Delirium Complicates Recovery for Senior Patients
Laura Ayers suffered a torn rotator cuff. Her doctor recommended that the 80-year-old undergo shoulder surgery right away. Arriving at the hospital, Laura was her usual self, joking with her daughter and the healthcare team. But after the surgery, she didn't recognize the family, her speech was incoherent, and she fought the nurses as they changed her dressing. Laura's daughter was terribly concerned. Had Mom suffered brain damage during the surgery? Then a nurse asked, "Is your mother usually disoriented?" "No!" said Laura's daughter. The nurse explained that Laura was experiencing delirium.
With today's increased emphasis on controlling healthcare costs, a common complication of medical procedures is receiving increased attention. Physicians have long wondered about the mysteries of hospitalization delirium—a temporary state of confusion that sometimes occurs after surgery or a serious illness.
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. Patients and family caregivers are also urged to be aware of this often preventable complication.
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.
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.
Does delirium have long-term effects?
Though most patients recover from delirium after a short time, there can be serious complications. Dr. Malaz Boustani of the Indiana School of Medicine says, “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.
Can delirium be prevented?
Dr. Sharon K. Inouye of Harvard Medical School reports that up to 40 percent of delirium episodes are preventable. She describes 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 recommends 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 says, “Most importantly, we need to make sure we are alert to signs of delirium and address it as soon as possible.”
What should family caregivers know?
Here are things to keep in mind if an elderly loved one is hospitalized:
Delirium is hard to diagnose. It may be mistaken for dementia or other conditions. Dr. Boustani confirms, "Delirium is unrecognized in 60 percent of patients who have it." Boustani, who is president-elect of the American Delirium Society, cautions 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 best judge. You know your loved one best, and you can serve as a valuable advocate during your loved one's hospitalization. Your presence may help keep your loved one calm and 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 says, "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."
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.
Vanderbilt University's ICU Delirium.org offers resources and information for professionals, patients and families.
Dr. Sharon Inouye and her colleagues in the Hospital Elder Life Program (HELP) offer "Ten Tips to Avoid Confusion in the Hospital" and other resources for seniors and family caregivers.
Read "Avoiding Re-Hospitalization with In-Home Care" to learn about the role home care plays in successful recovery.
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