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It’s an all-too-familiar situation: an elderly patient falls and fractures his hip. He is admitted to the hospital and undergoes surgery. During the recovery period, he becomes extremely confused and refuses to work with the physical therapist. Frustrated at not being able to get out of bed, the patient grows further agitated and distraught.
And from there can begin a rapid downward spiral. Given a sedative to calm down, the patient instead becomes overly lethargic – posing the risk of still more complications, including choking and pneumonia. Ultimately, his fragile medical condition can lead to long-term disability or even death.
At the root of this “cascade of adverse events” is delirium, an acute state of confusion that often affects older individuals following surgery or serious illness. Sometimes accompanied by disorientation, paranoia and hallucinations, delirium develops in 14 to 56 percent of all hospitalized seniors, complicating hospital stays for over 2.5 million elderly individuals in the U.S. each year.
“Delirium can affect any age group, but is most often seen in older patients,” explains Beth Israel Deaconess Medical Center gerontologist Dr. Edward Marcantonio, who as the Director of Research in BIDMC’s Division of General Medicine and Primary Care, has spent nearly 20 years conducting research on this condition. “Because it is a syndrome [a cluster of symptoms] that develops as the result of an acute event, the more risk factors you have prior to the acute event, the less precipitants you need to become delirious.”
In other words, while it might take a major trauma to bring about delirium in a young person, in a more fragile older person, the threshold is likely to be much lower – even taking a sleeping pill could trigger the problem.
Among the conditions known to lead to the onset of delirium are confinement to an intensive care unit, administration of anesthesia for surgery, bladder cathetherization, use of narcotic pain medications and sleeping pills, sleep deprivation, emotional stress, and pain.
The biologic mechanisms behind delirium remain unclear, although recent advances in neuroimaging and other technologies have greatly advanced scientific efforts to understand the condition. By examining biomarkers, for example, Dr. Marcantonio and colleagues have found some evidence that a group of inflammatory proteins known as chemokines may have a role in delirium’s onset among patients who have undergone cardiac surgery.
Measures to Help the Delirious Patient
But while delirium’s biological basis remains a mystery, it is clear that the condition can be reversed – or even prevented – if proactive measures are taken while the patient is hospitalized, as several studies and efforts have demonstrated.
In the Yale Delirium Prevention Trial, a large study by Dr. Sharon Inouye, now Director of the Aging Brain Center, Institute for Aging Research at Hebrew Senior Life, a BIDMC gerontologist, and a leader in the field of delirium research, it was demonstrated that delirium can be decreased or even avoided by implementing a number of straightforward interventions during patients’ hospitalizations.
“We were able to show for the first time that delirium is a preventable medical condition,” says Dr. Inouye, whose research is currently looking at the relationship between delirium and dementia. “We found that by taking a number of basic steps — making sure that patients are oriented and hydrated, getting patients up and walking, checking that they are using their hearing aids and vision aids, and avoiding the use of sleep medications – the incidence of delirium could be reduced by fully 40 percent.”
Known as the Hospital Elder Life Program (HELP), the cost-effective strategy is now in use at hospitals nationwide.
In a study of elderly hip-fracture patients, Dr. Marcantonio found that when geriatricians were actively involved in patients’ care from the time they first entered the hospital, the incidence of delirium was reduced by more than one-third. As a result, BIDMC has formally adopted this model: Working closely with members of the orthopedic surgery team, geriatricians have primary responsibility for the medical management of hip-fracture patients.
Last year, BIDMC also unveiled the inpatient Acute Geriatric Unit. “Hospitalists are good at taking care of inpatients, but most are not formally trained to deal with the unique needs of the elderly,” explains Dr. Melissa Mattison, who as both a geriatrician and a hospitalist serves as co-director of the unit, teaching physicians to think about the unique situations of their older hospitalized patients. For example, she notes, older patients often become delirious as the result of morphine or other pain medications and, therefore, what may be an appropriate dose in a younger patient may be too much for an older patient.
The good news is that with prompt interventions, a significant portion of delirious patients can recover within a few days.
“Several weeks ago, I was called in to consult on a gentleman who had undergone surgery and was now experiencing problems,” says Dr. Marcantonio. “He was mumbling, waving his arms about, he was clearly hallucinating. It looked to me like he was developing an infection. The members of the geriatric consult team wound up recommending that he be prescribed a course of antibiotics.
“Well, when I saw him the very next day he was a different person. He was lucid, he was conversational, everything he said made sense. In many ways, this is an example of the very reason that I decided to study the problem of delirium – it’s great to be able to give someone their mind back.”
Family Members Can Play a Key Role in Patients’ Recovery
Sometimes friends and family of the delirious patient assume that because their loved one seems “out of it,” they may as well not even bother visiting because he wouldn’t know the difference anyhow. But in fact, the confused and delirious patient needs company and support even more than the non-confused patient, in that companionship can help them settle down, while conversation and sharing photos or other mementoes can help restore orientation and memory.
One of Dr. Marcantonio’s current research efforts is a study to help empower family caregivers to be active participants in the care of patients with delirium. “These patients can’t advocate for themselves. We hypothesize that the family ‘advocate’ will help reduce a patient’s risk of developing long-term ill effects as the result of the delirium.”
After identifying patients who have risk factors that could lead to the development of long-term problems, the researchers will assign a gerontological nurse practitioner to work with the caregiver for a three-month period following the patient’s discharge from the hospital. He adds that family members should understand that while delirium is not usually a permanent condition, many cognitive deficits associated with the delirium syndrome can continue after the patient has left the hospital and careful monitoring of mental status and provision of adequate functional supports during this period are crucial.
An Urgent Issue
In a study by Drs. Inouye and Marcantonio published earlier this year in the Archives of Internal Medicine, the authors found that delirium takes a serious economic toll on the health-care system. Working with an economist, they determined that the one-year incremental cost associated with delirium totaled $60,000 per person, taking into account the costs of prolonged hospitalization.
As the population rapidly ages, growing numbers of older patients are undergoing elective surgeries and greater numbers of elderly patients are finding themselves hospitalized. Furthermore, as hospital stays continue to grow shorter, it’s critically important that caregivers recognize symptoms of delirium and treat the underlying causes early — before the condition escalates and leads to long-term adverse consequences, rehabilitation and long-term care.
“One of our goals is to better understand the fundamental changes that cause delirium and determine whether they result in permanent injury to the brain, in order to better devise ways to intervene and prevent this injury,” says Dr. Inouye. “Knowing that our population is rapidly aging, this problem is only going to worsen unless we do something now.”
Adds Dr. Marcantonio, “Delirium is an interesting clinical phenomenon in its own right, but more importantly, it’s an indicator of how well we are managing frail elderly at vulnerable periods in their lives.”
Above content provided by Beth Israel Deaconess Medical Center. For advice about your medical care, consult your doctor.