Hospital-associated delirium is a serious, and often avoidable, condition
It’s stressful enough when a loved one is hospitalized, no matter the reason. But that stress can be compounded when a loved one begins to suddenly show signs of hospital-associated delirium, a mental state characterized by agitation, lethargy and profound confusion, among other symptoms.
While hospital-associated delirium can affect anyone, it’s most common among older adults, and those with a variety of health issues. Up to 60% of hospitalized patients over age 70 experience some delirium symptoms, and those rates grow substantially if a patient has experienced a surgery or is in a critical-care setting; up to 80% of ICU patients experience delirium during their stay.
Despite its prevalence, many people have never heard of delirium — and aren’t prepared for it when it happens to a loved one for the first time. Delirium can come on fast, and it can be especially alarming for family and friends when a loved one is lucid one day, then talking nonsense the next.
It’sa serious public health issue with potentially serious, long-term consequences that, in 30-40% of cases,might be preventable.
What is delirium?
Delirium, which can occur inside or outside a hospital, is an acute form of mental impairment that develops quickly, and usually goes away — sometimes in a few hours, sometimes in a few days or weeks, and in some cases, patients can seem to drift in and out of lucidity from moment to moment. While delirium shares symptoms with dementia — and, in fact, people with dementia or Alzheimer’s disease are more prone to experiencing delirium — they are separate conditions.
For some, delirium means an agitated state: combative behavior, restlessness and hallucinations. We sometimes call this hyperactive delirium. For others, the opposite occurs: A person is less responsive, talking slowly or unintelligibly, and has difficulty holding focus, known ashypoactive delirium.
And most commonly, a patient will experience elements of both, called mixed delirium.
The lethargy of hypoactive delirium and the hallucinations of hyperactive delirium can give the appearance of a patient being “overmedicated,” leading family members to sometimes assume that the patient’s reduced cognition is a natural side effect of higher dosesof pain medicine.
While medications can play a significant contributing role in delirium, they are not necessarily the primary cause, especially in a hospital setting.
Why does it occur so often in the hospital?
If a patient is in the hospital, that means that they are pretty sick to begin with, which is typically an indicator for hospital-associated delirium. While it’s hard to pinpoint what exactly triggers delirium, a number of factors and conditions likely contribute to a patient’s altered state of mind, including dehydration, new combinations of medications and painkillers, low oxygen due to underlying lung diseases, unstable blood sugar levels, and infections (and the septic reactions that follow).
Sepsis in particular seems to be linked to delirium. Sepsis is a systemic inflammatory response to a widespread infection, such as pneumonia or a severe urinary tract infection; as the infection grows, it can trigger an overwhelming immune response, inflaming tissues and organs. The same inflammatory response that damages tissue may also cause brain and central nervous system dysfunction.
The hospital setting itself can also play a role. The general anxiety of being in a foreign environment, separation from loved ones, lights and noises, lack of sleep, the constant parade of health care providers, difficulty seeing or hearing (because glasses or hearing aids may have been left at home), sedation, intubation, mechanical ventilation, all stress the mind and body and interrupt the patient’s sense of routine.
And while delirium is often temporary, it almost always impacts a patient’s overall recovery — and it increases the length and cost of a hospital stay. It is associated with higher mortality risks and, much like long COVID, can continue to affect a patient’s well-being and cognition long after they’ve left the hospital.
How can hospital delirium be prevented?
Decades ago, health care providers might have attributed delirium’s confusion to a normal, unavoidable condition of old age. Older patients just get confused more often, right?
Today, we know that it’s not only avoidable, but that its symptoms can be iatrogenic — that is, caused to some degree by the treatment and the setting itself.
Providers play the largest role in preventing, identifying and treating delirium, and our industry has made a lot of progress over the last decade in changing hospital and ICU care protocols: promoting increased mobility in the hospital, weaning patients from medical equipment such as urinary catheters and ventilators more quickly, better screening techniques and multi-disciplinary prevention models, and new approaches in medication management.
But family members can help too:
• Be sure patients have routine visits from family and friends as well as some familiar items (family photos, drawings from grandkids) around them. The
longer the stay, the more important these familiar touchstones can be.
• Minimize vision and hearing impairments. That means packing eyeglasses, readers and hearing aids, to help patients process what is happening around them.
• Keep an eye out for behaviors and mood changes that aren’t typical. Flag unusual disorientation for caregivers. You know the patient best.
• Encourage physical activity, if possible. Even simple activities like sitting upright for meals or spending time out of bed in a chair can be beneficial.
• Minimize sleep deprivation. This is difficult, especially in a hospital. But as a visitor, heed visiting hours and quiet hours, and don’t unnecessarily disturb a sleepingpatient. At the same time, focus on keeping your loved one awake and engaged in conversation and activities during daytime hours, so days and nights don’tbecome mixed up.
Not all hospital delirium can be prevented. Some patients are simply too sick, and others are overly prone to the condition. But by working together, caregivers and patients’ families can improve care in the hospital and ensure that all patients have the best chance of preventing or shortening delirium symptoms.
Lyn Weinberg, M.D., is an Allegheny Health Network physician, director of the Geriatrics division within the AHN Primary Care Institute and Medical Director of AHN’s Hospital ElderLife Program (HELP). World Delirium Awareness Dayis March 13.