Tag Archives: Lasix

Feeling Anxious? Depressed? Check Your Meds

If you find yourself feeling on edge for no apparent reason while taking a cold medicine or diuretic, you most likely wouldn’t connect the two. However, anxiety happens to be just one of many mood-altering symptoms that can be brought on by certain meds.

“Many medications, whether prescribed or found over the counter, can cause psychiatric symptoms,” says Shiyun Kim, PharmD, BCACP, BCPP, CDE, a clinical pharmacist and clinical assistant professor at the University of Illinois Hospital & Health Sciences System, and a spokesperson for the American Pharmacists Association.

She explains that a wide range of factors influence the way a drug affects each person, including things like metabolism, underlying illness, and interactions with other drugs. “Any variations that occur, such as with improper doses or individual reactions, can result in undesirable psychiatric symptoms,” though they are relatively uncommon.

If you feel that you may be suffering from these side effects, notify your providers immediately. “Keep in mind that some medications can be stopped abruptly, while others need to be tapered to prevent further adverse effects,” Dr. Kim emphasizes. “Your provider can make the best decision with you.”

Take note of the following medications that can have these kinds of effects, and read on to find out how to minimize the risks.

Oxycontin and Similar Pain Medications

“Most prescription pain medication, such as oxycodone (OxyContin) or hydrocodone, can cause drowsiness, which can make one feel ‘cloudy’ and lack motivation — and these symptoms closely mimic depression,” according to Bree Meinzer, PharmD, CTTS, a pharmacy practice resident at Ohio Northern University. Opioids can also lead to more severe symptoms like paranoia, hallucinations, psychosis and dementia, especially at high doses. Signs that you may have taken too much of an opioid include trouble breathing and unconsciousness. People with opioid dependence and those who suffer from HIV, liver or lung disease or suffer from depression may be more susceptible to these effects, according to the World Health Organization. If you are on a pain medication that makes you drowsy or “cloudy” and you do not like how it makes you feel, you should talk to your doctor about other ways to adequately manage your pain.

Lasix, Microzide and Other Diuretics

Medications that reduce fluid retention and swelling, including furosemide (Lasix) and hydrochlorothiazide (Microzide), increase urination. This can lead to dehydration, especially in the elderly, and can result in hallucinations and dizziness, says Dr. Meinzer. SGLT2 inhibitors such as canagliflozin (Invokana) and empagliflozin (Jardiance), which are drugs used to treat diabetes, can also increase urination and cause dehydration. If you are taking these types of medication, be sure to drink plenty of water to stay sufficiently hydrated. The amount of water to drink should be discussed with your doctor and is dependent on your weight. “These medications should also be taken in the morning or early afternoon to avoid frequent urination at night,” which could disrupt sleep, she advises.

Ask your doctor to take a look at your current medication regimen to rule out potential drug-drug interactions that could cause psychiatric side effects.

Requip and Other Dopamine Agonists. Medications like ropinirole (Requip), often prescribed for restless leg syndrome and Parkinson’s disease, increase the brain chemical dopamine, which helps regulate mood and behavior. Too much dopamine can cause hallucinations, notes Dr. Meinzer, and more extreme potential side effects include confusion, mania, depression and impulse control disorders like compulsive gambling or eating. “There are other options for restless leg syndrome that don’t increase dopamine, though medications like ropinirole typically work best.” There are also different medications for Parkinson’s, though you and your doctor should carefully consider your particular treatment needs. If you experience these kinds of symptoms while taking this type of medication, it may be that your dose is too high.

Ritalin, Adderall and Other Stimulants

Drugs that are commonly used for the treatment of attention-deficit hyperactivity disorder (ADHD) include those sold under the brand names Ritalin and Adderall. Although these stimulant medications “help children and adolescents focus and stay on task, side effects include increased heart rate and insomnia, which can often cause anxiety and restlessness,” says Dr. Meinzer. Stimulants “excite the central nervous system and can disrupt normal communication between cells in the brain,” adds Dr. Kim. “This class of drugs may also cause bizarre behavior, agitation, mania, paranoia and nightmares.” Dr. Meinzer suggests talking to your healthcare provider if you feel extremely restless and anxious while taking this type of medication. Again, it is possible that your dose is simply too high.

