SMOKINCHOICES (and other musings)

February 20, 2015

Hospital stay can induce delirium

Stay at hospital can induce delirium

By Misti CraneThe Columbus Dispatch   

“What? What’s your name?” Carl Herfel asked, leaning closer for a better look.  “Bruce,” said Carl’s son.  Carl relaxed back into his chair at Arlington Court, a nursing and rehabilitation center in Upper Arlington.   “Oh, gee,” he said. “We’re very much OK. We try to do it.”

You could mistake the former high-school assistant principal, who wears his hair in a slender white braid, for a decade younger than his almost 81 years, despite what has happened to his mind.And his mind was mostly fine until Dec. 16, except for the occasional search for a word. He never had to search for the name of one of his children, Bruce Herfel said, and filed his own taxes, enjoyed family birthday parties, mowed the lawn, shopped for groceries and scrubbed the dishes after dinners with Sara, his wife of 59 years.Then came a minor car crash and subsequent hospitalization, during which Carl’s family watched him go from conversant and a bit shaken to utterly confused and in intensive care, his mind altered in such a profound way that he could not walk or feed himself.

Hospital-induced delirium was a term unfamiliar to Bruce Herfel until one of the doctors at OhioHealth Riverside Methodist Hospital told him that it’s common, especially among older patients, and could explain — at least in part — Carl’s transformation.

“He said we need to do whatever we can to help orient my dad . . . to help reverse it.”

Delirium is a severe state of confusion characterized by unclear thinking, inattention and sometimes hallucinations.  In intensive care, it’s rampant. About two-thirds of patients have delirium for at least a time, and 7 of 10 patients develop delirium while on ventilators or soon after.    A recent study found that more than half of those who survive a critical illness have cognitive impairment a year later; one-third of them experienced symptoms similar to Alzheimer’s disease.

But as recently as the turn of this century, delirium wasn’t recognized or understood, said Vanderbilt University’s Dr. Wes Ely, an expert on the subject whose team created protocols for helping patients retain their mental acuity.

  • “When I first started going to the (National Institutes of Health), they would write back, ‘This is not a thing; we don’t know what you’re talking about,’ ” he said.

Now, “This is becoming a very, very big deal,” Ely said, pointing to national initiatives, including efforts by the Society of Critical Care Medicine to improve care and decrease delirium.   “It’s an organ failing. This is the brain failing. There’s so much human suffering. This is a massive, massive public-health problem.”   Ely said much of delirium goes unrecognized because patients don’t act out. Rather, they’re quiet, a state known as “hypoactive delirium.”

Patients of all ages are vulnerable, but it is more common in older people and those who have dementia. Surgery increases the risk, as does depression and impaired vision or hearing. Experts say it can be triggered by infections, some medications (including sedatives and narcotics), pain and reduced oxygen to the brain.

  • It can come on within hours and usually clears up within days, but dementialike problems can last months or years.

Although dementia had not been diagnosed in Carl prior to his hospitalization, Bruce said the family has come to understand that the words he’d sometimes forget could have been an early sign of mental decline, which could have predisposed him to delirium.

Bruce said he wonders whether the antipsychotic drug Haldol, given to calm his father when he was agitated and tried to leave his hospital room, is partly to blame.   After his second dose, “He was unresponsive for about 30 hours,” Bruce said. “His carbon-dioxide levels were elevated to the point they were very concerned. They moved him to intensive care and put him on a ventilator.”

The car’s airbags deployed during the crash, and Carl had a knot on his forehead, a black eye and a cut on his head. CT scans revealed no evidence of brain injury, but because of his age and the risk of concussion, the doctors had wanted to keep Carl in the hospital overnight, his son said.

“We hear this over and over again, and it’s not limited to older adults. It’s affecting people who are in their 30’s and 40’s, and sometimes for the rest of their lives,” said Michele Balas, a delirium expert and associate professor at Ohio State’s College of Nursing.

Balas and Ely said many medical centers are paying more attention to delirium and employing tactics to help patients avoid it. That includes helping them walk as quickly as possible, even while they’re still on ventilators.

It also includes making sure they interact with family members, can see daylight and wear glasses and hearing aids when appropriate.

