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 7 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, even children, are at risk, according to the American Delirium Society.
Because this hospital-linked confusion often comes on toward the end of the day, some call it sundowning, and while it may be easier to pinpoint thanks to the time of day, other 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 recent meta-analysis of delirium in critical care settings — a review of all studies on the subject — 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.
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:
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, interim chief of 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. 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.
Drugs 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.
It’s common for the elderly, especially, to be taking a range of different drugs, another factor in delirium. Says Dr. Rudolph, who is also a board member of the American Delirium Society, 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 Dr. Rudolph. Doctors would want to avoid, to use one example, giving a patient an antidepressant he or she had been previously prescribed, but never took, that may then potentially trigger delirium.
Certain categories of drugs, such as OTC antihistamines, antidepressants, and certain gastrointestinal medications, have a high risk for precipitating delirium because they have anticholingeric side effects, explains Tamara Fong, MD, PhD, staff physician in neurology at Beth Israel Deaconess Medical Center in Boston, and an assistant scientist at the Aging Brain Center, Institute for Aging Research. A study recently published in the Journal of the American Medical Association found that taking even the minimum dose of these meds over a long time triggered delirium in older adults.
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. 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 can also be triggered by infection, dehydration, and lack of proper sleep. It occurs in hospitals and ICUs, but also in nursing homes and rehabilitation facilities.
My mother’s roommate had been blaring the TV 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 Dr. 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 Dr. Rudolph.
While hospital-induced delirium isn’t unique to the elderly, they may be more vulnerable, says James Jackson, PsyD, assistant professor of medicine in the Division of Allergy, Pulmonary, and Critical Care Medicine and the Center for Health Services Research 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.”
He 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 Dr. 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
Different patients exhibit delirium in different ways, with symptoms including confusion, agitation, difficulty concentrating or following directions, rambling speech or jumbled thoughts, hallucinations or paranoia, symptoms which come and go during the course of the day, says Dr. Fong.
Worse, patients may experience delusional memories, which means they misinterpret things that are actually happening around and to them, explains Dr. 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 incidences feel very real to patients even after they return to a normal state of mind, says Dr. Jackson, noting that 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 Dr. Jackson, “such as making sexual references that are at odds with their personality.” But family members should be aware that their loved one doesn’t realize what he or she is 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.
Fixing the Problem
Many hospitals have protocols in place to prevent sundowning 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 are also a good idea. My mother’s room 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. (Dr. 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 Dr. 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 as soon as possible.
One way family members and caregivers can prevent delirium if their loved ones becomes hospitalized is to stay with them as long as possible. “The family’s role is to be an orienting stimulus. Try to be present when they wake up so that there’s someone familiar there,” says Dr. Rudolph. And instead of sitting quietly with your elderly loved ones, or just turning on the hospital TV or a radio with favorite music, play cards or a board game, bring in albums of family photographs — anything you think might promote cognitive stimulation.
Another thing to do: Make sure they get out of bed. “That’s important because we think that mobility serves as a re-orienting stimulus,” explains Dr. Rudolph, as well as a way to promote physical recovery.
Patients should be both physically and mentally active. This year’s Alzheimer’s Association Conference presented 3 new studies that found physical exercise could be an effective treatment for improving the symptoms of Alzheimer’s and other dementia. “The wrong stance is to treat these patients as if they are cognitively fragile for the first 3 or 4 months after they are home,” says Dr. 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, or formally, such as taking a computerized cognitive training program.”
For those with a classic brain injury, such as from an accident or stroke, cognitive rehabilitation gets prescribed automatically, usually through a rehabilitation facility. Those with cognitive impairment caused by delirium face a tougher time getting the rehabilitative services they need, again, because the delirium often gets undiagnosed or misdiagnosed. Experts recommend elderly patients see a specialist, such as a geriatrician or a cognitive rehabilitation specialist, to coordinate their care.
A very few hospitals and medical centers have programs focused on helping people recover from ICU stays, and a study by Indiana University found that such 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 Bundle, 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 them to get family 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 Dr. 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 Dr. Ely.