Deliriously… Well, Delirious

This is seriously important information for anybody with an elderly family member.

I just atttended a geriatric medicine conference in Pittsburgh this weekend.  Geriatric medicine addresses the particular needs of elderly patients.  We had a variety of very good and informative talks, a couple of boring and unhelpful ones, and a few that were rock-your-world-OMG-I-had-no-idea good.

One of the ones that I know will change the way I practice medicine discussed delirium in hospitalized patients.  There are a few pearls that I particularly want all of my readers to bear in mind the next time you have an elderly family member in the hospital.  They deal with delirium in the hospitalized patient.

First of all let’s define delirium.  Delirium is an acute confusional state.  Basically either a normally coherent patient becomes confused and incoherent, or a patient who is confused at baseline becomes acutely worse.  Generally it also involves a change in level of consciousness as well (either drowsy or agitated) and the inability to focus on tasks like answering questions.  Patients may hallucinate (see or hear things no one else can see or hear).  It is very common:  estimates are that 14-24 percent of all hospitalized elderly patients and at least 70% of elderly patients sick enough to need to be in ICU become delirious.

What are the causes of delirium?  You name it, it’s on the list.  Infection, drugs, cardiovascular problems, pain, low oxygen levels, sleep deprivation, being out of their normal environment, the list goes on.  Usually it’s not just one cause but a combination of multiple triggers.

My big epiphany was learning that delirium in the hospital has long-term consequences.  There was a nice study published about heart-surgery patients, which showed that patients who get delirious after surgery have cognitive dysfunction (i.e. confusion and problems with memory and thought) that persist for up to a year after their surgery.  The longer the delirium lasts, the longer the cognitive dysfunction lasts.

In medicine we all sort of accept that elderly patients are going to get confused in the hospital.  I frequently tell patients’ families that “this happens, s/he will come out of it, and we’ll just keep him/her safe until it corrects itself.”  Now I think I’m going to be a lot less accepting and more aggressive about evaluating, identifying and treating the causes of acute confusion in elderly hospitalized patients!

So where do you come in?  Well we don’t always have an easy time recognizing acute confusion.  If a patient of Dr. Matt’s comes into the hospital and I’ve never met her before, how am I going to know she’s not typically confused?  It’s even harder to tell when the patient has baseline dementia or is forgetful normally.   Delirium also typically waxes and wanes, so if I see her first thing in the morning, and she gets confused in the evening, I may not know about it unless an astute nurse (or family member) calls to tell me.

Here’s your job:  if your parent or grandparent or other elderly family member is in the hospital FOR ANY REASON, organize family members to visit at various times of the day to check on them.  Pick people who know the patient well and can spot changes in their mental state.  Have them on the lookout for ANYTHING unusual and speak up to the nurse or call the doctor if something goes left-of-center.  Remember, we can only treat something if it’s recognized!

We want our elderly patients to be as functional and independent as they possibly can be.  We can’t always anticipate and head off confusion in the hospital, but the sooner it’s recognized and addressed, the sooner the patient will be back to normal mentally.  It turns out fixing delirium in the hospital is very important for long-term mental function and keeping people independent and out of the nursing home.

I frequently say patients (especially elderly patients) can’t be treated in a vacuum, we have to take their families into consideration.  Sometimes honestly families are more difficult to manage than the patient!  This is one instance (one of many, actually) where rallying the troops can help keep your family member safer and get them well faster.

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