Delirium is treated by identifying and remedying the underlying causes. Because of the associated morbidity and mortality, multiple causative pathways and treatments may need to be pursued and/or instituted simultaneously. Such causes might include electrolyte abnormalities, assessment of renal function, additional workup for other sources of infection (urinalysis or lumbar puncture if indicated), fecal impaction, and other myocardial/pulmonary causes of hypoxemia.
In this case, the best single explanation for the patient’s deterioration is progressive pneumonia resulting in worsened gas exchange and carbon dioxide retention. Thus, delirium was likely the presenting symptom of impending hypercarbic respiratory failure. More aggressive treatment of the pneumonia and associated CO2 retention was warranted. Additionally, medication review should have been conducted, resulting in the removal of sedative or anticholinergic medications. It is unclear why further workup or treatment was not pursued in this case.
In this case, the patient’s daughter was able to inform clinicians that her mother had never been confused or disoriented prior to hospitalization. In addition to their role in establishing the historical, behavioral, and cognitive baseline, family members and caregivers are an underutilized resource in the treatment of patients with delirium. For example, family members serve as a re-orienting stimulus for patients. In an average day on a hospital medical ward, 20 to 30 different staff members will enter a patient’s room (nursing, nutrition, housekeeping, house staff, consultants, attending physicians, etc.). As a result, patients with impaired cognition may misinterpret the in-room presence of these staff members, leading to paranoid thoughts and delusions. Family members or caregivers may be the only people whom the patient recognizes and, thus, can serve to reassure the patient about his or her current location and medical situation. Family or caregivers can also provide cognitive stimulation for the patient, such as by playing cards, doing crossword puzzles together, or viewing family photos. Additionally, family may be willing to participate in the care of the patient, which may reduce patient agitation, provide a constructive outlet for family concern, and decrease staff requirements.24 As a result, family should be involved in the care of the delirious patient to the extent possible. Formal “visiting hours” may need to be relaxed or eliminated to ensure that the family is able to be present to calm the patient during periods of confusion.
The failure to recognize delirium in this patient may have delayed recognition of her worsening pneumonia, which in turn led to a failure to escalate the level of care. Cognitive assessment at admission and appropriate use of collateral information from the patient’s daughter might have helped the physician realize that the patient’s altered mental status represented delirium and not dementia. Delirium is associated with severe clinical consequences, so earlier recognition of delirium should have prompted a thorough search for precipitants and aggressive treatment of the underlying illness. Actively encouraging the family’s participation in care may have helped identify delirium earlier and may have obviated the need for physical restraints in this case. In short, this patient’s death may have been preventable with optimal care; as such, this case represents an instructive cautionary note.
Take-Home Points
•Delirium, an acute change in cognition and attention, is common, morbid, and costly.
•All change in mental status should be assumed to be delirium until proven otherwise.
•The treatment of delirium is to identify and remedy the underlying causes.
•Elements of the hospital environment can contribute to delirium and expose patients to safety risk.
•Family members and caregivers are crucial to the diagnosis and management of delirium. Incorporating their contribution into the plan of care is strongly recommended.
James L. Rudolph, MD, SM
Assistant Professor of Medicine
Harvard Medical School
Associate Physician
Brigham and Women’s Hospital
Staff Physician
VA Boston Healthcare System
Faculty Disclosure: Dr. Rudolph has declared that neither he, nor any immediate member of his family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, the commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.