Night-time confusion in an elderly woman post-stroke

Abstract

For patients with acute ischaemic stroke, faster recanalisation improves the chances of a disability-free life and a quick discharge from the hospital. Hospital discharge, certainly after suffering a major life-changing event such as a stroke, is a complex and vulnerable phase in the patient’s journey. Elderly are particularly vulnerable to the stressors caused by hospitalisation. Recently hospitalised patients are not only recovering from their acute illness; they also experience a period of generalised risk for a range of adverse events. At the same time, elderly generally prefer living in their own homes and should be discharged from the hospital and return home as quickly as possible. Both premature and delayed discharge are potential threats to patient well-being. We present a 90-year-old patient who underwent successful thrombectomy but suffered from night-time confusion at the hospital and discuss the transition process from hospital to home.

Background

Stroke is the second most common cause of mortality worldwide and the most common cause of disability in high income countries.¹ In the Netherlands, as in most Western countries, the prevalence of stroke will continue to increase as a result of population ageing and improved care for stroke patients leading to lower mortality.²

For acute ischaemic stroke, studies show the clinical benefit of intra-arterial thrombectomy, even beyond a 6-hour onset of symptoms, up to 24 hours in certain cases.^{3 4} Reducing delay to thrombectomy is crucial, since every hour delay from stroke onset to successful reperfusion results in a 7.7% decreased probability of functional independence.⁵ Faster recanalisation not only improves the chances of a disability-free life but it also improves the chances of a quick discharge from the hospital. Shorter stays in hospital have benefits for both patients, who often prefer to be at home, and hospitals, which can treat more patients if hospital stays are shorter.

Older people are particularly vulnerable to the stressors caused by hospitalisation, such as disrupted sleep, changes to medication and inactivity,⁶ and older people with stroke are particularly vulnerable to delirium episodes.⁷ Sleep disturbance may have a deleterious impact on neurological recovery for patients post-stroke.⁸

Both premature and delayed discharge are potential threats to patient well-being, where a patient can either be discharged while requiring acute care or remain in the hospital despite the possibility that his or her recovery might improve at home.⁹ As such, the transition of an elderly frail patient from hospital to home is a challenge for both hospital staff, the patient and the patient’s family.

Case presentation

The patient was 90 years old and, with the exception of mild hypertension and age-related macular degeneration, in good health. She lived alone after her husband had died 37 years earlier. Every Saturday morning she went to her daughters’ home on her bicycle, to spend the day solving cryptograms and drinking tea. One Saturday morning, 23 December 2017, she did not show up.

When calling her, she did not answer the telephone. Her granddaughter found her on the floor with decreased responsiveness. The ambulance arrived in approximately 15 min.

Examination revealed a left facial droop and when helping her to stand up, she leaned slightly backwards and to the left. She could not recall how long she had been lying on the floor. Her bed was unslept and she had large bruises and haematoma on her back, hip and leg, suggesting she had been lying on the floor all night. The patient was taken to the emergency department (ED), where she arrived at 1 pm.

At the ED, her heart rate was 77 beats/min, blood pressure was 117/63 mm Hg, temperature was 36.5°C and oxygen saturation was 100% on room air. Clinical laboratory investigation findings are as given in table 1. Leucocyte count, C-reactive protein and creatine kinase levels were elevated, possibly explained by the patients’ fall and prolonged lying down on the floor.

Table 1.

