Update on Delirium and Dementia Lecture for Medical Students

This is just an update to the lecture I give to medical students about delirium and dementia. Every time I give the talk, I think of some way to improve it while I’m presenting.

By the way, I always tell medical students that I generally let them perform the bedside screen for delirium. This is just to demonstrate that you don’t always need a psychiatrist to detect delirium.

I sometimes tell the medical students about my little episode of delirium, just to show it can happen to anybody. It was my 50th birthday present, which is to say it was a colonoscopy. I got Demerol and Versed as premedication–and I don’t remember much after that.

My wife tells me that I had a tendency to slide down in the cart, so much so she had to keep dragging me back up from the foot of the bed. I kept mumbling something over and over again about how important it was for me to avoid taking nonsteroidals or some nonsense like that. That was probably more of an emergent delirium, which I’ve often seen in the outpatient surgery recovery bays. But I can tell you it doesn’t look any different than an acute delirium anywhere else in the hospital.

sleep deprivedIt’s hard to tell sometimes whether the medical students are getting the message, although I suspect most of them do. One or two always seem to have a real hard time keeping their eyes open though, no matter how hard I clown and act up to make the talk interesting.

When I gave the lecture a couple of days ago, I told them about the black floor mat effect on patients with dementia in nursing home (Ellison, J. M., MD, and D. Hsu, MD (2014) A Dark Side of Dementia Care. Psychiatric Times, http://www.psychiatrictimes.com/login?referrer=http%3A//www.psychiatrictimes.com%2Fdark-side-dementia-care). This was a new one on me. It’s free to register on the Psychiatric Times website and I think you might enjoy the story. It’s about using black floor mats to scare demented nursing home residents away from doors to the outside.

According to the authors:

Demented patients’ avoidance of dark mats, tiles, or even lines on the floor has long been observed—and sometimes exploited clinically—although we could not locate any studies of the effectiveness and safety of this maneuver. Patients avoid the dark mat because they visually misinterpret the blackness as a drop-off, the socalled visual cliff. Experimental observations of behaviors associated with the visual cliff in infants and in animals shed light on how we might understand the experience of a demented person faced with an unexpected chasm where floor had been expected. – See more at: http://www.psychiatrictimes.com/dementia/dark-side-dementia-care#sthash.Rp9XEUhB.dpuf

Cognitively impaired older adults are not infants or animals, of course, but in some respects their cognitive functions have retrogressed to a stage in which analytic thinking is more limited and catastrophic reactions are more likely than with cognitively intact adults. That persons with dementia might react fearfully to a visual cliff should not surprise us, when we think about the subjective experience of a disoriented person who may also have gait and balance problems and difficulty with visual contrast and interpretation. Many of our cognitively impaired patients also have had terrifying experiences with previous falls. Phobic anxiety, with or without insight, may remain as an emotional response – See more at: http://www.psychiatrictimes.com/dementia/dark-side-dementia-care#sthash.Rp9XEUhB.dpuf

Some of the comments on the article were interesting. Here’s a couple to think about:

Therapeutic lies, when used gently and with a care for the patient in mind, are beneficial. But nursing home should be as safe place as possible for the residents. Black floor mats are in the same category as barbed wire or electric fence. I don´t think any of us would like to live in a house where you can fall from a cliff, get cut or electrocuted. Locked door, I think, is much more humane. It does the same job but doesn’t evoke fear. – See more at: http://www.psychiatrictimes.com/dementia/dark-side-dementia-care#sthash.Rp9XEUhB.dpuf

This article seems like somebody had to say SOMETHING, rather than having something to say. The goal is to keep people safe. When my children were little, I used to point out the flattened road-kill when we walked. I would say that is what happened when children walk across the street not holding a grown-up’s hand. Having had a demented grandparent wander out of a nursing home, the risks of black mats are clearly lower than the benefits. – See more at: http://www.psychiatrictimes.com/dementia/dark-side-dementia-care#sthash.Rp9XEUhB.dpuf

What do you think?

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Author: Jim Amos

Dr. James J. Amos is Clinical Professor of Psychiatry in the UI Carver College of Medicine at The University of Iowa in Iowa City, Iowa. Dr. Amos received a B. S. degree in Distributed Studies (Zoology, Chemistry, and Microbiology) in 1985 from Iowa State University and an M.D. from The University of Iowa in Iowa City, Iowa in 1992. He completed his psychiatry residency, including a year as Chief Resident, in 1996 at the Department of Psychiatry at The University of Iowa. He has co-edited a practical book about consultation psychiatry with Dr. Robert G. Robinson entitled Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry. As a clinician educator, among Dr. Amos’s most treasured achievements is the Leonard Tow Humanism in Medicine Award.