Delirium In Hospitalization Finally Gets Attention

By Ricahard A Knox, The Boston Globe

When Dr. Sharon K. Inouye's 73-year-old father underwent surgery last year, she found herself helpless to stop doctors and nurses from inadvertently doing what she knew were the wrong things.

``They gave him all these medications we know can lead to delirium,'' recalls Inouye, who studies the mental disturbance. ``They left the urinary catheter in too long. They didn't get him out of bed. And there I was, an expert on delirium, sitting at his bedside, and I couldn't prevent it from happening. He had about 12 different doctors, and I couldn't get to all of them every day.''

Sure enough, the elder Inouye, a physician himself, developed a severe case of delirium, becoming agitated, not recognizing his family, and fighting against caregivers.

Inouye, a Yale University geriatrician, is perhaps the leading authority on delirium among elders.

Although the disturbance can result in confusion, disordered speech, and hallucinations in people of any age (it can be a reaction to alcohol withdrawal), delirium in older, hospitalized patients is often triggered by a number of surprising factors. These include common illnesses -- even urinary tract or other infections -- and a wide range of medications including over-the-counter cold remedies and prescription sleeping pills. Perhaps even more surprising is that one in three hospitalized elders suffer from delirium at some point during their stay.

From Inouye's research, she knows that elders who develop a bout of delirium have higher mortality rates, experience longer convalescence (if, indeed, they ever fully recover), are far more likely to end up in a nursing home, and generally impose far more burdens on families and the health care system. Such patients account for more than $4 billion in additional Medicare costs each year.

Her father's experience has galvanized Inouye to bring delirium to the forefront of awareness among elders -- who occupy almost half of all hospital beds -- their caregivers, families, and health care institutions. ``It just made me realize that our whole health care system is failing older people,'' Inouye says.

But drastically reducing the incidence of delirium is an achievable goal. Inouye and her colleagues at Yale recently reported in the New England Journal of Medicine that delirium can be cut by 40 percent through a series of simple environmental interventions _ including such things as warm milk and backrubs to reduce the need for sleeping pills, which can trigger delirium, and gentle but persistent ``orienting'' so patients literally know where they are in time and space.

The experiment involved 852 patients between the ages of 70 and 97 randomly assigned to ``usual care'' or targeted, but low-tech, interventions. The usual-care patients had 64 new episodes of delirium, while the others had 42 episodes. (The study participants had about half the usual delirium rate as other hospitalized elders because it excluded those who had delirium or any degree of cognitive impairment upon admission.)

The patients who got special treatment also had more cognitive improvement, required significantly fewer sleeping pills, and had improved mobility.

In addition to the backrubs and warm milk, the Yale researchers made sure patients had their eyeglasses and hearing aids, and ingested enough food and liquids to prevent dehydration and muscle atrophy. Several times a day, trained volunteers read the newspaper to patients, took them on walks, played word games, and showed them ``reminiscence'' cards of familiar scenes and situations to jog their memories.

Inouye's delirium-reducing measures are so effective that Yale-New Haven Hospital has adopted them as routine for elderly patients _ apparently the only hospital to make such a concerted effort to avoid delirium. The interventions cost $327 per patient, but a preliminary analysis shows that the program has saved the hospital money by preventing delirium.

``For many caregivers, delirium is just a routine expectation,'' says Dr. Edward R. Marcantonio of the Hebrew Rehabilitation Center for the Aged in Boston. ``For the elderly patient who is very ill or has undergone surgery, they sort of expect them to go bonkers or have hallucinations. We try to educate the staff that delirium is not a normal thing. It should be diagnosed, and it should trigger therapy.''

The first order of business is to foster understanding of what delirium is -- and what it's not.

It is completely different from Alzheimer's disease or other types of dementia, disorders that also affect memory and thinking ability. Although elders who already have some degree of dementia are at greater risk for delirium if they become ill or undergo surgery, dementia is a very gradual, slow-onset loss of cognitive abilities.

The hallmark of delirium, by contrast, is its suddenness. ``It's a sudden change in the ability to think,'' says Dr. Jonathan M. Flacker, another Hebrew Rehab researcher. ``Delirium can also fluctuate over minutes to hours, which distinguishes it from dementia.''

Mental confusion has been recognized as a manifestation of physical illness for at least two millennia. The first-century Roman encyclopedist, Aulius Cornelius Celsus, noted that sick people sometimes ``lose their judgment and talk incoherently. . . When the violence of the fit is abated, the judgment presently returns.''

Despite this antiquity, delirium wasn't listed as a diagnosis in psychiatry's bible, the Diagnostic and Statistical Manual (DSM), until 1980. That partly accounts for its lack of attention as a subject of medical training and research.

