It's Delightful, It's De-Lovely, It's Delirium!

Recently I helped take care of a 90-ish year old man who fell down and broke his hip.  He's moderately demented at baseline, and while waiting for and ORIF--our Anesthesia department was balking at his cardiac co-morbidities--he got more than a bit delirious.  Delirium is a common hospital-based problem, especially in older patients with cognitive losses at baseline who develop an acute illness or who have a condition which requires interventions such as bladder catheterization, NPO status, ICU observation, TPN, beeping IVs, and almost everything else I was compelled to order for this poor gentleman.

After a few days of hand-wringing and covering their eyes in despair, Anesthesia finally agreed to take the patient to the OR.  By this time, he'd sunk into a profound delirium-induced somnolence.  I can't really blame Anesthesia for balking when we rolled him down the hall in what must have looked like a moribund state, but I knew he was suffering from delirium and I had to spend a lot of time patiently explaining to the OR staff that delirious people look really, really abnormal.  Yet I knew this patient's life at baseline wasn't all that bad, and a lot of his quality of life derived from toodling around his house and garden.  Not trying to fix the hip would be a death sentence for him.

After recovery, he went to the ICU (Anesthesia's insistence) and there he languished for several days because Med-Surg was too full to move him back to a regular room.  I predicted he'd be somnolent after surgery, and indeed he was.  Nurses unfamiliar with his clinical course approached me because they were concerned he was on the verge of death.  I told them to stimulate him, talk to him, sit him up in bed--all the usual interventions for delirium, in which normalizing sleep-wake schedules and invoking familiar sights, smells and sounds are key to management--but the problem with the ICU is that the staff is used to patients being bed-bound and quiet, so every time I walked in there I'd see my nonagenarian lying in a dark cubicle. So I decided to light a fire under physical therapy.

On post-op day two, I was there when the PT arrived and, with the help of an ICU nurse, she managed to swing the old man around so that he was sitting at the edge of the bed.  He was barely able to keep his eyes open and mumbled when I said his name.  "Fred!"  I said.  "You look good today."

ICU NURSE:  "Yeah, you do, Fred."

PT (doing range of motion exercises with Fred):  "Hey Fred, push on my hand with your foot.  Like you're stepping on the gas pedal."

ME:  "Or tapping your foot, Fred."

PT:  "Right, like you're dancing.  Do you like to dance, Fred?"

ME:  "Oh I bet you do, Fred.  What kind of music do you like?"  (Fred looks at me blankly.)

ICU NURSE (repeating):  "What kind of music do you like?"

ME (looking intently at Fred's face):  "You look like a Big Band kind of guy, Fred."

PT:  "You like band music, Fred?"

ME:  "I bet you do."  (Singing tunelessly)  "Ba-da-da-DA-DA-DA-da-da-tah-da-da-da-DAH-da-da-da-da-DA-DA-DA-tah da da--come on you guys, you know the tune.  Glenn Miller."

ICU NURSE (Getting Into the Mood):  "Tah-da-da-da-DA, da-da-da-da, TAAAAH-da-da-da-da, DA-tah-da-da-da-da..."

ME:  "--DA-DA!"  (Mercifully changing gear)  "Wah-waaaah, wah-wah-wah-wah-wah-wah-wah-WAAAH--"

REST OF THE ICU STAFF (Chiming in behind us):  "Wah-WAAAAHH!"

ME and ICU NURSE:  "Wah-wah-wah-wah, wah-wah-wah-wah, wah-wah-WAAAH."

PT (Bopping her head):  "Do-do-doooo--"

ME and ICU NURSE:  "Wah-waaaaah!"

PT:  "--to0-do-do-do-do!  Woo-woo-woo--"

ME:  "Wah-Waaaaah!"

ICU NURSE and PT:  "--woo-woo-woo-woo-woo, WOO-woo-wooooooo--"

REST OF THE ICU:  "Wah-waaaaaah!"

ICU NURSE and PT:  "woo-woo-woo-woo-woo--"

ME:  "Wah-da-da, wah-da-da, wah-waaaaah-wah-wah-wah.  WAH-DA-DA-DA-DA-DA, DA-DA-DA-DAAAAAH...."

OK, you get the idea.  By this time, our patient had his eyes wide open and was looking back and forth at us.  The physical therapist said he was, indeed, tapping his toes against her hand.

Later that day I got him moved to Med-Surg, where his wife verified his favorite music:  "Old-fashioned dance tunes."  Had to pat myself on the back about that one.  Pretty soon he was answering questions and smiling at us, and finally eating some simple foods.  His new nurse knows all the words to "Chattanooga Choo-Choo," which I think will be a big help in his recovery.

It's amazing how much music and the other humanities play an essential role in medicine.  My kind of medicine, anyway.

Comments

[paggy]

ooh how sad but i have to do a paper on delirium for health but i don't find the right things it's either something i already have or not the right thing it really suck's!

[Julie]

My dad, now 95, suffers horribly from delirium when he's in the hospital. It's been frightening for us, his family, to see him seemingly lose his mind -- usually after about 4 days in the "total institution."

I wish hospital staffers would be more direct about this problem, explaining it and telling family members how they can help. Last time he was hospitalized, an old cassette tape of Art Tatum really helped pull us all through.

[TracyKM]

LOL! I've played "In The Mood" in both stage and concert bands, and it was nice to hear it from the original source. Sounds so much better than from where I usually sit. But I just can't seem to interpret your version, LOL!

[l33t MD]

Sounds like an awesome performance, wish I could have seen it. I definately would have chimed in with the wah-wah's! :)

[Reesha]

oh how I would have loved to have seen a you tube video of that!!!