Delirium Often Overlooked When Seniors Are Hospitalized

Increasing trouble navigating everything from the basement stairs to the golf course convinced Gail Richman to have the hip replacement her doctor had been recommending. The surgery went smoothly, the doctor told Gail’s son Will. But when Will arrived in the recovery room, Mom didn’t recognize him. She tried to pull out her IV, and moaned in distress. The nurse who was trying to change Mom’s dressing asked Will if Mom had Alzheimer’s disease! Will wondered—had something gone wrong during the surgery? Did Mom have brain damage? When the doctor arrived, she explained that Mom was suffering from delirium. By the next morning, Mom was tired, but pretty much back to her normal self.

There’s been a national movement to cut back on unnecessary hospitalizations in older adults, and that might be a healthy thing for more than a senior’s bank account or the Medicare bottom line. Hospitals, say experts, aren’t necessarily a healthy place for seniors! University of Michigan researchers recently reported that 25 percent of hospitalized seniors may pick up a so-called superbug—an organism that is resistant to common antibiotics. Seniors are also at high risk of falling while they’re in the hospital. Beeping monitors, pagers going off, squeaking carts in the hall, bright lights and perhaps a roommate’s TV often deprive them of nourishing sleep. Studies have found that the hospital environment can raise a patient’s blood pressure, impede healing, and lead to an often overlooked and underdiagnosed condition: hospitalization delirium.

Delirium can occur in patients of any age, but it is especially common in older adults. More than half of all hospitalized seniors will develop the problem—more than 2.5 million patients annually. More than $150 billion per year is spent on delirium-related healthcare costs, including re-hospitalization, rehabilitation and nursing home care.

Not so long ago, hospitals believed it was almost impossible to prevent delirium. But experts now say that much can be done. The U.S. Department of Health and Human Services is urging care professionals to take steps to prevent and manage delirium, and many hospitals have already put new protocols into place to lower the risk. The first step is to train personnel to recognize the signs of delirium; a research team from Indiana University School of Medicine recently found that emergency room staff, for instance, failed to recognize two-thirds of cases of delirium, and the team is working on an improved screening tool.

Meanwhile, patients and family caregivers are also urged to be aware of this often preventable complication. Here are some questions they often ask:

Q: What is delirium?

Delirium is a sudden, temporary change in brain function that causes confusion, hallucinations and memory problems. Patients with delirium may be lethargic or agitated. They may exhibit distressing personality changes, such as anger, paranoia and agitation.

Q: What causes hospital delirium?

Delirium in the hospital can be the result of sedatives and other medications, sleep deprivation due to strange surroundings, pain, excess light and noise, the effects of anesthesia, dehydration, infection, inactivity and the use of physical restraints, bladder catheters, the side effects of a patient’s underlying health problems or—most likely—a combination of these factors.

Q: Does delirium have long-term effects?

Though most patients recover from delirium after a short time, there can be serious complications. In an earlier Indiana School of Medicine study, Dr. Malaz Boustani said, “Having delirium prolongs the length of a hospital stay, increases the risk of post-hospitalization transfer to a nursing home, doubles the risk of death, and may lead to permanent brain damage." Researchers also suspect that delirium raises the risk of developing dementia, and may cause a decline in thinking skills and memory from which a patient doesn’t bounce back.

Q: Can delirium be prevented?

Dr. Sharon K. Inouye of Harvard Medical School reported that up to 40 percent of delirium episodes are preventable. She described precautionary measures that include a careful evaluation of the patient’s medications, treating infection if present, ensuring adequate oxygen levels and prompt identification of delirium when it does occur. The American Delirium Society’s Dr. James Rudolph recommended that hospitals create a less stressful healing environment that does not overload the brains of patients, and that patients receive sedative medications only when necessary. He said, “Most importantly, we need to make sure we are alert to signs of delirium and address it as soon as possible.” And a Brown University research team recently urged hospitals to bring in a geriatrics specialist when older patients are hospitalized for surgeries or for injuries such as hip fracture.

The role of family

Here are four things to keep in mind if an elderly loved one is hospitalized:

Delirium is hard to diagnose. It is often mistaken for dementia or other conditions. Dr. Boustani confirmed, "Delirium is unrecognized in 60 percent of patients who have it." Boustani cautioned healthcare providers not to overlook confusion in hospitalized senior patients, but instead to treat it as a medical emergency. Blood tests, brain imaging and improved evaluation tools can help doctors recognize the condition.

Family members may be the first to spot delirium. Chances are that hospital personnel have never met your loved one before, so they don’t know your loved one’s “normal.” They may mistake agitation or lethargy for dementia or depression. You know your loved one best, so you can serve as a valuable advocate during their hospital stay. Your presence may help keep your loved one calmer and more oriented. Report any personality or mental changes right away. They could be the first sign of delirium, and this could in turn alert healthcare providers to the presence of infection, medication side effects or other complications.

Delirium makes it difficult to follow aftercare instructions. Even after an uneventful hospital stay, absorbing a complicated set of instructions after discharge can be challenging. For a senior with even mild delirium, temporary memory loss and confusion make it unlikely they will understand or recall aftercare information. Dr. Lee Lindquist of Chicago’s Northwest Memorial Hospital said, "A helper on the day of discharge could make sure a senior understands discharge instructions and help her follow instructions safely. If a patient is by herself the day of a hospital discharge, it’s possible she won’t comprehend medical instructions, increasing medication errors and chances of re-hospitalization."

Delirium may complicate recovery. Most seniors who develop delirium return to their normal cognitive state within a few weeks of hospitalization. But delirium and its aftereffects make it more difficult for patients to comply with rehabilitation goals, manage their medications, and follow their healthcare provider’s instructions for safely resuming activities. Speak up if your loved one is having difficulties. Lindquist reminds families, "When a senior is no longer sick enough to be in the hospital, it doesn’t mean they’re 100 percent ready to be on their own. It’s a critical time and they need extra support and understanding from healthcare professionals and family." If your loved one isn’t going to a transitional care setting, such as a rehab facility, bringing in home care is a good idea if you aren’t able to be with your loved one 24/7.

Research is underway to improve the prevention, diagnosis and management of hospital delirium. Better management of this condition will be more and more important as our population ages.

Source: Assisting Hands Home Care in association with IlluminAge. Copyright © IlluminAge, 2016.