The Good Patient—Should You Worry When Hospital Patients Lose Touch With Reality?

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By Elizabeth L. Bewley

Mildred said fretfully, “I don’t see why I can’t join the family out on the patio.  Everybody is out there.  I can hear them.  Why do I have to stay inside?”

“Mom,” Carol said carefully, “You are in the hospital.  You broke your hip.  You had surgery yesterday to replace your hip joint.  The people you hear outside the door are hospital employees.  This isn’t the family reunion at my house.  That was two months ago.”

“But I just want to be with the family.  I don’t see what harm it will cause if I go outside to be with the family for just a little while.”

The next time she saw Mildred’s doctor, Carol said, “She’s irrational.  She keeps trying to fold the sheet that she’s lying under to put it away ‘upstairs in the linen closet.’  She hasn’t lived any place with an upstairs for seven years.  She thinks the television set is a window.  She thinks it’s night all the time because the TV is dark, since it’s turned off.  What’s happening?”

“Oh, don’t worry,” the doctor assured her.  “That’s completely normal.  It happens to everybody.  It’s disorienting to be in the hospital.  As soon as we can discharge her and get her back into a more familiar setting, she’ll be fine.”

Researcher Dr. Wes Ely at Vanderbilt University has created the website  www.icudelirium.org.  On it, he explains that hospital patients often lose touch with reality.  This altered mental state is called delirium.  Mildred’s doctor was right that this experience is very common.  However, he was mistaken in believing that people return to their normal state afterwards.

Research shows that people who experience delirium in the hospital are more likely to develop other medical complications, to be less able to take care of themselves once they get out of the hospital, to have trouble thinking clearly, to land in a nursing home, and to die within six months.

Laura Landro reported in a Wall Street Journal article, “50% to 80% of people who leave the ICU later suffer from long-term cognitive impairment that appears to be related to how long they were delirious in the hospital.”  She quotes Dr. Ely as saying that these memory and thinking problems may make it impossible for people to keep their jobs.  They may feel “‘like their brain is swimming in molasses.’”

Three of the biggest risk factors that determine whether people will become delirious are:

  1. How old they are.  About 60% of patients age 40-60 develop delirium.  The risk rises rapidly, and by age 85, about 85% of patients develop delirium.
  2. How sick they are.  Sicker patients are more likely to develop delirium.
  3. Whether they are given drugs called benzodiazepines.  People who are given one of these, midazolam, are three times as likely to become delirious.  Another, lorazepam, is almost certain to cause delirium at some doses.

It is best if delirium can be prevented.  Failing that, the harm patients suffer can be reduced if the delirium is short-lived.  However, Dr. Ely reports, delirium “remains unrecognized in 66% to 84% of patients whether they be in the ICU, hospital ward, or emergency department.”  If it isn’t recognized, it is unlikely that steps will be taken to halt it.

One worksheet that hospital staff might use to figure out if your friend or family member is delirious can be found at:   http://www.icudelirium.org/docs/CAM_ICU_worksheet.pdf.  It includes simple questions that doctors and nurses ask the patient.  An example is, “Will a stone float on water?”  Using a worksheet like this, it takes less than 30 seconds to tell if someone is delirious.

Some of the steps that doctors and nurses can take to help nip delirium in the bud are:

  • Bring the patient’s blood sugar and electrolytes back to appropriate levels
  • Check for and treat infections
  • Reduce the dose and frequency of drugs that sedate them
  • Remove restraints
  • Get patients up and moving around as soon as possible
  • Have lights on during the day and dimmed at night
  • Encourage interaction with family

If family members or friends are in the hospital and you’re concerned about their mental status, five steps you can take are:

  1. Recognize the risk.  One source for more information is a brochure that you can find at:  http://www.icudelirium.org/docs/delirium_education_brochure.pdf.
  2. Ask how often the staff will check the patient’s mental status and write the results in the patient’s chart.  A good answer to this question, according to Dr. Ely, is every 4-6 hours.
  3. Make sure that the patient has any eyeglasses or hearing aids that they normally use.  It is hard for people to stay alert and focused if they can’t see and hear the way they usually can.
  4. If possible, try to engage the patient with familiar photographs, music they enjoy, TV or radio programs they like, and/or conversation about familiar people and activities.
  5. Watch for behavior or thinking that is not typical of the patient and report it to the doctor or nurse.  Ask that these observations be written into the patient’s chart.  Ask what steps will be taken to figure out what is causing their altered mental state and how it will be addressed.

Elizabeth L. Bewley is President & CEO of Pario Health Institute and the author of Killer Cure:  Why Health Care is the Second Leading Cause of Death in America and How to Ensure That It’s Not Yours.  She also writes a weekly newspaper column, “The Good Patient.”  Contact  thegoodpatient@pariohealth.net.

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