Correspondence
Delirium in Hospitalized Older Patients
N Engl J Med 1999; 341:369-370July 29, 1999
- Article
To the Editor:
In their study of the prevention of delirium in hospitalized older patients (March 4 issue),1 Inouye et al. provide data on the cumulative incidence of delirium as a function of the length of hospitalization that suggest that prolonged exposure to the hospital environment itself is a significant risk factor for delirium. These data support the need for effective plans for early discharge of older patients and suggest the need to assess whether providing hospital-level care to older persons in more hospitable environments than acute care hospitals, such as home hospitals,2,3 could reduce the incidence of hospital-related complications such as delirium.
3 ReferencesBruce Leff, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 212241
Inouye SK ,Bogardus ST Jr ,Charpentier PA , et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-676
Full Text | Web of Science | Medline2
Leff B, Burton LC, Guido S, Greenough WB, Steinwachs D, Burton JR. Home hospital program: a pilot study. J Am Geriatr Soc (in press).
3
Gravil JH ,Al-Rawas OA ,Cotton MM ,Flanigan U ,Irwin A ,Stevenson RD . Home treatment of exacerbations of chronic obstructive pulmonary disease by an acute respiratory assessment service. Lancet 1998;351:1853-1855
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To the Editor:
. . . We have two criticisms of the study by Inouye et al. The first is related to the authors' decision to exclude almost 100 patients because of a language barrier. The reason for this decision is difficult to understand, since hospitals are required to provide translators for patients who do not speak English. Miscommunication resulting from a language barrier may in itself contribute to the development of delirium, particularly when it occurs in the setting of an acute and catastrophic illness. In our multicultural society, this possibility should be taken into account by physicians who are considering interventions to prevent delirium in the elderly.
Our second comment relates to the authors' failure to include a component concerning patients' families and their integration into the medical care system. The omission of this component is also difficult to understand, since the authors themselves cite a previous study in which such a component was reported to be beneficial.1 Perhaps having a gerontologic social worker involved would further reduce the risks of delirium in hospitalized elderly patients.
1 ReferencesV.A. Portnoi, M.D.
T. Redling, D.O.
S.C. Amesty, M.D.
Beth Israel Medical Center, New York, NY 100031
Chatham MA . The effect of family involvement on patients' manifestations of postcardiotomy psychosis. Heart Lung 1978;7:995-999
Web of Science | Medline
To the Editor:
Both the study by Inouye et al. and the accompanying editorial by Rowe1 discuss delirium as if it were a condition like coronary artery disease, which can be prevented by targeting base-line risk factors. These risk factors are the so-called benign causes of delirium (e.g., acute confusion in response to the novel and frightening hospital environment) in persons with cognitive, visual, or hearing impairment or all three conditions. The study by Inouye et al. demonstrates that we can potentially reduce the overall incidence of delirium by targeting these risk factors.
Delirium is, however, often the first sign of an impending medical disaster in elderly and other vulnerable patients. Its onset should trigger a rapid and thorough search for life-threatening medical illnesses that may have caused it. In his classic studies of delirium, Lipowski found that as many as one third of elderly patients who are hospitalized for medical reasons and in whom delirium develops die within 30 days.2,3 The leading cause is infection, with metabolic derangements and failures of other organ systems following close behind.4 As Eidelman et al. demonstrated in patients with sepsis, delirium is strongly associated with more severe disease and increased mortality rates.5 Clearly, all patients should have the type of prophylactic interventions that Inouye et al. propose as part of high-quality medical care. Nevertheless, when delirium occurs, it should be treated as a potentially life-threatening emergency.
5 ReferencesCharles E. Schwartz, M.D.
Montefiore Medical Center, Bronx, NY 104671
Rowe JW . Geriatrics, prevention, and the remodeling of Medicare. N Engl J Med 1999;340:720-721
Full Text | Web of Science | Medline2
Lipowski ZJ . Delirium in the elderly patient. N Engl J Med 1989;320:578-582
Full Text | Web of Science | Medline3
Lipowski ZJ . Transient cognitive disorders (delirium, acute confusional states) in the elderly. Am J Psychiatry 1983;140:1426-1436
Web of Science | Medline4
Wise MG, Lieberman JA III. Delirium, dementia, and amnestic disorders. In: Goldman LS, Wise TN, Brody DS, eds. Psychiatry for primary care physicians. Chicago: American Medical Association, 1998:140.
