Bewitched, Bothered, and Bewildered

I read an interesting article in the NY Times the other week regarding a phenomenon I’ve seen over and over in hospital intensive care units.  The report, published June 20, 2010, claims that nearly one third of patients over the age of 70 will experience some degree of delirium during a hospital stay, especially if they spend any time in the ICU.  With our current population pushing the curve of age distribution farther to the right we will be seeing more geriatric patients admitted to hospitals and with them more frequent cases of delirium.

A reasonable definition of delirium would be as follows (courtesy of medical-dictionary.com):

“An acute, reversible organic mental disorder characterized by reduced ability to maintain attention to external stimuli and disorganized thinking as manifested by rambling, irrelevant or incoherent speech. There is also a reduced level of consciousness, sensory misperceptions, disturbance of the sleep wakefulness cycle and level of psychomotor activity, disorientation to time, place or person and memory impairment.”

The key words in the definition that differentiate delirium from chronic mental illness or dementia are acute and reversible.  If you indulge yourself at a college frat party and strip to your skivvies for a night of dancing on the furniture, you’d be classified as delirious (since you’d presumably be of sound—although embarrassed—mind once the alcohol effect wears off).  A patient with Alzheimer’s, whose symptoms may include those in the definition cited above, would not be classified as delirious since the manifestations are neither acute nor reversible (typically).

To give you an idea what some of these patients are experiencing, allow me to cite the NY Times story:

No one who knows Justin Kaplan would ever have expected this. A Pulitzer Prize-winning historian with a razor intellect, Mr. Kaplan, 84, became profoundly delirious while hospitalized for pneumonia last year. For hours in the hospital, he said, he imagined despotic aliens, and he struck a nurse and threatened to kill his wife and daughter.

Justin Kaplan thought himself besieged by “thousands of tiny little creatures,” he said, “some on horseback, waving arms, carrying weapons,” during his bout with hospital delirium last year.

“Thousands of tiny little creatures,” he said, “some on horseback, waving arms, carrying weapons like some grand Renaissance battle,” were trying to turn people “into zombies.” Their leader was a woman “with no mouth but a very precisely cut hole in her throat.”

Attacking the group’s “television production studio,” Mr. Kaplan fell from his hospital bed, cutting himself and “sliding across the floor on my own blood,” he said. The hospital called security because “a nurse was trying to restrain me and I repaid her with a kick.”

My experience with hospitalized elderly people is similar.  I’ve seen patients who believe that long-dead relatives or ghostly strangers are roaming their hospital rooms.  Patients have told me of animals around their beds and scenes from their childhood being replayed before their eyes.  Many will simply become confused and disoriented.

And these are the more benign variety.  Some patients suffer impressive levels of paranoia, insisting that the doctors and nurses are out to kill or imprison them or that family members are conspiring to eliminate them.  They’ll refuse to take medication, fight back anytime a nurse or aide approaches, and yell out or become belligerent in the darkest hours of the night.

These episodes are not without their consequences.  As pointed out in the NY Times article, delirious patients tend to end up with longer and more complicated hospitalizations than lucid individuals.  I saw a patient last week who suffered a heart attack at an outside hospital and underwent a relatively uncomplicated angiogram.  While he was recovering from the procedure he became confused and agitated, whereupon his doctors responded by sedating him to the point that he aspirated and developed respiratory failure.  He spent a week on the ventilator—a week that would have been spent in the comfort of his home had it not been for his acute delirium and the treatment provided.

