The Overlooked Danger of Delirium in Hospitals - The Atlantic

The condition, once known as “ICU psychosis,” disproportionately affects seniors and those who have been heavily sedated—and the delusions can ... SkiptocontentSiteNavigationTheAtlanticPopularLatestSectionsPoliticsIdeasFictionTechnologySciencePhotoBusinessCulturePlanetGlobalBooksPodcastsHealthEducationProjectsAmericaInPersonFamilyEventsShadowlandInheritanceNewslettersTheAtlanticCrosswordPlayCrosswordThePrintEditionLatestIssuePastIssuesGiveaGiftSearchTheAtlanticQuickLinksDearTherapistCrosswordPuzzleManageSubscriptionPopularLatestSignInSubscribeOnlythroughNovember30:TrysubscribernewslettersforfreeWhenB.PaulTurpinwasadmittedtoaTennesseehospitalinJanuary,thebiggestconcernwaswhetherthe69-year-oldendocrinologistwouldsurvive.Butashebattledalife-threateninginfection,Turpindevelopedterrifyinghallucinations,includingoneinwhichhewasperformingonastagesoakedwithblood.Doctorstriedtoquellhisdelusionswithincreasinglylargedosesofsedatives,whichonlymadehimmoredisoriented.Nearlyfivemonthslater,Turpin’sinfectionhasbeenrouted,buthislifeisupended.Deliriousandtooweaktogohomeafterhishospitaldischarge,hespentmonthsinarehabcenter,wherehefelltwice,oncehittinghishead.Untilrecentlyhedidnotrememberwherehelivedandbelievedhehadbeeninacarwreck.“Itellhimit’smorelikeatrainwreck,”saidhiswife,MarylouTurpin.“Theykepttellingmeinthehospital,‘Everybodydoesthis,’andthathisconfusionwoulddisappear,”shesaid.Instead,heronce-astutehusbandhashadgreatdifficulty“gettingpastthescramble.”Turpin’sexperienceillustratestheconsequencesofdelirium,asuddendisruptionofconsciousnessandcognitionmarkedbyvividhallucinations,delusions,andaninabilitytofocus,thataffects7millionhospitalizedAmericansannually.Thedisordercanoccuratanyage—ithasbeenseeninpreschoolers—butdisproportionatelyaffectspeopleolderthan65andisoftenmisdiagnosedasdementia.Whiledeliriumanddementiacancoexist,theyaredistinctlydifferentillnesses.Dementiadevelopsgraduallyandworsensprogressively,whiledeliriumoccurssuddenlyandtypicallyfluctuatesduringthecourseofaday.Somepatientswithdeliriumareagitatedandcombative,whileothersarelethargicandinattentive.Untilrecently,hebelievedhehadbeeninacarwreck.“Itellhimit’smorelikeatrainwreck,”saidhiswife,Marylou.Patientstreatedinintensive-careunitswhoareheavilysedatedandonventilatorsareparticularlylikelytobecomedelirious;somestudiesplacetherateashighas85percent.Buttheconditioniscommonamongpatientsrecoveringfromsurgeryandinthosewithsomethingaseasilytreatedasaurinary-tractinfection.Regardlessofitscause,deliriumcanpersistformonthsafterdischarge.Federalhealthauthorities,whoareseekingwaystoreducehospital-acquiredcomplications,areponderingwhatactionstotaketoreducetheincidenceofdelirium,whichisnotamongthecomplicationsforwhichMedicarewithholdspaymentorforwhichitpenalizeshospitals.Deliriumisestimatedtocostmorethan$143billionannually,mostlyinlongerhospitalstaysandfollow-upcareinnursinghomes.“Deliriumisveryunderrecognizedandunderdiagnosed,”saidthegeriatricianSharonInouye,aprofessorofmedicineatHarvardMedicalSchool.Asayoungdoctorinthe1980s,Inouyepioneeredeffortstodiagnoseandpreventthecondition,whichwasthencalled“ICUpsychosis.”Itsunderlyingphysiologicalcauseremainsamystery.“Physiciansandnursesoftendon’tknowaboutit,”addedInouye,whodirectstheAgingBrainCenteratHebrewSeniorLife,aHarvardaffiliatethatprovideseldercareandconductsgerontologyresearch.Preventingdeliriumiscrucial,shesaid,because“therestillaren’tgoodtreatmentsforitonceitoccurs.”Researchersestimatethatabout40percentofdeliriumcasesarepreventable.Manycasesaretriggeredbythecarepatientsreceive—especiallylargedosesofanti-anxietydrugsandnarcoticstowhichtheelderlyaresensitive—ortheenvironmentsofhospitalsthemselves:busy,noisy,brightlylitplaceswheresleepisconstantlydisruptedandstaffchangesfrequently.Theunderlyingphysiologicalcauseofdelirium,oncecalled“ICUpsychosis,”remainsamystery.Recentstudieshavelinkeddeliriumtolongerhospitalstays:21daysfordeliriumpatientscomparedwithninedaysforpatientswhodon’tdevelopthecondition.Otherresearchhaslinkeddeliriumtoagreaterriskoffalls,anincreasedprobabilityofdevelopingdementia,andanaccelerateddeathrate.