Drowsiness...or delirium?
Posted on Thursday, January 03, 2008
By Wendy J. Meyeroff THE ERICKSON TRIBUNE More and more experts are warning older adults, their doctors, and caregivers that lethargy can be a sign of a too often unrecognized problem among older adults: delirium. What is delirium? “Delirium is confusion in mental function, but unlike dementia—which stays relatively stable or even declines—in delirium, someone’s mental status fluctuates,” says Mark Holden, M.D., Erickson Health medical director at Eagle’s Trace, a full-service retirement community in Houston, Tex. Also, delirium is generally temporary and usually reversible. “As people age, their odds of having delirium increase. The percentage of older people admitted to a hospital who already have delirium is 20–25%,” says Joseph Flaherty, M.D., associate professor of geriatrics at St. Louis University School of Medicine and the Veterans Administration in St. Louis, Mo. Flaherty has seen not fighting delirium bring serious health consequences, “like stronger infections.” And delirium ultimately costs more when ignored. In one study, 63% of patients with dementia who developed delirium after being hospitalized were readmitted to the hospital within 30 days. Common causes “When your system is fragile, anything that compromises it can cause delirium,” says Patricia Gavin, Elder Life specialist in the Hospital Elder Life Program at Caritas Norwood Hospital in Norwood, Mass. The most common symptoms of delirium include agitation and ranting, lessened ability to think or focus, and extreme drowsiness. Post-operative infections are one cause; one of the most common is medications. “Almost any drug can cause delirium, but especially drugs that work in the brain, like sedatives, anti-convulsants, and drugs for Parkinson’s disease,” Flaherty says. “So can cold medicines— especially ones containing diphenhydramine,” he adds. The impact of hospital stays “Older adults are more likely to have dementia, perhaps a low-level one that hasn’t been recognized. You’re more likely to develop delirium if you’re one of these people and enter a hospital,” Flaherty says. “The rate of delirium in older adults rises as high as another onethird once they are hospitalized.” What makes hospital stays so prone to causing delirium in older adults? “Change of environment is a big factor. They’re used to their routine, and the change is stressful. Hearing and vision impairments and other sensory deprivations confuse them, and they withdraw,” Gavin says.
“Sleep deprivation from noise or constant checkups is another factor,” Flaherty adds. Fighting ageism “The agitated type of delirium, where people yell or scream, gets addressed quickly. It’s what we call the lethargic (drowsy) type that is dangerous. An 80-year-old who’s admitted and is very quiet may actually be fighting an underlying infection,” Flaherty says. Left untreated, that can be dangerous, even deadly. Unfortunately, such quietude is too often dismissed as normal in an older person. “We hear, ‘They’re on so many medicines—of course they’re drowsy,’” Flaherty says. “But I test the attention of someone drowsy, and if it’s abnormal, I say, ‘This person is suffering from delirium.’” Changes in treatment “In medical education I’ve taught health professionals to look for and treat underlying problems that can cause delirium, like infections,” says Holden. But resistance to deliriumfighting programs still occurs. “It requires a definite commitment in personnel and money,” Gavin says. “A diagnosis of delirium may require further medical testing to find other, undiagnosed, illnesses,” Flaherty says. “I do an assessment on all patients over 70 within 48 hours of their admission. I check their vision and hearing, their appetite, and how they’re sleeping. We also do a brief assessment when they come in and before they leave,” Gavin says. Flaherty is an ardent advocate of such mental assessments. He and others working with older veterans in VA hospitals nationwide are proposing that health personnel regularly check mental health status, just as they check a patient’s blood pressure, temperature, and other physical signals. One simple test: asking someone to say the days of the week backwards. “Even people with dementia can often do it forward, but those with delirium may not [have the] concentration to do it backwards,” he says. The Delirium Room Most of the measures discussed are for preventing delirium, but for people already delirious, Flaherty developed a program called the Delirium Room. Instead of isolating and restraining delirious patients, they are put together where well-trained personnel can monitor them closely. Nurses look for dehydration to avoid further mental problems. An agitated patient may not need restraints, but a more comfortable IV line. Fall prevention is importantin Flaherty’s program to avoid additional physical problems and longer hospital stays. One thing the program doesn’t necessarily avoid is pain medication. “Pain itself can cause delirium, and pain medicines are fairly well tolerated by older adults,” Flaherty says. He thinks the key is to start the medicine and increase dosage until a balance is found for easing individuals’ pain without overly sedating them. What family and friends can do “Our volunteers work to keep patients mentally engaged. We talk about current subjects to keep them aware of days and times, we play cards, and we help with crossword puzzles. We
walk with them when possible. Opening their food container is a help; poor nutrition causes delirium in many seniors,” Gavin says. All of these are things family and friends can do. “Also, open the curtains and make sure your loved one gets a sense of night and day,” Holden says. Sleep problems are a doubleedged sword. Insomnia can cause delirium, but so can common sleep medications. Look for alternatives like massages and soothing music. Most importantly, “Confirm your loved one’s regular mental status with any health person who walks into their room—not just in a hospital, but in long-term care as well. You might say, ‘This is not the way my husband is normally,’” Flaherty says. The answer, “He’s on medicine,” or “just out of surgery” shouldn’t be an excuse; instead it should cause you to insist your loved one be watched even more closely.