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Get Clear on Delirium
Delirium—also known as acute confusional state—is a common and potentially serious condition for hospitalized geriatric patients. It is believed to complicate hospital stays for more than 2.3 million older people, account for more than 17.5 million in patient days, and cost more than $4 billion in Medicare expenditures.1
Many experts believe the numbers may be higher because clinical staff too often automatically attribute patients’ symptoms to age-related dementia.
Delirium is many times more likely to occur in older people.2 Because patients older than 65 account for nearly half of all inpatient days, hospitalists must be readily able to identify the signs and symptoms of delirium—as well as what factors put certain patients at an increased risk for developing delirium. Hospitalists with this knowledge and ability will be better equipped to reduce the risk for delirium in their patients and more effectively treat delirium when it occurs.
“Assuming that the patient’s confusion is a normal state for him or her, without speaking to the patient’s family or caregivers to establish the baseline mental status for the patient, is probably the biggest reason delirium is so often misdiagnosed and, consequently, left untreated,” says Sharon Inouye, MD, of the Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School.
Define and Diagnose Delirium
Delirium is a temporary state of mental confusion and fluctuating consciousness. Patients are unable to focus their thoughts or pay attention, are confused about their environment and individuals, and unsure about their daily routines. They may exhibit subtle or startling personality changes. Some people may become withdrawn and lethargic, while others become agitated or hyperactive. Some patients experience visual and/or auditory hallucinations and become paranoid.
Changes in sleep patterns are a typical manifestation of delirium. The patient may experience anything from mild insomnia to complete reversal of the sleep-wake cycle. All symptoms may fluctuate in severity as the day progresses, and it is common for delirious patients to become more agitated and confused at night.
Dementia is a chronic problem that develops over time. Delirium is acute—usually developing over hours or days. While patients with pre-existing dementia, brain trauma, cerebrovascular accident, or brain tumor are at higher risk for developing delirium, don’t automatically attribute unusual behavior in a geriatric patient to one of these diagnoses—especially if the behavioral change is sudden.
It is vital to obtain a solid history to determine the patient’s baseline mental status. The patient may not be the most reliable source of information regarding his or her normal level of cognition—particularly if he or she is beginning to show signs that may indicate delirium. Make every effort to question the patient’s family members and caregivers thoroughly to determine the patient’s normal level of functioning.
“The trick is that you have to have a nursing staff you can trust and who is attentive enough to changes in behavior—keeping in mind that they’ve only known the patient for a short time,” says Jonathan Flacker, MD, assistant professor of medicine at Emory University in Atlanta. “You have to rely a lot on the families and caregivers. You have to know whether the patient’s behavior is new or not, and sometimes that’s hard to establish.”
A simple tool nursing staff can use to monitor the patient’s mental status is the Confusion Assessment Method (CAM). The CAM is easy to use and interpret and only takes moments to complete. When staff on each shift use this tool and accurately document the results, it can help identify early changes that may indicate the onset of delirium.3
In addition to the CAM, other tools that can assist in cognitive assessment of the patient can include The Mini-Cog Assessment Instrument for Dementia, The Clock Draw Test, The Short Portable Mental Status Questionnaire (SPMSQ), The Geriatric Depression Scale, The Folstein Mini-Mental Status Exam, and The Digit Span Test.
Identify Etiology
Once the physician has determined that a patient is suffering from delirium, the challenge is to identify and treat the cause.
“It is important to remember that older folks often have atypical presentation of symptoms for medical problems,” says Dr. Inouye. “Physicians and clinical staff need to carefully consider all of the patient’s signs and symptoms, regardless of how insignificant they may seem.”
The physician can then order additional diagnostic tests based on the findings of the physical examination, which may include CBC, serum chemistry group, urinalysis, serum and urine drug screens, and possibly diagnostic radiographic studies as indicated.
Assessment must also include a careful review of the patient’s medications—possibly with input from a pharmacist. To do this, obtain a complete list of medications the patient was taking prior to admission to compare with the medications the patient is taking currently. Consider the possible effects of:
- Medications that have been discontinued;
- New medications;
- Changes in dosage;
- Possible drug interactions; and
- Possible drug toxicities that may require additional lab testing.
