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Recognizing & Treating Delirium

Delirium is an important preventable medical condition for geriatric patients.

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Delirium is an under-recognized, but surprisingly common problem, particularly among older adults who are hospitalized.

People who are delirious have trouble thinking clearly, focusing their thoughts, and paying attention, yet it's different than the long-term confusion seen with dementia or Alzheimer's disease. If left untreated, delirium can have serious consequences for recovery.

These are all topics that will be explored at the 16th Annual NICHE Conference [Nurses Improving Care for Healthsystem Elders], scheduled for April 10-12 at the Loews Philadelphia Hotel in Philadelphia.

Sharon Inouye, MD, MPH, professor of medicine, Harvard Medical School, Boston, will be delivering the keynote address about delirium at the NICHE conference to the more than 600 healthcare professionals expected to attend.

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Inouye is director of the Aging Brain Center at Harvard, which she established at the Institute for Aging Research in 2005, and currently she is the overall principal investigator of the Successful Aging after Elective Surgery (SAGES) study, an $11 million dollar program project on delirium funded by the National Institute on Aging.

In preparing for her keynote address, Inouye is focusing her efforts on hitting upon several major hot button topics.

"The major points are that delirium is very common in older hospitalized persons; it is serious with high morbidity and mortality; it is often unrecognized; and it is preventable in up to 30% to 50% of cases," Inouye said. "Thus, it is an important preventable medical condition for our older population."

Recognition & Response

A chief problem with delirium is often it goes undiscovered with many cases falling under the radar. It's important that people in the healthcare field recognize delirium so that a response can be formulated quickly.

"The key features at the bedside to recognize delirium are: An acute onset and fluctuating course of symptoms, inattention, global cognitive deficits, and an altered level of consciousness," Inouye said.

"Delirium often goes unrecognized for many reasons: 1) people often do not assess cognition at the bedside; 2) people often misattribute delirium to dementia, or to just aging, like consider it normal for people to get confused in the hospital; and 3) people don't realize how serious delirium can be, so they overlook it."

According to Inouye there are many contributing factors to delirium: Dementia, electrolyte disturbances, lung/other major organ system diseases, infection, Rx (drugs), injury/pain/stress, an unfamiliar environment, and metabolic (thyroid, cortisol, glycose disorders) conditions.

Her keynote will explore each of these issues and also talk about how one can best diagnose delirium both by simple tests and merely by observation.

"To recognize delirium, the clinician must be aware of the problem, and must administer brief cognitive testing," Inouye said. "A simple screen for attention is best, like asking the patient to say the days of week backward, or months of year backward can be quite effective. On the basis of this, the clinician should score the confusion assessment method (CAM), which is the most widely used screening instrument in the world."

Inouye's research focuses on delirium and functional decline in hospitalized older patients and she's developed and validated the CAM, the most widely used tool for the identification of delirium, as well as the Hospital Elder Life Program (HELP), a multi-component intervention strategy designed to prevent delirium.

Another important portion of her speech will deal with key strategies to prevent delirium so that healthcare workers can help to make sure that they are running an efficient program.

"The best strategies that are proven to be effective are multicomponent targeted intervention approaches, such as HELP," Inouye said.


"This program includes proven strategies targeted toward known risk factors for delirium, such as reality orientation and therapeutic activities for cognitive impairment; nonpharmacologic sleep enhancement for sleep deprivation; early mobilization (walking, exercise) for immobility; hearing and vision adaptations; and prevention of dehydration by pushing fluids."

Visit http://www.hospitalelderlifeprogram.org/ for more information about the program, which has been implemented in hundreds of hospitals internationally. 

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Talking Points

Delirium has serious consequences, Inouye said, and the keynote will look at some of the problems that are associated with it, including:

  • increased morbidity and mortality;
  • functional and cognitive decline; increased rates of dementia;
  • institutionalization;
  • increased healthcare utilization and costs;
  • post-traumatic stress disorder; and
  • caregiver burden.

Inouye said her take home messages from the keynote will be:

  • Do cognitive assessment: cognitive screening and CAM.  Get the history/time course of cognitive changes.
  • Medication/ chest biopsy
  • Use of nonpharmacologic approaches to management of sleep, anxiety, agitation.
  • Avoid bed rest orders.
  • Make sure glasses, hearing aids, dentures available.
  • Let patients know their schedule (tests, etc.). 
  • Keep patients and their families involved in their care.

It's a subject that not everyone still understands. Delirium can come on within hours, and may come and go throughout the day, it can happen because hospitalization involves many tests and therapies, which can lead to confusion, but there are many ways that the problem can be prevented or properly handled.

For her work with delirium, Inouye has been awarded many of the highest accolades in her field, and in 2011 was elected to the Institute of Medicine of the National Academies.

To learn more about the upcoming NICHE conference, click here.  For much more on the NICHE program, click here

Keith Loria is a freelance writer for ADVANCE.


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