Managing confusion in the hospitalized elderly

Key to halting cognitive decline is recognizing red flags and acting early. Delirium in hospitalized patients, including those with dementia, can be prevented in most cases if hospital staff is trained to recognize symptoms and act quickly.

An elderly patient enters the hospital with abdominal pain, seemingly alert and oriented. But several days later she becomes confused and agitated then enters a downward spiral that leads to a prolonged inpatient stay, loss of independence and the need for institutional care.

It's an all-too-common scenario in hospitals but one that's often avoidable, several experts said. Delirium in hospitalized patients, including those with dementia, can be prevented in most cases if hospital staff is trained to recognize symptoms and act quickly.

“When a patient comes into the hospital and is confused, the first thing that the physician should try to do is speak with a family member or a caregiver to determine if there is an acute change from the patient's baseline,” according to Sharon Inouye, ACP Member, professor of medicine at Harvard Medical School and Director of the Aging Brain Center at Hebrew SeniorLife in Boston.

“If there is an acute change, that person most likely has delirium. A lot of times a typical reaction that I see amongst doctors is, ‘Oh that just happens when older people come to the hospital.’ But if the delirium is not addressed, it becomes worse and worse and eventually the patient can't go home. Delirium really is an emergency that needs to be evaluated.”

Studies show that the prevalence of delirium at admission ranges from 14% to 24% and the incidence of delirium occurring during hospitalization ranges from 6% to 56% (NEJM, March 2006). Yet, delirium often goes unrecognized by hospital staff because its symptoms can be mistaken for depression, mania, a schizophrenic reaction or dementia, or attributed to old age. However, any number of factors may be contributing to the patient's confusion, experts advised, and it's important to pinpoint causes in order to intervene appropriately.

“I think of delirium as a symptom, an alarm bell, and what it usually means is that something else is wrong and causing the delirium,” said Bruce A. Leff, FACP, a geriatrician at Johns Hopkins. “The key is to find out what caused the delirium. Sometimes it's their underlying illness. Sometimes they have been started on a new medication. Sometimes they develop a second acute illness or maybe they developed a new urinary tract infection. It is important to ask about symptoms.”

Making the diagnosis

Both delirium and dementia are alterations in mental status that impact the course of therapy and carry a poor prognosis. Delirium is an acute confusional state that comes on abruptly and tends to last for a shorter period of time than dementia, which is a chronic, progressive confusional state. And while inattention is a key feature of delirium, inattention generally doesn't occur until late in dementia. Although considered separate conditions, delirium and dementia are both associated with decreased cerebral metabolism, cholinergic deficiency and inflammation (NEJM, March 2006).

Some patients with delirium may experience long-term cognitive decline that heralds the onset of dementia. And conversely, recovery from delirium will take much longer in a patient with dementia, according to Evelyn C. Granieri, MD, a geriatric medicine educator who heads Columbia University Medical Center's division of geriatric medicine and aging.

Simple cognitive tests are a good way to screen for delirium
Simple cognitive tests are a good way to screen for delirium.

Because delirium is characterized by inattention or a reduced ability to focus and follow a conversation, one of the best ways to screen for it is a brief but formal cognitive test (see “Management of confusion,” next page). The Mini-Mental State Examination, Digit Span test and Montreal Cognitive Assessment are simple tests that can be done at the bedside in five to 10 minutes.

Based on the results of such tests, delirium can be rated by the Confusion Assessment Method or the CAM. Developed by Dr. Inouye, the CAM is the most commonly used method for recognizing delirium at the bedside. The screening occurs in two steps: screening for overall cognitive impairment and for four features that distinguish delirium from other types of cognitive impairment: 1) acute onset and fluctuating course, 2) inattention, 3) disorganized thinking, and 4) altered level of consciousness. Using the CAM method, if features 1 and 2 plus either 3 or 4 are present, the diagnosis of delirium may be confirmed.

