Published in the June 2008 issue of Today’s Hospitalist
When elderly inpatients become delirious, they’re likely to face hospital stays that are days “or weeks “longer than patients without the condition. But they also face a much greater risk of falls, pressure ulcers and infections, and they are twice as likely to die within a year.
Unfortunately, most doctors “including hospitalists “fall short in preventing this “hazard of hospitalization.” That’s particularly disturbing because delirium occurs in anywhere from 15% to 60% of elderly patients, according to Heidi Wald, MD, assistant professor of medicine and health care policy at the University of Colorado, Denver (UCD).
Delirium is common, preventable, often iatrogenic and “linked to things we do to patients in the hospital,” said Dr. Wald, who is also co-director of UCD’s hospitalist medical group’s geriatrics service. That’s led some quality organizations, including the National Quality Forum, to contend that delirium can be used as an indicator of quality of care. “Higher rates of delirium” she said, “are associated with poor quality of care.”
At this spring’s Society of Hospital Medicine annual meeting, Dr. Wald explored seven common mistakes that hospitalists make in managing delirium, as well as strategies to help physicians do a better job.
#1 Don’t miss the signs
The first mistake physicians make is failing to diagnose delirium. “As many as one-third to two-thirds of cases are thought to be totally unrecognized, even by nurses,” Dr. Wald said.
Most physicians and nurses picture delirious patients as being hyperactive, agitated, hallucinating and acting inappropriately. But Dr. Wald pointed out that such patients account for only a quarter of individuals who have delirium. The much larger percentage “maybe 75% “are hypoactive and have reduced motor activity and lethargy.
And because delirium fluctuates in its course, Dr. Wald explained, it’s easy to miss if you’re not at a patient’s bedside 24 hours a day. Studies have likewise shown that delirium tends to be missed when patients also have dementia or vision problems, she said.
Once you identify patients at higher risk, Dr. Wald recommended spending a few minutes with those patients doing a mini cognitive assessment test.
“When you have done a cognitive assessment,” she said, “observe them for a few minutes and look for inattention, disorganized thinking or an alternate level of consciousness. If it is anything other than alert, it’s not normal.”
#2 Scrutinize the med list
When trying to predict who’s at risk for delirium, Dr. Wald said it’s helpful to think of the disease as “a geriatric syndrome,” which she defined as a clinical manifestation of multiple morbid processes. That’s different from “a typical medical syndrome,” which tends to be characterized by multiple manifestations of a single morbid process.
“It’s unlikely that you will find one underlying cause” for delirium, Dr. Wald pointed out. “There is likely a web of interacting causes, so you need to identify as many as you can and address all of them.”
Patients at greatest risk are older and more debilitated; those suffering from dementia or psychiatric illnesses such as depression; and those who are cognitively impaired. Other important risk factors include gender “males face a higher risk “as well as dehydration and the presence of multiple medications.
“Obviously, you don’t want to stop every medication,” Dr. Wald said. “But you want to look at what can be stopped in the hospital and then added again at discharge. Often, patients markedly improve just by taking them off all their drugs.”
The medications classically associated with delirium are agents that affect the central nervous system like sedatives and hypnotics. But there are other therapies commonly prescribed in hospitals that you should advise against for high-risk patients. They include Benadryl for sleep; any other medicine with anticholinergic effects; heart medications such as digoxin or beta-blockers; and even H2 blockers. Alcohol and drug withdrawal can also play a factor in delirium.
#3 Pay attention to environment
Dr. Wald pointed out that a patient’s environment can also increase the risk of delirium. Foley catheters, for instance, have been shown to be an independent risk factor for delirium.
Other high-risk environmental characteristics include sleep deprivation; immobility; sensory deprivation or overload, such as when a room is dark or noisy; and social isolation in which patients “don’t have their usual social clues around them.”
High-risk situations, she said, include uncontrolled pain; surgery, particularly non-cardiac thoracic surgery or orthopedic surgery; infections; poor nutritional status; and concomitant acute illness or neurologic disease.
And while it has long been thought that regional, as opposed to general, anesthesia is better for people at risk of developing delirium, Dr. Wald said the reality is that “the type of anesthesia has not been shown to have an impact.”
#4 Don’t forget preventive measures
One common mistake physicians make is failing to institute known preventive measures for patients at high risk. “Prevention may be our most effective tool,” Dr. Wald said. “All our interventions don’t work as well once the patient has delirium.”
The best work in this field has come from Sharon Inouye, MD, MPH, and her colleagues at Yale University. Their “HELP” (Hospital Elder Life Program) project has shown that physicians can reduce the number of both delirium episodes and days by addressing many risk factors.
Preventive strategies include providing orienting communication; reducing restraints; encouraging early mobilization; focusing on dehydration; and allowing for uninterrupted sleep by turning down the lights and prohibiting nurses from waking patients at night to take vital signs.
