State of Con­fu­sion

Ev­ery year, hun­dreds of thou­sands of pa­tients leave Cana­dian hos­pi­tals with delir­ium. So why don’t we know more about it?

Reader's Digest (Canada) - - Contents - SYD­NEY LONEY FROM THE WAL­RUS

Pa­tients na­tion­wide are leav­ing hos­pi­tals with delir­ium. So why don’t we know more about it?

AT 83 YEARS OLD, Ken­neth Mars­den, a re­tired car­pen­ter, had the mind of a Jeop­ardy! cham­pion. He could fin­ish a cross­word puz­zle in half an hour and re­cite, from mem­ory, the names of ob­scure towns from his child­hood in Eng­land.

“I swear he’d win that show if he were a con­tes­tant,” says his daugh­ter Dawn Clarke. That’s why it wor­ried her when, af­ter a short hospi­tal stay, her fa­ther took all day to com­plete the cross­word in The Hamil­ton Spec­ta­tor.

One Mon­day morn­ing in Fe­bru­ary 2017, Mars­den was watch­ing tele­vi­sion in his bed­room when his nose be­gan to bleed. “It was gush­ing,” Clarke says. “There was blood all over.” Hours later, Mars­den sat with his fam­ily in a small beige room at St. Joseph’s Health­care

Hamil­ton, a stained cloth pressed to his face, wait­ing to see a doc­tor.

Clarke and her mother, Rose, went search­ing for cof­fee. When they re­turned, Mars­den was sit­ting on the bed, cry­ing. A doc­tor had come in and wedged what looked like a giant tam­pon up his nos­tril. “My dad was in so much pain. He was ter­ri­fied,” Clarke says. An­other doc­tor later cau­ter­ized a rup­tured ves­sel in her fa­ther’s nose.

Mars­den was con­nected to an IV and didn’t get much sleep at the hospi­tal over the next few days—nurses had to wake him ev­ery three hours to check his vi­tal signs. He was dis­turbed by the noise, the lights, the con­stant com­ings and go­ings, and he wor­ried in­ces­santly that the bleed­ing would re­turn.

He was sent home on a Thurs­day night, but barely 48 hours later, Rose called Clarke, dis­traught. Mars­den had been up since 4 a.m. He was con­fused and restless, pac­ing around in his un­der­wear. Clarke rushed to her par­ents’ home, which is three doors from her own, and called 911. As the fam­ily waited for an am­bu­lance to ar­rive, Mars­den be­gan to hal­lu­ci­nate that he saw writ­ing on the blank tele­vi­sion screen.

Back in the ER, Mars­den be­came com­bat­ive. He swore at at­ten­dants and spat out his blood-pres­sure pills. Doc­tors de­ter­mined that Mars­den had a mag­ne­sium de­fi­ciency, pos­si­bly the cause of the ini­tial nose­bleed, and they pre­scribed sup­ple­ments. Clarke asked to have her fa­ther dis­charged a few days later—she could tell he wasn’t fully re­cov­er­ing at the hospi­tal. At a fol­low-up ap­point­ment weeks later, the fam­ily learned that Mars­den’s con­fu­sion and mood swings were un­re­lated to the rea­son for his nose­bleed. He was di­ag­nosed with hos­pi­ta­lac­quired delir­ium.



EV­ERY YEAR, hun­dreds of thou­sands of pa­tients leave Cana­dian hos­pi­tals with delir­ium. The causes of the con­di­tion aren’t fully un­der­stood but are be­lieved to be due, in part, to over­stretched med­i­cal re­sources. Pa­tients’ bro­ken bones and in­fec­tions are treated, but they de­velop shorter at­ten­tion spans, slurred speech, con­fu­sion and hal­lu­ci­na­tions. It can hap­pen to any­one, any­where: there’s the 87-year-old woman from ru­ral On­tario who broke her hip and then for­got why she was in the hospi­tal; an­other el­derly woman who started see­ing wa­ter­falls com­ing from the ceil­ing af­ter be­ing ad­mit­ted; a 78-year-old stroke vic­tim who kept los­ing all sense of who and where she was.

