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Delirium takes a toll in the ICU

The confusion and paranoia that arise during a hospital stay can have long-term effects. And scientists are just discovering how pervasive it is.

October 20, 2003|Jane E. Allen | Times Staff Writer

For many years, when patients were admitted to hospital intensive-care units, doctors struggled just to keep them alive. Lines and tubes pumped them full of oxygen and medication, and machines monitored their vital signs -- but no one paid much attention to their brains.

Then, as more people survived their intensive-care stays, doctors began recognizing patterns in these terribly weakened patients. Many became uncharacteristically quiet and withdrawn. Others developed hyperactivity and confusion. Even after their bodies recovered enough to leave the ICU, some didn't bounce back mentally, or their physical recuperation lagged.

Something about their hospital stays was changing patients' ability to speak, reason and relate to their loved ones. This combination of confusion and disorientation, often accompanied by paranoia and delusions, is called delirium.

Although its molecular and genetic underpinnings are still unknown, researchers are discovering just how pervasive delirium can be, the toll it can take -- and how to prevent it. By some estimates, 80% of elderly intensive-care patients develop the condition, which frequently leads to nursing home stays and a hastened death.

"Unfortunately, delirium is often a spiral downhill," says Dr. Sharon K. Inouye, a Yale geriatrician and leading delirium researcher. "Because people are so fragile at that age, it's like a house of cards."

Delirium also develops in an estimated 40% to 60% of younger intensive care patients and 30% of cardiac surgery patients. It can set in at almost any age after a serious illness such as pneumonia or injury such as a hip fracture -- any time a patient becomes weakened, immobilized, heavily medicated and cut off from normal routines.

Put simply, delirium is "brain failure," says Dr. Wes Ely, a critical care specialist at Vanderbilt University in Nashville. With some exceptions, he says, it remains an unmonitored complication of an ICU stay that can set off a cascade of devastating effects with long-term consequences. Patients who have dementia or Alzheimer's disease are particularly vulnerable because their thinking and memory already are under siege.

Although doctors don't understand precisely how delirium begins and progresses -- they suspect the problem lies in disturbances of key brain-signaling chemicals called neurotransmitters -- they know that it results from a combination of factors. Those include over-medication (particularly with opiates and sedatives), drug interactions, oxygen deprivation, dehydration, head trauma, infection and having to breathe with a ventilator. Because delirium contributes to longer hospitalizations and additional care, it's expensive. Delirium-associated costs run about $4 billion to $16 billion every year, Ely says.

The condition occurs in three forms. Easiest to discern is agitated delirium, which makes patients hyperactive, anxious and prone to hallucinations; sedation often exacerbates it. Harder to detect but more common among elderly patients is quiet delirium, which has a worse prognosis and can be mistaken for dementia or over-sedation. With it, patients become passive, withdrawn and unresponsive. Some patients suffer mixed delirium, with alternating bouts of the two forms.

Dr. Wallace Sampson of Palo Alto became delirious 10 years ago while suffering complications of colon cancer surgery. Then 63, the oncologist was put on a respirator and given a stew of intravenous medications, including morphine and sedatives. He began having fantastical, paranoid dreams involving elaborate conspiracies, including a plot among doctors and hospital workers to kill him and dump his body in Lake Tahoe.

"I imagined that the floor of the X-ray department was transparent and that they had stacked all these bodies of patients they had killed," he recalls. He would act normal around doctors, then ask his wife to help him escape. Today, he laughs at the absurdity of those thoughts, especially considering that Sampson, editor of the journal Scientific Review of Alternative Medicine, is a very rational man.

Sampson's delirium might have been prevented if doctors knew then what they're learning today. About half of all delirium cases could be averted, Inouye estimates. But that requires changing the mind-set of medical professionals, who often believe that delirium and confusion are inevitable among critically ill patients.

"We're trying to fight years and years of medical training that I'm a part of," said Dr. John M. Robertson, chief of cardiothoracic surgery at St. John's Health Center in Santa Monica. "Most physicians overmedicate their patients. It's easier to snow Grandpa than deal with him."

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