Delirium Is On the Rise in Health-Care Settings

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.