Often misdiagnosed as dementia, it can cause hallucinations and delusions
(This article originally appeared on KaiserHealthNews.org.)
When B. Paul Turpin was admitted to a Tennessee hospital in January
last year, the biggest concern was whether the 69-year-old
endocrinologist would survive. But as he battled a life-threatening
infection, Turpin developed terrifying hallucinations, including one in
which he was performing on a stage soaked with blood. Doctors tried to
quell his delusions with increasingly large doses of sedatives, which
only made him more disoriented.
Nearly five months later, Turpin’s infection has been routed, but his
life is upended. Delirious and too weak to go home after his hospital
discharge, he spent months in a rehab center, where he fell twice, once
hitting his head. Until recently he did not remember where he lived and
believed he had been in a car wreck. “I tell him it’s more like a train
wreck,” said his wife, Marylou Turpin.
“They kept telling me in the hospital, ‘Everybody does this,’ and
that his confusion would disappear,” she said. Instead, her once astute
husband has had great difficulty “getting past the scramble.”
Turpin’s experience illustrates the consequences of
delirium,
a sudden disruption of consciousness and cognition marked by vivid
hallucinations, delusions and an inability to focus that affects
7 million hospitalized Americans annually.
The disorder can occur at any age — it has been seen in preschoolers —
but disproportionately affects people older than 65 and is often
misdiagnosed as dementia.
While delirium and dementia can coexist, they are distinctly
different illnesses. Dementia develops gradually and worsens
progressively, while delirium occurs suddenly and typically fluctuates
during the course of a day. Some patients with delirium are agitated and
combative, while others are lethargic and inattentive.
Delirium Triggers
Patients treated in intensive care units who are heavily sedated and
on ventilators are particularly likely to become delirious; some studies
place the rate as high as 85 percent. But the condition is common among
patients recovering from surgery and in those with something as easily
treated as a urinary tract infection. Regardless of its cause, delirium
can persist for months after discharge.
They kept telling me in the hospital, ‘Everybody does this,’ and that his [my husband's] confusion would disappear.
— Marylou Turpin
Federal health authorities, who are seeking ways to reduce
hospital-acquired complications, are pondering what actions to take to
reduce the incidence of delirium, which is not among the complications
for which Medicare withholds payment or for which it penalizes
hospitals. Delirium is estimated to cost more than
$143 billion annually, mostly in longer hospital stays and follow-up care in nursing homes.
“Delirium is very underrecognized and underdiagnosed,” said
geriatrician Sharon Inouye,
a professor of medicine at Harvard Medical School. As a young doctor in
the 1980s, Inouye pioneered efforts to diagnose and prevent the
condition, which was then called “ICU psychosis.” Its underlying
physiological cause remains a mystery.
“Physicians and nurses often don’t know about it,” added Inouye, who
directs the Aging Brain Center at Hebrew SeniorLife, a Harvard affiliate
that provides elder care and conducts gerontology research. Preventing
delirium is crucial, she said, because “there still aren’t good
treatments for it once it occurs.”
Researchers estimate that about
40 percent of delirium cases are preventable.
Many cases are triggered by the care patients receive — especially
large doses of anti-anxiety drugs and narcotics to which the elderly are
sensitive — or the environments of hospitals themselves: busy, noisy,
brightly lit places where sleep is constantly disrupted and staff
changes frequently.
Recent studies have linked delirium to longer hospital stays: 21 days
for delirium patients compared with nine days for patients who don’t
develop the condition. Other research has linked delirium to a greater
risk of falls, an increased probability of developing dementia and an
accelerated death rate.
“The biggest misconceptions are that delirium is inevitable and that it doesn’t matter,” said
E. Wesley Ely,
a professor of medicine at Vanderbilt University School of Medicine who
founded its ICU Delirium and Cognitive Impairment Study Group.
Long-Term Effects
In 2013, Ely and his colleagues published a study documenting
delirium’s long-term cognitive toll.
A year after discharge, 80 percent of 821 ICU patients ages 18 to 99
scored lower on cognitive tests than their age and education would have
predicted, while nearly two-thirds had scores similar to patients with
traumatic brain injury or mild Alzheimer’s disease. Only 6 percent were
cognitively impaired before their hospitalization.
Cognitive and memory problems are not the only effects. Symptoms of
post-traumatic stress disorder are also common in people who develop
delirium. A recent meta-analysis by Johns Hopkins researchers found that
1 in 4 discharged ICU patients displayed PTSD symptoms, a rate similar
to that of combat veterans or rape victims.
David Jones, a 37-year-old legal analyst in Chicago, Ill., said that
he was entirely unprepared for persistent cognitive and psychological
problems that followed the delirium that began during his six-week
hospitalization for a life-threatening pancreatic disorder in 2012.
Terrifying flashbacks, a hallmark of PTSD, were the worst. “They
discharged me and didn’t tell me about this at all,” said Jones, whose
many hallucinations included being burned alive.
Jones’s ordeal is typical, said psychologist James C. Jackson of
Vanderbilt’s ICU Recovery Center, a multidisciplinary program that
treats patients after discharge.
Vivid Flashbacks
“They go home and don’t have the language to describe what has
happened to them,” said Jackson, adding that such incidents are often
mistaken for psychosis or dementia. “Some patients have very striking
delusional memories that are very clear distortions of what happened:
patients who were catheterized who think they were sexually assaulted
and patients undergoing MRIs convinced that they were fed into a giant
oven.”
