Old and delirious — it's not normal

Common geriatric affliction often
overlooked, preventable

By Samuel Jarjour

Is he delirious or demented?

Delirium in the elderly is a serious problem that's severely neglected, according to a study in the April 21 British Medical Journal. Everyone ages differently, and some do so better than others, but it's too often taken for granted that mentally, things simply go downhill. Sure, the march of time never ceases, but elderly mental health experts fear we're overlooking an important diagnosis, at the expense of the well-being of many seniors among us.

Study co-author Dr Sharon Inouye is a geriatrician at Beth Israel Deaconess Medical Center and director of the Aging Brain Center at the Institute for Aging Research in Boston. She thinks that delirium isn't taken seriously enough. "It's not receiving enough attention in healthcare at all," she says. "There's this concept that it's ok for older people to become confused. Like it's just a normal thing. If you or I suddenly went bonkers, there'd be concern, and a quick intervention, but if your 80-year-old grandmother does, it's ok, given her age."

What strikes Dr Inouye is that a big proportion of delirium cases are preventable.

DELIRIUM & DEMENTIA
Delirium is a common complication among the elderly. Described as an acute disturbance of consciousness and perception, it develops and fluctuates rapidly over time. This rapidity is a key difference from another — often comorbid — problem, dementia. Delirium is also distinguished by a profound loss of attentiveness and focus. To better detect it, doctors need to perform more routine cognitive assessments, according to Dr Inouye. Frequently aggravated in the hospital setting, common factors contributing to the confused state are medications, surgical intervention, serious infection and chemical or electrolyte abnormalities.

Delirium occurs in 11-42% of cases, although this is probably an underestimation. It's estimated to add an extra $2,500 US on the cost of a hospital stay, to say nothing of the distress it causes patients and their families.

But a state of confusion might be putting it lightly, considering the seriousness of the problem. Delirium in elderly patients actually produces a two-fold increase in discharge mortality, and is both a predictor and cause of death. In reality, delirium can act like a health barometer, says Dr Inouye, indicating there's been a bad turn in a patient's health. Dr David Conn, head of psychiatry at the Baycrest Centre for Geriatric Care in Toronto, agrees. "Delirium can also produce long term cognitive impairments if left unchecked," he adds. "These patients need to be monitored carefully, but are too often neglected."

HELPING HAND
Dr Inouye developed the Hospital Elder Life Program (HELP), an approach to dealing with elderly patients that consists of systematically applying treatments, some of which might seem like common courtesy for the elderly. The goal of the program is preventative, aiming to reduce the risk factors for delirium. It's currently being practised in several healthcare institutions across the USA, and a few Canadian ones too. So far HELP program participants have demonstrated that over a third of delirium cases are preventable.

"What's important is giving good basic care," notes Dr Inouye, referring to the HELP approach. The measures taken by the intervention strategy, which requires the involvement of treatment specialists and hospital volunteers alike, are giving results. Key components include effective communication with patients, keeping them mobile, helping them get a good night's sleep, managing pain, providing assistance as simple as making sure that they have their glasses and hearing aids, and, importantly, avoiding overmedication.

"Basically, one thing that's important in all the studies we've looked at is overmedicating patients, especially since a lot of medications have confusion as a common side effect - even ones that aren't primarily geared toward having psychological effects," notes Dr Inouye. "A lot of anti-ulcer drugs, H2 blockers, as well as antihistamines and some asthma medications too. People know about antidepressants, antipsychotics and narcotics, but may be neglecting the other types of drugs. Antipsychotics are commonly used for symptom treatment, but can worsen delirium symptoms."

Drawing on a broad range of available literature in the field, including work by Dr Inouye, the Canadian Coalition for Seniors' Mental Health (CCSMH) — co-chaired by Dr Conn — recently released the first ever Canadian mental health guidelines for seniors. The guidelines are aimed at improving the assessment, treatment, and prevention of key mental health issues for seniors, and include delirium as one of four areas of focus. Other issues targeted by the guidelines are depression, suicide prevention and mental health in long-term care facilities.

CCSMH National Guidelines are available at www.ccsmh.ca/en/guidelinesdownload.cfm (you'll have to fill in an electronic form).