SICU Psychosis: Prevent Delirium to Improve Prognosis and Stem Soaring Cost
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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Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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