Delirium: A Preventable Problem

by Guy McKhann, M.D.

December 14, 2011

About 20 years ago, my then-85-year-old father underwent surgery for possible cancer. The surgery, under general anesthesia, went well (there was no cancer), and he returned to his hospital room. When he was first coming out of anesthesia, he seemed fine, and when I visited him a few hours later he was sitting up in bed, talking away, and looking quite alert. After a few minutes I realized he wasn’t making any sense. He was surprised to see me in a white coat—he thought I was still in high school. He thought my mother, who had been dead for five years, was going be visiting that afternoon. Despite the various tubes for intravenous fluids and stomach drainage, he tried to get out of bed.

I was very alarmed by his behavior, and immediately called my brother, a professor of surgery at Yale Medical School. He calmly told me that this was post-operative delirium, a condition he saw  all the time. This was a little embarrassing for me—after all, I was the neurologist in the family!

Since then I have been interested in this phenomenon of postoperative confusion and abnormal behavior, as discussed by Susan Seliger in her New York Times article, “Another Hospital Hazard for the Elderly.”

Much of the emphasis has been on postoperative delirium, but it is also common on general medical wards where people are admitted for acute illnesses, and in long-term care facilities for the elderly. As Seliger notes, delirium in the hospital is a common occurrence, approaching 50 percent in some studies of surgery involving elderly patients.

It is not benign. People who experience this phenomenon stay longer in the hospital and have more hospital-acquired complications such as falls, infections and bedsores, higher mortality, and greatly increased hospital costs.

Prevention starts with identifying those at high risk for developing delirium: people over 65; people with some degree of cognitive problem prior to hospital admission; those with severe, acute illness; and those with hip fracture. This list adds up to a lot of people; additional factors help focus on those most at risk:

• Multiple medications. People may be taking a lot of medicine, and on entering the hospital other medications may be added, making the polypharmacy even worse.

• Intercurrent infections, particularly lung and urinary tract infections, which may be initially missed

• The strangeness of hospitals. Think of the last time you woke up in a hotel during a trip and wondered where you were. Imagine a different hotel room each night. A patient may be moved from the emergency room to an intensive care setting to a ward in a matter of days, all with different nurses and doctors.

• The noise and confusion of hospitals. Lights are on all the time. Patients are woken up 2-3 times each night for blood pressure recordings and medications.

• Sleep is at a premium. Medications for sleep may make the delirium worse.

All of these factors can be avoided with proper planning and recognition of their harmful effects. This requires that hospital personnel be aware of the issues and willing to change some of their habitual behavior. Simple things can help: provide a readily visible clock, so that the day-night confusion is lessened; carefully review medications; identify and treat infections; ask family and friends to visit to provide comfort; get patient out of bed as often as possible.

Back to my father: By Day Two, he was remarkably better, but had episodes of confusion toward the end of the day, a process that is known colloquially as “sundowning.” Dad was doing what many patients do, shifting in and out of delirium quickly. I camped out at his bedside as much as I could, particularly at night. I tried to keep him oriented, getting him to reminisce about his childhood in Ohio, and his time in China (he’d been a medical missionary there). He and I spent much more time walking together, up and down the hall, than we had previously.

He eventually went home, two days later than he would have without the interruption of delirium. I don’t know why he had his problem. I think it was a combination of age, general anesthesia, and some of the hospital factors I mentioned above. 

Physicians have neglected this problem to a certain extent. Even in my own hospital I have had a surgeon say to me, “Oh he’s just a little out of it. All old people do that.” Recognizing the problem, being aware of its implications, and introducing preventive factors can make a difference.

For those who want more information about delirium, look up the writings of Sharon Inouye, who has been one of the pioneers in delineating this problem, and also the report from England by a review group.