Monday, June 21, 2010

NY Times Article on Delirium

There is an article in today's New York Times about delirium, a VERY common but poorly understood condition among hospitalized elders. Delirium is an acute confusional state usually caused by an acute illness (or unfortunately the treatments we give acutely ill patients) or surgery. While patients with delirium clearly have serious brain dysfunction, the inciting causes are almost always outside of the brain.

Numerous studies suggest that delirium effects at least 1/4 of hospitalized persons over the age of 70. But it is properly diagnosed less than half the time. It is very serious. Hospitalized elders who become delirious are at much higher risk for bad outcomes including disabilty and death, as well as nursing home placement.

Delirium is commonly confused with dementia. Dementia is a chronic decline in cognitive function. Delirium is an acute change in cognitive function. Dementia and delirium commonly coexist---and patients with dementia are more likely to also get delirium. But, one generally should not make a new diagnosis of dementia during an episode of delirium. As illustrated in the NY times article, elders with normal cognitive function can become delirious.

Features in a hospitalized patient that may suggest delirium include:

  • A clear change in the patient's baseline mental state. (The family may note "something is not right." "Dad seems different" It is good to take such comments seriously and get more details)
  • The person has trouble focusing and paying attention. They are easily distracted
  • The mental status fluctuates over the course of the day
  • The person's thinking seems disorganized or incoherent. Answers to questions may seem tangential.
  • The patient sees or hears things that are not there
  • The patient is inappropriately somnolent or hypervigilant
The NY Times article puts most of its focus on stories in which the patient is very agitated and combative. It is very important to remember that this is probably far less than half of delirium. Most of delirium is of what is known as the hypoactive variety, which is probably why it so often goes unrecognized. The patient just stays quietly in bed all day, doesn't talk much, and doesn't touch their food. These patients may not cause as much angst for the hospital staff, but they just languish while in the hospital. This more common form of delirium is every bit as bad and dangerous as the agitated delirium described so vividly in the article.

One important point that is often not unrecognized: Once delirium occurs, it often gets better VERY slowly. Many, if not most patients will still have some delirium when they leave the hospital. It is very important doctors, nurses, and social workers recognize this. Who will help care for the patient? Will the family need help? You may have a wonderful discharge protocol in which you go over all the medicines and discharge instructions with the patient. Don't be surprised if they understand none of it.

Sharon Inouye's work shows that at least some cases of delirium can be prevented. The interventions are very common sense. Things like recognizing and compensating for sensory impairments, increasing mobilty, minimizing the use of restraining devices like IV and catheters, and minimizing sleep disruption. It is time for these interventions to be more widely implemented.

by: [ken covinsky]

1 comment:

Chrissy Kistler said...

I thought it was a great article, though I think the title is a bit of a ploy, not all delirium is hallucinations, though I'm glad to see it being more recognized as a true medical emergency.

Also, on a personal note, I loved seeing Dr. Malaz Boustani mentioned, he's a terrific geriatrician (and was a fellow at UNC-CH) and a great guy.