New framework to improve care for patients with delirium

A new national plan of action provides a roadmap for improving the care of patients with delirium, a poorly understood and often unrecognized brain condition that affects approximately seven million hospitalized Americans each year.

"Delirium: A Strategic Plan to Bring an Ancient Disease into the 21st Century," written on behalf of the American Delirium Society, appears in the supplement to the Nov. 2011 issue of the Journal of the American Geriatrics Society. Publication of the supplement, "Advancing Delirium Science: Systems, Mechanisms and Management" was supported by the John A. Hartford Foundation.

Delirium is a sudden alteration in mental status -- brain failure in a vulnerable individual, often an older adult with multiple health issues, caused by something else such as medications, urinary tract infection, lack of sleep, excessive light or noise or pain. In the United States, an estimated 80 percent of patients in intensive care units experience delirium during their hospital stay, however delirium is unrecognized in 60 percent of patients who experience it.

"Having delirium prolongs the length of a hospital stay, increases the risk of post-hospitalization transfer to a nursing home, doubles the risk of death, and may lead to permanent brain damage," said Regenstrief Institute investigator Malaz Boustani, M.D., M.P.H., associate professor of medicine at the Indiana University School of Medicine and director of the Healthy Aging Brain Center at Wishard Health Services. Dr. Boustani is an IU Center for Aging Research center scientist and president-elect of the American Delirium Society.

"Statistically having delirium is as serious as having a heart attack. Once delirium occurs, the same percentage of individuals die from it as die from a heart attack," said James Rudolph, M.D., president of the American Delirium Society.

Delirium, which occurs suddenly, is not the same as dementia, although individuals with dementia are more susceptible to developing delirium during hospitalization than individuals without dementia.

Delirium has plagued the ill and vulnerable with increased risk of death for centuries, at least since Hippocrates described the condition in the fourth century B.C. Today, as much as $152 billion is spent annually in the U.S. on delirium related costs such as hospitalization, rehabilitation services, or nursing homes residency.

The new framework outlines four broad goals and details steps to achieve them:

Goal 1: Improve clinical care related to delirium including screening patients for delirium risk and developing non-toxic treatments for delirium.

Goal 2: Improve delirium education especially improving public understanding that a change in mental status in an older patient is a medical emergency and correcting the misconception among health care providers that delirium is a 'normal' feature of hospitalization in older patients.

Goal 3: Invest in delirium science by funding research at levels comparable to diseases with similar outcomes. In 2009, NIH funding for delirium was only $12 million compared to $392 for pneumonia/influenza.

Goal 4: Develop a network of delirium professionals to advance the first three goals.

"Delirium may be averted or resolved but we are missing it because we are not focused on preventing, diagnosing or managing it. We need to improve inputs into the brain, create healing environments that do not overload their brains, and cautiously use medications tha act in the brain. Most importantly, we need to make sure we are alert to signs of delirium and address it as soon as possible," said Dr. Rudolph.

Ultimately the patient and his or her caregivers bear the burdens of delirium and the consequences thereafter. The focus of this call to action puts the patient at the forefront.

"Patients, family members, doctors, nurses, pharmacists and everyone involved in delivery of care need to be told about the short term and the long term impact of delirium in our society so we can have a delirium-free century," said Dr. Boustani.