5
Eidelman LA ,Putterman D ,Putterman C ,Sprung CL . The spectrum of septic encephalopathy: definitions, etiologies, and mortalities. JAMA 1996;275:470-473
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To the Editor:
Behavioral interventions and environmental control are important in the management of delirium, as the study by Inouye et al. underscores. It is also useful to prepare the family and the medical and surgical staff for the likely emergence of delirium in high-risk patients. Delirium is very likely to occur in elderly patients with dementia who are in pain and who are subjected to surgery, sedation, and new surroundings, such as those undergoing elective joint replacement. Families benefit from knowing that delirium is a possibility and from understanding what delirium entails. There is an associated risk of injury with delirium, of course, and this point should really be brought out in the informed-consent process. Metabolic encephalopathies in elderly patients with some degree of cognitive impairment may take 6 to 12 weeks to resolve.
Bruce D. Snyder, M.D.
Minneapolis Clinic of Neurology, Golden Valley, MN 55422Author/Editor Response
Dr. Inouye replies:
To the Editor: Dr. Schwartz stresses that delirium is often a warning sign of life-threatening disease and frequently serves as a barometer of the underlying health of elderly patients.1,2 The development of delirium should be handled as a potential medical emergency, prompting a careful medical evaluation and a search for the underlying causes. The high morbidity and mortality rates associated with delirium, however, highlight the need for broader approaches to prevent delirium by addressing known risk factors.3 The iatrogenic influences contributing to delirium during hospitalization (including the use of psychoactive medications, immobilization, sleep deprivation, dehydration, and disorienting influences) are far from benign; and as our findings suggested, reducing them will substantially reduce the rates of delirium.
Dr. Portnoi and colleagues raise the important clinical issue of the need to provide translators to minimize the risk of miscommunication and to keep patients oriented and informed during hospitalization. Although the lack of translators has not been demonstrated to increase the risk of delirium, we concur that it is likely to be a risk factor. Despite great efforts to maximize the use of existing translation services and to recruit translators from the hospital and the community, logistic constraints precluded us from enrolling many patients with a language barrier, because not enough translators were available to cover the multiple interactions with patients that were required by the protocol for 12 hours each day.
We considered many other interventions to prevent delirium, including those involving patients' families, physicians, social workers, and chaplains. The chief criticism of multicomponent intervention trials has concerned the number, complexity, and unfocused or difficult-to-replicate nature of the interventions. Thus, we limited the number of interventions in the trial. The final choices were based on the effectiveness, feasibility, and reproducibility of the interventions. We agree that many other important interventions were not examined and remain important areas for future research.
Dr. Leff's proposal that the home hospital is an environment that will reduce the risk of delirium is compelling, and it should be examined in future studies. On the basis of our work, we would recommend interventions to eliminate risk factors for delirium (e.g., avoid immobilization and provide reorientation) in the home setting as well.
3 ReferencesSharon K. Inouye, M.D., M.P.H.
Yale University School of Medicine, New Haven, CT 065041
Inouye SK . The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994;97:278-288
CrossRef | Web of Science | Medline2
Inouye SK . Delirium in hospitalized older patients. Clin Geriatr Med 1998;14:745-764
Web of Science | Medline3
Inouye SK ,Charpentier PA . Precipitating factors for delirium in hospitalized elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA 1996;275:852-857
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- Citing Articles (2)
Citing Articles
1
Jean-David Gaudreau, Pierre Gagnon, François Harel, Annie Tremblay, Marc-André Roy. (2005) Fast, Systematic, and Continuous Delirium Assessment in Hospitalized Patients: The Nursing Delirium Screening Scale. Journal of Pain and Symptom Management 29:4, 368-375
CrossRef2
Marianne McCarthy. (2003) Situated clinical reasoning: Distinguishing acute confusion from dementia in hospitalized older adults. Research in Nursing & Health 26:2, 90-101
CrossRef
