Keeping Delirium to a Minimum in the Hospital

Delirium is a common and sometimes serious medical condition that often strikes older people during hospital stays. Though it is associated with dementia, delirium is temporary and the majority of people who get it improve in a matter of days.

Michele Bellantoni, M.D., Associate Professor of Medicine and Medical Director, Johns Hopkins Bayview Care Center, explains, "It's important to understand that unlike dementia, delirium is a temporary problem that can be treated by figuring out the cause and addressing it."

Delirium Explained

The American Geriatrics Society estimates that one third of adults over 70 who are admitted to a hospital experience delirium, and the rates are higher for older adults in intensive care and nursing homes.

Delirium is not a psychological response to physical illnesses, as once thought. In fact, new scientific evidence suggests that abnormal biological processes in the brain are at work. A study published in the Journal of Gerontology compared the brain scans of 22 hospitalized patients taken before and after episodes of delirium. In roughly half the patients, decreased blood flow was specific to key regions of the brain known to control attention and orientation, perhaps explaining the inattention and disorientation associated with delirium.

This may also help explain why delirium can be dangerous: People who become delirious spend more recovery time in the hospital, are more likely to die, and are at higher risk for developing long-term cognitive impairment and dementia.

Delirium and Dementia Linked

The connection between delirium and dementia is still not fully understood, although doctors have known for quite some time that people who experience and episode of delirium and recover are more likely to go on to develop dementia. It's possible that the decrease in blood flow to the brain described above may be a contributing factor.

Delirium may set off a cascade into Alzheimer's in people who are already at risk. And there is osme evidence that this risk may go both ways: People at higher risk for Alzheimer's may be at greater risk for delirium. Another study published in the Journal of Gerontology found that patients who had the APOE susceptibility gene for Alzheimer's were more likely to experience in-hospital delirium.

That said, because people who develop delirium tend to be older and have coexisting health problems that increase their risk of developing both dementia and delirium, it's difficult to tease out the direct role, if any, that delirium plays in dementia.

Recognize Risks

According to Dr. Bellantoni, older adults at the highest risk tend to have underlying chronic medical conditions, such as diabetes or congestive heart failure, and existing memory problems or dementia — though you don't have to have preexisiting cognitive problems to develop delirium.

The typical triggers of delirium include infection, dehydration, a change in medication, and a change in environment, most commonly during a hospital stay.

"People who come to the hospital are sick in the first place," says Dr. Bellantoni, "They are given new medications to control their illness and they are in unfamiliar surroundings. They are often immobile, sleep deprived, and not eating and drinking their usual amounts. All of this can be very disorienting for patients."

Delirium also commonly strikes after surgery, when patients are woozy from the lingering effects of anesthesia and pain medications. This poses a particular challenge. Dr. Bellantoni explains, "Pain medications often cause delirium, but studies show that uncontrolled pain is also a risk factor for delirium — so we have to strike a delicate balance in keeping the patient comfortable but lucid."

The type of surgery may play a role as well; some procedures are more risky than others. But, doctors do not rule out any type of surgery simply because a patient may be at risk for delirium. "The riskiest surgeries are long, nonelective procedures, such as repair of a hip fracture or urgent coronary bypass surgeries," say Dr. Bellantoni. "People who get these operations are under general anesthesia and usually have other comorbid conditions that make delirium more likely to occur during the recovery."

Stopping It Before It Starts

Approximately 67% of patients who develop delirium will be back to normal within 4 days, while 15% — the oldest and sickest — may remain delirious for 10 days to 1 months.

For patients known to be at risk for delirium, prior to surgery or going to the hospital, it is a good idea to speak to a geriatrician or health provider familiar with treating adults with multiple medical conditions.

A study published in The New England Journal of Medicine found that when a geriatrician helped assess at-risk patients before and after surgery and continues with daily visits and consultations with nursing staff, incidences of delirium decreased by 18% compared with care that was not overseen by a geriatrician.

There are not enough geriatricians for every elderly patient undergoing surgery, but Dr. Bellantoni says that primary care medical providers, nurses, and other hospital staff, who are all part of a patient's postoperative team, are typically on the lookout for delirium. "During morning rounds, as they are checking for fever or dressing wounds, you should expect the doctor and nurse to do a mental status check."

And, Dr. Bellantoni adds, "As soon as possible a physical thereapist should get the patient out of bed and walking to the bathroom, for instance. This helps establish the usual routine, which will minimize disorientation as well as the risk of falling."

Hospital staff should also pay steady attention to physical and medical necessities such as oxygen, pain medications, normalizing sleep, noise reduction, food, and water.

What You Can Do

Family members can help minimize or prevent delirium by making sure that a loved one is not left alone for long periods, especially when he or she is coming out of anesthesia.

"Often the patient who is waking up after surgery may not know where he or she is, which can be very frightening, so simply knowing that family is close by is a major consolation," says Dr. Bellantoni.

You may want to arrange to stay overnight at the hospital — this way someone who knows how the patient normally acts can quickly alert hospital staff to any changes in behavior, particularly during the crucial days after surgery. "Family members know the patient best, so they can keep doctors and nurses posted if a loved one's behavior becomes uncharacteristic. It's a huge help if someone says, 'You know, this isn't my mother's normal behavior.'"

Family can also help patients maintain, or regain, mental orientation by reminding the patient they are in the hospital, periodically mentioning the time and date, and providing basic comfort and reassurance.

"It helps to tell someone why they may be feeling so disoriented," Dr. Bellantoni adds. "You might say something such as, 'Mom you have just had knee surgery and you are taking some new medicines that are affecting the way you think, but you are okay and you are going to get better."

Making sure that the hospital room is well lit and that curtains are regularly drawn during the day can help patients maintain a sense of time and get back to a regular schedule of sleeping at night and staying awake during the day.

Family members also can make sure that eyeglasses and hearing aids are worn. And familiar objects from home such as a favorite sweater, blanket, pillow, books, or family photos can also help patients maintain orientation and awareness while they are in the hospital.