When the HELP program’s interventions were used, Dr. Wald said, researchers found a 40% reduction “from 15% to 10% “in delirium rates.
#5 Take it easy on diagnostic tests
Another common mistake, said Dr. Wald, is the overuse of diagnostic tests. A good place to start is cutting down on the number of EEGs you order for patients who may have delirium.
An EEG will only help rule out occult seizures or differentiate delirium from a suspected psychiatric disorder like schizophrenia. Because the test produces a high number of false positives and negatives, she explained, “it is not a good standard for delirium.”
Neuro-imaging is another low-yield strategy, Dr. Wald said. An exception is testing a patient on Coumadin who has fallen and is now exhibiting a change in mental status. “Imaging ends up being appropriate in some small subset of patients, maybe 5% or less,” she pointed out.
Because it can be difficult to judge dehydration in frail elderly patients just by looking at skin turgor, hospitalists may find it useful to order some basic lab tests to rule out electrolyte abnormalities and dehydration. Infectious disease workups can also be useful, she said, because urinary tract infections “are a common underlying precipitant of delirium.”
#6 Prescribe medications carefully
When treating delirium, the biggest mistake doctors make is relying too heavily on medications. Instead, Dr. Wald said, therapy should consist largely of supportive care.
Protect the airways of people who aren’t able to breathe, and make sure they are getting enough nutrition. Examine patients’ skin if they are hypoactive, and make sure they get appropriate DVT prophylaxis if they’re not mobile.
“And you need bright lights during the day to help them revert back from their day-night reversal,” Dr. Wald explained. “Have somebody in the room with them, remove tethers, take away the telemetry monitor, and make sure the room is calm, well-lit, and not too noisy.”
As for medications, the only two indications for ordering antipsychotics are when patients are so severely agitated that they interfere with their own care, or when patients are a danger to themselves or others.
“I’m not talking about the little old lady saying, ‘Help me, help me,’ ” Dr. Wald pointed out. “That’s annoying, and you might be worried about what others are saying, but it is probably not interfering with her care. If she is not harming herself or others, hold off from pharmacologic care.”
Before writing the prescription, she added, “ask yourself if you are doing it for them or for you.” (See “Medication options and dosing," below.)
#7 Don’t ignore delirium at discharge
Finally, physicians often fail to add a care plan for delirium when discharging patients.
Given how long delirium lasts, Dr. Wald said, patients probably won’t be completely over it by discharge. Although symptoms tend to start abating after five days, studies find that only a minority of patients will be completely over their delirium in three or even six months after leaving the hospital.
Instead, they will likely be “suffering from functional decline, and they will need more care and more follow-up,” said Dr. Wald. “You need to arrange coverage and follow-up treatment.”
Deborah Gesensway is a freelance writer reporting on U.S. health care from Toronto, Canada.
The antipsychotic haloperidol (Haldol) has been shown in randomized controlled trials to shorten the course and severity of delirium, according to Heidi Wald, MD, co-director of the hospitalist medical group’s geriatrics service at the University of Colorado, Denver.
But there are extrapyramidal side effects with high doses, Dr. Wald pointed out. Atypical antipsychotics “risperidone, olanzapine and quetiapine “may be as effective as low-dose haloperidol, but they have been associated with increased mortality in patients with dementia when used long term.
“We don’t know what they mean for delirium,” Dr. Wald said, “especially because many patients also have dementia.”
That’s why she sticks with the tried-and-true Haldol, except when high doses are needed. “Then I might switch to an atypical to avoid the side effects.”
For acutely agitated, delirious patients, Dr. Wald recommends the following Haldol algorithm: Load patients with small doses (0.5-1.0 mg) every 30 minutes until they’re manageable, preferably avoiding the IV form because of its half-life. (Don’t use more than 5 mg over 24 hours in a Haldol-naÃ¯ve patient.) After the first 24 hours, give half of the loading dose twice a day for the next few days, and then start to taper off.
“These patients are not supposed to be on these meds for a long time,” she said. “You don’t want to send them out of the hospital on the medication.”
Because benzodiazepines can prolong and worsen delirium, she said, use them only if the patient has Parkinson’s disease or is in alcohol withdrawal.
Dr. Wald also noted that there is now some research on whether giving haloperidol to high-risk patients prophylactically can work to prevent the onset of delirium. One study, Dr. Wald said, found equivalent incidence, but decreased severity and reduced length of stay.
“Is this the wave of the future?” she asked. “I don’t know. I think you would want to target it to patients who are particularly high risk.”
Want help predicting who’s at risk?
WHEN TRYING TO PREDICT which patients are at high risk for developing
delirium, hospitalists can consult two validated prediction rules:
● One simple tool, developed at Yale University School of Medicine and published in 1993, considers only four factors: visual impairment, severity of illness, cognitive impairment and high levels of creatinine.
● The second tool, which was published in 1994, is a little more complex and focuses on perioperative risks.