Stopping delirium before it starts

Large-scale efforts to prevent delirium have been around for years, but hospitals also can take smaller measures if they don't have the immediate resources or ability to overhaul care.

Delirium so commonly flares in elderly hospitalized patients, it might appear to be an inevitable side effect of inpatient care. But the acute deterioration in thinking and attention can and should be more frequently prevented, according to geriatricians and critical care specialists.

To be effective, inpatient clinicians should move more quickly to identify patients most likely to benefit from intervention and take steps—some basic—to minimize the disorienting effects of hospitalization.

Photo by Thinkstock
Photo by Thinkstock.

“The best treatment is prevention,” said Aleta Borrud, MD, MPH, ACP Member, a consultant in hospital medicine at Mayo Clinic in Rochester, Minn. “Because really once a patient has delirium, it's supportive care for the most part. So it's best to recognize the high-risk [patient] to begin with.”

Early in 2013, the Society of Critical Care Medicine issued guidelines for the management of delirium in the intensive care unit (ICU). They emphasized the use of non-medication techniques for delirium prevention, including early mobilization of patients.

One well-respected tool to prevent delirium is the Hospital Elder Life Program (HELP), first developed by Yale University School of Medicine clinicians and now at an estimated 200 sites worldwide. Incorporating the full program, though, can be time- consuming and dependent upon having adequate staff and volunteers. So some hospitalists may need to take an à la carte approach to its components.

Assessing risk

Among older hospitalized patients, the risk of developing delirium ranges widely, from 14% to 56% depending upon patients' risk factors and severity of illness, according to a March 5, 2013, review article on delirium prevention programs published in Annals of Internal Medicine.

“Delirium is one of the absolutely most prevalent forms of harm that befall people in the hospital,” said Fred Rubin, MD, FACP, a geriatrician and chief of medicine at the University of Pittsburgh Medical Center (UPMC) Shadyside Hospital.

To get a better sense of a patient's delirium vulnerability, consider the interplay between two sets of risk factors, predisposing and precipitating, said Timothy Girard, MD, ACP Member, a delirium researcher and assistant professor of medicine at Vanderbilt University School of Medicine in Nashville, Tenn.

Predisposing risks include older age, alcohol dependence, high blood pressure and existing cognitive problems, among others. Meanwhile, precipitating risk factors are more likely to be related to the hospital admission, such as kidney failure, sepsis or the use of certain medications, like benzodiazepines. “If a patient has a high predisposing risk, then it's generally thought to take just a small increase in precipitating risk to put [her]into a delirious state,” Dr. Girard said.

To screen for delirium, physicians have several assessment options. For ICU patients, the Society of Critical Care Medicine's guidelines rate the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) as best among five tools evaluated. The guidelines gave the CAM-ICU and the ICDSC an A rating for validity and reliability.

Citing a moderate level of evidence, the guideline authors recommend screening all ICU patients considered at moderate to high risk at least once per nursing shift. ICU clinicians “often underestimate the presence of delirium” because it frequently takes the hypoactive form rather than the more visible restlessness, agitation and hallucinations of the hyperactive form, the authors wrote.

Watch out for those patients who don't seem to talk much, aren't ringing their bell or seem unusually sleepy, said Heidi Wierman, MD, ACP Member, a division director of geriatrics at Maine Medical Center in Portland, who also directs HELP there. “Always be aware of the really easy-to-take-care-of patients who also aren't eating and moving around much,” she said.

Once delirium is already present, no treatment has been proven to prevent long-term complications, Dr. Girard said. Still, early identification might help the patient in several ways, he said.

“Delirium itself can be a warning sign that something else is going on that hasn't been addressed,” Dr. Girard said. The patient, for example, might have contracted a hospital infection that hasn't yet been diagnosed, he said. Eradicating that infection might help, as could other measures, such as stopping a medication prescribed shortly before the delirium emerged.

Also, missing delirium can result in a less accurate long-term prognosis for the patient, he added. “Patients who have delirium tend to do worse than those who don't,” he said. “If you don't recognize that a patient has delirium, then your ability to assess their [health] risk going forward is going to be inaccurate.”

Preventing confusion

For decades, it was thought little could be done about patient delirium other than to recognize it, Dr. Rubin said. That all changed with a ground-breaking 1999 New England Journal of Medicine study, which outlined the approach now dubbed HELP, he said.

The study targeted 852 patients ages 70 and older at Yale-New Haven Hospital and focused on managing six risk factors associated with delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment and dehydration. The intervention, developed by Sharon Inouye, MD, ACP Member, and her colleagues, proved effective; delirium developed in 9.9% of the intervention patients compared with 15% of the typical-care patients, the study found.

The intervention team, which included a mix of clinicians and volunteers, strove to keep the patients connected with the wider world. They provided cognitively stimulating activities at least three times daily and encouraged the patients to use their glasses and hearing aids to keep senses sharp. Fighting immobility also was key and included range-of-motion exercises or walking at least three times daily. In addition, the program sought to limit catheter use, physical restraints and other mobility-limiting equipment.

