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Breaking through delirium

Hospitals target a common yet serious complication among elderly patients

Sumner Kessler, a 76-year-old Brookline resident, came through spinal surgery with few problems last month. But two days after the operation, as he recuperated at Beth Israel Deaconess Medical Center, a fog began to enclose his mind.

He thought it was December, not June. He didn't recognize his wife. Although he was bedridden, the salesman wanted to phone a store in Natick to see if he could make a sales call that afternoon.

Kessler was suffering from delirium, a complication of hospitalization far more common than bedsores or falls among elderly patients but often overlooked or confused with dementia. Millions of hospitalized seniors each year develop the sudden, serious mental confusion that typically lengthens their hospital stay, slows their recovery, and can hasten their death.

''It's one of the biggest problems older people can run into in the hospital," said Dr. Suzanne Salamon, associate chief of clinical geriatrics at Beth Israel.

Delirium is often brought on in the hospital by a combination of factors that disrupt the patient's routines and health. Common causes include infections, medications, malnutrition or dehydration, immobility, noise, sleep disruption, and not being able to use eyeglasses and hearing aids. Researchers are not sure how these factors trigger delirium but believe they may create an imbalance in neurotransmitters in the brain, according to Dr. Sharon Inouye, a specialist in delirium at Yale University School of Medicine.

The problem is getting new attention from some hospitals, which are devising programs to prevent delirium and to shorten its duration when it occurs. Beginning later this month, geriatricians at Beth Israel will intervene in the care of every older patient admitted for hip fractures or joint replacement surgery, in an effort to minimize the risk of delirium. Among these surgery patients nationally, more than half develop delirium, according to several studies. In addition, delirium strikes about 35 percent of elderly patients hospitalized for nonsurgical medical problems.

Massachusetts General Hospital is considering an initiative that would flag older patients who show signs of delirium in the emergency room for special care throughout their hospital stay. The initiative would take simple steps, such as reducing the number of medications prescribed and medical tests performed, removing catheters and IV-lines as quickly as possible to allow patients to move freely, and providing darkness and quiet at night to allow normal sleep.

Symptoms of delirium often include hallucinations, paranoia, and agitation that may lead patients to attempt to rip out intravenous lines or strike out at staff. But in the quiet form of the illness, the symptoms include withdrawal and extreme sleepiness, which can make it hard to diagnose. It can last anywhere from a day to months, with about half of cases resolving within a week, according to Dr. Edward Marcantonio, a delirium specialist at Beth Israel.

For Kessler, it was a terrifying experience. Along with the confusion, panic set in. He believed he had to get somewhere, but felt he was being left behind. He needed help but thought he couldn't find the call button.

''You feel confined, like in a 2-by-2 jail," he said. ''You almost feel as if you'd like to commit suicide."

Kessler's physician, Dr. Kathryn Agarwal, diagnosed the problem after speaking to him and realizing ''this was not my intelligent, with-it patient," she said. Initially restless and confused, Kessler began to show signs of a sleepy delirium and would trail off while speaking, she said.

She and other staff took him off a particular sleep medication and a muscle relaxant and all but one medication for pain. They disconnected his catheter and got him out of bed and into physical therapy. They tried to find the cause of a fever that they believe may have been one of the triggering causes. After two days, he was back to his old self.

Starting mid-month, Salamon, Agarwal, and other geriatric staff at Beth Israel plan to intervene in the same way before older patients go into surgery. They will streamline the patients' medications, discourage use of restraints and catheters, and check for blood chemical imbalances before surgery. After the operation, they will make sure patients have their hearing aids and glasses so they can stay oriented, will closely monitor patients' food and drink, and will work to manage pain without too many drugs.

''We decided to see if we can head some of this off right at the beginning," said Salamon.

The program, which requires orthopedic surgeons to work closely with geriatricians, is based on a study conducted by Marcantonio, director of research in Beth Israel's division of general medicine. The study, published in 2001, showed that similar interventions in the care of patients with hip fractures could cut the occurrence of delirium by 36 percent. Beth Israel has already been using some of these strategies in its special 30-bed unit for acute care of vulnerable elders.

A study at Yale-New Haven Hospital achieved a 40 percent drop in delirium among patients admitted with a range of illnesses. The initiative trained nurses and therapists to ensure patients are comfortable, mobile, and mentally stimulated, and enlisted volunteers for daily chats, reading sessions, or walks with patients. The Yale program, developed by Inouye, is being used by dozens of hospitals nationally. At Yale, the program did not affect the severity of delirium or the death rate, but it cut the duration of episodes by one-third and reduced medical costs. Inouye estimates the cost of delirium treatment nationally at about $8 billion.

At MGH, Dr. Claus Hamann has developed a program to catch delirium early and try to reduce its duration. The program has not yet been approved by MGH executives, but Hamann proposes using a geriatric team to follow patients, trying to change hospital practices that may lead to delirium.

A separate initiative started in 2002 at MGH has already resulted in earlier discharges for medical and surgical patients who became delirious. The methods helped those patients leave the hospital nearly two days earlier on average, according to Barbara Guire, a psychiatric clinical nurse specialist. She heads a team of nurses hired to help improve care and reduce the stress on other staff caused by delirious patients, who may become combative and often need one-on-one care.

In the past, she said, staff often didn't recognize delirium or realize it was treatable, but diagnosis has improved by 50 percent. The team uses intravenous haloperiodol, an antipsychotic drug helpful in acute delirium, and quickly makes changes to normalize patients' lives.

''The longer delirium goes untreated, the less likely it will clear," she said. ''Our goal is to get the patients back quickly to their previous level of functioning."

Alice Dembner can be reached at Dembner@globe.com.

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