The delirium epidemic in frail hospitalized patients

Marco Inzitari
 

 

Cardiff Delirium Study

Delirium, formerly known as acute confusion syndrome, affects around 20% of patients older than 70 years admitted to hospitals, such as reflected a recent study from Australia, a country of 24.6 million inhabitants with a population less aged than ours. This syndrome significantly increases the stays of hospitalized patients, for example, due to femur fracture (7.4 days on average), or aortic valve replacement (4.2 days), with avoidable extra costs. 

The three main ideas that I will develop in the post, with their corresponding messages, are:

1. Can we do something? Delirium is a syndrome that can be prevented and treated. Can its impact be minimized?
2. What could we do? The most effective and valuable interventions are non-pharmacological and structured programs in the hospital setting.
3. Who could do it? Nursing - if they wanted to- could lead this battle, which, however, must be interdisciplinary. Doctors would have to learn "not to do." The momentum of the managers is essential, so, at the end of the post, you’ll find a challenge!

It’s interesting that in a blog referring to clinical management like this one, the word "delirium" doesn’t appear even in tiny characters in the list of keywords ("tags"). Worse still, the response to the collapse of hospitals is usually asking to open more beds or being able to refer more patients to other devices, instead of attempting to prevent unnecessary admissions or shortening the length of stay, for example through a better management of delirium.

Are we following Advances in Clinical Management closely? The lack of interest in the subject on the part of clinical managers collides with some of the previous entries that have dealt with interventions of value in hospitals, as well as those of little value. I quote literally: 

– Support mental health in acute hospitalizations (post "10 priorities to integrate physical and mental health, according to The King's Fund", by Andrés Fontalba). "With an integrative vision, professionals who work in emergency and hospitalization services should have, among their skills, the ability to identify and attend to situations such as dementia, delirium, self-destructive ideation and acute psychosis”, dr. Fontalba says.

- Prevent iatrogenesis in frail patients admitted to hospitals (post "Hospitals and frail geriatric patients", by Jordi Varela). "During admissions, prevention guidelines for the main specific hospital iatrogenies must be practised and most involve nursing work: bedsores, disorientation (and delirium), infections, falls, thromboembolism, malnutrition, dehydration, etc. It must not be forgotten that prolonged hospital stay can, by itself, increase the frailty of the patient".

- Antipsychotics are not effective to treat delirium in palliative care. "A double-blind Australian clinical trial has verified that in 247 patients with delirium during the palliative care process, both haloperidol and risperidone have worse results in reducing delirium than placebo and can induce, on the other hand, the appearance of extra-pyramidal effects or, in the case of haloperidol, even advance death. "

Non-pharmacological management, based on recommendations such as stimulating physical activity, reducing the stay in bed, removing invasive devices such as tubes and non essential wires, recovering the person's circadian rhythm and that they are accompanied efficiently. And I think it’s a battle that nursing could lead and in which doctors, apart from collaborating in its promotion, would rather learn to "not do" (avoid drug over prescriptions, for example, and support non-pharmacological guidelines). But it requires expertise, training, teamwork, a little time and support and, above all, a decisive commitment on the part of managers and directors.

Finally, here are two real cases. A patient who comes to the emergency room due to aspiration was referred to as a sub-acute unit. He had advanced dementia, lived in a nursing home and it was his third admission in six months for the same cause. The patient, agitated by a hyperactive delirium, in the last 24 hours had torn off its i.v. access five times (which had been reinserted every time) to treat the pneumonia according to the recommendations of the clinical practice guidelines. Someone had even suggested immobilizing his hand, which, luckily, didn’t happen. Removing the intravenous tube, letting him see the light of day by raising the blind and sitting him in a chair was enough for the symptoms to subside. It was even possible to treat his pneumonia. In a second case, I had to personally call the head of a hospital department to implore him to persuade the responsible team to discharge a patient with dementia and superimposed delirium, the father of a friend, who had been admitted for scheduled surgery and, given his previous history of delirium and repeated escape attempts at night, he had been physically contained and sedated. Once at his home, after a couple of more "bumpy" days, he was oriented again, within his condition limits. 

In November 2021, the congress of the European Delirium Association will be held in Barcelona, ​​co-organized with the Catalan Society of Geriatrics and Gerontology and with the participation of the Catalan Society of Intensive Medicine and the Catalan Society of Psychiatry. I am looking for an acute hospital manager or a senior representative of the health administration willing to sit at a round table to discuss the subject. Does anyone who has had enough interest or sensitivity to go to the end of this post pick up the challenge?

Photo: "Visual hallucinations described by cardiac surgery patients participating in the Cardiff Delirium Study. delirium@cardiff.ac.uk"