Preventing Hospital-Induced Delirium


Have you ever dreamed of walking in a fog, unsure of where you are and what those strange sights and sounds at the edge of your awareness might be? It's frightening. It's also similar to what some patients--especially those who are elderly or very ill--may experience when they are hospitalized.

"Although hospital-induced delirium can happen in younger patients who are ill or in ICU, it's more commonly seen in geriatric patients," said Kellie Flood, MD, assistant chief medical officer for Care Transitions and Geriatric Quality Officer at UAB Hospital.

Kellie Flood, MD

"It was generally thought that the symptoms would usually fade when patients returned home to a familiar environment. Now we're finding that the symptoms and effects of delirium can persist and affect the patient's health long-term, especially if their muscles become weaker and their function declines. They may no longer be able to care for themselves, bathe, dress and participate in the normal routines of everyday life," Flood said.

"Younger brains tend to have more reserves, which is why younger patients usually have an easier time recovering. Older brains with lesser reserves have more difficulty dealing with new insults, especially multiple insults such as new medications, anesthesia, infections, dehydration, sleep deprivation or the simple strangeness of being isolated in an unfamiliar environment where unusual sounds, smells and lack of visual stimulation tend to blur one day into another."

Although patients with preexisting dementia or cognitive decline tend to be most at risk of developing delirium, it can happen to anyone. A new program at UAB Highlands that has been successful in helping to prevent and minimize delirium in the Acute Care for the Elderly (ACE) unit is being expanded to the Vascular Surgery unit.

Emilys Simmons, MSN, RN

"The delirium prevention project is part of our Hospital Elder Life Program (HELP)," Emily Simmons MSN, RN said. In addition to helping develop the program at UAB Highlands, she is advanced nursing coordinator for HELP and is working with multidisciplinary teams to implement it.

Awarded a fellowship by the Gerentological Nursing Leadership Academy, Simmons' project is aimed at finding out what works, training staff to use the new tools and strategies, then rolling them out to other units where successes can build on each other.

"In addition to training our staff to watch for signs of delirium, especially in those most at risk, a key part of our program is our volunteers, who are trained to interact with patients to increase cognitive stimulation and physical activity," Simmons said.

"Volunteers help patients stay oriented to today, where they are, and what's happening now. There are reminiscing games using pictures and remembering songs, singers and actors. Patients may need help with range of motion exercises to maintain function, or help ordering meals. We have a delirium toolbox with stress balls and other tools to give patients something to do with hands. There are teddy bears for tactile stimulation and comfort. We also watch for things like hearing difficulties and make sure patients have sound amplifiers or other assistance they may need to avoid unnecessary isolation.

Volunteers who participate in the program include students in occupational therapy and other health professions who not only help patients but also benefit themselves from gaining experience in direct patient interaction. It isn't necessary to have a medical background to volunteer. Training is provided. Many volunteers are retirees who find the project a worthwhile contribution of their time.

Flood said that all members of the health care team who interact with patients should be watchful for signs of delirium and aware of which patients are most likely at risk.

"Some cases of delirium are more difficult to diagnose. The hyperactive type is more obvious. Patients tend to be confused and agitated. They may not know where they are or understand what is going on, and their families are sometimes surprised by the language they use, which may not be typical of their personality.

"Hypoactive delirium is often more difficult to recognize, but can be equally detrimental, especially since it can result in a decline in muscle strength. Patients may be slow to respond, sleep more than usual, and may seem withdrawn. The third type is a combination of the two, with the patient fluctuating between the two extremes. Basically, we are looking for are new or sudden changes in behavior," Flood said.

"The work Emily Simmons is doing is making a real difference. We hope to soon be rolling out what we learn throughout the hospital to improve patient care and eventually to pass that information on to help other hospitals do the same."


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ACE Acute Care For The Elderly unit, Emily Simmons MSN RN, Gerentological Nursing Leadership Academy, Hospital Elder Life Program HELP, Hospital-induced dementia, Kellie Flood MD, UAB Highlands


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