Another Hospital Hazard for the Elderly

Posted on March 29, 2012

Hours before she fell and broke her hip, my mother, 85, lucid and whip-smart, was doing what she always did in the morning: drinking an entire pot of coffee and digesting both The New York Times and The Baltimore Sun.

The next day she came out of the hip surgery just fine. But within 24 hours, a totally different woman seemed to have taken over her capable mind and body.

She was disoriented. “This isn’t a very nice hotel,” she told us in the hospital room. “They haven’t even served cocktails. Let’s go.” My father, sister and I laughed, thinking it was just grogginess from the anesthesia. But then she developed trouble breathing, and the nurses clapped on an oxygen mask and whisked her off to another ward for more intensive monitoring.

Things quickly spiraled out of control. She tried to rip off her oxygen mask and IV tubes. She frantically tugged at the sheets and her skimpy hospital gown. Like the aged Lady Macbeth, she kept saying: “We have to clean this up! Clean this mess!”

They tied her hands to the bed. The medications to calm her down didn’t work. The doctors upped the sedation. Later, the physical therapist could barely rouse her to do the critical rehab on her brand-new hip.

What my family didn’t know at the time, because the doctors did not tell us, was that this frightening transformation was a classic case of hospital delirium — a brain dysfunction characterized by sudden confusion and inattention. It’s one of the most common, dangerous and costly complications of hospital stays for the elderly.

 

This type of delirium results in large part from the actions of medical workers, according to Dr. E. Wesley Ely, a professor of medicine and critical care at Vanderbilt University School of Medicine. “Even well-meaning doctors are doing damage without knowing it,” he said.

A host of medications can upset brain function and trigger delirium by interfering with the neurotransmitters (especially acetylcholine) that communicate between nerve cells. The long list includes sedatives, sleeping pills, narcotic painkillers and some allergy, blood pressure and incontinence drugs. Immobilizing patents can exacerbate the risk, experts say.

Each year 20 percent of the 11.8 million elderly patients in hospitals develop delirium, including 60 percent to 85 percent of those in intensive care on ventilationand more than half of postoperative surgical patients.

Even though it’s common, hospital delirium is still not being identified or treated as effectively as new research has shown it can be. “This dysfunction is grossly underrecognized, especially in the I.C.U.’s, because everybody in an I.C.U. is intubated and on a ventilator,” Dr. Ely said. “They can’t talk to you.”

Here’s another thing my family didn’t know: Even though the delirium may disappear by the time the patient leaves the hospital, debilitating cognitive problems can resurface. Imaging scans have linked delirium to reduced brain size, and it can result in long-term memory and mental impairment, according to Dr. Ely.

“Nobody knew this before, but experiencing delirium in the I.C.U. is a very strong predictor of dying — there’s a threefold rise in death within a year,” he said.

Yet the word has not spread. “When I went to medical school, we were taught delirium was transient and reversible,” said Dr. Sharon K. Inouye, a professor of medicine at Harvard Medical School and director of the Aging Brain Center at Hebrew SeniorLife in Boston.

But that was dead wrong. “Medical schools are now training the new generation about delirium’s dangers, but there are thousands of doctors in the older generation who don’t know how to recognize it or know that 30 to 40 percent of it could be prevented,” said Dr. Inouye. “We could solve our whole Medicare crisis by preventing delirium. We spend over $100 billion dollars annually on delirium in the hospital.”

Distinguishing between delirium and dementia, which even medical professionals often mix up, is critical. Delirium signals that something in the body is seriously wrong and needs attention, fast. Dementia, not so; it’s chronic confusion and memory loss that comes on gradually and gets worse. Delirium is confusion that comes on suddenly, often within hours, brought on by such triggers as infection, the stress of a disease or operation, not getting enough food or water or sleep, or medications often administered in the hospital, said Dr. Inouye.

How to know if your family member is suffering delirium? Caregivers who know the patient in normal times are the best judges of when things are not right. Look for any of these four signs:

  • Acute change of mental status: Not making sense when he or she talks? Disoriented, illogical, unable to focus? Trust your instincts. Let the staff know this is not normal behavior.
  • Inattention: As you hold the patient’s hand, ask him or her squeeze every time you say the letter A, as you clearly spell out “save a heart.” “If they miss two, or squeeze on the wrong letter, that is a sign of delirium,” said Dr. Michele Balas, assistant professor in the College of Nursing at the University of Nebraska Medical Center.
  • Altered level of consciousness: You’re looking for two possible extremes. In hyperactive delirium, patients are anxious, agitated, aggressive, picking at clothes or IVs. In hypoactive delirium, they’re lethargic, sleepy and not making eye contact.
  • Confusion and disorganized thinking: Can the patient track a conversation? “I ask simple questions, like, ‘Does one pound weigh more than two pounds?,’ or ‘Will a stone float on water?’” said Dr. Balas.

“Don’t let the doctors and nurses tell you this just happens in the hospital,” Dr. Inouye said. “Say, ‘This is not normal — this can be a medical emergency.’”

I wish we’d known all this before my mother’s episode. We got lucky — once the doctors pulled back on the sedation and the physical therapists got her up and moving for rehab on her hip, the delirium receded. My mother seemed to come back to herself.

But the story’s not over. More about what happened next week.

Originally published at newoldage.blogs.nytimes.com