The Importance of Routine and Familiarity

Picture this common hospital scene...

You are 75 years old, and have been on a water fast for a week, being woken every 2â€"4 hours (vital sign checks and the person shrieking all night in the bed next to you), you get upset and want to leave or just get up to pee. You have an IV in, so the nurse won't let you up, so you complain—perhaps loudly. Next thing you know, you get strapped down to the bed in a posey jacket and four point restraints. You can't get up now, so they stick a catheter up your bladder and rectum, while you are left half naked. This leaves you upset, so the staff drugs you with sedatives and antipsychotics. The catheter triggers bladder infections which disorient you further. Meanwhile, being drugged out leaves you paranoid and panicked, leading to, you guessed it, more drugs. You are in unfamiliar environs, and nothing identifies you as human. Instead, you are the 'Dementia in room 7.' No one knows you from before the hospitalization to know that this is not who you usually are. By now, you are near psychotic and of course unable to go home. Your family is given this disappointing news, having no idea the problem was preventable, and you get packed to a nursing home. To make you more manageable, you are kept on psychoactive drugs and treated like a child.

Welcome to "Hospital Induced Delirium & Dementia"
Until recently, hospital-acquired delirium was attributed to old age and not considered important to prevent or treat. But it is critical. People who develop delirium in the hospital end up in nursing homes a staggering 75 percent of the time, five times higher than those without hospital induced delirium. It also leads to longer stays in the hospital, an average of nine days compared to four without delirium, costing an average $60,000 per hospital stay.1 Add to that the average $70,000 yearly cost of being in a nursing home, and the emotional and financial benefits of prevention become staggering.

So How Can I Prevent Hospital Induced Delirium and Dementia?
Begin by simply remembering to provide familiarity for the hospitalized person. In addition, these measures remind staff that this is a real human being with a loving family, rather than 'The demented gallbladder in 26.' Here are simple ways hospital induced delirium and the vicious cycle it leads to can be avoided.

Early warning signs include:
  • Cognitive impairment, such as poor memory, particularly of recent events, disorientation, not knowing where one is, or rambling or nonsense speech.
  • Inability to stay focused on a topic, or getting stuck on an idea rather than responding to questions or conversation.
  • Hallucinations, extreme emotions, or combative behavior.
  • Elderly people who are recovering in the hospital are particularly vulnerable to delirium. Approximately seven million Americans experience delirium in the hospital each year, and it is undiagnosed 60 percent of the time.2

All of the above suggests that avoiding optional hospitalizations are a good idea. Ask these questions:

  1. Can having a visiting nurse or family member avoid the need for hospitalization?
  2. Is the person being admitted for a test or treatment that could be skipped?

The risk-benefit equation can change dramatically in the elderly when the risk of hospital-induced delirium is factored in. Meanwhile, it is not only hospitalization itself that increases risk. A large population-based study conducted by investigators at the Neurological Institute in Taipei Veterans General Hospital showed that the risk of developing dementia nearly doubled within three to seven years of anesthesia and surgery. In addition, the average time to dementia diagnosis was shorter in patients who had anesthesia and surgery compared with their counterparts who did not undergo these procedures.3,4 So ask if a given procedure is truly essential!

Tips for Avoiding Hospital Induced Delirium and Dementia

  1. Keep pictures of the person, spouse, children, grandchildren and even pets all over the hospital room. Even put them on the walls. This not only offers familiarity for the person, but helps the (sometimes exhausted) staff see them as people worthy of respect.
  2. Keep comforting and familiar items from home around, like their slippers, mugs, etc.
  3. Get the family 24/7 visiting hours. Catching disorientation early has a very different outcome when done by a family member who can be soothing and reassuring, and has the time and inclination to be so. This also allows the hospitalized person's needs to be met more quickly (like a glass of water or help to the bathroom), while offering socialization and interaction.
  4. If the family doesn't have the "manpower" or resources to have someone there all the time, have the number of a family member/friend that can be called in if disorientation or agitation occurs kept prominently on the wall by the person's bed, with an order to call that person if needed. Again, catching it early before the above vicious cycle gets a foothold is key.
  5. The more severe the illness, the greater the need to encourage family presence.
  6. To the doctors: Most families will be thrilled to have you share these thoughts with them, and have the option of having someone be present outside of visiting hours. For the rare cases where the person seems to have been abandoned, sometimes a reminder that the government will hunt down all the person's assets to pay any nursing home costs, even any assets transferred to others in the last five years: so abandoning the person can cost the family $70,000/yr if they have any hope of an inheritance.
Other helpful tips?
  1. Have a list of all the person's medications. Over medication can trigger delirium.
  2. Bring their glasses and hearing aids.
  3. Watch for obvious signs like intermittent confusion, that should be a warning to have a family member stay.

References:

  1. http://www.wndu.com/mmm/headlines/Tips_on_tackling_hospital-induced_delirium_144256245.html
  2. Ibid.
  3. Anesthesia, Surgery May Double Dementia Risk. Medscape.
  4. http://bjp.rcpsych.org/content/204/3/188

Jacob E Teitelbaum, MD

Jacob Teitelbaum, MD, is a board certified internist and Medical Director of the national Fibromyalgia and Fatigue Centers and Chronicity. He is author of the popular free iPhone application "Cures A-Z," and author of the best-selling book From Fatigued to Fantastic! (Avery/Penguin Group), Pain Free 1-2-3 (McGraw-Hill), Three Steps to Happiness: Healing Through Joy (Deva Press 2003), Beat Sugar Addiction NOW! (Fairwinds Press, 2010), and his newest book Real Cause, Real Cure (Rodale Press, July 15, 2011). Dr. Teitelbaum knows CFS/fibromyalgia as an insider — he contracted CFS when he was in medical school and had to drop out for a year to recover. In the ensuing 25 years, he has dedicated his career to finding effective treatment.

Website: www.EndFatigue.com