Corticosteroids

Medications like prednisone, cortisone and methylprednisolone are often prescribed “to help respiratory symptoms and decrease inflammation with chronic diseases,” Dr Meinzer explains. They are typically only “used for a short term to help alleviate symptoms, but if you are on these medications for a long time, they can cause some unwanted side effects.” Use of these drugs for more than a few months can increase the chances of experiencing mania, anxiety, depression, paranoia and psychosis, which have mostly been reported by patients using high doses or abusing the medication, says Dr Kim. Though experts are unclear about the exact reasons for such side effects with these drugs, research suggests that it may have to do with the way steroids work in the area of the brain that influences memory and emotion. It is also possible that “high levels of steroids result in brain damage and cause cognitive dysfunction.”

Zarontin and Other Anticonvulsants

Medications such as ethosuximide (Zarontin), which are used to control seizures in people with epilepsy, can cause symptoms resembling depression. These drugs have also been found to increase suicidal thoughts and behavior. “If you start to experience these symptoms on an anticonvulsant, you should talk to your doctor about other regimens,” Dr. Meinzer recommends. “There are other medications in the same class that are less likely to cause this side effect,” though your doctor may want you to stay on the medication because it may be the one that is most effective for you. “Anticonvulsants are usually tricky to dose and may need lab monitoring to make sure they are in the proper range.”

Dr. Kim offers the following general tips to help prevent or deal with these side effects:

  • When you are prescribed a drug, ask your provider about potential side effects that are commonly noted and reported.
  • Ask your provider to take a look at your current medication regimen to rule out potential drug-drug interactions that could cause psychiatric side effects.
  • Withdrawal of some drugs can cause symptoms such as anxiety, agitation or depression. Therefore, call your doctor before stopping medications on your own.
  • When purchasing an over-the-counter (OTC) medication, take the time to read the instructions on the package. If anything is unclear, ask the pharmacist for guidance.

The Top 8 Heart Meds: Risks Vs. Benefits

Prescription heart medications are so common — millions of Americans currently take at least 1 to treat everything from high blood pressure and high cholesterol to heart failure and stroke — that it’s easy for doctors and patients to breeze through important conversations about the serious side effects that can accompany these powerful drugs. Take Plavix, the so-called “superaspirin” that helps prevent blood clots: It can occasionally cause severe bleeding problems. ACE inhibitors, designed to help prevent further heart damage, can sometimes interfere with normal kidney function or even cause angioedema, a condition that can lead to obstructed airways.

Frightening stuff, to be sure, but because these meds are intended to keep your heart pumping, simply stopping them isn’t the right path to take. According to an American Heart Association report, patients who don’t take their meds as prescribed “are more likely to have adverse health events.” (That same report notes “fear of side effects” and “difficulty understanding the benefits and adverse effects of complex drug therapies” as 2 of the top reasons patients give for not taking their medications as prescribed.)

Understanding Heart Health Drugs

So how to solve the problem? It starts with understanding the meds you take, both their benefits and risks. “Studies show that patient compliance in their treatment program is increased when they understand why they’re being prescribed a drug and when there is a plan in place for how to take the drug and what to do if a side effect is experienced,” says Ana Barac, MD, PhD., FACC, a cardiologist and faculty staff with Medstar Heart and Vascular Institute in Washington, DC, where she is also medical director of the cardiac rehabilitation program.

Whether you’ve recently been prescribed a heart-health drug or have been taking 1 (or more) for years, use this helpful guide to the benefits and risks as a good conversation starter at your next doctor visit.

Important Note: Dr. Barac says any side effect warrants a call to your doctor. In most cases, the adverse effect can be treated by changing doses, switching to a different medicine, or adding a medicine that directly targets the reaction. Certain side effects may also go away relatively soon after you start taking a new drug, as your body adjusts to the medication. In addition, remember to tell your doctor and/or pharmacist about any other prescriptions, vitamins, supplements, and over-the-counter medications you take on a regular basis, in order to prevent dangerous drug interactions. Finally, because many of these medications are prescribed after a life-threatening cardiovascular event, or to prevent a life-threatening event, do not stop taking a prescribed heart medication without guidance from your doctor. This includes temporarily stopping a medication for elective surgeries (knee replacement, for example) or dental appointments.