Some hospitals are moving to prevent delirium through a more careful
use of medications, particularly tranquilizers used to treat anxiety
called
benzodiazepines,
which are known to trigger or exacerbate the problem. Others are trying
to wean ICU patients off breathing machines sooner, to limit the use of
restraints and to get patients out of bed and moving more quickly.
Still others are trying to soften the environment by shutting off lights
in patients’ rooms at night, installing large clocks and minimizing
noisy alarms.
A recent meta-analysis led by Harvard researchers found that a
variety of non-drug interventions — which included making sure patients’
sleep-wake cycles were preserved, that they had their eyeglasses and
hearing aids and that were not dehydrated — reduced delirium by 53
percent. These simple fixes had an added benefit: They cut the rate of
falls among hospitalized patients by 62 percent.
Inouye and other experts say that encouraging hospitals to recognize
and treat delirium is paramount. They have vehemently argued that
federal officials should not classify delirium as a “never” event for
which Medicare payment will be denied, fearing that would only drive the
problem further underground. (“Never” events include severe bedsores.)
Delirium “is not like pneumonia or a fracture” and lacks an obvious
physical indicator, said Malaz Boustani, an associate professor of
medicine at Indiana University. He proposes that Medicare create a
bundle payment that would pay for treatment up to six months after
delirium is detected.
Creating effective incentives is essential, said Ryan Greysen, an
assistant professor of medicine at the University of California at San
Francisco. Delirium, he said, suffers from a “pernicious know-do gap” — a
disparity between knowledge and practice. Many proven interventions, he
said, do not seem sufficiently medical. “There’s no gene therapy, no
new drug,” Greysen said. “I think we need to put this in the realm of
hospital protocol, which conveys the message that preventing and
treating delirium is just as important as giving people their meds on
time.”
Growing Awareness
Awareness that delirium is a significant problem, not a transitory
complication, is recent, an outgrowth of growing expertise in the
relatively new field of critical care medicine. The graying of the baby
boom generation, whose oldest members are turning 69, is fueling
interest in geriatrics. And many boomers are encountering delirium as
they help care for their parents who are in their 80s and older.
“In the early 1990s, we thought it was a benevolent thing to protect
people from their memories of having a tube down their throat, of being
tied down, by using large doses of drugs to paralyze and deeply sedate
patients,” Ely noted. “But by the late 1990s, I was just getting creamed
by families and patients who told me, ‘I can’t balance my checkbook, I
can’t find my car in the parking lot and I just got fired from my job.’
Their brains didn’t work anymore.”
Delirium “is now taught or at least mentioned in every medical and
nursing school in the country. That’s a huge change from a decade ago,”
said Inouye, adding that research has increased exponentially as well.
In some cases, delirium is the result of carelessness.
One woman said she was repeatedly rebuffed several years ago by
nurses at a Washington area hospital after her mother started acting
“stoned” after hip surgery. “She said things like ‘I’m having a dinner
party tonight and I’ve invited a nice young man to meet you,’ ” recalled
the daughter. She asked that her name be omitted to protect the privacy
of her mother, now 96, who lives independently in Northern Virginia and
“still has all her marbles — and then some.”
“The nurses kept telling me she was off all medication” and that her
confusion was to be expected because of her age. “It was only when I
insisted on talking to the doctor and going through her chart” that the
doctor discovered that a motion sickness patch to prevent nausea had not
been removed. “Within an hour, my mother was acting fine. It was very
scary because if she hadn’t had an advocate, she might have been sent to
a nursing home with dementia.”
Inouye, who developed the
Confusion Assessment Method, or CAM scale, now used around the world to assess
delirium, said that significant systemic obstacles to preventing delirium remain.
“We need to back up in our care of older patients so that we don’t
treat every little symptom with a pill,” she said. Sometimes, she said, a
hand rub or a conversation or a glass of herbal tea can be as effective
as an anti-anxiety drug.
Two months ago, Inouye, who is in her 50s, was hospitalized
overnight, an experience that underscored the ordeal that older,
vulnerable patients face. “I was woken out of the deepest sleep every
two hours to check my blood pressure,” she said. In addition, alarms in
her room began shrieking because a machine was malfunctioning.
“Medical care,” she added, “has evolved to be absolutely inhumane to older people.”
Hospital Elder Life Program (HELP)
In an effort to prevent or reduce delirium, Inouye created a program called HELP, short for
Hospital Elder Life Program,
currently operating in 200 hospitals around the country. While the core
of the program remains the same, each hospital implements the program
in different ways. Some enroll ICU patients, while others exclude them. A
2011 study found that HELP saved more than $7 million in one year at
UPMC Shadyside Hospital in Pittsburgh, Pa.
At Maine Medical Center in Portland, HELP is a voluntary program open
to patients older than 70 who have been in the hospital for 48 hours or
less and do not show signs of delirium. ICU and psychiatric patients
are excluded. The program relies on a cadre of 50 trained volunteers who
visit patients up to three times daily for half-hour shifts, providing
help and companionship and helping them stay oriented.
The CAM scale is built into the hospital’s electronic medical record,
said geriatrician Heidi Wierman, who oversees the program and heads a
medical team that sees patients regularly. HELP prevented delirium in 96
percent of patients seen last year, she said, adding that resistance by
doctors and nurses to the 13-year-old program has been minimal because
“we tied the incidence of falls to the prevention of delirium.”
Marylou Turpin, whose husband recently returned to their home outside
Nashville, is planning to enroll him at Vanderbilt’s ICU Recovery
Center as soon as possible. “I’m just hoping we can have some kind of
life after this,” she said.
Full Article & Source:
Delirium: A Surprising Side Effect of Hospital Stays