Laboratory findings

Investigations	On presentation	3 days post-IAT	5 days post-IAT	Reference ranges
Full blood count
Haemoglobin	148.2 g/L	125.7 g/L	133.7 g/L	116-153.1 g/L
Haematocrit	0.43 L/L	0.38 L/L	0.40 L/L	0.35–0.45 L/L
Platelet count	248×109/L	242×109/L	240×109/L	150–400×109/L
Leucocyte count	16.4×109/L	11.7×109/L	8.8×109/L	4.0–10.0×109/L
Neutrophils	14.16×109/L	9.38×109/L	6.28×109/L	1.50–7.50×109/L
Lymphocytes	0.73×109/L	1.20×109/L	1.49×109/L	1.00–3.50×109/L
Monocytes	1.47×109/L	1.02×109/L	0.79×109/L	0.20–0.90×109/L
Blood chemistry and electrolytes
Glucose	7.5 mmol/L	ND	ND	3.5–7.8 mmol/L
C-reactive protein	30 mg/L	19 mg/L	10 mg/L	0–8 mg/L
Sodium	133 mmol/L	140 mmol/mL	139 mmol/L	135–145 mmol/L
Potassium	3.6 mmol/L	4.4 mmol/L	4.2 mmol/L	3.2–4.7 mmol/L
Creatinine	47 μmol/L	71 μmol/L	64 μmol/L	50–95 μmol/L
Urea	8.0 mmol/L	ND	5.0 mmol/L	2.5–7.5 mmol/L
Creatine kinase	3190 U/L	ND	ND	<145 U/L
Blood coagulation
PT	11.8 s	ND	ND	10.0–13.5 s
PT INR	1.09	ND	ND	0.9–1.3
APTT	31 s	ND	ND	24–33 s
Urine analysis	ND	ND
Specific gravity			1.016	1.002–1.035
pH			6	4.50–8.00
Leucocytes			1+	Negative
Erythrocytes			4/μL	<9/μL
Nitrates			<1/μL	<6/μL
Proteins			Negative	Negative
Glucose			Negative	Negative
Ketones			Negative	Negative
Urine culture, midstream	ND	ND	Leucocytes negative	Negative
			Gram-positive cocci 0–5	Negative

APTT, activated partial thromboplastin time; IAT, intra-arterial thrombectomy; INR, international normalised ratio; μL, number of cells per microliter; ND, not done; PT, prothrombin time; U/L, units per litre.

Her ECG revealed atrial fibrillation. A non-contrast CT scan and a CT angiography scan were performed, showing an occlusion of the right M2-segment of the middle cerebral artery but no recent ischaemia.

The onset of symptoms was unknown and her symptoms were mild, therefore at that time there was no indication for thrombectomy. However, acute deterioration occurred at 15:30, while the patient and her family were still at the ED exam room. The patient suddenly murmured, started to yawn and stopped reacting. She became somnolent and developed left-sided haemiplegia. The doctors agreed on an indication for thrombectomy.

Intra-arterial thrombectomy was successfully performed. After the procedure, the patient was admitted to the stroke unit and showed rapid neurological improvement and no paralyses. She had no trouble walking, but liked the walking aid the physiotherapist had given her for extra support.

Every evening, the patient became confused. She could not recall where she was and why she was there. Each night, she left her bed and wandered around, worrying about crying children who were sleeping in the cold because ‘there was clearly no outside wall in her room’.

Every morning, she was alert again, making coherent conversation with the hospital staff and her family.

Days went by, the patient was being a perfect patient. She read her newspaper as usual, did her exercises with the physiotherapist and knitted socks like she also did at home. Two days post-thrombectomy, an occupational therapist tested her on coherent thoughts and actions. The patient had to make three cups of coffee in a simulation kitchen. That evening during visiting hours, she told her daughter that she ‘failed the coffee-exam’, and that ‘they’ probably would not let her go home now.

She was right: during a multidisciplinary staff meeting the team members worried about the patients’ wish to go home. The physiotherapist stated that the patient could not find her room after exercising and the occupational therapist said the patient was probably cognitively more affected than she seemed at first glance. The patient was screened for delirium using the Delirium Observation Screening Scale (DOS), a scale with 13 items, designed to capture early symptoms of delirium that nurses could observe during regular care. Each item can be rated as normal (score: 0) or abnormal (score: 1). A total score of 3 or more points indicates delirium.¹⁰ Our patients’ total scores were always 1 or 2 during daytime. Occasionally, a total score of 3 was noted during the night shift, indicative for possible delirium.

