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Delirium takes a toll in the ICU

By Jane E. Allen, Los Angeles Times

October 20, 2003

For many years, when patients were admitted to hospital intensive-care units, doctors struggled just to keep
them alive. Lines and tubes pumped them full of oxygen and medication, and machines monitored their vital
signs — but no one paid much attention to their brains.

Then, as more people survived their intensive-care stays, doctors began recognizing patterns in these
terribly weakened patients. Many became uncharacteristically quiet and withdrawn. Others developed
hyperactivity and confusion. Even after their bodies recovered enough to leave the ICU, some didn't bounce
back mentally, or their physical recuperation lagged.

Something about their hospital stays was changing patients' ability to speak, reason and relate to their loved
ones. This combination of confusion and disorientation, often accompanied by paranoia and
delusions, is called delirium.

Although its molecular and genetic underpinnings are still unknown, researchers are discovering just how
pervasive delirium can be, the toll it can take — and how to prevent it. By some estimates, 80% of elderly
intensive-care patients develop the condition, which frequently leads to nursing home stays and a hastened

"Unfortunately, delirium is often a spiral downhill," says Dr. Sharon K. Inouye, a Yale geriatrician and leading
delirium researcher. "Because people are so fragile at that age, it's like a house of cards."

Delirium also develops in an estimated 40% to 60% of younger intensive care patients and 30% of
cardiac surgery patients. It can set in at almost any age after a serious illness such as pneumonia or injury
such as a hip fracture — any time a patient becomes weakened, immobilized, heavily medicated and cut off
from normal routines.

Put simply, delirium is "brain failure," says Dr. Wes Ely, a critical care specialist at Vanderbilt University in
Nashville . With some exceptions, he says, it remains an unmonitored complication of an ICU stay that can
set off a cascade of devastating effects with long-term consequences. Patients who have dementia or
Alzheimer's disease are particularly vulnerable because their thinking and memory already are under siege.

Although doctors don't understand precisely how delirium begins and progresses — they suspect the
problem lies in disturbances of key brain-signalling chemicals called neurotransmitters — they know that it
results from a combination of factors. Those include over-medication (particularly with opiates and
sedatives), drug interactions, oxygen deprivation, dehydration, head trauma, infection and having to
breathe with a ventilator. Because delirium contributes to longer hospitalizations and additional care, it's
expensive. Delirium-associated costs run about $4 billion to $16 billion every year, Ely says.

The condition occurs in three forms. Easiest to discern is agitated delirium, which makes patients
hyperactive, anxious and prone to hallucinations; sedation often exacerbates it. Harder to detect but more
common among elderly patients is quiet delirium, which has a worse prognosis and can be mistaken for
dementia or over-sedation. With it, patients become passive, withdrawn and unresponsive. Some patients
suffer mixed delirium, with alternating bouts of the two forms.

Dr. Wallace Sampson of Palo Alto became delirious 10 years ago while suffering complications of
colon cancer surgery. Then 63, the oncologist was put on a respirator and given a stew of
intravenous medications, including morphine and sedatives. He began having fantastical, paranoid
dreams involving elaborate conspiracies, including a plot among doctors and hospital workers to kill
him and dump his body in Lake Tahoe..
"I imagined that the floor of the X-ray department was transparent and that they had stacked all these
bodies of patients they had killed," he recalls. He would act normal around doctors, and then ask his
wife to help him escape. Today, he laughs at the absurdity of those thoughts, especially considering
that Sampson, editor of the journal Scientific Review of Alternative Medicine, is a very rational man.

Sampson's delirium might have been prevented if doctors knew then what they're learning today. About half
of all delirium cases could be averted, Inouye estimates. But that requires changing the mind-set of medical
professionals, who often believe that delirium and confusion are inevitable among critically ill patients.

"We're trying to fight years and years of medical training that I'm a part of," said Dr. John M. Robertson, chief
of cardiothoracic surgery at St. John's Health Center in Santa Monica. "Most physicians overmedicate their
patients. It's easier to snow Grandpa than deal with him."