UMPC's Shadyside Hospital was one of the early HELP adopters in 2002, and the program now assists more than 7,000-plus patients annually on seven hospital units, Dr. Rubin said. Prior to the program's launch, the baseline combined delirium rate—both new cases and patients with preexisting delirium—was 41% in the targeted population of patients ages 70 and older. By 2008, that combined rate had declined to 18%, according to findings published in 2011 in the Journal of the American Geriatrics Society (JAGS).

From 2004 to 2008, no more than 3% of patients annually were newly diagnosed with delirium, the study also found. That low rate has been maintained through early 2013, according to Dr. Rubin.

These days the Shadyside program, which by mid-2013 should be expanded to a total of eight units, costs about $400,000 annually, primarily for the salaries of nurses who conduct delirium assessments and staff who supervise volunteers, Dr. Rubin said. The financial return, from both delirium prevention and boosted revenue generated by freeing up hospital beds, totaled $7.3 million in 2008, according to the 2011 JAGS analysis. The upfront costs are “money very well spent,” he said.

For hospital systems, delirium is typically costly. One analysis at Yale-New Haven Hospital found that the daily treatment costs for patients with delirium run two and a half times higher than for patients without delirium. Those costs, extrapolated nationally, translate to a delirium-related bill of $38 billion to $152 billion annually, according to findings published in 2008 in Archives of Internal Medicine.

Staffing the program

One of the biggest challenges for delirium prevention efforts is finding enough staff or volunteer hours in the day. In a time-pressed hospital environment, Dr. Borrud stressed, “You cannot even begin to approach this without the full engagement of nursing. The people who ensure all of these measures are instituted are nurses.”

Shadyside relies on nearly 100 volunteers, and their constant recruitment and retention is a “big headache,” Dr. Rubin said. Hospitals can implement HELP with a mix of staff help along with volunteers, but the fewer volunteers they have, the fewer patients they will reach, he said.

At Maine Medical Center, about 40 volunteers are involved with HELP, allowing them to assist about 90 patients monthly with the full program, and another 90 or so with more limited interaction, Dr. Wierman said. The volunteers work at least one three- or four-hour shift each week; their visits with patients average about 30 minutes.

The volunteers are asked to make at least a six-month commitment, given the training investment involved, Dr. Wierman said, but turnover is still a limiting factor. Volunteers focus on patients in non-ICU areas, particularly patients with one or two risk factors, who are most likely to benefit from the time investment. In a 2001 study in the journal Medical Care, researchers determined that the intervention was most effective in patients at moderate, but not high, delirium risk.

“What they found was that the patients who were at intermediate risk of delirium were those in which they had the biggest bang for the buck,” Dr. Rubin said.

At Maine Medical Center, physical therapists screen patients and recommend those who can safely walk with a HELP volunteer, Dr. Wierman said. The volunteers fall under the hospital's insurance coverage, but there is still some caution exercised, given the fall risk, she said. “Out of concern for liability, we probably don't walk some people that we could walk.”

Strategic measures

Even when hospitals don't implement the full HELP package, clinicians can implement a number of its components to hopefully prevent patients from becoming disoriented, according to delirium prevention experts.

Protecting a patient's sleep should be given a high priority, when feasible, Dr. Wierman said. Medications and vital sign checks can be scheduled to allow longer blocks of sleep. Ask yourself, she recommends: Does that medication have to be scheduled for every six hours, or can a larger dose be given every eight? Other helpful steps might include hand massage, blanket warmers and nighttime herbal tea, she said.

By implementing a battery of sleep-promoting strategies, clinicians at Johns Hopkins Hospital in Baltimore reduced delirium frequency among ICU patients by 54%, according to a study published in March 2013 in Critical Care Medicine. Along with minimizing nighttime lights and unnecessary equipment alarms, the researchers batched medication, vitals and other nighttime visits. They also discouraged prescribing of benzodiazepines for sleep, as the drugs have been associated with delirium.

The Mayo Clinic has instituted a protocol to promote sleep at night on the general care floors, Dr. Borrud said. Nonessential nighttime interruptions are minimized, such as routine blood draws. Physical restraints are avoided when feasible, as well as what she describes as clinical tethers, such as urinary catheters or IV poles.

“I never just drip in IV fluids overnight,” said Dr. Borrud, who works in non-ICU areas. “I give IV fluids as small boluses to reduce the duration that the patient is tied to the IV pole.”

Hospitalists also can encourage other staffers, particularly aides assigned to sit with delirious patients for safety, to interact with them to help with their orientation, Dr. Borrud said. At Mayo, conversation starters, such as pets or favorite hobbies, are jotted on a board near the patient.

Particularly given the number of patients these days who are further isolated in infection-control rooms, with clinicians and visitors obscured by gowns and gloves, maintaining that outside world connection has never been more challenging or more important, Dr. Borrud said.

“People need stimulation,” she said. “Patients still need somebody to sit there and interact with them and talk to them. Talk to them about their interests, their families, their life, their work life.”