“Thebiggestmisconceptionsarethatdeliriumisinevitableandthatitdoesn’tmatter,”saidE.WesleyEly,aprofessorofmedicineatVanderbiltUniversitySchoolofMedicinewhofoundeditsICUDeliriumandCognitiveImpairmentStudyGroup.In2013,Elyandhiscolleaguespublishedastudydocumentingdelirium’slong-termcognitivetoll.Ayearafterdischarge,80percentof821ICUpatientsages18to99scoredloweroncognitiveteststhantheirageandeducationwouldhavepredicted,whilenearlytwo-thirdshadscoressimilartopatientswithtraumaticbraininjuryormildAlzheimer’sdisease.Only6percentwerecognitivelyimpairedbeforetheirhospitalization.Cognitiveandmemoryproblemsarenottheonlyeffects.Symptomsofpost-traumaticstressdisorderarealsocommoninpeoplewhodevelopdelirium.Arecentmeta-analysisbyJohnsHopkinsresearchersfoundthatoneinfourdischargedICUpatientsdisplayedPTSDsymptoms,aratesimilartothatofcombatveteransorrapevictims.DavidJones,a37-year-oldlegalanalystinChicago,saidthathewasentirelyunpreparedforpersistentcognitiveandpsychologicalproblemsthatfollowedthedeliriumthatbeganduringhissix-weekhospitalizationforalife-threateningpancreaticdisorderin2012.Terrifyingflashbacks,ahallmarkofPTSD,weretheworst.“Theydischargedmeanddidn’ttellmeaboutthisatall,”saidJones,whosemanyhallucinationsincludedbeingburnedalive.RecommendedReadingRethinkingHospitalRestraintsCOVID-VaccineMandatesforKidsAreComingRachelGutmanYou’reBoosted!NowWhat?KatherineJ.WuJones’sordealistypical,saidthepsychologistJamesC.JacksonofVanderbilt’sICURecoveryCenter,amultidisciplinaryprogramthattreatspatientsafterdischarge.“Theygohomeanddon’thavethelanguagetodescribewhathashappenedtothem,”saidJackson,addingthatsuchincidentsareoftenmistakenforpsychosisordementia.“Somepatientshaveverystrikingdelusionalmemoriesthatareverycleardistortionsofwhathappened:patientswhowerecatheterizedwhothinktheyweresexuallyassaultedandpatientsundergoingMRIsconvincedthattheywerefedintoagiantoven.”Somehospitalsaremovingtopreventdeliriumthroughamorecarefuluseofmedications,particularlytranquilizersusedtotreatanxietycalledbenzodiazepines,whichareknowntotriggerorexacerbatetheproblem.OthersaretryingtoweanICUpatientsoffbreathingmachinessooner,tolimittheuseofrestraints,andtogetpatientsoutofbedandmovingmorequickly.Stillothersaretryingtosoftentheenvironmentbyshuttingofflightsinpatients’roomsatnight,installinglargeclocks,andminimizingnoisyalarms.Arecentmeta-analysisledbyHarvardresearchersfoundthatavarietyofnon-druginterventions—whichincludedmakingsurepatients’sleep-wakecycleswerepreserved,thattheyhadtheireyeglassesandhearingaids,andthattheywerenotdehydrated—reduceddeliriumby53percent.Thesesimplefixeshadanaddedbenefit:Theycuttherateoffallsamonghospitalizedpatientsby62percent.Inouyeandotherexpertssaythatencouraginghospitalstorecognizeandtreatdeliriumisparamount.Theyhavevehementlyarguedthatfederalofficialsshouldnotclassifydeliriumasa“never”eventforwhichMedicarepaymentwillbedenied,fearingthatwouldonlydrivetheproblemfurtherunderground.(“Never”eventsincludeseverebedsores.)Delirium“isnotlikepneumoniaorafracture”andlacksanobviousphysicalindicator,saidMalazBoustani,anassociateprofessorofmedicineatIndianaUniversity.HeproposesthatMedicarecreateabundlepaymentthatwouldpayfortreatmentuptosixmonthsafterdeliriumisdetected.Creatingeffectiveincentivesisessential,saidRyanGreysen,anassistantprofessorofmedicineattheUniversityofCaliforniaatSanFrancisco.Delirium,hesaid,suffersfroma“perniciousknow-dogap”—adisparitybetweenknowledgeandpractice.Manyproveninterventions,hesaid,donotseemsufficientlymedical.“There’snogenetherapy,nonewdrug,”Greysensaid.