Six Questions to Protect Elderly Patients

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Hospital delirium affects about a third of patients over 70.

This week, Pam Belluck reported in The Times on the risk that elderly patients may become confused and delirious while in the hospital. Here she offers advice on how to prepare when an elderly patient is headed to surgery or a hospital stay.

About a third of patients over age 70 experience hospital delirium, and the consequences can be serious, delaying a patient’s recovery and even leading to placement in a nursing home. Elderly patients who experience delirium are also more likely to develop dementia later on, and more likely to die sooner than patients who do not become delirious.

Many readers have asked me what family members can do to help lower an elderly patient’s risk. To find out, I turned to three experts – Dr. Margaret Pisani at the Yale University School of Medicine, Dr. Wes Ely at Vanderbilt University School of Medicine and Dr. Sharon Inouye at Harvard Medical School. Based on their advice, here are six questions family members should ask to lower an elderly patient’s risk for hospital delirium.

1. Do the nurses and doctors routinely screen for delirium or identify high-risk patients?

Older and younger patients who develop severe infections or heart, liver or kidney problems are at higher risk for delirium. But about 75 percent of delirium cases are missed when the hospital or its intensive care unit is not actively screening for it. While delirium can cause patients to become aggressive, disruptive or incoherent, it can also manifest itself in much less obvious ways, making a patient seem withdrawn or disconnected. Even with regular screening, family members are often the first to notice subtle changes. If you detect new signs that could indicate delirium — like confusion, memory problems or personality changes — it is important to discuss these with the nurses or physicians as soon as you can.

2. How does the hospital deal with agitation or delirium in patients if it develops?

The longer the duration of the delirium, the greater the chances of poor consequences for the patient, so it should be addressed quickly. Experts say hospitals can treat delirium by helping patients sleep, making sure patients are hydrated, allowing family members to stay at patients’ bedsides to help them become reoriented, and getting patients up and walking when it is safe to do so. Family members should also inquire about hospital policies involving restraints for confused patients. Removing restraints is often recommended because they can cause patients to feel paranoid or trapped. Some hospitals use anti-psychotic medications like haloperidol, but some experts caution that these should be used in moderation and are not yet proven to work.

3. What does the hospital do to keep patients from becoming disoriented?

Situations like being without one’s eyeglasses, being in a darkened room and being unaware of the day and time can trigger delirium. Hospital rooms should have clocks, calendars and adequate light, and nurses and doctors should ensure that patients have their glasses, hearing aids and dentures. Family members should make sure the hospital staff knows if the patient needs these items. The family can also bring a few familiar objects from home to help a patient stay oriented. Things like family photos, a favorite blanket for the bed, a beloved book or relaxation tapes can be comforting for all patients. Family members can also help by speaking in a calm, reassuring tone of voice and reminding the patient where he or she is and why. Massage can be soothing for some patients, and if it is all right with the medical staff, family members can walk with the patient in the hallways. Families should limit the length of visits and number of visitors to prevent patients from feeling overwhelmed, but they should also try to make sure the patient is rarely alone. If the patient experiences an acute episode of delirium, relatives should try to arrange shifts so someone can be present around the clock.

4. What policies are in place to make sure patients get adequate sleep?

Family members should find out if patients are able to sleep through the night or if they will be awakened for medical tests. Find out how the hospital controls noise and whether it offers any nondrug measures like back rubs or warm tea to promote sleep.

5. If my family member needs a urinary catheter or other bedside interventions, how does the hospital decide when to remove them?

A common procedure like a catheter insertion can spur anxiety in frail, vulnerable patients. Experts say it’s important to remove catheters, intravenous lines and other equipment whenever possible because they can make patients feel trapped, leading to delirium.

6. Will the physicians and pharmacy staff review my family member’s medications to identify medications that increase delirium risk?

Bring to the hospital a complete list of all medications and dose instructions, as well as over-the-counter medicines. It may help to bring the medication bottles as well. Prepare a “medical information sheet” listing all allergies, names and phone numbers of physicians, the name of the patient’s usual pharmacy and all known medical conditions. Also, be sure all pertinent medical records have been forwarded to the doctors who will be caring for the patient.


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New York Times
June 24, 2010
By PAM BELLUCK