Family members become appropriately concerned when they see grandma or grandpa “going nuts” and want to know the cause.  Here are a few possibilities:

• Pain medications often accompany a stay in the hospital and can wreak havoc on an elderly patient’s level of coherency.  Older people tend to metabolize narcotics and sedatives more slowly, resulting in an excessive accumulation of the active chemical in the patient’s body.  Other drugs—even those we don’t typically think of as sedating—can significantly impair clear cognition in susceptible geriatric patients.  A good example is diphenhydramine (Benadryl) with its potent anticholinergic effect.
• Illness tends to affect older patients differently than the rest of us.  I’ve always been impressed with how a problem as simple as a bladder infection can trip a debilitated nursing home patient into an incoherent stupor.  Medical students learn very quickly to screen for simple infections when older patients are admitted for confusion.
• Being in the ICU is a bit like being on the Las Vegas strip at midnight (and, no, I’m not referring to the revealing nature of the hospital garb)—the lights are always on, the pumps and monitor beep incessantly, and alarms sound for every physiological aberration from the norm.  Doctors, nurses and technicians enter the room randomly at all hours with stethoscopes, needles, and x-ray equipment.  Night and day become theoretical concepts to a patient who drifts in and out of non-restorative, interrupted sleep.  This deprivation of normal diurnal cycle—a staple of combat interrogators eager to “break” a captive—can degrade a patient’s mental lucidity to the point of psychosis.
• Older patients with early or borderline dementia can often function in their normal environment without family members suspicious of the beginnings of mental impairment.  At home, in their usual daily routine, there is nothing that challenges their ability to perform the simple tasks expected of them.  Put them in a hospital, however, with a constant turnover of new faces and unexpected stresses, and what appears to be a new case of delirium is nothing more than the unmasking of dementia.  (It should be noted that patients who suffer hospital delirium are more likely to develop dementia at a later point—an association that underscores the idea that the stress of the hospital simply unveils early dementia in these individuals.)
• Other, random things can impair a patient’s ability to hold on to reality: they change rooms, sometimes in the middle of the night; their glasses and hearing aids are placed in closets and drawers, leaving the patients in effective sensory deprivation; they can be left isolated from the usual company of known family members and friends; they suffer sleep deficiency, eat strange foods, are overheated or chilled—even the interruption of usual bowel patterns add to the mix of ingredients that bake up a potpourri of confusion and hallucinations in their heads.

What can be done about this?  The first and most obvious step is to recognize it for what it is and not overreact to it.  Family members shouldn’t get too anxious about what they perceive as “craziness” on the part of grandpa—in nearly all cases the patients return to normal once they are back in a less disruptive environment.

We doctors need to try to resist the reflexive use of sedatives or antipsychotics in patients with mild cases of delirium.  Rather, we should expend the effort to sort out what type of environmental, medical, or pharmacological trigger is to blame for the change in mental status, then try to rectify it.

Finally, hospital personnel should do all they can to stabilize the environment for geriatric patients.  Numerous facilities have adopted the Hospital Elder Life Program (HELP), a method of patient care that aims to prevent the development of delirium “by keeping hospitalized older people oriented to their surroundings, meeting their needs for nutrition, fluids, and sleep and keeping them mobile within the limitations of their physical condition.”  Their website has numerous suggestions that are simple, easy to implement, and have been scientifically tested and validated.

I’ll conclude this post with a final anecdote:

On my first call night as a new medical intern my resident and I were called to the coronary unit to help calm an older patient who had become disruptive.  He had a history of mild dementia and had already begun to annoy the unit staff by performing a series of a cappella renditions of old show tunes at the top of his lungs.  We were called only when he began carrying on about bats flying around his hospital room.  He had become a little more anxious and seemed to be perseverating on the subject to the extent that his performance playlist now consisted only of songs about flying rodents.

We wrote for some haloperidol (at the time, a medication on the short list of any new intern) and headed back to our call room.  Within minutes we received a panicked call from the nursing station: get back here immediately.  When we arrived we were greeted by the muffled panting of nurses as they huddled under the nursing station desks and the anxious hands pointing up into the air.  Around the corner flew a bat, swooping in and out of the open rooms of the ICU.  Before the night was done more than a dozen bats were apprehended, all of which appeared to have entered the hospital by an open window in the room where our demented, operatic patient was now resting blissfully.

The moral of the story?  Close the windows to the ICU if the belfry of the 100-year-old building across the street is undergoing construction.

Well, at least that’s one moral.  Another would be to take a close look at a newly delirious patient before reaching for your prescription pad and try to find the root cause.  Maybe they aren’t as crazy as they look.