Pay attention to psychoactive medications the patient is taking, such as sedative-hypnotic agents, narcotics, and antidepressants. It is important to note whether the patient has recently received anesthesia or pain medications.4 It is also important to determine whether the patient has a history of alcohol or drug dependency.
“The first thing I would think if a patient is not acting right is drugs—some new drug that we’re administering or some drug that he or she is withdrawing from,” says O’Neil Pyke, MD, medical director of the Hamot Hospitalist Group in Erie, Pa. “You have to consider the possibility of side effects, drug interactions, and withdrawals. You also have to recognize polypharmacology as a major risk factor and try to curtail unnecessary medications.”
Dr. Flacker cautions that even once a problem has been identified, the physician must follow through on the complete examination and evaluation of the patient, keeping in mind that the cause for delirium may be multifactorial. “The problem is that like a lot of things in older folks, if you look for ‘the’ cause, you’re likely to be frustrated,” he says. “It’s often a combination of stressors causing the patient’s delirium.”
Treatment
Once the underlying problem or problems have been identified, treat those medical conditions accordingly—by administering antibiotics, fluids, and electrolytes as needed and adjusting or discontinuing medications.
However, resolution of the etiologic cause does not necessarily mean the symptoms of delirium will spontaneously resolve. These symptoms likely will require specific interventions to reorient the patient.
Encourage family members to participate in these efforts and spend as much time as possible with the patient. It may also be helpful to have family members bring in a few familiar items from the patient’s home—such as family photographs—to help calm and reassure the patient.
David Meyers, MD, hospitalist and chief of inpatient medicine at the Veterans Administration Medical Center in Madison, Wis., says: “You can use very simple modifications that really don’t take much time or effort. It’s really trying to recreate the patient’s environment and getting him or her to identify with certain things.”
To help the patient remain oriented to time and assist with disturbances in sleep patterns, staff should turn lights on and off and open and close curtains and blinds at the appropriate times. Make wall calendars and clocks visible to the patient. Try to keep the patient as active as possible during the day and minimize sleep interruptions.
Maintain as calm an environment for the patient as possible, minimizing ambient noise and activity. Place the patient in a room without a roommate if possible, close enough to the nurses’ station to facilitate close observation—but not so close that they’re disturbed by beepers, telephones, monitors, and other noises. Keep televisions at a reasonable volume and turned off when no one is watching. However, don’t isolate or abandon the patient, or let him/her spend too much time in bed. Assist the patient with mobilization several times daily.
If the patient has a vision or hearing impairment, staff and family should make every effort to ensure that the patient has access to and uses the appropriate corrective devices.4 Staff will also need to pay special attention to ensure that the patient eats appropriately, maintains an adequate fluid intake, and is assisted to the restroom regularly.
If safety concerns make it absolutely necessary to use physical restraints on a delirious patient, remember to explain all actions and instructions in clear, simple terms, using a low, calm tone of voice. Apply restraints carefully, release at frequent intervals, and discontinue as soon as possible. The patient likely will not understand why he or she is being restrained—and this lack of comprehension can worsen the patient’s fear and agitation.4,5
If nonpharmacologic interventions are not effective in controlling the patient’s agitation, physicians may prescribe antipsychotic agents and intermediate-acting benzodiazepines to immediately control an extremely agitated patient. However, some antipsychotic drugs can have anticholinergic side effects, which may aggravate delirium. Benzodiazepines can also exacerbate the patient’s delirious symptoms in the long term. Use these medications only for initial control of the patient’s behavior, and reduce and discontinue as soon as possible.
Dr. Meyers encourages consultation by a geriatrician. “The biggest consult service I utilize for suggestion of treatment options is geriatrics,” he says. “They’re very good at working with the patient and family and thinking of other behavioral and medical modifications.
“We can’t give a pill to reverse delirium. This is a shift in paradigm from what physicians are taught. In this setting, you actually want to get rid of medications and limit interventions.”
