The patient who is not “sleeping”

I was woken up by a phone call from the night duty doctor at 3 am. “Sir, the patient in room 832 is restless. The bystander says that he is constantly muttering and not letting him sleep”. Frustrated at having been called at this unearthly hour for such a frivolous complaint, I asked him to try and talk to the family, before resorting to administering him any medicine. After all, this was discussed this morning with the 92-year-old patient’s son. This acute confusion –‘Delirium’ was common in hospital settings and the fluctuating course of alertness was characteristic. The patient had not had a bowel movement for the last few days and that seemed to be the trigger, but that was yesterday.

An hour later, I was disturbed again by another phone call. “Sir, the attender is very restless. He says the patient is not sleeping even after the injection that was given.” Half asleep, I was not in any mood to try and counsel and explain to him the nuances of geriatric practice. I was ready to reproach him to call on me for this when he mentioned “He is also a bit breathless”. I was now fully awake. Realizing this was probably a worsening of his heart condition, the registrar was called in and swift measures were taken to stabilize him.

The next morning, the irate son explained how all measures simply were not helping and his father hadn’t slept for the past few nights. Before I could try and explain what actually was happening, he broke down and cried like a child. It was my turn to feel sorry.

Although delirium- an acute disturbance of attention and sensorium is common in older hospitalized patients, precipitants must be carefully looked for. Older patients, especially those with underlying dementia may not be able to express themselves and may appear agitated or restless, disturbing the caregivers, who may think a sleep medicine may be best. Constipation, pain, hunger, a full bladder, or breathlessness are common precipitants. While the agitation needs to be addressed, it is prudent to look for a correctable cause, before brushing it off as an “irritable patient” or “age-related problem”.