When 86 year-old Jane was admitted to the hospital for pneumonia, the biggest concern was whether she would survive. As she fought a life-threatening infection, Jane developed terrifying hallucinations, including spiders crawling all over her bed, and seemed to be in a state of delirium about family members dying. The medical staff attempted to subdue her delusions and agitation with large doses of sedatives, which only contributed to her disorientation.

Prior to Jane’s hospitalization, she lived alone and was independent with her daily activities. She shopped, cooked, drove her car, enjoyed gardening, and playing bridge with friends. She managed her medications and finances independently and only used a cane outdoors. When Jane’s pneumonia resolved, she was too weak and confused to return home. She spent two months in a rehab center, and finally returned home with assistance due to safety concerns.

Delirium Definition and Sub-types

The definition of delirium has changed over the years and is now considered a neuropsychiatric syndrome with characteristics of disturbances in cognition and attention and perception, altered level of consciousness, periods of inattention, and disorganized thinking. The cardinal signs of delirium are its acute and sudden onset with a fluctuating nature. Often delirium is called “a change in mental status,” “sundowning,” or “ICU psychosis.” Furthermore, delirium is frequently confused with dementia, although both conditions can co-exist.

Delirium has three distinct types: 1) hyperactive phase is the most recognizable characterized by agitation, restlessness, pulling at or out lines, hitting, biting, and often requiring restraints; 2) hypoactive phase presents as depression or dementia characterized by lethargy, withdrawn, flat affect, and apathy; 3) mixed delirium exhibits signs of both hyper-and hypoactive delirium, or fluctuating between the two types.

The Prevalence of Delirium across Care Settings

Each year more than 7 million Americans will develop delirium, and with it comes higher mortality rates post discharge. Recent studies indicate that delirium is common for older persons in the hospital setting, with occurrence rates ranging from 29-64%. Other high risk settings include:

  • Postoperative: 12-51%
  • Intensive care: 19-82%
  • Nursing home: 20-56%
  • Stroke units: 27%
  • Emergency room: 8-17%
  • Palliative care: 47%

 

Predisposing and Precipitating Factors for Delirium

Several risk factors exist for developing delirium. Often a simple change to an unfamiliar environment can precipitate an episode of delirium. Several other factors have been identified in precipitating and predisposing an individual to delirium including:

  • Age
  • Gender: males
  • Vision and hearing impairments
  • Impaired nutrition
  • Brain disorders such as dementia, CVA, Parkinson’s
  • Medical illnesses: pneumonia, UTIs, sepsis
  • Surgeries/Anesthesia
  • Medications: narcotics, benzodiazepines, cholinergic drugs, antihistamines
  • Immobility/Low activity tolerance
  • Impaired ADLs
  • Low albumin levels
  • Low sodium/creatine ratio
  • Alteration in day/night orientation
  • Sleep disturbance
  • Urinary retention
  • Heavy sedation and ventilators
  • Isolation

Lack of Education/Awareness among the Health Care Team

Unfortunately, many physicians and nurses lack the education to diagnose delirium, often confusing it with dementia. Elderly patients often present with higher levels of acuity; hearing and vision, deficits, and multiple co-morbidities, thus increasing the prospect that delirium will go unrecognized. It is estimated that the detection rate for delirium among the healthcare team is an appalling 25%, and is often believed to be a normal part of the aging process.

According to geriatrician Sharon Inouye, a professor of medicine at Harvard Medical School, “delirium is very under recognized and under diagnosed.” Inouye believes that preventing delirium is critical because “there still aren’t good treatments for it once it occurs.” The underlying physiological cause of delirium once called “ICU psychosis,” remains a mystery.

Researchers estimate that approximately 40% of delirium cases are preventable. Many cases are triggered by large doses of anti-anxiety drugs and narcotics, to which the elderly are sensitive. This can also be triggered due to hospital environments which are busy, noisy, and brightly lit where sleep is constantly disrupted and staff is constantly changed. Disorientation to day/night is very common, especially in facilities where windows with natural light are sparse, or sensitivity to glare isn’t recognized and the blinds are kept down.

Residual Impairments as a Result of Delirium

In 2013, Dr. E. Wesley Ely, a professor of medicine at Vanderbilt University School of Medicine, published a study documenting delirium’s long term cognitive toll:

  • A year after discharge, 80% of 821 ICU patients ages 18-99 scored lower on cognitive tests than their age and education would have predicted
  • Two-thirds had scores similar to patients with traumatic brain injury or mild Alzheimer’s disease
  • Only 6% were cognitively impaired prior to their hospitalization

Cognitive and memory problems are not the only residual effects. Symptoms of post-traumatic stress disorder (PTSD) are also common in people who develop delirium. A recent study of ICU patients found that one in four exhibited PTSD symptoms, a rate similar to that of combat veterans or rape victims. Many patients report terrifying flashbacks, hallucinations, and delusions after discharge. Sadly, such incidents are commonly mistaken for psychosis or dementia.

The High Cost of Delirium

Federal health officials, who are seeking ways to reduce hospital-acquired complications, are pursuing actions to take to reduce the incidence of delirium. Delirium is not among the complications for which Medicare withholds payments or penalizes hospitals.