ACE INHIBITORS (Angiotensin-Converting Enzyme)

Brand names: Prinivil, Accupril, Monopril, Capoten, Vasotec, Aceon, Altace, Mavik, Zestril

How they help: These medicines block the production of a hormone called angiotensin II, which causes arteries to constrict. They were originally introduced to lower blood pressure (BP); used alone they promote a moderate BP reduction (if you need a more significant reduction, you might take one along with a diuretic). ACE inhibitors are also commonly prescribed after a heart attack or congestive heart failure to prevent further heart damage. In some cases they’re also given to those who are at high risk of heart failure.

Possible risks: These drugs are generally considered to be safe and well tolerated, but a too-steep drop in blood pressure, which can cause dizziness and fainting, has been noted. Other side effects to look for include hives or other allergic reaction and dry cough.

Most worrisome side effects: Reduced kidney function and increased potassium levels (which can lead to abnormal heart rhythms); swelling of the face and throat, which could signal angioedema, a condition that can lead to obstructed airways.

BETA BLOCKERS (Beta-Adrenergic Blocking Agents)

Brand names: Toprol-XL, Coreg CR, Zebeta, and others

How they help: By slowing the heart rate and decreasing the strength of heart-muscle contractions, these drugs minimize how hard your heart works. For that reason they’re most often prescribed after a heart attack or when congestive heart failure has been diagnosed. Another use is to prevent ventricular arrhythmia. They were once considered a “first choice” drug to treat high blood pressure, but no more, especially for patients who have no other diagnosed heart condition.

Possible risks: Fatigue and nausea are the most commonly reported side effects. Less common is the onset of depression. Also look for any signs of an allergic reaction.

Most worrisome side effects: They can slow the heart rate down too much, resulting in dizziness or fainting. Beta blockers constrict airways and should not be used by those with chronic lung diseases or asthma.

DIURETICS (also known as water pills)

Brand names: Lasix, Bumex, Demadex, Diuril, Midamor, Chlorthalidone, Esidrix, Hydrodiuril, Lozol, Zaroxolyn, Dyrenium

How they help: Diuretics help to ease the heart’s workload by reducing fluid and sodium buildup in the lungs and other parts of the body. In turn, there is less pressure on the walls of your arteries. Each diuretic works a bit differently in your kidneys, and removes fluid at varied rates. They are often the first line of defense when treating high blood pressure and heart problems related to high blood pressure. Diuretics are also often given to improve heart failure symptoms.

Possible risks: Diuretics are generally considered safe and well-tolerated. The most common side effect is increased urination (that’s why patients are often told not to take these drugs at night). Other risks include: allergic reactions; too low blood pressure (causing dizziness); headaches; increased thirst; muscle cramps; the development of gout (rare); menstrual changes; and impotence.

Most worrisome side effects: If too much fluid is removed, you could have reduced kidney function; low or high potassium, magnesium and/or calcium levels, all of which come with their own set of serious side effects, such as heart problems, vomiting, diarrhea, and more.

CALCIUM CHANNEL BLOCKERS

Brand names: Norvasc, Cardizem, Tiazac, Cardene SR, Procardia, Sular, Calan, Verelan, Covera-HS, and others

How they help: As the name implies, these medications prevent calcium from getting into cells of the heart and blood vessel walls. They also relax and widen blood vessels so that the heart is able to pump more easily. Some can also slow the heart rate. They’re prescribed to control irregular heartbeat (arrhythmia) and relieve angina (chest pain). They also lower blood pressure, although their effectiveness is not universal: Studies show that African Americans with hypertension do well controlling their BP with calcium channel blockers, however among other patient groups the other BP medications have been shown to be more effective.

Possible risks: Along with allergic reactions, side effects associated with calcium channel blockers include constipation or diarrhea; dizziness or lightheadedness; flushing or feeling warm; nausea; headaches; fatigue; and swelling in the feet and lower legs.

Most worrisome side effects: Certain calcium channel blockers reduce your body’s ability to eliminate the medication, allowing for an unsafe build-up. Tachycardia, or rapid heartbeat, has also been noted.

ANTICOAGULANTS (blood thinners)

Brand name: Coumadin

How they help: For heart failure patients who also have atrial fibrillation (a common type of arrhythmia), blood thinners are used to treat and prevent the formation of blood clots. They block vitamin K, a nutrient that the liver uses to produce clotting proteins.

