SAN ANTONIO – Simple steps such as treating infections, avoiding physical restraints, and letting patients sleep at night can go a long way toward reducing delirium episodes among elderly patients in acute and postacute settings, delirium experts said at the annual meeting of the American Association for Geriatric Psychiatry.
"Starting anywhere is better than the status quo," said Dr. David J. Loreck, director of Baltimore VA Medical Center Mental Health Consultation Services, and assistant professor of psychiatry at the University of Maryland in Baltimore.
Delirium is an insidious, underrecognized problem associated with significant morbidity and mortality. It frequently falls through the cracks between different disciplines and services within the hospital, he said.
"Delirium is common among older people and is associated with significant morbidity and mortality, but we still underrecognize it," said Dr. Yesne Alici, a geriatric psychiatrist at Central Regional Hospital in Butner, N.C.
She pointed to a meta-analysis of studies of delirium in elderly patients, which showed that patients with delirium had a nearly twofold risk for death, compared with controls, and that "delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia" (JAMA 2010;304:443-51).
But every difficult case of delirium also provides educational, clinical, and/or performance-improvement opportunities for hospital administration, medical and surgical services, nursing, geriatrics, pharmacy, and other disciplines, Dr. Loreck noted.
Early recognition and intervention are critical, because the longer the episode of delirium, the less likely the patient is to fully recover to baseline status, both noted.
Unit-Based Solution
The unique leadership, administrative structure, and work environment of each hospital unit will suggest the best approach to preventing delirium among patients in that unit, Dr. Loreck said.
One option is to identify a "dementia champion" within each unit – whether the champion is a physician, nurse manager, or clinical nurse specialist – and work with that individual to be a dementia leader who can develop a team within the unit to help identify those patients most at risk for delirium.
A more practical and realistic option, however, is for the hospital to have a specific consultation service composed of geriatricians, psychiatrists, or neurologists who act as institution-wide dementia specialists to help identify delirium triggers and institute measures appropriate to each unit for reducing delirium.
"Even though you’re not training a whole team, you’re still going to need a point person on the unit to trigger the consult team into action," Dr. Loreck said.
Clocks, Calendars, Caregiver IDs
Nursing staff, who spend the most time with patients, are the clinicians most likely to detect changes in patient mental status. But generally, nurses are not that good at recognizing delirium, both Dr. Loreck and Dr. Alici said.
Nonetheless, nurses are often well positioned to implement delirium prevention strategies; identify delirium risk factors, signs, and symptoms; and intervene early to ameliorate the negative effects of delirium when it occurs. Nursing staff can be trained to differentiate delirium from dementia, and to distinguish between hypoactive delirium and the effects of illness, medications, fatigue, or environmental influences on sleep.
All unit staff also should be aware of delirium triggers, such as infections (especially urinary tract infections), constipation, hypoxia, hypotension, pain, and medications.
Simple time and place cues such as easily visible clocks, calendars, and caregiver IDs, can help orient patients to their whereabouts. The unit also should allow for appropriate sensory stimulation of patients, with a quiet room, adequate light, and engagement in only one task at a time.
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