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Delirium
takes a toll in the ICU
By
Jane E. Allen, Los Angeles Times
October 20, 2003
For many years, when
patients were admitted to hospital intensive-care units, doctors struggled
just to keep them alive. Lines and tubes pumped them full of oxygen and
medication, and machines monitored their vital signs — but no one paid
much attention to their brains.
Then, as more people survived their intensive-care stays, doctors began
recognizing patterns in these terribly weakened patients. Many became
uncharacteristically quiet and withdrawn. Others developed hyperactivity
and confusion. Even after their bodies recovered enough to leave the ICU,
some didn't bounce back mentally, or their physical recuperation lagged.
Something about their hospital stays was changing patients' ability to
speak, reason and relate to their loved ones. This combination of
confusion and disorientation, often accompanied by paranoia and delusions,
is called delirium.
Although its molecular and genetic underpinnings are still unknown,
researchers are discovering just how pervasive delirium can be, the toll
it can take — and how to prevent it. By some estimates, 80% of elderly
intensive-care patients develop the condition, which frequently leads to
nursing home stays and a hastened death.
"Unfortunately, delirium is often a spiral downhill," says Dr.
Sharon K. Inouye, a Yale geriatrician and leading delirium researcher.
"Because people are so fragile at that age, it's like a house of
cards."
Delirium also develops in an estimated 40% to 60% of younger intensive
care patients and 30% of cardiac surgery patients. It can set in at almost
any age after a serious illness such as pneumonia or injury such as a hip
fracture — any time a patient becomes weakened, immobilized, heavily
medicated and cut off from normal routines.
Put simply, delirium is "brain failure," says Dr. Wes Ely, a
critical care specialist at
Vanderbilt
University
in
Nashville
. With some exceptions, he says, it remains an
unmonitored complication of an ICU stay that can set off a cascade of
devastating effects with long-term consequences. Patients who have
dementia or Alzheimer's disease are particularly vulnerable because their
thinking and memory already are under siege.
Although doctors don't understand precisely how delirium begins and
progresses — they suspect the problem lies in disturbances of key
brain-signaling chemicals called neurotransmitters — they know that it
results from a combination of factors. Those include over-medication
(particularly with opiates and sedatives), drug interactions, oxygen
deprivation, dehydration, head trauma, infection and having to breathe
with a ventilator. Because delirium contributes to longer hospitalizations
and additional care, it's expensive. Delirium-associated costs run about
$4 billion to $16 billion every year, Ely says.
The condition occurs in three forms. Easiest to discern is agitated
delirium, which makes patients hyperactive, anxious and prone to
hallucinations; sedation often exacerbates it. Harder to detect but more
common among elderly patients is quiet delirium, which has a worse
prognosis and can be mistaken for dementia or over-sedation. With it,
patients become passive, withdrawn and unresponsive. Some patients suffer
mixed delirium, with alternating bouts of the two forms.
Dr. Wallace Sampson of
Palo Alto
became delirious 10 years ago while suffering
complications of colon cancer surgery. Then 63, the oncologist was put on
a respirator and given a stew of intravenous medications, including
morphine and sedatives. He began having fantastical, paranoid dreams
involving elaborate conspiracies, including a plot among doctors and
hospital workers to kill him and dump his body in
Lake Tahoe
.
"I imagined that the floor of the X-ray department was transparent
and that they had stacked all these bodies of patients they had
killed," he recalls. He would act normal around doctors, then ask his
wife to help him escape. Today, he laughs at the absurdity of those
thoughts, especially considering that Sampson, editor of the journal
Scientific Review of Alternative Medicine, is a very rational man.
Sampson's delirium might have been prevented if doctors knew then what
they're learning today. About half of all delirium cases could be averted,
Inouye estimates. But that requires changing the mind-set of medical
professionals, who often believe that delirium and confusion are
inevitable among critically ill patients.
"We're trying to fight years and years of medical training that I'm a
part of," said Dr. John M. Robertson, chief of cardiothoracic surgery
at
St. John's
Health
Center
in
Santa Monica
. "Most physicians overmedicate their
patients. It's easier to snow Grandpa than deal with him."
