It sounds like something from a scary movie. An elderly person
goes into the hospital for routine surgery or other treatment and
suddenly is unable to recognize his wife of 30 years... is
convinced that ants are crawling all over his bed... and becomes
agitated, even violent.
This is delirium, and it’s a horrible experience not only for
those who go through it but also for their loved ones who witness
it. It doesn’t happen only to hospital patients, but the problem
arises much more frequently in hospitals than when people are in
their own homes, and for reasons that -- upon analysis -- make
perfect sense.
WHO’S AT RISK?
Delirium can affect people of all ages and for a variety of
reasons, including fever, alcohol withdrawal, extreme stress,
dehydration, malnourishment, sepsis and, perhaps most commonly, a
reaction to anesthesia -- particularly a problem among the elderly.
Delirium is defined as a sharp and sudden, usually transient,
change in mental status, unlike dementia, which comes on gradually.
It is characterized by an inability to pay attention...
disorientation... confusion... and fluctuations in consciousness.
Some patients recover from delirium within hours or days, but it
affects others for much longer stretches -- and the sad truth is
that research shows quite clearly that having a bout with delirium
puts elderly patients at increased risk for dementia, for
institutionalization and for death within one year.
To learn how to help patients avoid or reduce risk for
delirium, I called geriatrician James Rudolph, MD, from Brigham and
Women’s Hospital, the Veteran’s Administration Boston Healthcare
System and Harvard Medical School.
DELIRIUM DANGER ZONE
People who have cognitive impairment (even mild) are more
likely to develop delirium than those who have diabetes, heart
disease or cancer.
Just being in the hospital elevates delirium risk -- many
patients are given medications, such as sedatives and painkillers,
that can trigger delirium... the hustle and bustle of the hospital
environment can be overstimulating... being isolated in a room
without windows, a clock or a calendar (such as in the ICU) can
contribute. And sleep deprivation, common in hospital patients, is
another major cause. Because many elderly patients undergoing
intensive treatment or monitoring are unable to wear their glasses
or use their hearing aids while in the hospital, they end up
experiencing what Dr. Rudolph calls a "sensory deficit" that makes
it easier to lose touch with reality.
Another factor: All day long, hospital staff
members continuously and wordlessly enter and leave patients’
rooms. "There might be 30 people a day coming in, and it can
overwhelm patients who may already be confused about where they
are," says Dr. Rudolph.
WHAT CAN BE DONE?
Dr. Rudolph and other researchers are working to help
hospitals recognize and treat delirium quickly (important because
prolonged delirium can cause a precipitous decline in a patient’s
mental status) and also to develop policies to reduce the
likelihood that patients will experience delirium. Some helpful
measures include...
- Assessing patients for
cognitive function when they’re admitted. If
health-care providers are aware that a particular patient has
cognitive deficits, they can adapt accordingly. For instance,
patients with cognitive deficits won’t be given medications (such
as sedatives) that would exacerbate the problem, and staffers can
be trained to deliver information in a way that helps an impaired
patient to process it better.
- Minimize or periodically
remove intravenous (IV) lines and catheters. Delirium
is less likely to set in if patients can move around freely --
they’re less likely to feel trapped, which leads to fear and
agitation.
- Communicating directly with
hospital patients. Simple courtesies make a
difference. "We are encouraging staff to introduce themselves when
they enter patients’ rooms and to briefly explain why they are
there, which goes a long way to reduce a patient’s confusion," says
Dr. Rudolph.
- Providing a better sleep
environment. Not all patients require nighttime
monitoring of vital signs... sound can be lowered and lights can be
dimmed... staff can be reminded to speak quietly in the
halls.
- Keeping additional reading
glasses, hearing amplifiers and false teeth at
hand. Once patients can see and hear more clearly and
feel more like themselves, disorientation ebbs.
WHAT FAMILY MEMBERS CAN DO
Last but not least, Dr. Rudolph stresses that family members
can and should step in to protect and support patients who might be
vulnerable to delirium. Try to be with the patient as much as
possible so you can identify who is entering the room and why he or
she is there. It’s also helpful to gently but persistently remind
your loved one where he/she is and why.
Keeping patients engaged helps, too. Dr. Rudolph suggests
keeping a clock, calendar and family photos in the room and also
chatting, playing cards and perhaps reading the newspaper
together.
This type of loving, supportive presence is especially
important in the evening, when patients become more easily
disoriented and more apt to move into delirium. Anyone who has
cared for someone with advanced dementia will know this effect --
it’s called "sundowning." But whatever the time of day, having
family members there to hold patients’ hands and gently prod their
attention back to the present reality can become an invaluable
gift.