Remember to reassure patients and their families that most people recover fully if delirium is rapidly identified and treated. However, also caution them that some of the patient’s symptoms may persist for weeks or months, and improvement may occur slowly. Discharge from the hospital may be in the patient’s best interest—but the persistence of symptoms may necessitate home healthcare or temporary nursing home placement.
“In the absence of an acute medical problem, it may be preferable to get the patient to a less acute setting that can be more orienting and more therapeutic,” says Dr. Flacker.
While experts agree that it is not possible to prevent every case of delirium, knowing what puts patients at higher risk gives us the ability to reduce that risk for many patients.
In 1999, Dr. Inouye and her colleagues at the Yale University School of Medicine developed The Hospital Elder Life Program (HELP). The HELP program utilizes a trained interdisciplinary team consisting of a geriatric nurse-specialist, specially trained Elder Life specialists, trained volunteers, geriatrician, and other consultants (such as a certified therapeutic recreation specialist, a physical therapist, a pharmacist, and a nutritionist) to address six facets of delirium risk:
- Orientation. Provide daily communication and a daily schedule on a dry-erase board or chalkboard;
- Therapeutic activities. A variety of cognitively stimulating, fun activities like word games, reminiscence, trivia, or current events;
- Early mobilization. Get all patients up and walking three times a day;
- Vision and hearing adaptations;
- Feeding assistance and hydration assistance with encouragement/companionship during meals; and
- Sleep enhancement. Provide a nonpharmacologic sleep protocol, such as warm milk or herbal tea, backrub, and relaxation music.
A study of the HELP program published in The New England Journal of Medicine showed a 40% reduction in risk for delirium when these measures were applied to at-risk patients included in the study. Implementing the program cost $6,341 per case of delirium prevented. That is significantly less than the estimated cost associated with preventing other hospital complications, such as falls and myocardial infarction.
Prevention is preferable to treatment. But when delirium cannot be prevented, Dr. Inouye concludes with this advice for hospitalists: “Recognition is huge. The single most important thing that hospitalists can do for patients suffering from delirium is to know the signs and symptoms and recognize them when they occur. Earlier recognition means earlier intervention—and that is what’s in the best interest of the patient.” TH
Sheri Polley is a frequent contributor to The Hospitalist.
References
- Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med.1999 Mar 4;340:669-676.
- Rummans TA, Evans JM, Krahn LE, Fleming KC. Delirium in elderly patients: Evaluation and management. Mayo Clinic Web site. Available at www.mayoclinicproceedings.com/inside.asp?AID=4031&UID. Last accessed May 14, 2007.
- Clinical Toolbox for Geriatric Care. Society of Hospital Medicine Web site. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.
- McGowan NC, Locala JA. Delirium. The Cleveland Clinic Web site. Available at www.clevelandclinicmeded.com/diseasemanagement/psychiatry/delirium/delirum1.htm. Last accessed May 15, 2007.
- Restraint Alternative Menu. Clinical Toolbox for Geriatric Care 2004 Society of Hospital Medicine. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.
Delirium—also known as acute confusional state—is a common and potentially serious condition for hospitalized geriatric patients. It is believed to complicate hospital stays for more than 2.3 million older people, account for more than 17.5 million in patient days, and cost more than $4 billion in Medicare expenditures.1
Many experts believe the numbers may be higher because clinical staff too often automatically attribute patients’ symptoms to age-related dementia.
Delirium is many times more likely to occur in older people.2 Because patients older than 65 account for nearly half of all inpatient days, hospitalists must be readily able to identify the signs and symptoms of delirium—as well as what factors put certain patients at an increased risk for developing delirium. Hospitalists with this knowledge and ability will be better equipped to reduce the risk for delirium in their patients and more effectively treat delirium when it occurs.
“Assuming that the patient’s confusion is a normal state for him or her, without speaking to the patient’s family or caregivers to establish the baseline mental status for the patient, is probably the biggest reason delirium is so often misdiagnosed and, consequently, left untreated,” says Sharon Inouye, MD, of the Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School.
