Older Patients, Wiser Care

5 Reasons a Very Common Hospital Problem Is Often Overlooked

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Your mom seemed her usual self when she went into the hospital for hip surgery, but two days later you find her restless -- tossing in bed and hardly making sense, even though the surgeons say her operation went well.

I hear this scenario from mystified caregivers all the time. And not surprisingly. Nearly a third of older people experience new or worsened mental confusion during a hospital stay. So do more than half of those with a dementia such as Alzheimer's! The numbers are highest for post-surgical recovery.

This state of worse-than-usual mental confusion, known as delirium, is brought on by stress to the body. And hospitals are full of stressors, from infections and the physical demands of recovery to simply being in an unfamiliar place.

Delirium is dangerous because it puts an older person at risk for falls, a slower recovery, and even a higher chance of dying in the hospital. Also, an older person can take days to even weeks to recover his or her usual mental function once the stress on the body has been removed, and some people with dementia never get back to as good as they used to be. (Delirium that occurs at home can also be a sign of a life threatening illness that demands treatment, but with all the hospital monitoring that takes place, a dangerous infection would be noticed through other symptoms, such as a fever.)

I know you expect your loved one to get better, not worse, in a hospital. Why are the mental changes that can be so glaringly obvious to family members often missed by professionals?

1. Because hospital and rehabilitation staff don't always know what a patient is like "normally."

Doctors and nurses change shifts and cases pretty often, and it can be hard to assess personality changes if you haven't known a person long. These days, most people aren't cared for in the hospital by their long-term doctors.

2. Because delirium and dementia are easily confused in the hospital setting.

If a sick patient has a dementia diagnosis in his or her chart, staffers often tend to think, "Well, I suppose she's always confused."

3. Because hospital staff -- just like laypeople -- often misunderstand what delirium looks like.

They tend to incorrectly assume that delirium always causes amped-up behavior that seems crazy or psychotic. Although it's certainly true that a bout of delirium can turn a usually mild-mannered person into a flailing patient yanking constantly on his IV (this is called "hyperactive delirium"), older people are more likely to get something called "hypoactive delirium." This makes a person confused but also drowsier and quieter. It can take a little more effort to notice that a quietly delirious person is no longer sure where she is. Sometimes the only change a caregiver notices is that Dad is just not following the conversation the way he normally does. But that too can be delirium: a delirious person usually has a lot of trouble focusing his attention. So if you notice your loved one is not herself in the hospital, don't just chalk it up to being tired and sick. It's always best to bring your concerns to the attention of a doctor or nurse.

4. Because the hospital is a hectic place.

Even when doctors, nurses, and others get to know a patient, the quieter changes of hypoactive delirium might not get picked up in a brief visit. This means delirium often goes undetected for longer than it should.

5. Because even though medical institutions know delirium is a serious matter, prevention techniques aren't standard.

For one thing, not all delirium is preventable. But caregivers can be hugely helpful by helping hospital staff notice delirium, and making sure a work-up is done. This usually includes checking for new infection, minimizing medications that can cause confusion (like anti-histamines, which are sometimes given to help hospitalized patients who can't sleep), and checking for inadequately treated pain or constipation.

You can also help minimize confusion by making sure your loved one has glasses or a hearing aid, if he or she uses one. Gentle reorientation also helps, such as saying when someone wakes, "You're in the hospital, Mom, the operation went well." Some hospitals (ideally!) have Acute Care for Elders units that do other delirium-avoiding measures, like skip those disorienting 2 a.m. blood pressure checks.

But your familiar, reassuring, and watchful presence at the bedside is one of the most valuable things that can happen. As you wait for the sick person to get better, you accomplish a lot by supporting him, minimizing anything that could further stress or confuse him, and quickly telling hospital staff if you notice uncharacteristic changes.