Older Patients, Wiser Care
He said he felt fine, but he was talking nonsense
The case: He suddenly stopped making sense
Many years ago, I was half way through my third year of medical school when one evening my mother phoned me, with panic in her voice.
"Something's wrong with your father. He's saying things that don't make any sense!"
Sure enough, she passed the phone to my 61-year old physicist father, and he began very seriously telling me about an equation that he needed to go to Australia to solve.
My heart sank. A university professor, my father was usually very, even excessively, logical and precise. For him to be talking like this, something had to be very wrong.
Actually, we already knew that something was very wrong. After two years of strange symptoms, my father had recently been given a diagnosis of lymphoma, and he had just had his first round of chemotherapy several days prior.
Now he was talking nonsense. Although over the phone he insisted to me that he felt fine, something was clearly more wrong than before.
"You need to take him to a doctor, right away," I told my mother, once my father passed the phone back to her.
"I already did," she answered. "I made him go to the emergency room at that little hospital down the road from us. But when the nurse asked him what was wrong, he said he was fine and didn't want to stay, and then he went back to the car and wouldn't go back inside. And the nurse wouldn't do anything about it."
"I've never seen him like this," my mother continued. "What do you think the problem is?"
The challenge: a serious problem that can be easily missed (when caregivers don't speak up)
The problem was that my father's sudden decrease in mental clarity was awfully concerning for delirium. In delirium, a person develops problems with thinking and attention, which are a significant change from the person's usual mental abilities. Unlike problems like dementia, or stroke, which involve damage directly affecting the brain, delirium is usually a side effect of another illness or stress affecting the body, such as infection, dehydration, or a medication side effect.
Basically, when under stress, the brain can start to go haywire, and a person can start having more difficulty paying attention and making sense. Delirium can cause a person with a perfectly healthy mind to behave like a person who has dementia. For persons with dementia, delirium makes their mental state worse. Older people and those with dementia are especially at risk for becoming delirious when sick, although younger people can also develop delirium during an illness.
Delirium is very common, and lots of research studies have confirmed both the link with a serious underlying problem, as well as the dangers of leaving delirium untreated. Because of this, it's essential that a person with delirium be quickly evaluated by doctors.
Caregivers and family members are often the first to notice that a loved one is acting strangely or seems confused. However, doctors in hospitals, emergency rooms, and clinics may often not notice delirium unless caregivers make a specific effort to point out the mental changes to them. This is because doctors are often lacking a sense of what a person's usual mental state is like, especially when it come to older people.
In my father's case, even though to his wife and daughter it was glaringly obvious that his thinking was scrambled, he was still walking and talking and answering simple questions normally. And like many confused people, he was denying that anything was wrong and wanted to stay in familiar environments (like the family car).
The solution: Insist on getting the sick person to a doctor, and make sure the doctor realizes there's been a sudden change in mental function
Especially given that my father had recently gotten a round of chemotherapy (chemotherapy can often weaken the immune system or cause other very serious side effects), it was crucial that he get a good medical evaluation ASAP.
We considered trying to take him to the local small hospital, since it was close to my parents' house. I was pretty sure that the doctors would take my father's case seriously, once they found out that a sudden change in mental function had happened, especially just a few days after chemotherapy.
But after quickly thinking it over, we decided to call the advice nurse at the academic cancer center where my father was being treated. We figured there was an advantage in getting advice from a clinic that already knew him as a patient.
Her recommendation was emphatic: "Bring him to our emergency room right away. He probably will have to be hospitalized."
Sure enough, the doctors found that my father's white blood cell count (which often correlates with immune system function) had fallen dangerously low. Later that night, he developed a fever and a bad pneumonia. His confusion got worse. I flew home to Arizona. He recognized me but was still incoherently talking about his equations.
It was a scary time for us, but eventually he pulled through. His pneumonia resolved, and his thinking finally cleared up.
For me, as a doctor in training, and as a caregiver, it was a lesson I never forgot: A sudden change in mental function should never be ignored.
My prescription for caregivers:
Know that new confusion or a change in mental function is a sign of delirium and can sometimes be the only outward sign of a serious illness. Don't delay in seeking medical advice.
It's not uncommon for a delirious person to resist getting medical care. Find a way to persist and get him or her to the doctor.
Understand that doctors and nurses can easily miss delirium, unless a caregiver is very clear and specific in pointing out that there's been a change in mental function.
Caregivers are often the most likely to notice a change in mental or physical function. Noticing and speaking up about these changes is often essential to getting better medical care for your loved one.
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