ICU management.
     Delirium can manifest as hyperactive, or it may be so severely hypoactive  that it borders on unconsciousness or a vegetative state. Having dementia is one of several factors that can predispose one to delirium, and -- according to the American Psychological Association's textbook on neuropsychiatry -- "when delirium and dementia are both in effect, the delirium phenomenology tends to overshadow the dementia," which it certainly did in both of my parents. I could find no studies on how this is possible and how, on a neurological level, it works..
    Delirium often manifests as disorganized or incoherent speech, purposeless behavior, such as rummaging, strange beliefs or visual hallucinations, especially the "crawly" objects my father had seen.
    Delirium may be caused by physical illness, which can be mild, or any process which interferes with the normal metabolism or function of the brain. Fever, pain, brain injury, surgery, traumatic shock, lack of food or water or sleep, and drug withdrawal can cause delirium.
    During both of my father's bouts of delirium, he had mentioned several times that when he was in bed at night a black guardian angel held vigil over him -- a "very gracious woman who never says a word." In spite of our grief over what was happening to Daddy, this was one detail that was heartwarming and delightful. It seemed so right -- since he had harbored such affection and compassion for black people since his childhood in Savannah -- that this particular image of comfort had manifested itself.

    I have tried in vain to learn how it was possible for delirium to enable the incredible "firing" that had occurred in my father's nearly-gone brain. It was like a rebirth, or a sort of remission, despite its disturbing aspects. My mother is remembering fragments of her childhood that she had also forgotten, but her condition is more about generalized anguish and fear, and fantasies, and hallucinations.
    I continue to search for the answer. I can find nothing on delirium that doesn't regard it as an acute and dangerous medical condition. Still, I wonder: In what way, neurologically, did delirium open up and bring back to life my dad's brain, which had seemed so far gone?  How does it happen, and where does it happen, and does this have any implications for treating dementia? Delirium turned the lights back on in my father's brain, although what was illuminated was more a haunted house than "a beautiful mind." Is it conceivable that delirium could be induced and then harnessed in those with dementia, in order to revive at least part of their intellects, memories and personalities?   
    An $11 million grant from the National Institute on Aging has enabled a team of scientists from Harvard Medical School, the Institute for Aging Research at Hebrew SeniorLife, Beth Israel Deaconess Medical Center (BIDMC), and Brigham and Women’s Hospital (BWH) to study the causes and effects of delirium, with the goal of developing new ways of preventing delirium and its long-term consequences.
    I think we need to examine its potentially positive as well as its negative implications. To me, at least in my father's case, it was miraculous, despite the ways in which it tormented my father and us.