I wasn’t prepared for the late-night call from the hospital. My elderly mother, who’d recently been admitted, was swearing at the nurses, demanding they call me. They put her on the line, and to my shock my normally sweet mom unleashed fury on me, speaking rapid-fire in her native Italian, saying I’d “gotten rid of” her, and refusing to listen to my reassurances. Meanwhile, the nurse who’d handed my mom the phone had left the room. My only choice was to hang up on my mother, and call the main desk to persuade the head nurse to rush to her room to calm her down.
What was going on? It took a call to my mother’s hospice physician to clue me in to the answer: Hospital-induced delirium, which is when patients (most often elderly ones) become confused, anxious, aggressive and in some cases have verbal and physical outbursts while in the hospital.
This sudden and severe change in mental status affects more than seven million hospitalized Americans each year. It’s most common in the elderly, those with preexisting mental impairments, and the terminally ill, though anyone who is hospitalized, are at risk, according to the American Delirium Society.
This hospital-linked confusion often comes on toward the end of the day, and is often called sundowning. This type of delirium may be easier to pinpoint thanks to the time of day, but other types of hospital-induced delirium can go unrecognized, or misdiagnosed, and can have devastating consequences for the short-term and long-term health of the patient. One meta-analysis of delirium in critical care settings found the chance of dying is more than double in those admitted to intensive care units who become delirious. In addition, nearly a third of ICU patients will develop this brain dysfunction, and those that do face a 30% increased risk in long-term cognitive decline.
There is some good news about early identification of patients. According to one recent study, researchers identified blood-based biomarkers associated with both delirium duration and severity in critically ill patients. This finding opens the door to easy, early identification of individuals at risk for longer delirium duration and higher delirium severity and could potentially lead to new treatments of this brain failure for which drugs have been shown to be largely ineffective, according to the study.
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Delirium Triggers
So what causes delirium in patients admitted to an ICU or hospital? It’s often triggered by a combination of the unfamiliar setting and routines of the hospital — and possible drug reactions and interactions. What’s scary is that it can mimic dementia, and bring about the use of even more meds to help “calm down” the patient. Some drugs that can either cause or exacerbate delirium:
Sedatives
While sedatives appear to help in the short term to mitigate the effects of hospital-induced delirium, in many patients, particularly the elderly, they can contribute to a snowball effect, exacerbating and/or prolonging the delirium.
James Rudolph, MD, who practices geriatrics and palliative care at the VA Boston Healthcare System (VABHS), cautions against the use of sedatives for the elderly, particularly benzodiazepines. “There’s now good evidence that these medications can lower the threshold at which patients develop delirium,” he says.
Studies have found that sedatives may produce the opposite of their desired effect, causing rather than soothing agitation, disinhibition and confusion in elderly patients, notes a 2011 National Institutes of Health report, which refers to this type of delirium as ‘sundowning’ because it often occurs in the late afternoon. According to UpToDate, an evidence-based, physician-authored online clinical resource, some classes of drugs, especially sedatives such as lorazepam (Ativan) and diazepam (Valium), can build up in the bloodstream and cause the person to become more confused.
Diuretics
Medications that work to pull excess fluid from the body and are known to have cognitive side effects. It happened to my mother. The reason I’d taken her to the ER that last time was because her feet and legs were swollen, causing pain and difficulty walking. There, she was diagnosed with congestive heart failure. Worried that fluid would begin to accumulate in her lungs, my mother was put on an IV drip of Lasix, a powerful loop diuretic. Not only was that a likely trigger for delirium (she had a change in mental status on another occasion she’d been given a diuretic), but the congestive heart failure itself is associated with impaired cognitive function. Studies show that the condition often manifests as delirium in hospitalized patients. As for my mom, once off diuretics the last time she’d taken them, her mental ability improved, but she never quite regained the total recall she once had.
Medication pile-on
It’s common for the elderly, especially, to be taking a range of different drugs, another factor in delirium. Rudolph says, the aging human body is “a variable system. No one is going to be able to tell you what’s going to happen” when an elderly patient starts taking a lot of different drugs.
