July 16, 2003 ST. LOUIS -- The best way to treat hospitalized elderly patients who become delirious defies conventional wisdom and common practice, according to new research from Saint Louis University published in the July issue of Journal of the American Geriatrics Society.
Delirium, a common problem among the hospitalized elderly, causes patients to be confused, unclear in their thinking and incoherent. Their behavior may be disturbed - agitated, lethargic or a combination of the two. Those delirious patients who are sleepy and lethargic often are undiagnosed because they don't make a ruckus.
Typically, elderly delirious patients who are agitated are cared for in private or semi-private rooms, isolated from others. They may be placed in physical restraints for protection and given medications that are calming.
Now a new treatment model created by Saint Louis University geriatricians at Saint Louis University Hospital, the only one of its kind in the country, throws many of those ideas for treatment out of the window.
The geriatricians found that elderly patients with delirium do better if they are placed together and cared for in the Delirium Room, essentially a four-bed intensive care unit. Because there are no walls in the Delirium Room, a highly trained certified nursing assistant or registered nurse can constantly monitor their conditions, picking up on potential problems early to prevent them from escalating. Physical restraints are not used and medication to quiet patients is the last-choice treatment.
"Since 1997, we've been doing it and if it's done correctly, it works," says Joseph Flaherty, M.D., associate professor of geriatrics at Saint Louis University School of Medicine and principal investigator. "The nursing literature says agitated patients cause agitation in normal patients, so they need to be separated. We just don't see it happen."
Delirium is a very common problem among hospitalized elderly patients, Dr. Flaherty says. Between 15 and 20 percent of older patients are delirious when they are admitted and up to 30 percent become delirious while they're in the hospital.
Delirium is caused by a host of medical problems that include illnesses, dehydration and medications. It is treatable, reversible and must be diagnosed so the patient's other medical problems aren't missed.
"The few keys to delirium are early recognition and early identification of the medical problems causing the delirium," Dr. Flaherty says. "With proper care, it's so reversible."
Typically, though, delirious patients don't do well in hospitals. They stay in hospitals longer, fall and become injured more frequently, lose their ability to physically function and are more likely to die than hospitalized elderly patients who are not delirious.
The Saint Louis University model for treatment eliminates the disparity between elderly patients who were delirious and those who were not. "We studied delirious patients during the first 18 months after opening the Delirium Room. We kept the length of stay equal to non-delirious patients. We maintained their physical function. Our fall rate is near zero in that room because they're constantly supervised. Our mortality rate was zero. None of the delirious patients died during that time," he says.
Nurses in the Delirium Room rely on strategies to treat delirium that don't involve physical restraints and avoid medications. They try to reorient the confused patient and figure out why the patient is becoming agitated. In many cases, the reason for the patient's agitation is easily solved: the patient's IV is uncomfortable, he needs to use the restroom or her pain medication is wearing off.
"It's intensive nursing," Dr. Flaherty says. "Medications are used, but after every non-pharmacological method has been tried."
He suggests that hospitals treat patients who are at high risk of developing delirium to put the breaks on the mental disorder before it takes hold.
"There are patients we know who have a high risk for developing of delirium. They include the very old, patients with an underlying dementia, patients who have problems with their hearing or sight and patients who are at risk for dehydration," Dr. Flaherty says.
An 80-year old woman who is hospitalized with pneumonia, has Alzheimer's disease and lives at home with her husband, would be an ideal candidate for the Delirium Room. There, she would be carefully observed to make sure she does not become delirious.
The Delirium Room is part of Saint Louis University Hospital's Acute Care for the Elderly (ACE) unit, which is designed to prevent loss of physical function while patients are treated for an acute illness so they can return to their previous state of independence. Instead of treating the acute illness, then sending the patient for "rehab," the ACE Unit emphasizes "pre-rehab" by starting therapy on day one, eating meals together and focusing on other strategies that are important in treating older patients.
Having a dedicated place to care for elderly patients who become delirious calls attention to the syndrome, so doctors and nurses are less likely to miss diagnosing an underlying problem, Flaherty says.
"It's an education tool itself. Everyone hears 'Delirium Room' and doctors and nurses start to learn what is a delirious patient. They weren't taught this in medical school."
Established in 1836, Saint Louis University School of Medicine has the distinction of awarding the first M.D. degree west of the Mississippi River. Saint Louis University School of Medicine is a pioneer in geriatric medicine, organ transplantation, chronic disease prevention, cardiovascular disease, neurosciences and vaccine research, among others. The School of Medicine trains physicians and biomedical scientists, conducts medical research, and provides health services on a local, national and international level.
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