Balas led a study that tested a protocol for caring for ICU patients. The protocol involved using techniques for reducing delirium among 296 patients in five ICUs, one step-down unit and one oncology/hematology unit.

The researchers found that employing the prevention strategies that go by the acronym ABCDE almost cut in half the chances a patient would develop delirium. Those who received the extra attention also spent more days breathing on their own.

  • Besides being devastating to patients and families, delirium also increases the chances a person will die or develop other medical problems, Balas said.

Ohio State is using several of the techniques in the hospital routinely, she said, adding that in the next year, a collaborative of 60 hospitals will undergo training on the best approaches to avoid delirium.  “It’s hard work,” Balas said, adding that it requires manpower, consistency, commitment and teamwork among professionals who don’t always work together easily.

OhioHealth hospitals are striving to decrease delirium through a variety of techniques, including encouraging healthy sleep/wake cycles for patients by keeping rooms dark at night and minimizing disruptions while patients sleep, said Dr. Marian Schuda, medical director of the Gerlach Center for Senior Health and of patient services at Riverside.

  • Limiting medications when possible also is a priority, Schuda said.  “Taking good care of people is the best way to handle things, but with that, you can still have the delirium.”

OhioHealth Grant Medical Center has a special acute-care unit for older patients where additional work is being done to improve and tailor care. Schuda said she hopes the lessons learned there will be more widely applied.

  • Balas said tackling the medication issue means rethinking long-held beliefs about how to best care for critically ill patients.   “We were always thinking we were doing the right thing in terms of heavily sedating people while they were in the ICU,” she said. “Now we know it’s associated with hurting them and hurting their brain.”

Once a person has delirium, health-care providers frequently miss the signs, Balas said. Screening is an important step in identifying those who’ve been impaired during a hospital stay. Early identification means you can work to eliminate the cause, whether it’s medication or immobility or something else.

“We were told for years and years that this was normal. You go to the hospital, you’re going to get confused,” said Dr. Sergio Bergese, director of neuroanesthesiology at Ohio State. “We know today that delirium kills people. If you have delirium in the hospital, your mortality goes up significantly.”

And it’s not just a problem in the ICU. It can happen anywhere in the hospital and can be made worse by strange noises, restraints and a lack of daylight, said Bergese, who researches the condition and is about to study the potential benefit of exercises that engage the mind prior to elective surgery.

Carl Herfel is more alert and is quicker to respond to questions or conversation than he was a month ago, his son said. His family walks the halls of Arlington Court with him every day and keeps the conversations going even when they take mysterious turns.

Mrs. Herfel said she’s “working on staying OK.”  “But I am concerned how it’ll be a year from now. I try not to dwell on that.”

For more information on delirium, including advice on how to help family members in the hospital, go to www.icudelirium.org.

mcrane@dispatch.com

(My comment:  

There is no question about the dislike of the need to go to a hospital. We have been told for years now about death threats  we face when having to enter one for any procedure.  Theoretically, this threat is triggered by hospital mishaps such as wrong medicines or some kind of mix-up relating to their usage;  wrong body part or organ in surgery and other inconceivable woes.  

One cannot paint the entire industry as uncaring or callous or inept as most are certifiably humane and dedicated.  While the glaring statistics can’t be denied [tho anything CAN be done with numbers], there seem to be enormous pressures on the overall administration of hospitals.   Cost-cutting remains one of the foundations of a profitable business. . .just the way stuff works.  And because of this and other regulatory elements. . .speed and shortcuts can undermine legitimate efforts.  No matter how, what, why or who — it’s the sick or injured person which should be the ultimate priority, ALWAYS, no matter what.  Everything else is just NOISE,  unwelcome noise.  

In light of safety issues and patient outcome,  hospitals are a place to stay away from.   This article reveals  still another issue most of us would not have guessed nor contemplated.  This is an enormous burden which hospitals and the practicing doctors and associated staff therein MUST deal with.  It is a good thing [however late in arrival],  that light is being focused on this and action is being taken — our medical professionals are trying to see with new eyes and solve problems.  To be applauded!  Jan)

 

 

 

 

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