Part of the Age-Friendly Health Care Special Report
(Editor’s note: This story is part of a series for The John A. Hartford Foundation.)
As many as half of hospital patients age 65 and older develop delirium.
Once thought of as something ordinary — something that “just happens” to people as they get older — today, geriatricians and hospitals across the U.S. recognize the dangers of delirium and are increasingly creating programs and protocols to prevent, detect and treat it.
Delirium refers to a change in the brain’s neurochemistry that causes a person to become highly confused and unable to think clearly. People with delirium often can’t remember recent events or where they are. The condition usually comes on quickly, but the symptoms can come and go.
If you’re visiting a loved one in the hospital and you notice a significant behavioral change, tell a nurse or doctor immediately.
It happens when there is a major disturbance to the body, such as an infection (pneumonia or a urinary tract infection, for example), severe chronic illness, surgery or organ failure. Other causes of delirium could be medications, a metabolic imbalance (such as low sodium or potassium) and alcohol or drug intoxication and withdrawal.
Besides hospitals, delirium is also common in long-term care facilities and often one of the first signs that a resident has become very ill, says Dr. Paul Takahashi, a geriatrician at Mayo Clinic in Rochester, Minn.
How Delirium Presents
Delirium manifests in two primary ways: high agitation (which is called hyperactive delirium) or, more commonly, as inactivity (which is called hypoactive delirium). It’s possible to experience both hyperactive and hypoactive delirium throughout the course of an illness.
It’s more difficult to catch hypoactive delirium because this type of delirium is much less obvious. When patients have hyperactive delirium, they’re doing things like shouting at family members or hospital staff, trying to pull out intravenous tubes or even striking out at people.
“But more often, people just become really withdrawn and they stop eating, stop moving around,” Takahashi says. “When I’m talking to patients or their families, I say: ‘If you notice mom has become less interactive, her mood and behavior changes, she’s less alert and she’s not really responding to you, that’s as serious as the overactive type.’”
Delirium’s mortality rate is high — the same in-hospital mortality rate as having a heart attack, says Dr. Stephanie Rogers, a geriatrician and physician lead for the University of California San Francisco’s (UCSF) Delirium Reduction program.
“It causes a lot of patient and family distress. There’s been reported cases of post-traumatic stress disorder after hospitalization,” Rogers says. “It increases the likelihood that you’re going to have to go into a nursing home after discharge rather than going home.” Delirium is also associated with patient falls in hospitals.
How Delirium Is Treated
When delirium is detected, physicians will examine the patient and order tests to determine what other medical issue might have led to the condition. “Oftentimes, it’s an infection like pneumonia or a urinary infection,” Takahashi says. “Or it could be a heart issue or breathing issue, an adverse reaction to a medication. So, there’s a way to try to treat the delirium directly, but more importantly, we try to work with what’s causing this delirium,” Takahashi says.
In addition to dealing with the infection or other medical problem, treatment for delirium involves making sure the patient is getting the right nutrition, fluids and enough sleep.
Also important for recovery are the familiar faces of family and friends who can help the patient reorient, Takahashi says.
When these medication-free methods fail to reverse delirium, physicians might prescribe an antipsychotic medication. “But we really try to avoid those unless we really need them,” Takahashi says. “If there’s a lot of danger to the patient or other people [due to hyperactive delirium], then sometimes these medications can help with the confusion.”
In the medical/surgical intensive care unit at Helen Diller Medical Center at Parnassus Heights, UCSF’s main hospital, nursing staff encourage family members to help with the process of bringing their loved ones with delirium back from confusion, says ICU registered nurse Denise Barchas. She’s been working on the unit’s delirium program for 10 years.
“We encourage family members to help us orient (their loved ones), tell them where they are, talk to them, tell them news of the day about their family and their lives,” Barchas says. Family and friends also can help by bringing in photos and familiar items from the patient’s home to recognize and talk about.