As any third-year medical student soon learns, delirium can be disturbingly dramatic, with paranoia, extreme agitation, and hallucinations. These prototypical delirium cases are ``impossible for nurses to take care of,'' Flacker notes.

``A nurse will put in an IV or urinary catheter and they will rip it out,'' he continues. ``They'll pick at the bedsheets and clothing. They often won't recognize family and friends. They'll strip naked in the hallway. They're almost invariably incontinent. They'll fight the nurses when they try to give routine care. They often end up in restraints, which makes their delirium worse.''

Needless to say, such hospital dramas are nightmares for the patient's family and friends. To them it's obvious that something's terribly wrong. But delirium researchers say doctors and nurses too often don't recognize it, don't explain it, or they say, ``It's normal.''

``Patients often aren't aware what's happening to them, but families can get very, very distressed,'' Inouye says. ``Patients either don't recognize their family, or they sayfthings like, `Why did you put me in here? They're experimenting on me!' '' However, patients suffering such florid delirium may actually be in the minority. As many as two-thirds of cases, Marcantonio estimates, are a ``quiet delirium,'' a subtle ``ou it'' confusion, noticeable only to close family members.

``Quiet delirium may have a worse prognosis because no one picks it up,'' says Dr. Terry Rabinowitz, a psychiatrist at Fletcher Allen Health Care, the University of Vermont teaching hospital in Burlington. ``The agitated patient may strike out at someone, try to leave the hospital, or do something goofy that brings attention. The subtle cases just sit in bed, quietly confused.''

What causes delirium? Rabinowitz lists what he calls the top three causes: ``Drugs, drugs, and drugs.''

Anesthesia is often thought to be the culprit by health professionals and laypeople alike. But ``anesthesia is only one small part of it,'' says Inouye, and there is some controversy about whether general anesthesia is more likely to precipitate delirium than local anesthesia combined with sedatives.

The trauma of surgery itself, apart from anesthesia, is a major risk factor for delirium, although no one understands exactly why. About half of all hip fracture patients suffer delirium, but hip replacement carries a lower risk, probably because the procedure is elective and involves younger and healthier patients.

A wide range of medications can touch off serious mental confusion in elders. That includes sleeping pills -- which is why the Yale group goes to great lengths to minimize their use. Pain medication is also a culprit, but so is untreated pain, raising a difficult ``tightrope'' issue of under-treatment versus over-treatment of pain. Walking the line involves attention to medication type, dose, timing, and interaction with other drugs.

``I'm taking care of a lovely, lovely 90-year-old lady who came in with arthritis and supposed dementia,'' Flacker says. ``But her `dementia' was really delirium, caused by 5 milligrams of Valium three times a day. After we got her off all that medicine, she's sharper than I am.''

It makes intuitive sense that sleeping pills and pain relievers could induce confusion. Less obvious is the fact that delirium often can be traced to other common drugs, such as the allergy drug Benadryl, antihistamine-containing cold remedies, and stomach acid-blockers such as Pepcid, available now over the counter.

The reason, researchers are finding, is that delirium results from an imbalance in neurotransmitters, the chemicals that transmit signals from one nerve cell to another in the brain. Delirium can result from too much or too little of a number of neurotransmitters, such as acetylcholine, dopamine, and serotonin. Many drugs alter one or another of these brain chemicals.

But the list of delirium-inducers doesn't end with medication. Infection of any kind is one of the most common causes, and delirium can be the only sign of the underlying physical illness.

Flacker tells of a call he got from a woman whose elderly husband had locked himself in the bathroom, convinced people were out to kill him. ``I said, `You've got to bring him in,' and called the ambulance,'' he says. ``Lo and behold, he had pneumonia.'' Others say the first thing to do in diagnosing an elderly nursing home patient with delirium is to check her urine for signs of infection.

Once delirium occurs, it's not entirely clear how to treat it, beyond identifying the likely causes and doing everything possible to remove them. The interventions in the Yale study didn't seem to reduce the severity of delirium episodes, but the Yale study was aimed at prevention, not treatment. Inouye and others are just beginning to study treatment measures.

In any case, it's clear that doctors and nurses are only part of the delirium problem. Those who know the patient best are crucial in flagging the sudden change in mental status and behavior that marks delirium.

``Families need to know they should report these problems and be adamant that they should be followed up,'' says Katharine M. Murphy, a Hebrew Rehab researcher who had to cope with serious, infection-related delirium in her 70-year-old mother, Rosemary Murphy of Needham, Mass.

It took a long time, but the elder Murphy is back to her pre-delirious state of good health. ``I had dealt with delirium a lot as a geriatric nurse-practitioner,'' Murphy said. ``But when it's someone close to you, it's a much more emotional and frightening experience.''