The AIDS beat I covered during more fearful times in the 1980s and early 1990s made my usually unflappable mother extremely nervous.
She was disinterested in the science and the sociology that I'd excitedly describe, and terrorized by the possibility that transmission could become airborne, or that she could get it from sharing lunch with an infected co-worker.
"Aren't you worried that you will catch it too, given all the patients you spend so much time with?" she would ask.
Her irrational fear was so great that when she was hospitalized after a bad—and subsequently fatal—reaction to her first dose of chemotherapy in 2001, it was the threat of AIDS that seemed to haunt her the most. Her imagination went to work.
After a week or so in intensive care, her doctors extubated her and she was finally able to speak, though her voice was hoarse and histrionic.
"They were here all last night," she told me, her eyes anxious and wide with fear.
"Who, Mom? Who was here?" I asked.
"The AIDS people," she anxiously replied. "They're making an AIDS movie here, and they took over this whole hospital and they were bringing in patients to film it here," she said. "They brought in lots of gurneys with patients. There were a lot of cameras and bright lights."
They told her not to tell anyone, because they were doing this in secret. But she felt that she must, and that I should tell the doctor and get it stopped. It was wrong to use her hospital for a movie production, she complained. Lord help them if they showed her picture in any AIDS movie.
I mentioned this to the nurse, a hardened caregiver with an intensivist's mettle, who lowered her chin and closed her eyes.
"It's SICU Psychosis"—surgical intensive care unit psychosis, she replied.
"Of course we're not making a movie about AIDS or anything else in this hospital," she said, or something to that effect. "When people are this sick and in a hospital for this long, their minds become delusional."
She mumbled something about how hospital rooms without natural light disturb the patient's ability to distinguish between day and night, and their biorhythms get confused. But she really couldn't explain the cause.
"Wasn't there medication we could give?" I asked.
"No," the nurse replied. There wasn't much they could do. Would it go away? I asked. She shrugged to indicate she didn't know.
Now, it appears, researchers are stepping up efforts to understand and grapple with the problem. There's now recognition that SICU psychosis, or persistent delirium, can affect a patient's prognosis as a disease process separate from the admitting diagnosis.
Perhaps some of that new appreciation is because delirium costs a lot of money in longer lengths of stay and cost of care.
In a February report in the Journal of Hospital Medicine, Malaz A. Boustani, MD of the Center for Aging Research at Indiana University, found that patients with delirium stayed longer in the hospital (9.2 days versus 5.9) and were more likely to be discharged into institutional settings and were more likely to receive tethers during their care than patients without delirium. Also, they had higher mortality, 9% versus 4%.)
"Delirium is an all-too-common complication of hospitalization that is often unrecognized by healthcare providers, says Sharon K. Inouye, director of the Aging Brain Center at Hebrew Senior Life and Professor of medicine at Harvard Medical School. "Most importantly, delirium is often preventable." often unrecognized by the healthcare providers.
In a 2008 article in the Archives of Internal Medicine, Inouye and colleagues quantified the impact. Those who did become delirious accumulated average costs of care per day that were 2.5 times more than patients without delirium. "Total cost estimates attributable to delirium ranged from $16,303 to $64,421 per patient, implying that the national burden of delirium on the healthcare system ranges from $38 billion to $152 billion a year.
In a 2006 issue of the New England Journal of Medicine, Inouye and colleagues quantified a variety of reasons why delirium should be prevented.
- Care of such patients accounts for more than 49% of all hospital days.
- Delirium complicates stays for at least 20% of the 12.5 million patients 65 years of age or older who are hospitalized each year.
- The one-year mortality rate associated with delirium cases is 35% to 40%.
- It increases hospital costs by $2,500 per patient or $6.9 billion (in 2004 dollars) of Medicare expenditures are attributable to delirium.
- Unquantified costs for post discharge institutionalization, rehabilitation, home healthcare and informal care giving add up even more cost.
- Delirium is present on admission between 14% and 24% of the time, but presents during hospitalization for between 6% to 56% of hospitalized patients, most often in intensive care.
Yet, Inouye wrote, "Delirium represents one of the most common preventable adverse events among older persons during hospitalization. . . . The condition . . . frequently iatrogenic, and integrally linked to processes of care."
Inouye goes into some detail regarding the impact drugs can have in exacerbating delirium and hallucinations among patients. Cytokines (e.g., the interleukins), anticholinergic, and dopamine drugs are one hypothesis she explored.
An article in Monday's New York Times described what some clinicians are doing to manage delirium, such as removing catheters, intravenous lines and other equipment if possible to keep patients from feeling trapped.
Some strategies are having success, such as the Hospital Elder Life Program, launched at Yale New Haven Hospital Inouye says.
The program screens all older patients on specified units for six delirium risk factors (cognitive impairment, sleep deprivation, immobility, vision impairment, hearing impairment, and dehydration).
According to an article in the Journal of the American Geriatrics Society, interventions include daily visitor, such as a volunteer, with daily orientation, therapeutic activities, early mobilization after surgery, providing the patient with hearing and vision aids, such as fluorescent tape on the call bell, assistance with feeding and encouragement during meals and sleep enhancement efforts, such as making schedule adjustments to allow sleep.
"The intervention resulted in a significant reduction in new delirium cases, (9.9% vs 15% in usual care)...total numbers of days with delirium (105 vs 161) and in total number of delirium episodes (62 vs 90)."
The increasing recognition of delirium as a costly illness in and of itself, and one that is often hospital caused, and preventable, may go a long way toward stimulating research into preventing its development.
I often think back at how much my mother must have suffered not just from her cancer treatment—which had only just begun—but from the terror those imaginary AIDS movie people obviously provoked. And if she had not been so frightened by those "AIDS people," might she have survived?
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