This New York Times article is on hospital delirium, which affects one-third of patients over 70.

Some excerpts:

"The cause of delirium is unclear, but there are many apparent triggers: infections, surgery, pneumonia, and procedures like catheter insertions, all of which can spur anxiety in frail, vulnerable patients. Some medications, difficult for older people to metabolize, seem associated with delirium."

"But new research shows significant negative effects. Even short episodes can hinder recovery from patients’ initial conditions, extending hospitalizations, delaying scheduled procedures like surgery, requiring more time and attention from staff members and escalating health care costs. Afterward, patients are more often placed, whether temporarily or permanently, in nursing homes or rehabilitation centers. Older delirium sufferers are more likely to develop dementia later. And, Dr. Inouye found, 35 percent to 40 percent die within a year."

"Dr. Malaz A. Boustani...found that elderly patients experiencing delirium were hospitalized six days longer, and placed in nursing homes 75 percent of the time, five times as often as those without delirium. Nearly one-tenth died within a month. Experts say delirium can contribute to death by weakening patients or leading to complications like pneumonia or blood clots."

Here's the full article.


http://www.nytimes.com/2010/06/21/scien ... irium.html

June 20, 2010
Hallucinations in Hospital Pose Risk to Elderly
By Pam Belluck
New York Times

No one who knows Justin Kaplan would ever have expected this. A Pulitzer Prize-winning historian with a razor intellect, Mr. Kaplan, 84, became profoundly delirious while hospitalized for pneumonia last year. For hours in the hospital, he said, he imagined despotic aliens, and he struck a nurse and threatened to kill his wife and daughter.

“Thousands of tiny little creatures,” he said, “some on horseback, waving arms, carrying weapons like some grand Renaissance battle,” were trying to turn people “into zombies.” Their leader was a woman “with no mouth but a very precisely cut hole in her throat.”

Attacking the group’s “television production studio,” Mr. Kaplan fell from his hospital bed, cutting himself and “sliding across the floor on my own blood,” he said. The hospital called security because “a nurse was trying to restrain me and I repaid her with a kick.”

Mr. Kaplan’s hallucinations lifted as doctors treated his pneumonia. But hospitals say many patients are experiencing such inexplicable disorienting episodes. Doctors call it “hospital delirium,” and are increasingly trying to prevent or treat it.

Disproportionately affecting older people, a rapidly growing share of patients, hospital delirium affects about one-third of patients over 70, and a greater percentage of intensive-care or postsurgical patients, the American Geriatrics Society estimates.

“A delirious patient happens almost every day,” said Dr. Manuel N. Pacheco, director of consultation and emergency services at Mount Auburn Hospital in Cambridge, Mass. He treated Mr. Kaplan, whom he described as “a very learned, acclaimed person,” for whom “this is not the kind of behavior that’s normal.” “People don’t talk about it, because it’s embarrassing,” Dr. Pacheco said. “They’re having sheer terror, like their worst nightmare.”

The cause of delirium is unclear, but there are many apparent triggers: infections, surgery, pneumonia, and procedures like catheter insertions, all of which can spur anxiety in frail, vulnerable patients. Some medications, difficult for older people to metabolize, seem associated with delirium.

Doctors once dismissed it as a “reversible transient phenomenon,” thinking “it’s O.K. for someone, if they’re elderly, to become confused in the hospital,” said Dr. Sharon Inouye, a Harvard Medical School professor. But new research shows significant negative effects.

Even short episodes can hinder recovery from patients’ initial conditions, extending hospitalizations, delaying scheduled procedures like surgery, requiring more time and attention from staff members and escalating health care costs. Afterward, patients are more often placed, whether temporarily or permanently, in nursing homes or rehabilitation centers. Older delirium sufferers are more likely to develop dementia later. And, Dr. Inouye found, 35 percent to 40 percent die within a year.

“It’s terrible, more dangerous than a fall,” said Dr. Malaz A. Boustani, a professor at the Indiana University Center for Aging Research, who found that elderly patients experiencing delirium were hospitalized six days longer, and placed in nursing homes 75 percent of the time, five times as often as those without delirium. Nearly one-tenth died within a month. Experts say delirium can contribute to death by weakening patients or leading to complications like pneumonia or blood clots.

Ethel Reynolds, 75, entered a Virginia hospital last July to have fluid drained that had been causing her feet to swell. She wound up hospitalized for weeks, sometimes so delirious that “she screamed constantly, writhed,” said her daughter, Susan Byrd. “I had to get in bed with her because she thought someone was coming and they were going to hurt us,” Ms. Byrd said.

Ms. Reynolds ended up needing dialysis and surgery after an infection, and she died in September.

“We got her death certificate, and the No. 1 cause of death was delirium,” said Ms. Byrd, an ophthalmology nurse. “I was just blown away. As a nurse, I was expecting a quote-unquote medical reason: kidneys, heart, lung, an organ that I could understand had failed, and it wasn’t. It was delirium.”

Other triggers involve disorienting changes: sleep interrupted for tests, isolation, changing rooms, being without eyeglasses or dentures. Medication triggers can include some antihistamines, sleeping pills, antidepressants and drugs for nausea and ulcers. Dr. Inouye said that many “doctors don’t know how to appropriately use meds in older people, in terms of dosing” and compatibility with other medications.