In 2016, Dr. Ku­mar Dhar­mara­jan, a former pro­fes­sor at the Yale School of Medicine, an­a­lyzed data from a clin­i­cal trial in­volv­ing 469 el­derly pa­tients in Con­necti­cut. Fif­teen per cent de­vel­oped delir­ium dur­ing their hospi­tal stays. Those pa­tients also had a sig­nif­i­cantly in­creased risk of dy­ing within 90 days of their ad­mis­sion—in part be­cause of poor nu­tri­tion, dis­turbed sleep and the use of re­strain­ing de­vices, which can cause in­jury (“A catheter isn’t meant to be a re­straint, but it ac­com­plishes the same pur­pose,” Dhar­mara­jan says).

De­spite its preva­lence, hos­pi­ta­lac­quired delir­ium (HAD) re­mains un­der­rec­og­nized and un­der­diag­nosed. “Health care providers are trained to fo­cus on the con­di­tion that re­sulted in hos­pi­tal­iza­tion, not on the ex­pe­ri­ence of the per­son while they’re there,” says Dhar­mara­jan.

HAD was first iden­ti­fied in the 1960s, when it was re­ferred to as ICU psy­chosis. But symp­toms in to­day’s pa­tients are still mis­taken for ev­ery­day signs of ag­ing. And since most of those af­fected are se­niors, their com­plaints are of­ten dis­missed—up to 40 per cent of older hospi­tal pa­tients suf­fer from the syn­drome, as op­posed to less than five per cent of peo­ple un­der 50. HAD may look like de­men­tia, but delir­ium is an acute con­fused state, whereas de­men­tia is a chronic con­di­tion char­ac­ter­ized by mem­ory loss. Most sig­nif­i­cant, delir­ium usu­ally has an ex­ter­nal trig­ger—which means it could, in the­ory, be pre­vented.

Dr. Gor­don Boyd, a neu­rol­o­gist and crit­i­cal care clin­i­cian at Queen’s Uni­ver­sity in Kingston, Ont., says hos­pi­tals are faced with a pub­lic-health cri­sis fea­tur­ing a con­di­tion that can lead to many long-term men­tal health prob­lems. Then there are the as­so­ci­ated costs, es­ti­mated to be in the bil­lions, since pa­tients with HAD re­quire more med­i­cal ser­vices and fol­low-up care— a sit­u­a­tion that will only worsen as life­spans lengthen and se­niors ac­count for an in­creas­ingly large part of the pop­u­la­tion (20 per cent by 2024).

The health care sys­tem in Canada is hospi­tal-cen­tric: it re­volves around the emer­gency room. Not only are se­niors ad­mit­ted more of­ten than any other age group, they also stay longer and use more re­sources. Their time in hospi­tal in­creases their sus­cep­ti­bil­ity to delir­ium, due to ex­po­sure to risk fac­tors such as inat­ten­tive care, falls or in­fec­tion. That, in turn, makes it more likely that they’ll need to come back. It’s a dev­as­tat­ing cy­cle: in ef­fect, our health care sys­tem is work­ing against it­self.

AF­TER MARS­DEN re­turned home, his ap­petite de­te­ri­o­rated; on some days he re­fused to eat al­to­gether. He even­tu­ally stopped want­ing to get dressed in the morn­ing and stopped get­ting out of bed. Four months af­ter his di­ag­no­sis, he was back in the hospi­tal with short­ness of breath.

Once a pa­tient has ex­pe­ri­enced delir­ium, they’re vul­ner­a­ble for the rest of their lives, says Dr. Joye St. Onge, the head of geri­atrics at St. Joseph’s. “I’ve seen peo­ple get a cold and be­come deliri­ous again.” HAD can cause cog­ni­tive im­pair­ment and per­ma­nently change the brain, though the ex­act rea­sons why are not un­der­stood. Cur­rent re­search shows that hav­ing ex­pe­ri­enced the con­di­tion once is a sig­nif­i­cant risk fac­tor for en­coun­ter­ing it again. Ac­cord­ing to St. Onge, the brain is more vul­ner­a­ble af­ter delir­ium.