Delirium, as it is often iatrogenic and linked to processes of care, serves as a marker for quality of care in the hospitalized elderly patient, according to the Agency for Healthcare Research and Quality's National Quality Measures Clearinghouse. After adjusting for case mix, higher delirium rates would be expected to correlate with lower quality of care in the hospital.

Prevention of delirium

Researchers have found that recognizing risk factors early and intervening decreases the likelihood of patients developing delirium while in the hospital. The Yale Delirium Prevention Trial (NEJM, March 1999), for example, targeted six known predisposing (present upon admission) risk factors for delirium—cognitive impairment, sleep deprivation, immobilization, visual impairment, hearing impairment and dehydration—and found that following appropriate interventions reduced development of delirium in the hospital by 40%.

Delirium risk also hinges on certain precipitating factors, which include use of physical restraints, addition of more than three medications in 24 hours, malnutrition, use of a urinary catheter, and unanticipated or emergency surgery. “Each one of those risk factors probably increases the risk of developing delirium two- to threefold,” Dr. Leff said.

There are some fairly simple ways to make the hospital environment less conducive to the onset of delirium, experts said.

Keep familiar routines. “In the hospital, days and nights can get confused very easily for the elderly. Let them sleep at night as much as possible and keep them awake during the day,” said Melissa L. Mattison, ACP Member, at Beth Israel Deaconess Hospital in Boston.

Check what's missing. Make sure the patient has his or her glasses hearing aids, and dentures.

Move around. Write an order to get patients out of bed and moving three times a day and up to a chair for meals. Avoid use of Foley catheters because they set up a risk for urinary tract infections and tend to make the patient incontinent once removed.

Many medications such as opioids and sedatives are known to cause delirium
Many medications, such as opioids and sedatives, are known to cause delirium.

Review medications. “The most common cause of developing delirium in the hospital is medications that have been added to someone's regimen,” Dr. Leff said. Many medications are known to cause delirium, such as sedatives, opioids and anticholinergics. Many medications, such as opioids and sedatives, are known to cause delirium. But others are often not as well known for contributing to delirium, including H2-blockers, nonsteroidal anti-inflammatories, antidepressants, antihistamines and cardiac drugs.

Choose pain meds carefully. Although uncontrolled pain can cause delirium, so can many pain medications. “I've been able to get a lot of my older patients under control with just a regimen of Tylenol alternating with Trilisate,” Dr. Inouye said. “If an elderly person has normal liver function, you can give 1,000 mg Tylenol four times a day without problems.” As long as the patient does not have renal disease, GI bleeding, or platelet dysfunction, a nonsteroidal like Trilisate can be alternated with Tylenol. Morphine can be used when a narcotic is necessary. Avoid meperidine because it is associated with a very high risk of delirium.

Consider natural remedies. Dr. Inouye's Hospital Elder Life Program, or HELP, recommends nonpharmacological approaches instead of sleeping medications, if possible, such as a glass of warm milk, relaxation music, or a backrub. The patient's water pitcher should be within reach to encourage adequate hydration.

Dementia: a more complex diagnosis

Although delirium can be diagnosed at the bedside, the diagnosis of dementia is more complicated and is usually not done in the hospital. Dr. Inouye recommends starting a workup for dementia in the hospital with basic screening and blood work, but referring the patient to a dementia expert for follow-up after discharge. It often, but not always, includes brain imaging, obtaining old records, and a comprehensive interview with the patient and their family.

Managing pain in a patient with dementia is sometimes difficult. Family members may be able to help the hospitalist understand when the nonverbal patient looks uncomfortable. And there is an observational tool, the Pain Assessment in Advanced Dementia (PAINAD) scale, which can help clinicians to assess pain in nonverbal demented patients. It is based on common sense observation of the patient's facial expressions, body language, consolability, breathing, and negative vocalization.

“One of the questions that patients and families always have if the patient develops delirium is, ‘Will this lead to a dementia?’” Dr. Inouye said. “That is not known right now. Some people who develop delirium take a very long time to recover and sometimes people never recover back to their baseline. It's an area that we're actively investigating.”