Hospital Delirium Puts the Elderly At Risk

2010-06-21 14:10

Hospitals are increasingly becoming aware of a sudden, fluctuating, and usually reversible disturbance of mental function that occurs during hospitalization, particularly in elderly patients. Physicians call the condition “hospital delirium”, and it is thought to affect about one-third of patients over the age of 70.

“A delirious patient happens almost every day,” said Dr. Manuel N. Pacheco, director of consultation and emergency services at Mount Auburn Hospital in Cambridge, Mass. “People don’t talk about it, because it’s embarrassing. They’re having sheer terror, like their worst nightmare.”

Delirium usually begins suddenly and progresses over hours or days. It is characterized by the inability to think clearly, feelings of disorientation, and fluctuations in the level of alertness. It can progress to a state that includes hallucinations and paranoia. Delirium is never normal and often indicates a serious, newly developed problem, especially in older people.

The cause of hospital delirium is unclear but there appear to be some common triggers, including dehydration or undernutrition, infections such as pneumonia, and anxiety of upcoming procedures or surgery. Patients in ICU are more susceptible to delirium because patients are isolated and the units rarely have windows and are often lit every hour of the day causing sensory deprivation. Some medications such as opioids, antihistamines, sleeping aids, and drugs used for nausea and ulcers are also associated with delirium.

Because hospital delirium is usually transient, doctors previously thought that the condition was relatively harmless. Research now indicates significant negative effects, according to Dr. Sharon Inouye, a Harvard Medical Professor who was interviewed in a recent article for the New York Times.

In the short-term, delirium extends hospital stays. Hospitalized patients who have delirium are up to 10 times more likely to develop complications. An Indiana University Center for Aging Research study found that elderly patients experiencing delirium were hospitalized six days longer. The condition also makes it much more likely for patients to be placed in either short-term rehabilitation or long-term care situations (nursing homes) after discharge from the hospital.

In the long-term, older delirium sufferers are more likely to develop dementia and approximately 35 to 40% die within a year of their episode. Delirium can contribute to death by weakening patients or leading to complications such as pneumonia or blood clots.

Hospitals are now adopting delirium-prevention programs especially for those at risk. These include schedule and environmental adjustments to help patients sleep, nursing checklists to ensure patient needs are met, and the inclusion of activities to ease anxiety.

Families of older patients can also play a role in the prevention of hospital delirium. Work with your loved one’s doctors and nurses to learn about hospital practices such as the use of restraints, medications involved in their care, and nursing activities that occur at times when you are not there, such as having appropriate sleeping conditions. Judith Graham of the Chicago Tribune also offers these ten steps for families to take to reduce the risk of delirium:

1. Bring to the hospital a complete list of all medications (with their dosages), as well as over-the-counter medicines. It may help to bring the medication bottles as well.
2. Prepare a "medical information sheet" listing all allergies, names and phone numbers of physicians, the name of the patient's usual pharmacy and all known medical conditions. Also, be sure all pertinent medical records have been forwarded to the doctors who will be caring for the patient.
3. Bring glasses, hearing aids (with fresh batteries), and dentures to the hospital. Older persons do better if they can see, hear and eat.
4. Bring in a few familiar objects from home. Things such as family photos, a favorite comforter or blanket for the bed, rosary beads, a beloved book and relaxation tapes can be quite comforting.
5. Help orient the patient throughout the day. Speak in a calm, reassuring tone of voice and tell the patient where he is and why he is there.
6. When giving instructions, state one fact or simple task at a time. Do not overwhelm or over stimulate the patient.
7. Massage can be soothing for some patients.
8. Stay with the hospitalized patient as much as possible. During an acute episode of delirium, relatives should try to arrange shifts so someone can be present around the clock.
9. If you detect new signs that could indicate delirium -- confusion, memory problems, personality changes -- it is important to discuss these with the nurses or physicians as soon as you can. Family members are often the first to notice subtle changes.
10. Find out more about delirium. The American Psychiatric Association's "Patient and Family Guide to Understanding an Identifying Delirium" is available on line at Google Books.

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