Until recently he did not remember where he lived and believed he had been in a car wreck. The disorder can occur at any age — it has been seen in preschoolers — but disproportionately affects people older than 65 and is often misdiagnosed as dementia. While delirium and dementia can coexist, they are distinctly different illnesses. Dementia develops gradually and worsens progressively, while delirium occurs suddenly and typically fluctuates during the course of a day. Some patients with delirium are agitated and combative, while others are lethargic and inattentive.
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Patients treated in intensive care units who are heavily sedated and on ventilators are particularly likely to become delirious; some studies place the rate as high as 85 percent. But the condition is common among patients recovering from surgery and in those with something as easily treated as a urinary tract infection. Regardless of its cause, delirium can persist for months after discharge. Federal health authorities, who are seeking ways to reduce hospital-acquired complications, are pondering what actions to take to reduce the incidence of delirium, which is not among the complications for which Medicare withholds payment or for which it penalizes hospitals.
Researchers estimate that about 40 percent of delirium cases are preventable. Many cases are triggered by the care patients receive — especially large doses of anti-anxiety drugs and narcotics to which the elderly are sensitive — or the environments of hospitals themselves: busy, noisy, brightly lit places where sleep is constantly disrupted and staff changes frequently. Other research has linked delirium to a greater risk of falls, an increased probability of developing dementia and an accelerated death rate. Only 6 percent were cognitively impaired before their hospitalization.
Cognitive and memory problems are not the only effects. Symptoms of post-traumatic stress disorder are also common in people who develop delirium.
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A recent meta-analysis by Johns Hopkins researchers found that 1 in 4 discharged ICU patients displayed PTSD symptoms, a rate similar to that of combat veterans or rape victims. David Jones, a year-old legal analyst in Chicago, said that he was entirely unprepared for persistent cognitive and psychological problems that followed the delirium that began during his six-week hospitalization for a life-threatening pancreatic disorder in Terrifying flashbacks, a hallmark of PTSD, were the worst. Some hospitals are moving to prevent delirium through a more careful use of medications, particularly tranquilizers used to treat anxiety called benzodiazepines , which are known to trigger or exacerbate the problem.
Others are trying to wean ICU patients off breathing machines sooner, to limit the use of restraints and to get patients out of bed and moving more quickly. These simple fixes had an added benefit: They cut the rate of falls among hospitalized patients by 62 percent. Inouye and other experts say that encouraging hospitals to recognize and treat delirium is paramount.
He proposes that Medicare create a bundle payment that would pay for treatment up to six months after delirium is detected. Creating effective incentives is essential, said Ryan Greysen, an assistant professor of medicine at the University of California at San Francisco. Many proven interventions, he said, do not seem sufficiently medical. Awareness that delirium is a significant problem, not a transitory complication, is recent, an outgrowth of growing expertise in the relatively new field of critical care medicine.
The graying of the baby boom generation, whose oldest members are turning 69, is fueling interest in geriatrics. In the only population-based prospective study of delirium, older persons had an eight-fold increase in dementia and faster cognitive decline.
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Another way of looking at dementia, however, is not strictly based on the decline component, but on the degree of memory and executive function problems. The societal implications can be enormous when considering work-force issues related to the inability of wage-earners to work due to their own ICU stay or that of someone else they must care for. The causes of delirium in such patients depend on the underlying illnesses, new problems like sepsis and low oxygen levels, and the sedative and pain medicines that are nearly universally given to all ICU patients.
Outside the ICU, on hospital wards and in nursing homes, the problem of delirium is also a very important medical problem, especially for older patients.
Subtypes of Delirium
Delirium is one of the oldest forms of mental disorder known in medical history. English medical writer Philip Barrow noted in that if delirium resolves, it may be followed by a "loss of memory and reasoning power. Sims , p. The American Delirium Society is a community of professionals dedicated to improving delirium care.
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