Blog – Why Dementia Patients Deteriorate in Hospital

In March this year we lost my grandfather. Sergeant Geoffrey Smith was a former Coldstream Guard; those are the ones with the red coats and the funny hats. Geoff was an extraordinary and very proud man. He stood tall, loved hiking in the Lakes or the Peaks and practiced the military principles of respect, discipline, and organised routines in his personal life. He took pride in his garden, counting down the days to Spring when he could go out and get planting what he wanted to grow that year. Geoff was particularly proud of his runner beans which came up every year just in time to serve with the rainbow trout he would go out to catch. He loved whisky, conversation and taught me a lot of life principals.

Lockdown hit him and my grandmother hard. We had started to suspect he may be showing signs of cognitive decline before everything shut down. Both sets of my grandparents had to shield and, while my mother’s side faired well, the isolation affected my grandpa Geoff and my grandma Olga. When things finally opened, my grandma’s physical condition meant she needed constant care. Even more worryingly, my grandpa was clearly entering into a very diagnosable phase of dementia. He is probably another of the many examples of how the isolations of repeated lockdowns accelerated cases of dementia. Stimulation can keep symptoms at bay to some degree and this was severely lacking in lockdown.

I would regularly visit them at the care home once they got settled. I could see the changes in my grandpa but he was still Geoff. We would talk freely but he would occasionally get confused. This was easy to recover by pulling out a map of the Lake District so we could talk about our favourite walking routes. His memories of those days spent hiking the fells of Borrowdale were immaculate. He would always tell me my favourite spots were “too touristy”. If there was another person within half a mile, you weren’t doing the Lakes properly.

Each time I visited I would notice he was declining but it was a slow decline. The last time I saw him as ‘still my grandpa Geoff’ was just before Christmas last year. We shared his favourite whisky and talked about all the dogs he trained back in his showing days. After that things changed very quickly and it all started when he fell in the home and had to go to hospital.

In hospital his dementia accelerated at an alarming rate. He rapidly regressed, showing signs of very advanced dementia such as confusing people for friends and family he would have known 60 years ago. His severity seemed to go from 20 to 100 in weeks and he was by no means an outlier. This is common for dementia patients. I’m sure every neurologist has had patients that rapidly declined after a hospital admission. There’s actually a clinical term for it; ‘Hospital Delirium’.

Hospital delirium is a common complication for individuals with dementia who are admitted to the hospital. The unfamiliar environment, disruption of routine, changes in medication, sleep disturbances, and increased sensory stimulation in the hospital setting can trigger or exacerbate delirium in people with dementia. Delirium is a temporary state of confusion and is different from the long-term cognitive decline associated with dementia. Hospital delirium in individuals with dementia is associated with several negative outcomes, including prolonged hospital stays, increased risk of falls, functional decline, higher healthcare costs, and increased mortality rates. Furthermore, if the patient gets an infection, their dementia can accelerate even further.

The infection can cause even more delirium, but it goes way beyond that. Infections lead to inflammation. Chronic inflammation can have detrimental effects on the brain and accelerate cognitive decline in individuals with dementia and in advanced cases like my grandfather, those infections are really hard to treat.

There are a few reasons for this but, in essence, dementia weakens the immune system, making it less efficient at fighting off infections. The body’s natural defence mechanisms are be compromised, making it harder to clear the infection. They persist and cause prolonged inflammation which can wreak havoc on the brain. Doctors can turn to antibiotics to try and treat the infection but they often have to administer high doses and these in turn have negative effects.

Some of those antibiotics carry side effects that can cause confusion. On top of that, antibiotics are designed to target and kill bacteria, including both harmful and beneficial ones. When antibiotics are administered, they can disrupt the balance of the gut microbiome by reducing the diversity and abundance of beneficial bacteria that play a role in maintaining a healthy gut environment. If you want to know more about why this is a big deal, listen to our podcast with Dr Alan Desmond.

The gut microbiome is involved in the production of certain neurotransmitters, such as serotonin and dopamine, which are essential for brain function and mental well-being. Disruption of the gut microbiota through antibiotic use could potentially affect the production and availability of these neurotransmitters, potentially impacting cognitive function. Additionally, alterations in the gut microbiome caused by antibiotics can weaken the immune system and make individuals more susceptible to infections. Infections, as mentioned earlier, can accelerate cognitive decline in dementia patients. It’s a vicious cycle where the attempts to treat an infection can increase the risk of a new one.

Furthermore, the gut microbiome has been shown to play a role in maintaining the integrity of the blood-brain barrier, which protects the brain from harmful substances. Disruption of the gut microbiome through antibiotics may compromise the blood-brain barrier, potentially allowing harmful molecules or inflammatory factors to enter the brain, further contributing to cognitive decline.

It’s a catch 22. The doctor must try and treat the infection. If they don’t, the patient will likely die. Dementia doesn’t kill people. Things like infections do because the patients body no longer knows how to fight them. This is what happened to my grandpa. He went to hospital, developed an infection (it was probably there already brewing) and entered this cycle. By the time he was discharged, he was in palliative care. A week later, we lost him.

The worsening of dementia in the hospital setting is a distressing phenomenon that many patients and their caregivers have to witness. However, healthcare providers and caregivers are becoming increasingly aware of the challenges and are actively working to address this issue. Efforts are being made to improve the hospital environment, implement specialized dementia care protocols, and enhance staff training to provide better support for individuals with dementia. Additionally, ongoing research and advancements in the field of dementia care are paving the way for more effective interventions and strategies. It is my hope that with continued dedication and progress, the experience of worsening dementia in the hospital will eventually become a thing of the past, and individuals with dementia will receive the specialized care and support they deserve to maintain their well-being and dignity.

Dr Sam Moxon

Author

Dr Sam Moxon is a Research Fellow at the University of Birmingham. His expertise falls on the interface between biology and engineering. His PhD focussed on regenerative medicine and he now works on trying to develop 3D bioprinting techniques with human stem cells, so that we better understand and treat degenerative diseases. Outside of the lab he hikes through the Lake District and is an expert on all things Disney.

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