State of Confusion
Every year, hundreds of thousands of patients leave Canadian hospitals with delirium. So why don’t we know more about it?
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.
IT’S A DEVASTATING CYCLE: OUR HEALTH CARE SYSTEM IS WORKING AGAINST
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.”
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