A 67-year-old man saw plants growing through his ceiling. Another man was frightened by the mountain lion in his room. A third had to defuse a mine in Italy during World War II, to keep it from killing the infant Virgin Mary. An older woman feared assassins were peering into her room from nearby rooftops. Another saw long-dead relatives standing in her doorway.
All these people arrived at the hospital sick but lucid, and then slid into the terrifying state of hallucination, disorientation, forgetfulness and confusion the medical profession calls delirium.
Many more -- as many as one in three older patients -- arrive at the emergency room already lethargic, dazed, agitated or talking nonsensically in what emergency personnel call "word salad."
Everyone who works in a hospital sees delirium. It is so common that up to a third of older patients, and half of all heart surgery and hip fracture patients, will suffer from it. Despite this, for older patients and their families, like those who poured out the stories above in response to an arresting New York Times article, this dark truth about the patient experience is generally only discovered the hard way: by living through it or seeing it in a loved one.
Although the young are not exempt, delirium strikes older patients hardest. Between 15 and 50 percent of older post-operative patients, and as many as 87 percent of intensive care patients will experience delirium. While the better-known condition delirium tremens ("the DTs"), which often accompanies drug or alcohol withdrawal and gives rise to the phrase "seeing pink elephants," looks similar, hospital delirium almost always strikes people who do not drink, use drugs or who do not even seem terribly sick. Something as innocuous as a urinary tract infection or an over-the-counter drug with anti-cholinergic effects (such as a sleeping pill, an antihistamine, antidepressant, antipsychotic or anticonvulsant) can be enough to trigger delirium in a frail older person or a person with a pre-existing dementia, such as Alzheimer's disease. (Less frail people may require a more dramatic event, such as extreme pain or heart attack, to unleash delirium.)
You might expect that a condition this common and this upsetting would be easily recognized and controlled. But aside from geriatricians, for whom delirium prevention and detection is a particular mission, the rate of overlooking, misdiagnosing and mishandling delirium is sky high. Only one-fifth of doctors generally diagnose it correctly, and only half of nurses. Many consider it either inevitable, a short-term necessary evil, or both. But this is dangerously wrong.
In fact, delirium is life-threatening, according to Malaz Boustani, M.D., of the Healthy Aging Brain Center at Indiana University, president-elect of the newly formed American Delirium Society and a past recipient of the Paul B. Beeson Career Development Awards in Aging Research Program. Delirium increases a patient's risk of death while in the hospital ten-fold, and doubles the risk of death for the first 30 days after leaving the hospital. Six months later, older patients who had delirium are still seven times more likely to be dead than people with equivalent illness but no delirium.
Older patients with delirium are also three to five times more likely to get hospital-acquired complications, like infection or injury, in part because they are prone to struggling, pulling out IVs and catheters and falling while climbing out of bed, and are more than three times more likely to require nursing home placement afterward.
Beyond being heartbreaking, delirium is expensive, increasing hospital costs by 2.5 times higher per patient, and costing between $16,000 and $64,000 per year for affected patients. Overall, when long-term care, rehabilitation, caregiving and other post-hospitalization needs are considered, delirium costs run to a staggering $40 to $150 billion per year.
Worst of all, the symptoms, including hallucination, confusion and memory loss, can drag on for months, sometimes up to two years. In the worst cases, patients never fully recover. Ongoing research at Vanderbilt University Medical Center's ICU Delirium Study Group is exploring the long-term effects of delirium in critically ill patients in the intensive care unit, as well as preliminary evidence that delirium may actually cause, or make people more vulnerable to, long-term cognitive impairment, such as Alzheimer's disease or other dementias.
Even the study of delirium is a relatively young one. One of the landmark breakthroughs was that of my former student and now colleague and friend, Sharon Inouye, M.D., professor of medicine at Harvard Medical School, Director of the Aging Brain Center at Hebrew SeniorLife, and Milton and Shirley F. Levy Family Chair, and an American Federation for Aging Research (AFAR) grantee . Inouye and her colleagues observed that delirium was multifactorial; that is, it had multiple causes. Some were pre-existing problems, such as dementia, extreme old age, hearing or vision loss, or multiple chronic illnesses. (Men are also more predisposed to delirium than women.) Add to that the precipitating problems, often emerging in hospital settings, such as immobility, sleep deprivation, infection, malnutrition, dehydration, pain, multiple medications and even constipation.
While the pathophysiology of delirium remains poorly understood, Inouye led the Yale Delirium Prevention Trial to target six risk factors and address them with largely non-pharmacologic, even low-tech interventions. When applied consistently, they can prevent about one-third of delirium cases. While not perfect, this is enormously important because there is still no failsafe way of reversing or stopping delirium once it takes hold.
The delirium prevention program calls for hospital staff to help patients by:
1) Staying oriented. By providing orienting communication and keeping patients abreast of their daily schedule. Every visitor should wear a name tag and introduce her/himself. Clocks, calendars and a few familiar items from home in hospital rooms help people keep track of the day, time and place, as do discussions of the day's schedule and word games. Avoid leaving bright lights on all night, but provide enough light that patients can identify people and objects. And minimize late-night interruptions. Too many hospital patients have been awakened from a sound sleep to take their sleeping pill.
2) Improving mobility by avoiding the use of restraints and catheters wherever possible, and encouraging gentle exercise such as walking. This also helps avoid de-conditioning and constipation.
3) Improving sleep by providing a warm drink at bedtime, relaxing music, and a back rub. Minimal use of sleep medication.
4) Improving nutrition by providing feeding help, having dentures available, and, almost tragicomically, making certain patients actually receive three meals a day and have a chance to eat them.
5) Avoiding dehydration by encouraging fluids -- at least six cups of water or unsweetened fluids per day.
6) Reducing sensory impairment. Patients need to have their glasses and hearing aids on hand. Vision and hearing testing while in the hospital is appropriate.
The Inouye intervention, now called the Hospital Elder Life Program (HELP), has the best track record of any known protocol for preventing delirium, and it is remarkable, and deplorable, that more hospitals have not adopted it. For families, the message is clear: Everyone in the hospital needs an on-site advocate. Many of the interventions listed can be carried out by a family member or friend, and simple vigilance can help ensure that much of the good medicine that is embedded in this intervention actually gets carried out.
Hospital personnel should be on the lookout for delirium in all older patients, and routinely administer brief cognitive testing and the Confusion Assessment Method (CAM), also created by Inouye.
Multiple medications, especially sedating or anti-cholinergic ones, should be investigated as well, and reduced as much as possible. While many hospitals still give anti-psychotic drugs to sedate delirious patients, this is a dangerous and counterproductive practice that should be discontinued, not least because of the high rate of stroke and even death associated with these drugs in elderly patients.
Commenting on the Times story, one writer described her grandmother who spent two post-operative weeks believing that the hospital was being lifted and moved by a crane, that there were listening devices in her room and that her adult children had gathered around to kill her so she would not bother them anymore. This is tragic, dangerous, and preventable. It is essential that both the public and the health professions come to their senses and recognize that delirium is a killer.