To curtail the effects of overuse or misuse of medication, patients or family members should bring an active medication list or actual medications to the hospital. “With computerized medical records, we may know what medications have been prescribed, but that’s often entirely different from what the patient is actually taking,” says Rudolph.
Anticholinergic drugs
Certain categories of drugs, such as OTC antihistamines, antidepressants, and certain gastrointestinal medications, have a high risk for precipitating delirium because they have anticholinergic side effects, explains Tamara Fong, MD, PhD, cognitive neurologist and assistant professor of neurology at Harvard Medical School and assistant scientist at the Institute for Aging Research, Hebrew SeniorLife in Boston.
However, that doesn’t mean it’s a good idea to abruptly stop any medications for the elderly, including OTC medications, without talking to their doctor during and after hospitalization.. Limiting the effects of delirium during hospitalization and after discharge often involves pairing down the number of medications an elderly person takes or reducing their dosages. In my mother’s case, her hospice doctor eliminated the use of statins, and reduced her use of torsemide, the diuretic she had been prescribed.
Other Delirium Triggers
In addition to medications and drug interactions, delirium triggers include infection, dehydration, and lack of proper sleep. It occurs in hospitals and ICUs, nursing homes and rehabilitation facilities. My mother’s roommate had the TV blaring the night my mother called me accusing me of dumping her somewhere, making it difficult for her to fall or stay asleep. And the diuretics, which drained my mother of excess fluid, could also have dehydrated her.
I later asked the nurses to see if her roommate would wear earphones or lower the volume at least, so my mother could get a good night’s sleep. Getting to know the patient’s hospital team, in fact, is another recommendation by Rudolph to help prevent delirium or catch it before it does serious damage. “A hospital doesn’t necessarily know what the patient’s baseline is or isn’t, but if you tell us that a week ago your parent was managing their own care, cooking, managing their finances and now she can’t, this signifies to everyone that there’s been a pretty dramatic change. Getting a baseline from the family allows us to set a reference,” explains Rudolph.
While hospital-induced delirium isn’t unique to the elderly, they may be more vulnerable, says James Jackson, PsyD is assistant director of The ICU Recovery Center at Vanderbilt (one of the only clinics in the United States devoted to treating survivors of critical illness) and the lead psychologist for the CIBS Center at the Vanderbilt University School of Medicine.Older people, he says, may “come into the ICU or hospital already predisposed to not only develop delirium, but also to be particularly impacted by the effects of the delirium.” Something as simple as transitioning from daytime to evening—with a change of shift, a realization of how much their normal routine is disrupted by being in the hospital, or anything else that someone younger might handle better—can be the trigger for sundowning, tipping an elderly person into a cognitive decline.
Hospital-induced delirium can continue for months after the patient is discharged from the hospital. These patients are also at an increased risk of developing dementia, says E. Wesley Ely, MD, MPH, professor of medicine at Vanderbilt University School of Medicine and associate director of aging research for the VA Tennessee Valley Geriatric Research and Education Clinical Center. “A person who used to be okay can get delirium and then can look like they have had dementia for months or even years. We call that a dementia-like syndrome, or a delirium-acquired dementia. The person might need cognitive rehabilitation or an adjustment in medications.”
Ely calls hospital-induced delirium “one of the largest health problems the public doesn’t know about.” It could be, he notes, that people are being diagnosed with Alzheimer’s after an ICU stay that induced dementia-like problems, and no one (doctors or family members) connected the dots.
More than half of those with pre-existing dementia will experience delirium while hospitalized, another reason the elderly may be more at risk, says Fong. Unlike dementia, however, a mental condition that gets progressively worse, delirium is a reversible cognitive condition that can be fixed if it’s caught and treated early. Knowing what to look for makes the difference.
What Delirium Looks Like
Each patient exhibits delirium in different ways, with symptoms including confusion, agitation, difficulty concentrating or following directions, rambling speech or jumbled thoughts, hallucinations or paranoia. These symptoms come and go during the course of the day, says Fong.