The patients’ family worried about the night-time confusion and wanted to take her home as soon as possible to assess whether her confusion would improve in her own environment. Since discharge was not yet a subject during morning rounds, on day 3 post-thrombectomy the patients’ family requested to talk to the neurologist. It took another day before that meeting could be arranged. During the meeting the neurologist stated that a psychiatrist would first need to assess the patient to rule out a delirium. Also, blood and urinary samples would be checked the next day, 5 days post-thrombectomy.

Another day passed without a discharge decision. The results of the full blood count, blood chemistry and electrolytes confirmed that no infection, electrolyte imbalances or other metabolic problems were present. The urine specimen had a pH of 6, a specific gravity of 1.016 and contained 1+ leucocyte; all other parameters were negative. The urine culture showed 0–5 Gram-positive cocci, but no other bacterial growth (table 1). A delirium was ruled out by the psychiatrist. The patients’ family kept insisting that they wanted her to be discharged. Six days post-thrombectomy, the patient went home on weekend leave.

Immediately after entering her own home, she left her new walking aid in her hall, asking her daughter whether she would like to have some coffee and went into her kitchen. After approximately 20 min, she entered the living room with two cups of coffee with hot milk, saying: ‘That went a lot better than during my coffee-exam’. During the weekend, she was not confused or disoriented. She was forgetful, and according to herself that had become much worse since the stroke.

Outcome and follow-up

The patient had to return to the hospital for another 2 days to enable the hospital staff to formally arrange her discharge. Both nights she was confused again, with the same hallucinations about the crying children in the cold. At daytime she was alert. On 2 January 2019, 11 days post-thrombectomy, she was officially discharged home, with pantoprazol, metoprolol and dabigatran. Home care plans, an emergency alert device and other home arrangements were not installed yet, but the patients’ daughter forced the discharge.

In the weeks after her discharge, several care professionals visited her at her home. After 3 weeks, the patients’ family cancelled all extra care because the patient experienced these additional visitors as burdensome and disconcerting. Before she was admitted to the hospital, she had home care once a week, by the same person each week. This was continued. The patient kept everything exactly as before her hospital admission, living alone with her cat in her own home.

Discussion

We presented the case of an elderly patient who underwent successful thrombectomy but suffered from night-time confusion at the hospital which resolved when discharged home.

An acute change in consciousness and orientation, also known as acute mental confusion or delirium, is a complication seen in 25%–60% of hospitalised elderly.¹¹ Stroke patients are particularly vulnerable to delirium episodes⁷ as a consequence of the direct cerebral insult¹² and the occurrence of risk factors such as cognitive, visual and functional impairments.¹³ Awareness toward patients with post-stroke delirium is required because significant more complications occur in these patients.¹⁴

Several screening instruments for the diagnostic evaluation of delirium exist,¹⁵ such as the Confusion Assessment Method¹⁶ and the Montreal Cognitive Assessment, a short cognitive test used in patients with cerebrovascular diseases.¹⁷ In the current case the DOS¹⁰ was used, a time-efficient, easy to use and reliable method for measuring and monitoring severity of delirium by nurses. A standardised screening of delirium performed three times a day is recommended to detect also short delirious episodes, especially during the night.¹⁴ Older patients with limited cognitive reserve might be more susceptible to cognitive fluctuations triggered by environmental factors, including time-of-day,¹⁸ and even short delirious episodes are associated with more complications and increased disability.¹⁴

Ageing is associated with altered circadian regulation of physiology and behaviour. Among elderly, institutionalised patients, this may result in the exacerbation of behavioural symptoms, including disorientation, confusion, agitation, restlessness, wandering and anxiety, often occurring at the end of the day, in the evening or at night. This condition, the so-called ‘sundown syndrome’,¹⁹ is associated with neuropsychiatric symptoms identical to delirium. While it can be confused with depression or dementia, it is triggered by low illumination and can affect all patients with cognitive impairment. Symptoms may worsen when shadows appear, and may also include mood changes, distrust and hallucinations.²⁰

Besides delirium and sundown syndrome, another possible diagnosis for our patient is psychosis, which results in hallucinations and/or delusions.^{21 22} Approximately 3%–10% of medical inpatients are suffering from delusional symptoms and approximately 4% are having hallucinations.^{21 22}

For our patient, no diagnosis for the night-time confusion was made and delirium was ruled out by the psychiatrist. However, the presence of an attention disorder and cognitive fluctuation are indicative of our patient having had a delirium or a delirium-like condition. Right hemisphere stroke, such as our patients’ stroke, may predispose to delirium.²³ It is possible that delirium was not recognised by the psychiatrist because of time-of-day.

