Interventions May Lessen Delirium in Hospitalized Elders

Q:  It seems like older people who have to be hospitalized frequently become confused. As a result, I'm afraid of going to the hospital or having surgery since I, too, could "lose my mind." What can you tell me about this?

A:  Your observation is interesting and not surprising. You are presumably referring to the medical condition delirium. Among non-physicians this could also be termed an acute confusional state. Delirium is most often a complication of a medical illness, drug/substances effect on the brain, or a surgical procedure most often involving general anesthesia. Delirium results from a disturbance in the neurotransmitters (chemical messengers) in the brain that control consciousness, thinking and behavior.

The hallmarks of delirium are an abrupt onset of depressed level of consciousness, alterations in memory and behavior, and sometimes hallucinations. It is more common in older adults, possibly due to normal age-related changes in the nervous system and brain, diminished eyesight and hearing associated with age, greater use of medications in elderly patients, and diseases which injure the brain and predispose to delirium. For example, it is known that the condition dementia places a person at higher risk for developing delirium than people who are not afflicted with dementia.

A report by Inouye and colleagues in the New England Journal of Medicine (NEJM 1999; 340:669-76 "A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients") is quite informative in this regard. This group from Yale University found that among hospitalized general medicine patients aged 70 or above who had no delirium on admission, and who were at risk for developing delirium, 10-15% of the group went on to develop the problem. Risk factors for delirium included visual impairment, severe illness, cognitive impairment, and abnormal renal function blood tests. In order to try to prevent delirium, these researchers developed a service at Yale Hospital called the Elder Life Program.

Utilizing a specialized staff expert in geriatrics and trained volunteers, this program intervened to reduce the risk of delirium. Intervention included:

• Special efforts to keep patients oriented while in the hospital
• Activities to stimulate the mind
• Promoting sleep without the use of hypnotic drugs and ensuring the environment was conducive to sleep
• Avoiding excessive bed rest and keeping patients mobile
• Reminders to bring and use communication aids (e.g. eyeglasses, hearing aids, etc.)
• Providing aids to promote communication (e.g. magnifying glasses, large-print directions, cleaning wax from ear canals)
• Utilization by staff of special communication techniques when needed
• A protocol to detect and treat low fluid intake (dehydration)

In this study of hospitalized medical patients, it was found that when the above interventions were applied, the incidence of delirium could be reduced from 15% of patients to 10% of patients. Stated differently, with the intervention a person's chance of developing delirium was reduced by 40% for the group receiving the intervention. The number of days of delirium and the number of episodes of delirium were both reduced. It is noteworthy that those at lower risk for developing delirium seemed to benefit the most, suggesting that for severely ill persons with marked dementia, prevention may be more difficult.

In summary, I believe you have reason to be concerned that acute illness, hospitalization or surgery can be associated with delirium on occasion in older persons. Your description of "losing my mind" is perhaps a bit of an overstatement and you should keep in mind that with appropriate treatment of the precipitant of the delirium a person should return to baseline status.

You should be reassured that there are measures evolving to help physicians and nurses identify those at highest risk for delirium and to prevent it from occurring, though completely eliminating delirium would seem an unrealistic expectation. Further clinical research and basic neuroscience investigation should help reduce the effects of this problem on hospitalized and ill elders.

Edmund H. Duthie, Jr. MD
Medical College of Wisconsin Professor of Medicine
Chief, Department of Medicine/Division of Geriatrics & Gerontology

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