“Ithinkweneedtoputthisintherealmofhospitalprotocol,whichconveysthemessagethatpreventingandtreatingdeliriumisjustasimportantasgivingpeopletheirmedsontime.”Awarenessthatdeliriumisasignificantproblem,notatransitorycomplication,isrecent,anoutgrowthofgrowingexpertiseintherelativelynewfieldofcritical-caremedicine.Thegrayingofthebaby-boomgeneration,whoseoldestmembersareturning69,isfuelinginterestingeriatrics.Andmanyboomersareencounteringdeliriumastheyhelpcarefortheirparentswhoareintheir80sandolder.“Somedelusionsarecleardistortionsofwhathappened,likepatientsundergoingMRIsconvincedthattheywerefedintoagiantoven.”“Intheearly1990s,wethoughtitwasabenevolentthingtoprotectpeoplefromtheirmemoriesofhavingatubedowntheirthroat,ofbeingtieddown,byusinglargedosesofdrugstoparalyzeanddeeplysedatepatients,”Elynoted.“Butbythelate1990s,Iwasjustgettingcreamedbyfamiliesandpatientswhotoldme,‘Ican’tbalancemycheckbook,Ican’tfindmycarintheparkinglot,andIjustgotfiredfrommyjob.’Theirbrainsdidn’tworkanymore.”Delirium“isnowtaughtoratleastmentionedineverymedicalandnursingschoolinthecountry.That’sahugechangefromadecadeago,”saidInouye,addingthatresearchhasincreasedexponentiallyaswell.Insomecases,deliriumistheresultofcarelessness.OnewomansaidshewasrepeatedlyrebuffedseveralyearsagobynursesataWashingtonareahospitalafterhermotherstartedacting“stoned”afterhipsurgery.“Shesaidthingslike‘I’mhavingadinnerpartytonightandI’veinvitedaniceyoungmantomeetyou,’”recalledthedaughter.Sheaskedthathernamebeomittedtoprotecttheprivacyofhermother,now96,wholivesindependentlyinNorthernVirginiaand“stillhasallhermarbles—andthensome.”“Thenurseskepttellingmeshewasoffallmedication”andthatherconfusionwastobeexpectedbecauseofherage.“ItwasonlywhenIinsistedontalkingtothedoctorandgoingthroughherchart”thatthedoctordiscoveredthatamotion-sicknesspatchtopreventnauseahadnotbeenremoved.“Withinanhour,mymotherwasactingfine.Itwasveryscarybecauseifshehadn’thadanadvocate,shemighthavebeensenttoanursinghomewithdementia.”Inouye,whodevelopedtheConfusionAssessmentMethod,orCAMscale,nowusedaroundtheworldtoassessdelirium,saidthatsignificantsystemicobstaclestopreventingdeliriumremain.“Weneedtobackupinourcareofolderpatientssothatwedon’ttreateverylittlesymptomwithapill,”shesaid.Sometimes,shesaid,ahandruboraconversationoraglassofherbalteacanbeaseffectiveasananti-anxietydrug.“Medicalcarehasevolvedtobeabsolutelyinhumanetoolderpeople.”Twomonthsago,Inouye,whoisinher50s,washospitalizedovernight,anexperiencethatunderscoredtheordealthatolder,vulnerablepatientsface.“Iwaswokenoutofthedeepestsleepeverytwohourstocheckmybloodpressure,”shesaid.Inaddition,alarmsinherroombeganshriekingbecauseamachinewasmalfunctioning.“Medicalcare,”sheadded,“hasevolvedtobeabsolutelyinhumanetoolderpeople.”Inanefforttopreventorreducedelirium,InouyecreatedaprogramcalledHELP,shortforHospitalElderLifeProgram,currentlyoperatingin200hospitalsaroundthecountry.Whilethecoreoftheprogramremainsthesame,eachhospitalimplementstheprogramindifferentways.SomeenrollICUpatients,whileothersexcludethem.A2011studyfoundthatHELPsavedmorethan$7millioninoneyearatUPMCShadysideHospitalinPittsburgh.AtMaineMedicalCenterinPortland,HELPisavoluntaryprogramopentopatientsolderthan70whohavebeeninthehospitalfor48hoursorlessanddonotshowsignsofdelirium.ICUandpsychiatricpatientsareexcluded.Theprogramreliesonacadreof50trainedvolunteerswhovisitpatientsuptothreetimesdailyforhalf-hourshifts,providinghelpandcompanionshipandhelpingthemstayoriented.TheCAMscaleisbuiltintothehospital’selectronicmedicalrecord,saidthegeriatricianHeidiWierman,whooverseestheprogramandheadsamedicalteamthatseespatientsregularly.HELPpreventeddeliriumin96percentofpatientsseenlastyear,shesaid,addingthatresistancebydoctorsandnursestothe13-year-oldprogramhasbeenminimalbecause“wetiedtheincidenceoffallstothepreventionofdelirium.”MarylouTurpin,whosehusbandrecentlyreturnedtotheirhomeoutsideNashville,isplanningtoenrollhimatVanderbilt’sICURecoveryCenterassoonaspossible.“I’mjusthopingwecanhavesomekindoflifeafterthis,”shesaid.ThisarticleappearscourtesyofKaiserHealthNews.