The patients’ family wanted to have her discharged prematurely to test whether her confusion would resolve in her home situation. The threats to safe discharge for stroke survivors are considerable, including falls, inappropriate medicines use and psychological distress.⁹ In the general population, one in five patients experiences an adverse event in the transition from hospital to home.²⁴ For older patients, who are more likely to have complex health and social needs, and who may be anxious, confused and disoriented, the risks associated with transitions of care are greater than in the general population. This may result in a higher-than-average rate of readmission to hospital.²⁵ Hospital discharge, certainly after suffering a major life-changing event, is a complex and vulnerable phase in the patient’s journey.⁹ Recently hospitalised patients are not only recovering from their acute illness; they also experience a period of generalised risk for a range of adverse events.⁶ Physiological systems are impaired and reserves are depleted.⁶ At the same time, elderly generally prefer living in their own homes²⁶ and should be discharged from the hospital and return home as quickly as possible.²⁷

A potentially risky discharge decision should be carefully discussed with the patient and his or her family in an early stage.²⁸ However, patients feel that they are not always listened to and that they did not have ‘a lot of say’ in their care.^{29 30} Also, the older generation tends to meet their situation with an attitude of acceptance and a denigration of their own needs, which masks their vulnerability in the care-transition process.³¹ Some elderly patients do not request involvement or participation in the decision-making about discharge or transition, because ‘the doctor always knows best’. It is crucial that healthcare professionals focus on the older person’s individual needs and preferences, keeping in mind that priority is placed on maintaining one’s independence at a time when older people are most vulnerable,³² during the transition from hospital to home or a care facility. For this, involvement of the patient and his or her family using open communication and discussion is needed.²⁸

If the patient recovers to such an extent that hospital care is no longer needed, difficulties arranging a safe home environment may delay the discharge. Unfortunately, it takes time to arrange interventions such as home care, a walking aid and an emergency alert device. Therefore, the patients’ wishes and needs after hospital admission should be discussed in an early stage with the patients and their family. Moreover, improvements in the discharge process are needed. Timely interventions to enable daily life at home for stroke survivors are likely to be cost-effective when they reduce inpatient days.

Stroke survivors and stakeholders have identified home-time as a meaningful and highly prioritised outcome.^33–35 Our patient and her family could not agree more.

Concluding remarks

Possibly, the patient suffered from sundown syndrome or a delirium which was not recognised as such. Since time-of-day may affect cognitive performance of older patients after a stroke, the timing of psychiatric assessment matters.

We thank the neurologists and radiologists who treated the patient described in this case report, who is the 90-year-old mother and grandmother of three of this case study’s authors. We are grateful for the possibility of intra-arterial thrombectomy treatment at such high age. We are grateful for the loving care of all healthcare professionals involved in her hospital stay.

We believe that the planning of care transition and discharge process should be improved to reduce unnecessary and potentially harmful delays.

The patient and her family are enjoying home-time for over 2 years post-thrombectomy now. Each Saturday she spends the day at her daughter’s solving cryptograms and drinking tea.

Learning points.

• Time-of-day may affect cognitive performance of older patients after a stroke.

• Stroke patients are particularly vulnerable to delirium episodes.

• Involvement of the older patient and his or her family in the discharge process using open communication and discussion is needed.

• The planning of care transition and discharge process should be improved to reduce unnecessary and potentially harmful delays.

• Timely interventions to enable daily life at home for stroke survivors are likely to be cost-effective when they reduce inpatient days.