Possible risks: Because it blocks vitamin K, which is found in leafy, green vegetables, changes in your eating patterns can lead to too much or too little blood thinning. (Spinach lovers don’t necessarily need to give up a favorite food, but your doctor or a nutritionist may need to review your food choices to make appropriate, safe recommendations.) Blood thinners also are sensitive to many other medications that either decrease or increase its anticoagulant effects.

Most worrisome side effects: See above, as both too much and too little blood thinning can  pose serious challenges. To protect you from these risks, your doctor will likely monitor the drug’s effects with frequent blood tests.

ANTIPLATELETS & ASPIRIN

Brand name: Plavix (antiplatelet clopidogrel)

How they help: Both are used to prevent blood clots from forming in the heart or brain in patients with heart disease. Plavix is more potent than aspirin and is often prescribed in combination with aspirin. These drugs work by interfering with normal platelet functions, chiefly stopping prostaglandins, which are naturally occurring substances that help blood platelets clump together. They’re often prescribed after a patient has had a heart attack or stroke.

Possible risks: It’s widely known that aspirin carries an increased risk of internal bleeding. Some of this is fairly minor, such as a nosebleed. When stomach bleeding occurs, patients and their doctors must carefully weigh the pros and cons of being on an aspirin or Plavix regimen. (About 3% of Plavix patients experience moderate or severe bleeding problems.) Some patients who deem their heart attack risk greater than dealing with stomach bleeding often take a proton pump inhibitor to protect the stomach lining. Other allergic reactions can occur.

Most worrisome side effects: Bleeding into the brain is extremely dangerous and life threatening. Signs this might be happening include a sudden severe headache, seizures, changes in vision, weakness on one side of the body, a sense of numbness, and/or difficulty speaking.

STATINS (Cholesterol lowering drugs)

Brand names: Zocor, Lipitor, Crestor and others

How they help: These drugs have been shown to lower LDL (often referred to as “bad”) cholesterol by 20 to 50%. They prompt the liver to remove more cholesterol from the blood than it does naturally. They’re commonly prescribed for individuals with high cholesterol, as well as those who’ve had a heart attack or who’ve been diagnosed with heart disease.

Possible risks: It’s prudent to avoid grapefruit juice as it increases the effects of atorvastatin, simvastatin and lovastatin. Grapefruit is fine to drink if you’re on pravastatin or rosuvastatin. The most common side effect is mild muscle discomfort (myopathy). This pain is often dosage-related and lowering the dose can lessen or remove the pain. Statin-takers sometimes complain about cognitive declines – forgetfulness and fuzzy thinking. CoQ-10 taken with statins has been shown to decrease mild to moderate muscle pain in about a third of users with symptom improvement in 75% of users. There’s no concrete evidence linking statins to liver damage, but your doctor may nevertheless have you take regular liver function tests. As with any medication, allergic reactions are possible.

Most worrisome side effects: Recent research has suggested that statins increase the risk for type 2 diabetes by 9% on average with women at a slightly higher risk. Rare cases of severe muscle damage (rhabdomyolysis) requiring hospitalization have been noted. Alert your doctor if you have extreme muscle pain, especially if your urine has a tea-colored hue.

VASODILATORS (also known as nitrates)

Brand names: Nitroglycerin, Apresoline, minoxidil, Isordil, Natrecor

How they help: These drugs work directly on the muscles in the walls of arteries to dilate blood vessels so blood flows more easily and your heart doesn’t have to work as hard. They are most often prescribed after heart failure to improve symptoms and prolong your survival. Doctors may also prescribe one for pulmonary hypertension (blood pressure that affects the arteries in your lungs); for high blood pressure during pregnancy or childbirth; and less often to treat high blood pressure (generally as a last resort medicine when other blood pressure medications haven’t worked).

Possible risks: Vasodilators are powerful drugs with a number of associated side effects, including headaches, dizziness, flushing, varying degrees of sodium and water retention (edema), facial changes, excessive hair growth, allergic reactions, and increased risk of developing lupus (although this is very rare).

Most worrisome side effects: Chest pain, rapid heartbeat, heart palpitations, and a severe headache that doesn’t go away should be immediately reported.

Further Reading

Hospital-Induced Delirium

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.

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, 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.

Diuretics

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.

Medication pile-on

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.

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 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.

Further Reading: