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New way of treating elderly patients with delirium defies conventional
medical wisdom
Science
Daily,
July 16, 2003
ST. LOUIS - The best way to treat hospitalized elderly patients who
become delirious defies conventional wisdom and common practice, according
to new research from Saint Louis University published in the July issue of
Journal of the American Geriatrics Society.
Delirium, a common problem among the hospitalized elderly, causes patients
to be confused, unclear in their thinking and incoherent. Their behavior
may be disturbed - agitated, lethargic or a combination of the two. Those
delirious patients who are sleepy and lethargic often are undiagnosed
because they don't make a ruckus.
Typically, elderly delirious patients who are agitated are cared for in
private or semi-private rooms, isolated from others. They may be placed in
physical restraints for protection and given medications that are calming.
Now a new treatment model created by Saint Louis University geriatricians
at Saint Louis University Hospital, the only one of its kind in the
country, throws many of those ideas for treatment out of the window.
The geriatricians found that elderly patients with delirium do better if
they are placed together and cared for in the Delirium Room, essentially a
four-bed intensive care unit. Because there are no walls in the Delirium
Room, a highly trained certified nursing assistant or registered nurse can
constantly monitor their conditions, picking up on potential problems
early to prevent them from escalating. Physical restraints are not used
and medication to quiet patients is the last-choice treatment.
"Since 1997, we've been doing it and if it's done correctly, it
works," says Joseph Flaherty, M.D., associate professor of geriatrics
at Saint Louis University School of Medicine and principal investigator.
"The nursing literature says agitated patients cause agitation in
normal patients, so they need to be separated. We just don't see it
happen."
Delirium is a very common problem among hospitalized elderly patients, Dr.
Flaherty says. Between 15 and 20 percent of older patients are delirious
when they are admitted and up to 30 percent become delirious while they're
in the hospital.
Delirium is caused by a host of medical problems that include illnesses,
dehydration and medications. It is treatable, reversible and must be
diagnosed so the patient's other medical problems aren't missed.
"The few keys to delirium are early recognition and early
identification of the medical problems causing the delirium," Dr.
Flaherty says. "With proper care, it's so reversible."
Typically, though, delirious patients don't do well in hospitals. They
stay in hospitals longer, fall and become injured more frequently, lose
their ability to physically function and are more likely to die than
hospitalized elderly patients who are not delirious.
The Saint Louis University model for treatment eliminates the disparity
between elderly patients who were delirious and those who were not.
"We studied delirious patients during the first 18 months after
opening the Delirium Room. We kept the length of stay equal to
non-delirious patients. We maintained their physical function. Our fall
rate is near zero in that room because they're constantly supervised. Our
mortality rate was zero. None of the delirious patients died during that
time," he says.
Nurses in the Delirium Room rely on strategies to treat delirium that
don't involve physical restraints and avoid medications. They try to
reorient the confused patient and figure out why the patient is becoming
agitated. In many cases, the reason for the patient's agitation is easily
solved: the patient's IV is uncomfortable, he needs to use the restroom or
her pain medication is wearing off.
"It's intensive nursing," Dr. Flaherty says. "Medications
are used, but after every non-pharmacological method has been tried."
He suggests that hospitals treat patients who are at high risk of
developing delirium to put the breaks on the mental disorder before it
takes hold.
"There are patients we know who have a high risk for developing of
delirium. They include the very old, patients with an underlying dementia,
patients who have problems with their hearing or sight and patients who
are at risk for dehydration," Dr. Flaherty says.
An 80-year old woman who is hospitalized with pneumonia, has Alzheimer's
disease and lives at home with her husband, would be an ideal candidate
for the Delirium Room. There, she would be carefully observed to make sure
she does not become delirious.
The Delirium Room is part of Saint Louis University Hospital's Acute Care
for the Elderly (ACE) unit, which is designed to prevent loss of physical
function while patients are treated for an acute illness so they can
return to their previous state of independence. Instead of treating the
acute illness, then sending the patient for "rehab," the ACE
Unit emphasizes "pre-rehab" by starting therapy on day one,
eating meals together and focusing on other strategies that are important
in treating older patients.
Having a dedicated place to care for elderly patients who become delirious
calls attention to the syndrome, so doctors and nurses are less likely to
miss diagnosing an underlying problem, Flaherty says.
"It's an education tool itself. Everyone hears 'Delirium Room' and
doctors and nurses start to learn what is a delirious patient. They
weren't taught this in medical school."
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