Earle Helton, 80, a retired chemist hospitalized after a stroke, ordered his family to “throw a rope over the hedge so he could escape,” said his daughter, Amanda. He tried removing his hospital gown, loudly sang “Lullaby and Goodnight,” and doctors had to tie down his hands to prevent him from leaving, said his wife, Ginnie. Only when Dr. Inouye stopped some medications that other doctors had prescribed did he become lucid.

Delirium is sometimes treated with antipsychotics, but doctors urge caution using such drugs.

Delirium can wax and wane, not always causing aggressive agitation.

“It is often the person quietly in bed,” and the condition can linger for weeks or months, landing patients back in the hospital, said Dr. Julie Moran, a geriatrician at Beth Israel Deaconess Medical Center in Boston. “We would have to build 100 more floors to keep everybody until they cleared their delirium. There are times when we could be working round the clock seeing patients with delirium.”

Frequently, geriatricians say, delirium is misdiagnosed, or described on patient charts as agitation, confusion or inappropriate behavior, so subsequent doctors might not realize the problem. One study found “delirium” used in only 7 percent of cases; “confusion” was most common. Another study of delirious older emergency-room patients found that the condition was missed in three-quarters of them.

People with dementia seem at greater risk for delirium, but many delirious patients have no dementia. For some of them, delirium increases the risk of later dementia. In such cases, it is unclear if delirium caused the dementia, or was simply a signal that the person would develop it later.

Some hospitals are adopting delirium-prevention programs, including one developed by Dr. Inouye, which adjusts schedules, light and noise to help patients sleep, ensures that patients have their eyeglasses and hearing aids, and has them walk, exercise and do cognitive activities like word games.

Dr. Moran’s hospital removes catheters, intravenous lines and other equipment whenever possible because they can make patients feel trapped, leading to delirium. She said nurses repeatedly assess cognitive function so patients “don’t have smoldering symptoms of delirium for days before they end up yelling and screaming.”

Mr. Kaplan, a biographer of Mark Twain and Walt Whitman, later jotted notes about his hallucinations, including being in a police helicopter “tracking fugitives with enormous light.”

“Exhilarating until I become one of the fugitives,” he wrote. “End up cold and naked in some sort of subway passage.”

His fall bruised his elbow, leg and wrist, said his wife, the writer Anne Bernays. The next day, “he was gaga till about noon,” and even “looked me in the eye and said ‘I’m going to kill you,’ ” she said. “He didn’t know where he was and didn’t recognize me.”

Fortunately, his delirium was discovered very quickly and he made a very good recovery, Dr. Pacheco said. “But,” he said, “delirium is very disruptive for the patient, family, hospital caregivers.”

As Mr. Kaplan understated later, “It was a lot of unpleasantness.”

I believe this is the heart of the problem!!! Good article, Robin. Thanks for bringing it to our attention.

The article has a good list of possible triggers (one of which never occurred to me): infections (such as pneumonia), surgery, procedures like catheter insertions, and medications.

One I would've added to the list is being in a different environment. Another article I read a year or so ago said that giving patients their eyeglasses and hearing aids did a lot for preventing delirium.

Very interesting article! Immediately following several of my dad's falls over the last 18 mo. he became delirious. Only after being in the hospital for a day or so did his confusion and delirium decrease some, and he wasn't given any new meds at those times. Possibly he was delirious BEFORE falling? He was alone each time, so hard to tell.
Thanks for posting. Lynn

Thanks so much for posting this, Robin. My dad has had this since his first surgery, which was about 20 years ago. Any other surgery brought on the same thing. When he broke a hip five years ago, he never did come out of it. Unfortunately, the extent of the problem was unknown, except to my mother, for that many years. My dad was very good at "show time." My sibs and I are wondering now if we face the same fate. He's just now being diagnosed and I think he's between stage three and four.

My husband (age 68) had his first bout with delirium about 15 years ago following gallbladder surgery. He thought he was in church naked. No one could convince him other wise. Recovered next day. Then he had a crush injury to his pelvis in 2001. Same delirium returned. Lasted several days. Even had to be restrained and sent to the psych ward. I researched all meds at the time, and discovered he was being given Adavan, every 4 hours. Commonly used to put one to sleep for surgery. I requested all Adavan be stopped. Met with a lot of resistance with the doc's. We were at a Medical sciences hospital with all the training dr's. They all thought I was the crazy one. However after the Adavan was finally stopped, my husband recovered and we have since listed it as a allergic med. But now I am wondering if that could have contributed to the LBD that he is now suffering. I believe he is between stage 2 and 3. Is hindsight really 20/20 or do we only cause ourselves more pain by trying to pick out something to cling to???? If your LO is being given Adavan, I would be VERY careful......

Many with LBD can tolerate Ativan. I don't think any MDs have listed it on their lists of drugs to avoid with MD. But many cannot tolerate it -- whether they have LBD or not. Since the half-life of Ativan is rather short, I assume that's why it's often given.

It's good you know your husband cannot tolerate Ativan (lorazepam). Perhaps all benzodiazepines should be avoided in your husband's case?