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Elderly hospital patients facing risk of delirium

CHICAGO — Dr. Sharon Inouye was distraught when her elderly father, a brilliant physician, became delirious after cardiac surgery several years ago.

Inouye had been doing research for years on seniors who become disoriented and confused in the hospital. She knew what was happening to her dad, even though she wasn't able to prevent it.

"My feeling of helplessness impressed on me how much our health care system has to change before we do a better job of taking care of older people," said Inouye, a professor of medicine at Harvard Medical School and director of the Institute for Aging Research at Hebrew SeniorLife in Boston.

Delirium in seniors admitted to hospitals is a case in point.

This often overlooked medical condition is defined as an abrupt change in a patient's mental status. Typically, symptoms are intermittent and include inattention, forgetfulness, an inability to concentrate and sometimes paranoia, agitation or hallucinations.

"People will say my loved one was doing OK but she looks different, her thinking is disorganized, she's a lot more confused. She's just not herself," said Dr. Malaz Boustani, associate professor of medicine at Indiana University School of Medicine.

Delirium affects 2.5 million seniors admitted to medical institutions every year. Elderly people at higher-than-average risk include those 75 or older and those with cognitive impairments or severe underlying illnesses. Estimated Medicare expenses associated with delirium run to about $7 billion each year.

The condition is important because it increases the chance that an older person will lose his or her independence, become more disabled and die.

"If you develop delirium, you have two times the risk of death within 30 days of hospitalization and twice the odds of being discharged into a nursing home or another institutional setting," Boustani said.

Yet research indicates that two-thirds of the time, the medical staff doesn't recognize delirium in hospitalized elderly patients, Inouye said. Also, they don't realize how hospital practices can foster delirium or how changing practices can help prevent this distressing condition.

Inouye's research has clarified what needs to be done. Look for factors that may be contributing to the older patient's disorientation and agitation. Does he have his eyeglasses and hearing aids to see and hear what is going on? Is the patient being restrained unnecessarily in bed?

Is there a clock in the room so a senior can tell what time it is? Is the room dark and quiet at night so sleep is undisturbed? Is the staff getting the patient up and about quickly, so he or she doesn't lose mobility? Is someone talking to the patient several times a day, and explaining what to expect? Most important, have all medications been reviewed and assessed?

Tactics like these have reduced instances of delirium in hospitalized seniors by up to 40 percent, according to research published in the New England Journal of Medicine.

Sometimes, very agitated patients with delirium will require medication. Boustani recently published a review of pharmacologic strategies for this condition in the Journal of General Internal Medicine. The conclusion: Anti-psychotics are probably the best first-line treatment, Boustani said.

"Most physicians are prescribing overly high doses. Our study found you can use a much lower dose and potentially improve the management of these patients," he said.

The Food and Drug Administration hasn't approved any drug for treatment of delirium in hospitalized patients.

Distributed by McClatchy-Tribune Information Services.