Formerly known by the term "ICU psychosis," now considered a misnomer, delirium goes unrecognized by
doctors one-third to two-thirds of the time, often because they don't know how to detect it. In addition, health
professionals — along with families — are sometimes reluctant to name the problem because the term
"delirium" is often associated with crazy, out-of-control behaviour, says Dr. Edward Marcantonio, an assistant
professor of medicine at Harvard Medical School. But acknowledging delirium makes it easier to avoid long-
term problems.

In a study of hip fracture patients published in 2000, Marcantonio reported that 39% of the patients who
developed delirium in the hospital were still delirious when they were discharged, 33% were delirious a
month later and 6% were delirious after six months. He currently heads a federally funded delirium study
designed to detect the disorder in nursing home patients and another to assess delirium in cardiac surgery

Today, several relatively quick bedside tests can be used to measure delirium, including one modified by
Inouye and Ely for ICU patients unable to speak because they have breathing tubes in their throats. Without
these tests, "nurses can look right at a patient that's delirious and think they're not, or they can think they are
delirious and they're not," Robertson said.

Those tests helped nurses confirm that Sharon Kirk of West Los Angeles , a 58-year-old former flight
attendant, developed delirium while battling complications of parathyroid and thyroid surgery this spring.
While on a ventilator in a deliberately induced coma, she began dreaming that she was drowning and people
were ignoring her cries. "Friends of mine told me I was tied down with restraints and that I was trying to get
out of them," she says now.

As Kirk emerged from the coma, "it was obvious she was delusional," recalls her friend Dorothy Froix.
"Sometimes, she would speak about something that wasn't happening, or she would think that somebody
else was there talking to her." That behaviour frightened both Froix and Kirk's husband, Greg Flavall, who
said his wife still grapples with memory lapses more than three months after her release from St. John's. It's
hard to know whether the lingering effects stem from the delirium or the overall shock to her system.

"It's hard to separate those two," said Chris Maupin, a critical care nurse at St. John's. For example, she
said, Kirk's memory lapses could stem from too little oxygen flowing to her brain when she suffered life-
threatening bleeding.

The key to reducing delirium is prevention. A few hospitals have instituted programs modelled on a program
Inouye pioneered at the Yale University School of Medicine.

In a March 1999 study published in the New England Journal of Medicine, Inouye showed that several
simple changes reduced delirium by 40% among 852 hospitalized, non-ICU patients 70 and older. For
example, the program reduced the use of sleeping pills by having volunteers provide back rubs, relaxation
tapes, warm milk and tea. Other interventions included providing cognitive stimulation through games,
discussion of current events and memory aids designed to jog recollections; by helping get patients out of
bed and walking three times daily; by improving surroundings to minimize sleep disruptions, and by giving
enough fluids to prevent dehydration.

According to another study Inouye published in April, delirium can be reduced by 89% in patients who
receive all the recommended interventions.
Some hospitals are eliminating irritating sounds of ringing bells and buzzers. Others are designing hospital
rooms with windows that let in natural light and preserve the rhythms of day and night so patients feel less

Robertson spearheaded a new program at St. John's to reduce and prevent delirium. Nurses evaluate
intensive care patients several times a day. Doctors there and elsewhere have begun changing many of the
medications they use, said Dr. Gilbert Kuhn, a St. John's pulmonologist and critical care specialist who was
among those treating Kirk.

If a patient must be put into a coma, he often uses propofol (Diprovan), an anaesthetic that passes out of the
body more quickly than some older anaesthetics. Furthermore, Kuhn tries to wake up sedated patients once
daily to evaluate their level of consciousness.

Pharmacists also check drug doses, look for drug interactions and help determine if pain relievers milder
than narcotics can be used.

Harvard's Marcantonio said he hopes continued research will make preventing delirium a priority.

"The more we can show we can do something about it, will hopefully motivate people to look for it more."

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