How to Recognize Signs of Delirium in the Hospital

Diagnosing and treating this state of confusion can avoid extended hospital stays.

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Especially if they are older and in intensive care, some patients go through episodes of delirium—a word that may suggest shouting and thrashing, but it's more a state of confusion. It may not be obvious at all. It may reveal itself as disorientation, inattentiveness, or difficulty in following instructions. Or it may be more extreme—paranoid statements, claims of bugs crawling on the body, or sudden efforts to rip out wires and IV tubes. Less frequently, younger patients who are neither in intensive care nor on a ventilator are affected.

While enormously distressing to families, these occurrences typically are written off as benign, just one of those problems that come and go. Often the symptoms do fade quickly. But in the past few years, researchers have unearthed evidence that "sundowning," as delirium states are nicknamed because of their timing, may be far from benign and could have lasting effects.

"Delirium is a predictor of death, a longer hospital stay, and increased costs," says Wesley Ely, a critical-care specialist who founded the ICU Delirium and Cognitive Impairment Study Group at Vanderbilt University School of Medicine. It may also be a risk factor for dementialike illness.

A key finding of Ely's group is that delirium is far more likely to affect patients who are sedated and ventilated. These cases often go undiagnosed, says Ely, because the breathing tube prevents the patients from talking. He developed a quick nonverbal way to check such patients' mental state: For example, they are instructed to squeeze a nurse's hand only when she comes to an A as she spells "save a heart" out loud.

Disrupted sleep. Diagnosis is crucial, because delirium signals other issues. Ely is studying possible problems posed by common sedatives. Established factors include pneumonia, infection, low blood oxygen, a specific drug or combination of medications, too much fluid in the body, and out-of-balance electrolytes. A suddenly changed sleep cycle may induce delirium. The disruption could be due to sedation or, as happens too often, because a patient is awakened during the night for a routine chore such as getting a bath or having blood drawn. What's more, "it's fairly rare that you'd see a single factor causing the delirium," says Laura Fochtmann, professor of psychiatry and behavior science at Stony Brook University in New York.

Family and friends can help keep patients oriented. Remind them every day where they are and what is going on, says Ely. Bringing familiar or helpful items from home—glasses, hearing aid, clock, calendar—can better anchor them in reality.

After a bout of delirium, caregivers can be pressed to hunt down and address the cause. A psychiatric specialist can be consulted, a ban on late-night wake-ups can be requested, and the need for a prescribed psychoactive drug can be re-evaluated. The biggest problem, says Ely, is that too often "doctors are focused only on the organs that got the patient into the hospital."

Learn more about Vanderbilt University's delirium research at icudelirium.org.

This story was originally reported on 7/15/07.