Patients may also experience delusional memories, which means they misinterpret things that are actually happening around and to them, explains Jackson.
“For example, they have a catheter inserted and they think they are being assaulted or violated. Or they are being put into an MRI machine and they think they are being put in an oven.” These incidents feel very real to patients and even after they return to a normal state of mind these memories can become the basis of mental health difficulties related to anxiety. In severe forms, it can lead to post-traumatic stress disorder (PTSD).
Another feature of hospital-induced delirium in elderly patients is dis-inhibition. “They may say and do some things that would otherwise be shocking,” says Jackson, “such as making sexual references that are at odds with their personality.” Family members should be aware that their loved one doesn’t realize what they are doing or saying. “It’s really important for families to try to relate to their elderly loved ones with understanding and compassion, rather than shame or scolding,” he says.
Sundowning: A Common Form of Delirium
Many hospitals have protocols in place to prevent sundowning, a form of delirium, in the elderly. One good idea is light therapy, in which rooms are kept bright during the day, with curtains open, and are darkened at night. Reminders of the time and day can also be helpful.My mother’s room also had a clock and white boards on the wall in front of each patient’s bed that told the time of day, and the name of the nurse on duty for various shifts.
Preventing other forms of hospital-induced delirium is more complex and only now beginning to be understood and implemented. The good news is that up to 40% of delirium cases are preventable says Dr. Fong, whose colleague, Sharon Inouye, MD, director of the Aging Brain Center at the Institute of Aging Research, developed an intervention program for at-risk older adults known as HELP, the Hospitalized Elder Life Program. (Inouye also developed what’s called the Confusion Assessment Method or CAM, a widely-used means of identifying delirium). Now used in more than 200 hospitals worldwide, HELP has been successful at returning older adults to their homes following hospitalizations, says Fong. Some ways hospital settings can prevent delirium include careful use of sedatives, anesthesia and other medications that cause cognitive side effects; limiting the use of restraints; ensuring the patient gets proper nighttime sleep; and getting the patient up and moving.
Post Hospital Rehabilitation
Family members and caregivers can prevent delirium if their loved ones become hospitalized by staying with them as long as possible. During the Covid-19 pandemic this was not possible for safety reasons, but as restrictions were lifted across the country, families are able to play a larger role in helping patients reorient and recover. Try to be present when they wake up so that there’s someone familiar there,” says Rudolph. Instead of turning on the hospital TV or a radio with music, play cards or a board game, bring in albums of family photographs — anything you think might promote cognitive stimulation.
Patients should be both physically and mentally active. Make sure they get out of bed. “That’s important because we think that mobility serves as a re-orienting stimulus,” explains Rudolph, as well as a way to promote physical recovery.
“Avoid treating patients as if they are cognitively fragile for the first 3 or 4 months after they are home,” says Jackson. “Even as you are trying to mobilize them physically, you should also mobilize them cognitively—either informally, such as trying to get them to read books, play chess, have conversations via Zoom—or through formal means such as taking a computerized cognitive training program.”
A recent study done during the pandemic shows that the COVID-19 pandemic presented unprecedented new challenges to public health and medical care delivery. The study concluded that in the future, telehealth, including VR, may be available to some patients.
Some medical centers now have programs focused on helping people recover from ICU stays. Critical care recovery models can decrease the likelihood of further serious illness after discharge. Vanderbilt University has one such program, an ICU Recovery Center that offers a comprehensive online guide for families and patients. Also, many ICUs around the country are starting to implement an approach known as the ABCDEF (A2F), a step-by-step system that aims to guide healthcare professionals caring for ICU patients. The approach prompts healthcare providers to assess how much medication a patient needs, and — most importantly — prompts families to get them involved in their loved one’s care.
Most people who are experiencing the problem of hospital-induced delirium suffer a great deal, as do their families, says Ely. But “no one should accept that hospital delirium is inevitable, or accept the fact that it’s not a big deal, because it is a big deal,” says Ely.