The ICU involves families in a few other ways. They are included in the medical staff “rounds,” when doctors, nurses and other medical staff visit patients’ rooms to discuss their care and progress. “Oftentimes, we try to get the family involved because they have great questions and insight,” Barchas says.
The department also has a patient and family advisory council made up of former ICU patients and family members who occasionally attend staff meetings and advise the department on ways to improve the patient experience.
UCSF has a Delirium Reduction webpage for family members to find additional information on how to prevent delirium and help loved ones recover from it.
AWOL Delirium Screening
At UCSF’s medical/surgical ICU, nurses screen patients for delirium at least once during every 12-hour shift. And, as part of UCSF’s delirium program, every patient admitted to the Helen Diller Medical Center or UCSF’s Medical Center at Mission Bay hospital is screened for delirium, regardless of age.
The screen for all patients (there’s a different one for the ICU), is called “AWOL,” designed by UCSF researchers to determine whether a patient is at low or high risk for developing delirium. AWOL is an acronym for the screen’s assessments of cognitive function and severity of illness:
Age: Is the patient 80 or older?
World: Can the patient spell “world” backwards?
Orient: Is the patient oriented? Does the person know their name, city and state, as well as the hospital and floor they’re on?
Illness: How ilL is the patient, from moderate to severe?
“Age is part of that screen, but it’s only one component of what gives us a risk,” Rogers says. “A lot of older people will end up in the high-risk protocol, but that’s not the only thing (that determines the risk). If someone is high-risk, they go into the delirium prevention protocol.”
When a physician orders this protocol, a number of practices are set into motion. A hospital pharmacist will review the patient’s medications to look for drugs that are more likely to cause delirium, such as ones for treating urinary incontinence, and make recommendations to the physician about what drugs could be tapered or replaced.
The nursing staff will work to ensure the patient gets quality sleep at night and quality awake time during the day. Daytime means lights on, window blinds open and interaction with others — plus any hearing aids and eyeglasses on the patient, since seeing and hearing properly is important for prevention. Daytime also means staying mobile: getting out of bed and walking around when possible.
At night, nurses make sure the room is dark, the television is off and that checking vital signs and other tests are scheduled so the patient will be disturbed as little as possible.
These practices also are put into action for patients who have delirium to help them recover as quickly as possible.
“These things seem obvious and really simple, but, unfortunately, in the daily care at hospitals, they can fall by the wayside,” Rogers says.
UCSF’s Delirium Reduction program has seen success since it became system-wide in March 2018. In the Helen Diller Medical Center’s general medicine department, where patients are at highest risk for developing delirium, the rate has decreased by 5%, Rogers says.
Is It Delirium or Dementia?
It’s tougher to detect delirium in people who have dementia because the behavior can look similar. However, people with dementia who develop delirium will usually begin to show a different type of behavior than they’ve had, and the change generally comes on quickly.
“Has this been happening within the last few days? Then that tells us it’s more likely we have delirium, as opposed to this is something that’s been going on for months or half a year, and it’s been very gradual,” Takahashi says.
Another clue for someone with dementia is whether the behavior change seems to coincide with another medical issue, like starting a new medication, having a cough or symptoms of a urinary issue.
“It can be challenging to make that diagnosis, but we all lean toward making sure that we evaluate for potential delirium because that’s something that can be reversed or improved,” Takahashi says.
What to Do If You Suspect Delirium
If you’re visiting a loved one in the hospital and you notice a significant behavioral change, tell a nurse or doctor immediately. “And be very specific about what you’re noticing,” Takahashi says. “Like, ‘I’m noticing mom is not really interacting at all with us now. … She can’t really remember what she had for breakfast this morning, and she just seems like she’s talking and things don’t make any sense to me.’”
If your loved one is at home and you notice a change, get the person to a doctor immediately. You could either call 911 or, if it’s possible to have your loved one seen right away by a primary care physician and you feel it’s safe to take them yourself, that’s an option, Takahashi says.
“If there’s any evidence they can’t move, they don’t have that kind of strength or mobility, then oftentimes calling an emergency service is reasonable,” he says.
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