Patients with delirium or dementia have inferior treatment during hospital stays, a large population study from the University of Stirling shows. Professor Emma Reynish, the study’s author and lead researcher, uncovered markedly different results in outcomes.
“People who are admitted to hospital with confusion seem to do badly, and are at an increased risk of dying, increased risk of re-admission, and a hospital stay nearly two weeks longer than those without confusion,” said Reynish.
What the Research Found
In studying more than 10,000 admitted patients aged 65, Reynish’s team analyzed the care results of patients with dementia, delirium, and undiagnosed dementia, broadly termed cognitive spectrum disorder (CSD). Within the study group, 25 percent had known delirium and 17 percent had known dementia. In all cases, patients with one of these disorders fared worse than other patients when visiting the hospital.
Specifically, patients with some type of CSD were more likely to suffer from one or more of the following:
- Extended stay: Patients without cognitive issues averaged 12 days in the hospital, compared to 25 days for CSD patients.
- Readmission: Patients with CSD were likely to be readmitted within 30 days at a rate of 59 percent, compared to 49 percent for non-CSD patients.
- Death: Patients with CSD had a 40 percent mortality rate within a year of their stay, compared with a 26 percent mortality of non-CSD patients.
These poorer outcomes were significant given adults with cognitive disorders make up half of hospital patients over the age of 85 and one-third of the population over the age of 65.
Reynish said it’s unclear if the poor outcomes are because of inferior care from hospital staff or because of the impact of poor cognitive on general recovery. Further study is needed to determine causality.
The study was published in the BMC Medicine journal. Research by the University of Stirling was conducted in partnership with experts from the University of Dundee and NHS Fine, all located in Scotland.
The Link Between Hospital Delirium and Dementia
Delirium is a temporary but sever form of mental confusion. In a hospital setting, delirium can be triggered by stress, medication side-effects, sedatives, infection, dehydration, poor nutrition, and isolation. The National Institute of Health estimates 11 to 42 percent of patients experience some type of delirium, citing it as the leading hospital complication.
Symptoms of delirium include an inability to focus, poor orientation, incoherence, and poor cognition. Delirious patients may even hallucinate or become aggressive and belligerent. Symptoms can fluctuate, making it difficult to diagnose. Unlike dementia, delirium symptoms come on quickly—over the course of hours or days—rather than gradually. There is no specific test for hospital delirium. Often doctors rely on family members to alert them to abnormal behavior by the patient.
For patients with some form of dementia, the risk of hospital delirium is higher by as much as 300 percent, according to research by Dr. Daniel Davis at University College London, published in JAMA Psychiatry. One hypothesis is brains with dementia are more vulnerable to sicknesses such as infection, which causes delirium.
Davis’s research also showed hospital patients diagnosed with delirium are 8 times more likely to be diagnosed with dementia within the next three years.
Further, the long-term impacts of delirium may cause dementia complications well after a hospital stay, such as severe progression of dementia, pneumonia, or blood clots.
“If delirium is causing brain injury in the short and long-term, then we must increase our efforts to diagnose, prevent, and treat it,” Dr. Davis said. “Ultimately, targeting delirium could be a chance to delay or reduce dementia.”
In a reaction to Dr. Davis’ research, Professor Clive Ballard from the Alzheimer’s Society said delirium needs to be a larger focus in the prevention of dementia.
“With hospitalization thought to be a cause of delirium,” Ballard said, “it’s vital that healthcare professionals recognize the potential long-term impact of delirium and are aware that older people who experience episodes could be susceptible to developing dementia.”
Teaching Hospital Caregivers How to Deal with Dementia and Delirium
Despite the large number of elderly patients admitted with dementia or other cognitive issues, hospital caregivers may not be familiar with the particulars of interacting with and effectively treating these patients.
Hospitals are selectively adjusting care to deal with a range of dementia issues, such as creating cross-functional teams trained to look for dementia symptoms and involving family more in hospital care. A few hospitals reported reengineering floor layouts to minimize distractions and the number of times a patient needs to be moved. Overall, though, efforts by hospitals have been selective and voluntary.
If you are caring for a family member with dementia that needs a hospital stay, be sure to alert staff to the concern; don’t assume the dementia diagnosis is obvious or known. Additionally, you should educate medical staff on how best to interact with your loved one. This may include the following techniques.
Get the patient’s attention. While the hospital is confusing for most patients, it becomes a twisted maze for patients with dementia. Therefore, focus and alertness is critical for dementia patients, though hard to earn. Teach medical caregivers how to gain eye attention, when to speak loudly, and how to make appropriate physical contact before speaking to your family member. When possible, demonstrate the techniques in person with the patient. Write the instructions down on a large paper and post in the room so that rotating staff members are aware of how to gain attention.
Be clear and ask simple questions. Translating complicated medical advice into simple explanations is often taught in medical school and learned even better on the job, but staff may not be familiar with just how clear and simple interactions may need to be with a dementia patient. Give examples of how to simplify questions while still treating the patient with respect.
Break down actions into a series of steps. With non-dementia patients, loose instructions may result in a few minor mishaps. With a dementia patient, vague instructions could be deadly. Teach hospital staff how specific they need to be by giving an example of how you might explain to your loved one how to brush their teeth. Also request all instructions be written down and any major consultations take place with you or another family member present.
Listen with your eyes. Dementia patients become expert at feigning understanding to avoid embarrassment. Teach caregivers how to spot confusion by monitoring the patient’s eyes and actions. Explain how conversations and instructions may be lost moments later and emphasize the need for repetition.
Try not to contradict. It’s natural for hospital staff to seek to educate patients and contradict any misperceptions. Teach these staff that constant “correction” with a dementia patient is often fruitless and creates a hostile environment. Alternate techniques may include asking more questions about why the patient has the perception or changing the subject.
Minimize noise and visual distractions, but have information available. Noises and distractions, like a blaring television, can compound confusion when dealing with a stressful situation and hospital delirium. Make sure glasses and hearing aids are available for the patient, if needed. Have a 24-hour clock in the room and easily visible calendar.
The Bottom Line
If you’re caring for a person with dementia, understand the person is at a higher risk for extended stay, readmission, or even death during a hospital visit. Dementia symptoms may be accelerated if the patient also suffers from delirium during the visit. Educate hospital staff on how best to interact with the patient and advocate for the patient during their stay.