Formerly known by the term "ICU psychosis," now considered a
misnomer, delirium goes unrecognized by doctors one-third to two-thirds of
the time, often because they don't know how to detect it. In addition,
health professionals — along with families — are sometimes reluctant
to name the problem because the term "delirium" is often
associated with crazy, out-of-control behavior, says Dr. Edward
Marcantonio, an assistant professor of medicine at Harvard Medical School.
But acknowledging delirium makes it easier to avoid long-term problems.
In a study of hip fracture patients published in 2000, Marcantonio
reported that 39% of the patients who developed delirium in the hospital
were still delirious when they were discharged, 33% were delirious a month
later and 6% were delirious after six months. He currently heads a
federally funded delirium study designed to detect the disorder in nursing
home patients and another to assess delirium in cardiac surgery patients.
Today, several relatively quick bedside tests can be used to measure
delirium, including one modified by Inouye and Ely for ICU patients unable
to speak because they have breathing tubes in their throats. Without these
tests, "nurses can look right at a patient that's delirious and think
they're not, or they can think they are delirious and they're not,"
Robertson said.
Those tests helped nurses confirm that Sharon Kirk of
West Los Angeles
, a 58-year-old former flight attendant, developed delirium while
battling complications of parathyroid and thyroid surgery this spring.
While on a ventilator in a deliberately induced coma, she began dreaming
that she was drowning and people were ignoring her cries. "Friends of
mine told me I was tied down with restraints and that I was trying to get
out of them," she says now.
As Kirk emerged from the coma, "it was obvious she was
delusional," recalls her friend Dorothy Froix. "Sometimes, she
would speak about something that wasn't happening, or she would think that
somebody else was there talking to her." That behavior frightened
both Froix and Kirk's husband, Greg Flavall, who said his wife still
grapples with memory lapses more than three months after her release from
St. John's
. It's hard to know whether the lingering
effects stem from the delirium or the overall shock to her system.
"It's hard to separate those two," said Chris Maupin, a critical
care nurse at
St. John's
. For example, she said, Kirk's memory lapses
could stem from too little oxygen flowing to her brain when she suffered
life-threatening bleeding.
The key to reducing delirium is prevention. A few hospitals have
instituted programs modeled on a program Inouye pioneered at the Yale
University School of Medicine.
In a March 1999 study published in the New England Journal of Medicine,
Inouye showed that several simple changes reduced delirium by 40% among
852 hospitalized, non-ICU patients 70 and older. For example, the program
reduced the use of sleeping pills by having volunteers provide back rubs,
relaxation tapes, warm milk and tea. Other interventions included
providing cognitive stimulation through games, discussion of current
events and memory aids designed to jog recollections; by helping get
patients out of bed and walking three times daily; by improving
surroundings to minimize sleep disruptions, and by giving enough fluids to
prevent dehydration.
According to another study Inouye published in April, delirium can be
reduced by 89% in patients who receive all the recommended interventions.
Some hospitals are eliminating irritating sounds of ringing bells and
buzzers. Others are designing hospital rooms with windows that let in
natural light and preserve the rhythms of day and night so patients feel
less disoriented.
Robertson spearheaded a new program at
St. John's
to reduce and prevent delirium. Nurses evaluate
intensive care patients several times a day. Doctors there and elsewhere
have begun changing many of the medications they use, said Dr. Gilbert
Kuhn, a
St. John's
pulmonologist and critical care specialist who
was among those treating Kirk.
If a patient must be put into a coma, he often uses propofol (Diprovan),
an anesthetic that passes out of the body more quickly than some older
anesthetics. Furthermore, Kuhn tries to wake up sedated patients once
daily to evaluate their level of consciousness.
Pharmacists also check drug doses, look for drug interactions and help
determine if pain relievers milder than narcotics can be used.
Harvard's Marcantonio said he hopes continued research will make
preventing delirium a priority.
"The more we can show we can do something about it, that will
hopefully motivate people to look for it more."
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