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Treating delirium a puzzling mix of cause, effect

Updated 10:08 am, Wednesday, August 14, 2013


  • Dr. Edgar Pierluissi (left) visits with patient Eldoretha Tyler at the Acute Care for Elders unit at S.F. General Hospital. Tyler doesn't have delirium and keeps active. Photo: Brant Ward, The Chronicle


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Betsy Gullickson visited her mother in an intensive care ward in early 2006, just as her health was really beginning to decline, expecting to see her mom weak and in pain, tied to a bed by tubes and wires and feeling awful.

What she wasn't prepared for was the delirium.

"She told me and my sister that there were Israelis with Uzis in the hallway," Gullickson recalled of that first visit with her mother, Ruth Raskin. "She thought the nurses were putting things in her IV. She'd grab my hand and say, 'Don't leave me.' It was very frightening for her, and very frightening for us.

"You think you're prepared to see your parent in the hospital. But this? This was out of the blue, to see her off the rails like that," Gullickson said. "We weren't prepared for Mom just being bonkers."

The delirium was so traumatic that Gullickson, who lives in Kentfield, and her sister agreed to donate money set aside in their mother's estate to research improving care for these patients. Last week, the first paper was published from research funded by Raskin's money - a UCSF study that may help doctors and nurses determine which patients are most likely to suffer delirium.

There's no standard treatment for delirium, which almost always resolves itself after a few days. But there are steps health care providers can take that could help patients recover faster. And studies have shown that many episodes of delirium could be preventable with relatively simple strategies - things like keeping certain drugs away from patients, letting patients sleep through the night, and hanging calendars and clocks in hospital rooms to make patients aware of the time and date.

At risk

If doctors are able to determine which patients are most at risk, they can take steps to keep those people mentally sharp, said Dr. Vanja Douglas, a UCSF neurologist and lead author of the UCSF delirium study.

"Typically, delirium has been thought of as something temporary, something that resolves itself on its own, so you just have to reassure the family that everything will be fine," Douglas said. "There's been this attitude that there's not much to do about it. But it's probably not quite right to think of it that way."

Gullickson's mother was very ill in early 2006, suffering from cancer and a connective tissue disease that would kill her by the end of the year. But she was still cognitively healthy - engaged in her care, and able to talk and relate to her family and friends.

During at least three hospital stays that year, however, Raskin slipped into delirium, a state of sudden, severe confusion that is remarkably common among hospital patients. Studies have shown that roughly 10 to 20 percent of hospitalized patients suffer bouts of delirium, and the rates are even higher among the elderly.

Delirious patients often will suffer hallucinations, and they can appear disoriented and unable to focus on their surroundings. They may be unable to recognize friends or family members. They usually alternate between hyperawareness - yelling or crying, or trying to climb out of bed or tear out IV lines - and hours when they are so sleepy that they can barely be aroused to eat.

For many decades, delirium had been dismissed by health care providers as an often unavoidable, and relatively harmless, consequence of serious illness in the elderly. But recently, doctors and researchers have noted that patients suffering delirium have an increased risk of later developing dementia.

In fact, delirium is tied to several poor health outcomes. Delirious patients have longer hospital stays than those who don't suffer delirium, and they are more likely to go straight from the hospital to a nursing home.

'Bottom line'

"The bottom line is that a lot of people don't quite get back to where they were before their episode of delirium," Douglas said.

Doctors don't know what happens in the brain, biologically, to cause delirium, although they know many of the medical and environmental triggers. Hospital-acquired delirium is common because people who become delirious almost always are very ill or injured.

Trigger points

In younger people, things like very high fevers or major surgery can prompt delirium. But in people 65 and older, less serious events can set off a delirious episode. People who are already showing some signs of dementia are more likely to become delirious, but so are people with vision or hearing problems.

Once they're in the hospital, even relatively simple problems - bladder infections, insomnia, constipation and immobility - can make patients more vulnerable to delirium. That's why, for many doctors, treating the underlying illness or problem is the first step toward treating delirium.

"There usually is something that happens to that person that tips them into delirium. Maybe it's an infection, electrolyte abnormalities, they're on the wrong pain meds," said Dr. Clay Angel, assistant chief of the hospital medicine department at Kaiser San Rafael Medical Center. "You want to treat the underlying cause first."

At Kaiser San Rafael, Angel helped organize delirium teams, which make rounds every day to visit delirious patients and develop treatment plans specific to their needs. For example, a social worker might ask family members to bring personal items from home like photographs, to help the patient stay aware or at least make him more comfortable.

Team work

The team will make sure patients aren't missing hearing aids or glasses that might have been left behind if the move to a hospital was urgent. The team will analyze medications to make sure they aren't contributing to the delirium, and as necessary, suggest antipsychotics that may help end hallucinations.

The program was started at Kaiser San Rafael and proved so successful at easing symptoms of delirium that it's now being expanded all over Kaiser's Northern California region. Similar strategies are being implemented at hospitals around the Bay Area.

Dr. Edgar Pierluissi heads the Acute Care for Elders unit at San Francisco General Hospital. Its 22-bed ward was designed specifically to create a healthier environment for older patients, ideally resulting in shorter hospital stays and better mental and physical health when they leave.

Patients in the unit are encouraged to remain active by taking walks around the ward, leaving their beds to use the bathroom instead of relying on catheters, or visiting a cafeteria for their meals.

The unit also has installed several measures to help prevent delirium, including large clocks in every room and whiteboards that display the date and remind patients where they are.

"Just keeping people in bed and putting in catheters can be a risk factor for delirium," Pierluissi said. "All these things - urinary incontinence, pressure ulcers, falls, delirium - they're all related, and it can turn into a vicious cycle."

Gullickson said it's a relief to know that doctors and other health care providers are now taking delirium seriously and recognize that both patients and their families suffer when it's untreated.

"My mother had to go through a certain amount of pain because of her illness. But the delirium was adding suffering on top of pain," Gullickson said. "If there's a way to get a handle on it or prevent it, or support the patient and the family - if we can alleviate one piece of suffering, that's huge."

Dealing with delirium

A UCSF study developed a tool for quickly determining which patients admitted to the hospital are most at risk for becoming delirious. The tool, named Awol, scores patients based on four markers:

-- Age 80 or older.

-- Inability to spell the word "world" backward.

-- Confusion about where they are.

-- Suffering from moderate to severe illness.

In the study, 19 percent of patients who had three or four of the markers became delirious, compared with only 4 percent of patients with none of the markers.