A study in 2013 found that 74 per cent of adults ad­mit­ted to the med­i­cal or sur­gi­cal in­ten­sive care unit of a med­i­cal cen­tre and hospi­tal in Nashville de­vel­oped delir­ium dur­ing their stay. One year later, one-quar­ter to one-third of the pa­tients showed symp­toms of long-term cog­ni­tive im­pair­ment sim­i­lar to those of a trau­matic brain in­jury or mild Alzheimer’s.

Many Cana­dian hos­pi­tals have in­tro­duced delir­ium-screen­ing pro­ce­dures, but there are no uni­ver­sal guide­lines for pre­ven­tion yet. Dhar­mara­jan thinks that in­sti­tu­tions should model them­selves af­ter pa­tient-cen­tric chil­dren’s hos­pi­tals, where pos­i­tive and less dis­rup­tive en­vi­ron­ments shel­ter pa­tients from the stresses of ill­ness. Boyd re­cently helped set up an ICU fol­low-up pro­gram at Kingston Gen­eral that in­vites peo­ple back to talk about their ex­pe­ri­ences and visit their former hospi­tal rooms to dis­pel neg­a­tive as­so­ci­a­tions and cre­ate new, pos­i­tive ex­pe­ri­ences. Dr. Roger Wong, ex­ec­u­tive as­so­ciate dean of ed­u­ca­tion at the Uni­ver­sity of Bri­tish Columbia’s fac­ulty of medicine, would like to use tech­nol­ogy to help reorient pa­tients by con­nect­ing them with fa­mil­iar pho­tos on so­cial me­dia.

Wong has made HAD part of the cur­ricu­lum at UBC and ad­vo­cates for stan­dard­iz­ing the train­ing for all stu­dents in the field. But Canada’s 17 med­i­cal schools, he says, are sub­ject to the same in­con­sis­ten­cies as the health care sys­tem as a whole. For now, one of the most re­li­able pre­ven­tion strate­gies is the Hospi­tal El­der Life Pro­gram, de­vel­oped in 1993 by Dr. Sharon Inouye, now a pro­fes­sor of medicine at Har­vard Med­i­cal School. The pro­gram, which is de­signed to keep pa­tients mo­bile, ori­ented, hy­drated and well rested, is slowly be­ing adopted world­wide.

The strate­gies it rec­om­mends— put­ting cal­en­dars in pa­tients’ rooms to avoid con­fu­sion about the date, min­i­miz­ing the use of seda­tives, co­or­di­nat­ing nurs­ing staff so that peo­ple aren’t wo­ken up sev­eral times a night— re­duce the chances of ac­quir­ing delir­ium by 40 per cent. St. Joseph’s has im­ple­mented some pre­ven­tion tac­tics, in­clud­ing hav­ing vol­un­teers con­duct ori­ent­ing con­ver­sa­tions (dis­cussing

news­pa­per head­lines, for ex­am­ple) with pa­tients, but there’s lim­ited co­or­di­na­tion be­tween wards. “It’s about pri­or­i­ties and re­sources,” St. Onge says. “Hos­pi­tals are strug­gling to deal with acute is­sues, so pre­ven­ta­tive pro­grams have a hard time.”

To­day, Mars­den doesn’t re­mem­ber much about his or­deal, and his daugh­ter is thank­ful for that. Clarke be­lieves that if there had been more in­for­ma­tion avail­able, fam­ily mem­bers could have bet­ter pre­pared them­selves for what hap­pened. Mars­den is home again and tak­ing an­tide­pres­sants, but his fam­ily is ter­ri­fied that his delir­ium will re­turn. Clarke says this time she’s ready to take ac­tion at the first sign of the con­di­tion. “I don’t care if I make peo­ple mad—my dad will get the care he de­serves.”


Hedge­hogs. Why can’t they just share the hedge? DAN ANTOPOLSKI, comic

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