Part of the Transforming Life as We Age Special Report
Paula Duncan looks for delirium, a serious problem that often goes undetected in older hospital patients. So Duncan, a registered nurse at Park Nicollet Methodist Hospital in St. Louis Park, Minn., has learned to look beneath the surface, including in patients’ dreams.
People who’ve experienced delirium often have horrific and haunting dreams, she says. It’s not always something they’ll readily talk about. She asks them how they’re sleeping and if they’re dreaming, and watches their faces for clues. “Sometimes you can see by the look on their face that they’re having this experience, but they don’t want to tell you because it’s so awful,” Duncan said.
Duncan leads the Hospital Elder Life Program (HELP) at Methodist Hospital. HELP is a set of simple assessment, monitoring and prevention measures proven to reduce the incidence of delirium. Unlike dementia, which is constant and gets progressively worse, delirium tends to come and go, fluctuating even in the course of a day. The symptoms are transitory, yet for people who develop delirium, it can be the start of a permanent decline in health and independence.
HELP is available at more than 200 hospitals across the U.S. and in 11 other countries; much of the program is carried out by trained volunteers. The non-medical nature of the prevention means that where HELP is not offered, families can take these preventive steps on their own.
Some studies show continued signs of delirium six or 12 months after onset. Some patients never fully bounce back.
Know the Signs of Delirium
Delirium is defined as an acute and fluctuating disorder of attention and cognition. It’s a sudden mental change that can look different from person to person. Someone with delirium might seem more foggy mentally and have trouble focusing, speak without making sense, hallucinate or act out in fear and paranoia.
Some people are aware of delirium as it’s happening, some are not, said Dr. Daniel Mendelson, a geriatrician who is associate chief of medicine at the University of Rochester’s Highland Hospital in New York and part of the HELP program there. “It’s generally more distressing to their family and caregivers.”
Delirium can happen at any age. Patients in the intensive care unit of a hospital are at risk, for example, because it’s hard to withstand a combination of pain or infection, sedation, disrupted sleep and a disorienting environment. But Dr. Sharon Inouye, now a professor at Harvard Medical School, developed HELP in the 1990s as it became increasingly clear that age itself was a risk factor for delirium.
“Older adults are simply less able to withstand stressors than younger adults,” said Inouye, who directs the Aging Brain Center at Hebrew SeniorLife, an affiliate of Harvard Medical School, in an email to Next Avenue. “Decreased cognitive reserve, loss of brain plasticity” and multiple health problems and medications all make older people more vulnerable.
HELP targets hospital patients who are 70 and older and tries to minimize six factors beyond age that contribute to the risk of delirium. They are: dehydration; visual impairment; hearing impairment; immobilization (such as being stuck in bed); sleep deprivation and cognitive impairment. People with dementia, for example, are more prone to developing delirium on top of it.
As many as half of older hospital patients develop delirium. Anywhere from one-third to two-thirds of cases are believed to go undiagnosed. Inouye said many clinicians still aren’t trained to understand delirium and look for it. They might not see it because the symptoms come and go. Also, patients with delirium can appear sleepy, which might seem unremarkable in someone who’s ill or recovering from surgery. “Their nurses and physicians may not recognize they are actually delirious,” said Inouye.
Delirium eventually clears up in most people who have it, but not quickly. Duncan said when patients develop delirium at her hospital, where the average length of stay is 3 1/2 days, just 4 percent of them have fully recovered from it by the time they’re discharged. As long as delirium persists, they’re more prone to other risks, such as falls. Some studies show continued signs of delirium six or 12 months after onset. And some patients never fully bounce back, but slide into deeper physical and mental decline.
“That’s why prevention is the way to go,” Duncan said.
Use Talk to Keep Them Grounded
When patients 70 and older are admitted to Methodist Hospital, they get a cognitive assessment from a nurse trained to use the HELP method. If they don’t already have delirium or one of a few other complicating factors, they’re encouraged to enroll in HELP.
Methodist has more than 200 HELP volunteers, trained by Duncan. They’re available to visit patients in shifts between 9 a.m. and 9 p.m. six days a week. Most patients who choose HELP get two visits a day. The volunteers use social time and conversation to look for risk factors and symptoms and to provide the mental stimulation that keeps delirium at bay.
Talk is at the core of both detecting signs of delirium and using an intervention called “orienting conversation.” Duncan gave an example:
“[A patient] could tell you a story about their children and all of a sudden,” she said, “they’re talking about their siblings, so they get the two groups of people mixed up.” Duncan or a volunteer would then ask clarifying questions to echo back to the person the specifics of what they were saying: “’So where did you go to the beach with your children?’ or whatever the conversation is about,” Duncan said. Hearing details spoken back to them helps people notice that they’re going off track and many times they reground themselves. “You just pepper details in through your conversation that help them stay oriented to where they are,” Duncan added.
Why Families Have an Advantage in Delirium Prevention
HELP brings in medical staff if delirium develops. But the preventive program is mostly non-medical. It answers each of the six targeted risk factors with these simple interventions:
Dehydration: Encourage drinking, unless fluids are restricted for some reason.
Immobility: To the extent possible, help the person go for walks or encourage him or her to move arms and legs in bed.
Sleep deprivation: When disrupted sleep cycles are a problem, the medical team can decide not to wake the person at night to check vital signs if it’s not essential. Volunteers — or families — can alert the staff to sleep problems. They can also move the person toward a normal sleep cycle by helping the patient stay awake during the day and creating a quiet, peaceful sleep environment in the evening. HELP volunteers use aromatherapy and hand massage to soothe patients.
Hearing impairment and vision impairment: “A lot of people don’t bring their hearing aids [to the hospital] because they’re afraid they’re going to get lost and they’re expensive,” Duncan said. But when families know about delirium and hearing impairment as a risk factor, they can make sure their loved one has hearing aids in place and a supply of batteries. The same is true with glasses and dentures, to help the person stay attuned to the environment and communicate clearly.
Cognitive impairment: At Methodist, everyone enrolled in HELP gets a folder of word and number games and coloring supplies for mental stimulation. Beyond that, volunteers try to learn patients’ personal interests and abilities so they can match them with a lending library of music, tablet computers loaded with games, books, audiobooks and even craft supplies, such as knitting baskets. Family members already know about personal interests and can bring favorite things from home.
Families also know something that’s even more important in preventing, detecting and managing delirium and that’s their loved one’s normal personality and normal cognitive abilities. Knowing those things, families are often the first to notice changes.
“One of the biggest challenges we have in the hospital setting is [in 3 1/2 days] to get to know [patients] and somehow understand what their baseline is,” Duncan said. “That’s probably the most difficult piece” of HELP, she added.
The HELP website has information and resources for families who want to learn more. It includes a downloadable brochure with 10 tips for preventing confusion in the hospital and 10 more on caring for a loved one who has delirium.
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