Dementia and Hospital Stays: Delirium, Discharge and Returning to the Care Home

The National Institute on Aging says it is common for people living with dementia to be hospitalized at some point in their illness, and that the change in surroundings and routine can make the stay uncomfortable. An unfamiliar place, new medicines, invasive tests and surgery may leave a person with dementia confused, anxious or agitated.

Not all hospital staff have the same knowledge of dementia, the Institute notes, so you may need to explain what works with your parent and what distresses them.

MedlinePlus, from the National Library of Medicine, describes delirium as a mental state in which a person is confused, disoriented and not able to think or remember clearly. It usually starts suddenly, and it is often temporary and treatable. Its risk factors include being in a hospital, having dementia, older age, surgery and infection.

Delirium does not always look like agitation. MedlinePlus describes a hyperactive type, in which the person is restless or agitated, a hypoactive type, in which they are inactive and seem sleepy, tired or depressed, and a mixed type.

MedlinePlus says the two conditions have similar symptoms, can be hard to tell apart, and can occur together. It sets out the differences this way:

The National Institute on Aging advises helping hospital staff understand the person's usual functioning and behavior, so they can tell dementia symptoms from signs of a more serious problem like delirium. It says to tell the doctor immediately if the person seems suddenly worse or different, and names fever, infection, medication side effects and dehydration as causes. MedlinePlus says treating the cause often leads to a full recovery, which may take weeks or sometimes months. How your parent's case is assessed and treated is for the hospital team.

The National Institute on Aging's suggestions for the stay include these:

• Tell emergency room and hospital staff that the person has dementia, and explain how to talk with them.
• Have a family member, friend or hired caregiver stay with the person as much as possible, including overnight if you can.
• Give staff a personal information sheet: normal routine, how the person likes to be addressed, likes and dislikes, behaviors and what triggers them, and nonverbal signs of pain.
• Help the person eat and drink, and encourage them to get up and move as much as is safe.
• Bring a list of medicines, insurance cards and any advance directives.
• Plan early for discharge, and ask the discharge planner about the options.

Memory care in California is provided in assisted living communities and board and care homes, licensed as residential care facilities for the elderly (RCFEs).

Title 22, section 87463 says the home's written appraisal of a resident must be updated as often as necessary to note significant changes in condition. Its examples include physical trauma such as a heart attack or stroke, changes in cognitive functions, and illness or injury that results in a significant change in the resident's health care or dietary needs. When there is such a change, the home must bring it to the attention of the appropriate medical professional, communicate with the resident and their representative, make matching changes in care and supervision, and arrange a meeting or call to share the reappraisal.

If your parent comes back with a new restricted health condition, such as oxygen, a catheter or a healing wound, section 87613 says staff caring for them must complete any additional training the physician or a designated licensed professional decides is needed. These are the things to settle before the return:

1. 1

   Find the discharge planner early

   The Alzheimer's Association suggests asking to speak to a discharge planner before or at admission. This person helps decide what kind of care is needed afterward.

2. 2

   Ask the home what it needs to see

   Ask who will review your parent's condition before the return, and which hospital records, medication lists and orders the home wants.

3. 3

   Ask whether a rehabilitation stay is being recommended

   The Alzheimer's Association notes that a short stay in a nursing home is sometimes needed for rehabilitation before a person is well enough to go back. See skilled nursing to assisted living.

4. 4

   Ask for the reappraisal meeting

   If your parent's condition has changed significantly, the regulations call for the reappraisal to be shared with you. Ask whether the care level or the monthly charge will change.

The hospital side of the process, including discharge planning rights, is in hospital discharge to assisted living.

There are things a California RCFE is not allowed to do. Under Title 22 it may not keep a resident who requires 24-hour skilled nursing or intermediate care, and section 87615 lists prohibited health conditions, among them stage 3 and 4 pressure injuries, feeding tubes and depending on others for all activities of daily living. For a condition the license does not allow, section 87637 has the Department of Social Services order relocation, with written notice and a right to ask for a review.

Short of that, a home's own view that it can no longer meet a resident's needs is handled through the eviction rules, not at the hospital door. California Advocates for Nursing Home Reform (CANHR) says an RCFE may not refuse to readmit a resident following a hospital stay. If the home believes a reason for eviction exists, it must readmit the resident until it has complied with all of the legal eviction procedures. The reason that fits this situation, in section 87224, applies when a resident is found to have a need not previously identified, a reappraisal has been done, and the home and the person who did the reappraisal believe the home is not appropriate. It requires 30 days' written notice.

The full rules, including what a notice must contain and how to contest one, are in assisted living eviction rules in California. This is a legal matter, and this page only describes the rules. CANHR advises seeking help from the Long-Term Care Ombudsman program or a legal services program.

A home may also be right that your parent now needs more than it can give. The National Institute on Aging suggests talking with the person, after a diagnosis, about the care they would want, including situations in which they may prefer hospice care to going to the hospital. See late-stage dementia and hospice in memory care.

Hamssa Benrekia is a senior living placement specialist in Torrance who works with families in the South Bay and Harbor area of Los Angeles County. She has worked with families whose relative was in a hospital or a skilled nursing facility at the time, and has coordinated with case workers and social workers during discharge. If your parent cannot go back to the same home, she can help with hospital discharge placement or memory care placement in a licensed home that fits the new care needs. She does not place people in skilled nursing facilities, contest evictions or give legal advice.

To talk through a discharge, contact Hamssa. Other topics are in the California Assisted Living Placement Guide.