Last week's column offered action steps you can take to combat delirium in hospitalized loved ones. Today's column takes a step back and offers more comprehensive strategies you can use to address this deadly complication.
First, take it seriously. When I was an executive for a big corporation in the healthcare industry, one way that my colleagues would signal that they were describing a critical issue that they wanted other executives to pay attention to was to say, "I'm serious as a heart attack."
That was, of course, a figure of speech. But delirium is literally as serious as a heart attack. Most people know that it's critical to get medical attention very quickly for people having heart attacks. The same is true for people experiencing delirium.
Heart attacks often - although not always - announce themselves. Delirium is not necessarily so forthcoming. Most delirium is "silent" and can exist for days or weeks without doctors or nurses realizing it. The odds of permanent damage increase hour by hour.
Second, be prepared. In our house, we have a "delirium notebook" to remind family members what to do if another family member is hospitalized. You can duplicate this notebook yourself, by printing out these items:
1. News articles reporting on relevant medical studies, in case other family members or medical professionals aren't familiar with the issues. Search online by headlines (quotations provide highlights):
a. "Hospitals Combat an Insidious Complication: Delirium in ICU Patients, Once Thought Temporary, Can Inflict Lasting Damage," by Laura Landro, Wall Street Journal, 17 Oct. 2007 ("The condition can have devastating long-term consequences - and ... is preventable with simple changes in care.")
b. "Hallucinations in Hospital Pose Risk to the Elderly," by Pam Belluck, New York Times, 20 June 2010 ("Elderly patients experiencing delirium were. . . placed in nursing homes 75 percent of the time, five times as often as those without delirium.")
c. "Changing Intensive Care to Improve Life Afterward," by Laura Landro, Wall Street Journal, 15 Feb. 2011 ("Fifty percent to 80 percent 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.")
d. "After Hospitalization, Mental Trouble for Elderly Patients," by Judith Graham, New York Times, 23 March 2012 ("It's as if people became 10 years older, from a cognitive standpoint, than they actually were before a hospitalization.")
e. "Vigilance about the Dangers of Delirium," by Jane Brody, New York Times, 01 Oct. 2012 ("Delirium could be prevented in up to 40 percent of cases. . . Yet, more often than not, delirium is misdiagnosed and mistreated.")
f. "Delirium in the ICU May Pose Ongoing Risk of Thinking Problems," by Thomas Andrew Gustafson, NPR, 03 Oct. 2013 ("We weren't aware, frankly, of delirium that can be very silent. And only 5 percent of delirium is. . . hyperactive.")
2. "Delirium in the Intensive Care Unit: A Guide for Families and Patients," by Vanderbilt Medical Center, found at http://www.icudelirium.org/docs/delirium_education_brochure.pdf
3. CAM-ICU (Confusion Assessment Method for the ICU) worksheet at http://www.icudelirium.org/docs/CAM_ICU_worksheet.pdf and a guideline for sedation use in the ICU, including the RASS (Richmond Agitation and Sedation Scale) at http://www.mc.vanderbilt.edu/surgery/trauma/Protocols/SedationAnalgesiaG.... While intended for doctors and nurses and referring to separate instructions, tests, and training manuals, these can give you a feel for how delirium can be diagnosed and current thinking about how much sedation is considered too little or too much. Doctors can refer to http://www.icudelirium.org/delirium/monitoring.html#page-nav-camicu.
4. Four of my columns in this newspaper (search online by headline) that offer action steps you can take: "Should you worry when hospital patients lose touch with reality?" March 27, 2011; "Hospital delirium can lead to permanent mental decline," Nov. 10, 2013; "How to help loved ones avoid delirium in the hospital," Nov. 17, 2013; and today's article.
Third, insist on frequent assessments and action plans. Ask that patients be formally checked for delirium every four to six hours and that action be taken if scores show that they are delirious. If patients have not been diagnosed with delirium yet say or do irrational things not typical of them, alert a nurse or doctor and ask for a treatment plan to address the situation.