Posts Tagged ‘Delirium’

Delirium part two: prevention strategies and risk factors

Saturday, July 14th, 2012

A familiar photo may help

I went back to the JAMA article I briefly mentioned in my last post; one of its most striking comments is that postoperative delirium is significantly under-diagnosed. The physicians and other staff taking care of surgical patients may miss connecting the dots correctly 80% of the time!

With that in mind, my wife and I decided each should, as a baseline, have a list of all the medicines the other is taking. If one of us needs a major operative procedure, the other can help prevent an episode of delirium in several ways.She handed me a list of her meds the next morning and said our dentist had wanted it the last time she was seen, so she had it put into her computer's word processing program. I finally got mine typed up this morning.

There are a number of other things we could do for each other and some our local hospital could start doing. Bringing in a familiar picture/photo from home, our bedside clock and perhaps a few other objects we see every day would help "de-sterilize" the hospital environment. Of course, if one of us were in an ICU we'd have to check what the rules are, but I'd push the envelope here.

Some hospitals have established senior units in their emergency departments, ICUs and wards. I can remember seeing a calendar with the day of the week, month and year during one of my postoperative stays in the past 13 years here (I've had a total knee replacement, two lower back surgeries and two cataracts removed). The JAMA article advocated a daily delirium check with diagnoses, evaluation and treatment detailed in the medical record.

An intensive care setting can be disorienting with its machines, constant lighting and noise

Dimming the area's lights to maintain a "normal" day and night pattern can be helpful as can co-management of older patents by geriatrics specialists, intensivists or hospitalists, although, in my case, I'd like to see my primary care physician dropping by even if she had nothing to do with managing my care

A May 2012 publication online in Critical Care of a prospective controlled trial of the use of nighttime ear plugs by adult ICU patients showed promising results in a relatively small study. The most significant difference was in the percentage of patients who had an episode of mild confusion. The authors felt there was a correlation with improved sleep patterns.

Of the associated major risk factors: "advanced age" i.e., >70-75 years, preexisting dementia and functional disability, are crucial, but among surgical patents the procedure itself and the anesthesia used also play highly important roles (e.g., major heart and vascular procedures are far more likely to be associated with an episode of delirium than cataract surgery).

We've visited a number of older friends in medical settings in the last six months. In each case a spouse was omnipresent and we think we need to do the same for each other. We'll also be advocates for dimmer lights in the evening and maybe even try ear plugs.


Hospital-induced delirium: part one: the basics

Friday, July 13th, 2012

When they return from surgery, will some be delirious?

About two months ago I visited a friend in the hospital. He's a little over 80 years old, has several significant chronic medical problems and had recently undergone surgery. When I arrived in his room, he was in bed, didn't recognize me and then sat up and started rowing. Obviously he was delirious and hallucinating.

I've seen him at home since and he's back to baseline, but the topic of post-surgery delirium surfaced in the July 4, 2012 issue of JAMA, so I started reading on the subject

I found an article in a 2004 issue of the American Journal of Psychiatry (AJP) that was a good start, but was clearly aimed at medical folk, especially those who would be prescribing medication for the mostly severely affected patients with delirium. The AJP piece said the first step is determining the cause...if possible. It mentioned that the word itself comes from the Latin word delirare, loosely translated as "to be out of one's furrow." My online dictionary defines delirium as an acute (as opposed to chronic) disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech.

The most recent mental health Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR, a much-used but somewhat controversial tome (I'll write about the DSM in a later post), says delirium is a syndrome (a collection of symptoms and physical signs) of many different causes and that its major features are confusion and loss of short-term memory. It mentions one classic sign, not seen in all cases by any means, is carpologia, a term I'd never heard before, but a behavior I've seen many times; it means picking at the bed sheets in a purposeless, repetitive fashion. The patient may be agitated, have delusions and hallucinations, and may try to remove their IV lines or climb out of bed.

On the other hand, some people have a lethargic, hypoactive form of the syndrome; those may be even tougher to diagnose.

A Mayo Clinic website mentions one hallmark of delirium is a sudden or relatively sudden onset with symptoms that tend to wax and wane. Input from family members as to the patient's pre-illness/surgery mental status may be very helpful in sorting out those who had pre-existing dementia from those who didn't, as the two conditions not infrequently co-exist.

too much alcohol can lead to delirium

It's not just surgical patients, of course; when I was in practice the term internists used was "ICU-itis, and medical patients, especially the elderly who were in Intensive Care for a prolonged period, were the ones we had to deal with most commonly. So a better term might be hospital-induced delirium. But some delirious patients have ingested substances causing the condition (PCP would be one example and alcohol withdrawal another), have heavy metal poisoning, medication-caused delirium, infections involving the central nervous system or metabolic disorders.

It's common, but much more so in older patients and a 2010 meta-analysis of forty-two high-quality studies concluded that delirium in this group is associated with poor outcomes, regardless of age, gender, preceding dementia, and other illnesses.

I'll come back to this frequent and often ominous issue in my next post. As our population ages, we'll likely see more of this condition. Planning in advance for hospital stays may help prevent some episodes of delirium.