According to Malaz Boustani, an associate professor of medicine at Indiana University, “delirium is not like pneumonia or a fracture” and lacks an obvious physical sign. He suggests that Medicare create a bundle payment that would pay for treatment up to six months after delirium is detected.

Delirium results in longer hospital stays ranging from 9 to 21 days, a 63% risk of developing dementia within 48 months of becoming delirious, and a 62% increase in mortality. Delirium costs Medicare approximately $164 billion per year attributed to:

  • Hospital costs (>$11billion/year)
  • Post-hospital costs (>$153 billion/year)
  • Re-hospitalization
  • Emergency department visits
  • Rehab
  • Formal Home Care Services
  • Caregiver burden when patients are able to return home

With the aging of the world’s population, delirium is a problem that will continue to increase unless effective prevention and treatments can be found.

HELP is on the Way

After a harrowing hospital experience as a patient, Dr. Sharon Inouye created a program called HELP, known as Hospital Elder Life Program, currently in operation at 200 hospitals worldwide. The goals of HELP include the following:

  • Maintain cognitive and physical functioning of high risk older adults throughout hospitalization
  • Maximizing independence at discharge
  • Assisting with the transition from hospital to home
  • Preventing unplanned hospital readmissions

HELP encompasses a multidimensional intervention strategy. In addition, it involves a targeted interdisciplinary assessment with a structured curriculum for volunteers to deliver daily orientation, early mobilization, feeding and hydration assistance, therapeutic activities, nonpharmacologic sleep protocol and hearing/vision adaptations.

Results of HELP

The core program remains the same; however, each hospital implements the program in different ways. The success of HELP can be measured financially with significant savings in healthcare costs. A 2011 study found that HELP saved more than $7.3 million in one year for 7,000 patients. Further results include:

  • Delirium prevention with a reduction of 53%
  • Decreased length of stay at the hospital
  • Decreased nursing home placements with a savings of $9,446 per/person/year in SNFs
  • A 62% reduction in falls among hospitalized patients
  • Decreased sitter use
  • Decreased burden on caregivers/families
  • Decreased mortality

Most importantly, quality of life for patients significantly increases once they are discharged to home with the incidence of cognitive and functional decline, PTSD, hospital readmission, falls, and in-home care greatly reduced.

Awareness of Delirium is Slowly Growing in Hospitals

Some hospitals are taking efforts to prevent delirium through a more careful use of medication, especially tranquilizers used to treat anxiety which are known to exacerbate the problem. Others are attempting to wean ICU patients off ventilators sooner, reduce restraint use, and mobilize patients sooner. Others are modifying the environment by shutting off lights in patients’ rooms, installing large clocks, and minimizing noisy alarms. Inouye states, “We need to back up our care of older patients so that we don’t treat every little symptom with a pill. Sometimes a hand rub or a conversation or a glass of herbal tea can be effective as an anti-anxiety drug.”

Dr. Inouye developed a standardized assessment known the Confusion Assessment Method scale (CAM). This assessment is used world-wide allowing non-psychiatric trained clinicians to identify delirium quickly and accurately. The assessment includes behaviors such as:

  • Acute onset
  • Inattention
  • Disorganized thinking
  • Altered level of consciousness
  • Disorientation
  • Memory perceptual disturbance
  • Psychomotor agitation
  • Altered sleep-wake cycle

CAM is a vital assessment in identifying delirium during hospitalization and initiating intervention to ameliorate the devastating effects. Educating the healthcare team across all settings about the risk factors, signs/symptoms and seriousness is the first step in prevention and early intervention.

Conclusion

Six months after Jane’s discharge to home, memory impairments persist affecting her ability to remain in her home safely and independently. Her family needs to assist her with medication management, finances, shopping, and other home management tasks. Jane is no longer safe to drive since she frequently gets lost and has difficulty using a navigational system. Jane’s family is pursuing placement in an assisted living facility to provide the support she requires and improve her quality of life.

Delirium is preventable if the risk factors are identified and intervention is provided early on when patients are admitted to hospitals and nursing homes. Many of the interventions are easy to implement; modifications to the environment that promote the sleep-wake cycle, early mobilization, large clocks, calendars, reducing the noise level, and calming strategies without the use of drugs to treat anxiety.

Therapists can play a key role in educating staff and family members about the risk factors contributing to delirium, implementing environmental modifications, the importance of early mobilization, and cognitive stimulation for the prevention of delirium. Unfortunately, many of the delirium behaviors exhibited by older patients are written off as “dementia.” The quality of life and financial costs are too high to ignore any longer.

 

References

Geriatric Medicine; Detecting Delirium. Mimi Kovaleski, MSN, RN, ACNS-BC,

CCRN. Volume 10, No. 2

Hospital Elder Life Program; Why Delirium Is Important. www.hospitalelderlife program.org/for-clinicians/why-delirium-is-important

The Atlantic: The Overlooked Danger of Delirium in Hospitals. Sandra Boodman. June 7, 2015

 

Author: Mike Sperling

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