VA research on delirium featured in journal supplement
Delirium—an acute change in a person's mental status that results in a decreased awareness of his or her environment and confused thinking—is a serious and under-recognized illness, especially in hospitalized older adults. There's evidence suggesting that individuals who develop delirium in the hospital are as likely to die as those with a heart attack. When they do survive, their recovery is often difficult or incomplete.
The Veterans Health Administration has been a world leader in finding the best ways to recognize delirium in patients and to treat it promptly. VHA's research leadership is on display in a just-released special supplement to the Journal of the American Geriatrics Society, sponsored by the Hartford Foundation.i The supplement is solely devoted to the illness, its prevention, and possible treatment.
Nine of the twelve articles in the supplement were written, in whole or in part, by VA researchers, including James L. Rudolph, MD, SM, a geriatrician with the VA Geriatric Research, Education and Clinical Center at the Boston VA Medical Center. Rudolph is also a VA Career Development award recipient, the president of the American Delirium Society, and an assistant professor at Harvard Medical School. Rudolph co-edited the supplement along with Marianne Shaughnessy, PhD, RN, CRNP, a nurse researcher who is the associate director of education and evaluation at VA's Baltimore Geriatric Research, Education and Clinical Center.
According to Rudolph, physicians fail to diagnose as many as two-thirds of all delirium cases. "That's because doctors are not trained to address the problem," he says. "We detect that a patient's mental state has deteriorated, but we tend to blame other conditions, such as reactions to medication." If the illness is not properly diagnosed, however, its outcome can be fatal.
There is no single cause for delirium, but Rudolph and others believe there are ways to prevent it from occurring in a hospital setting. "It really comes down to providing good, old-fashioned care," he says.
Based on his clinical experience, Rudolph believes improving cognitive stimulation in older hospital patients by getting elderly hospital patients out of bed regularly to improve their mobility; making certain that they have the ability to see and hear; having the more than 30 unique health care workers the average hospitalized patient sees in a day introduce themselves and their role on the team to the patient; and helping patients to read and stay in contact with the outside world are all good ways to keep them from succumbing to delirium. Other prevention strategies include giving elderly patients the opportunity to sleep through the night if they can; and ensuring that they remain hydrated and have eaten sufficiently.
Delirium is caused by the added effects of multiple insults to the brain. While one single prevention measure may not have an impact, the combination of these measures can be very effective. Once delirium is diagnosed, there are few good treatment options. "The best thing to do is to identify and treat the causes in the patient," according to Rudolph. That includes not only addressing the illness that first brought the patient to the hospital, but also other stressors in their care and environment that may cause the delirium.
One treatment for delirium that is frequently used today but may not, in fact, be helpful is the use of antipsychotic medications. In a review of 13 previous studies of the subject, ii published in the journal supplement, authors Joseph H. Flaherty, MD; Jeffrey P. Gonzalez, PharmD, , and Birong Dong, MD, found that "the studies in this review do not support the use of antipsychotics in the treatment of delirium in older hospitalized adults."
The authors hypothesized that antipsychotic medications may not work because
these medications are designed to correct neurotransmitter imbalances in the brain (neurotransmitters are chemicals released from nerve cells which transmit impulses to other nerves, muscles, organs or other tissue) and it is not clear which neurotransmitter imbalances actually exist in patients with delirium. Therefore, physicians can't know which antipsychotic medication to prescribe!
Rudolph pointed out another article, titled "Delirium: A Strategic Plan to Bring an Ancient Disease into the 21st century." iii Four of the article's five co-authors are affiliated with VA, including Kenneth Shay, DDS, MS, Director of Geriatric Programs for VA's Office of Geriatrics and Extended Care. The article offers four goals for delirium treatment, including improving clinical care related to delirium; improving delirium education; investing in delirium science; and developing a network of delirium professionals. VA, he said, is already on its way towards achieving each of these goals.
"In the delirium world, publication of this supplement is a momentous event," he concludes. "I'm proud VA is taking a leadership role."
i. Journal of the American Geriatric Society, November 2011-Vol. 59, No. 52
ii. Flaherty JH, Gonzalez JP and Dong B. Antipsychotics in the Treatment of Delirium in Older Hospitalized Adults: a Systematic Review. JAGS 59:S269-S276, 2011.
iii. Rudolph JL, Boustani M, Kamholz B, Shaughnessy M and Shay K. Delirium: A Strategic Plan to Bring an Ancient Disease into the 21st Century. JAGS 59:S237-S240, 2011.