Define and Diagnose Delirium
Delirium is a temporary state of mental confusion and fluctuating consciousness. Patients are unable to focus their thoughts or pay attention, are confused about their environment and individuals, and unsure about their daily routines. They may exhibit subtle or startling personality changes. Some people may become withdrawn and lethargic, while others become agitated or hyperactive. Some patients experience visual and/or auditory hallucinations and become paranoid.
Changes in sleep patterns are a typical manifestation of delirium. The patient may experience anything from mild insomnia to complete reversal of the sleep-wake cycle. All symptoms may fluctuate in severity as the day progresses, and it is common for delirious patients to become more agitated and confused at night.
Dementia is a chronic problem that develops over time. Delirium is acute—usually developing over hours or days. While patients with pre-existing dementia, brain trauma, cerebrovascular accident, or brain tumor are at higher risk for developing delirium, don’t automatically attribute unusual behavior in a geriatric patient to one of these diagnoses—especially if the behavioral change is sudden.
It is vital to obtain a solid history to determine the patient’s baseline mental status. The patient may not be the most reliable source of information regarding his or her normal level of cognition—particularly if he or she is beginning to show signs that may indicate delirium. Make every effort to question the patient’s family members and caregivers thoroughly to determine the patient’s normal level of functioning.
“The trick is that you have to have a nursing staff you can trust and who is attentive enough to changes in behavior—keeping in mind that they’ve only known the patient for a short time,” says Jonathan Flacker, MD, assistant professor of medicine at Emory University in Atlanta. “You have to rely a lot on the families and caregivers. You have to know whether the patient’s behavior is new or not, and sometimes that’s hard to establish.”
A simple tool nursing staff can use to monitor the patient’s mental status is the Confusion Assessment Method (CAM). The CAM is easy to use and interpret and only takes moments to complete. When staff on each shift use this tool and accurately document the results, it can help identify early changes that may indicate the onset of delirium.3
In addition to the CAM, other tools that can assist in cognitive assessment of the patient can include The Mini-Cog Assessment Instrument for Dementia, The Clock Draw Test, The Short Portable Mental Status Questionnaire (SPMSQ), The Geriatric Depression Scale, The Folstein Mini-Mental Status Exam, and The Digit Span Test.
Identify Etiology
Once the physician has determined that a patient is suffering from delirium, the challenge is to identify and treat the cause.
“It is important to remember that older folks often have atypical presentation of symptoms for medical problems,” says Dr. Inouye. “Physicians and clinical staff need to carefully consider all of the patient’s signs and symptoms, regardless of how insignificant they may seem.”
The physician can then order additional diagnostic tests based on the findings of the physical examination, which may include CBC, serum chemistry group, urinalysis, serum and urine drug screens, and possibly diagnostic radiographic studies as indicated.
Assessment must also include a careful review of the patient’s medications—possibly with input from a pharmacist. To do this, obtain a complete list of medications the patient was taking prior to admission to compare with the medications the patient is taking currently. Consider the possible effects of:
- Medications that have been discontinued;
- New medications;
- Changes in dosage;
- Possible drug interactions; and
- Possible drug toxicities that may require additional lab testing.
Pay attention to psychoactive medications the patient is taking, such as sedative-hypnotic agents, narcotics, and antidepressants. It is important to note whether the patient has recently received anesthesia or pain medications.4 It is also important to determine whether the patient has a history of alcohol or drug dependency.
“The first thing I would think if a patient is not acting right is drugs—some new drug that we’re administering or some drug that he or she is withdrawing from,” says O’Neil Pyke, MD, medical director of the Hamot Hospitalist Group in Erie, Pa. “You have to consider the possibility of side effects, drug interactions, and withdrawals. You also have to recognize polypharmacology as a major risk factor and try to curtail unnecessary medications.”
Dr. Flacker cautions that even once a problem has been identified, the physician must follow through on the complete examination and evaluation of the patient, keeping in mind that the cause for delirium may be multifactorial. “The problem is that like a lot of things in older folks, if you look for ‘the’ cause, you’re likely to be frustrated,” he says. “It’s often a combination of stressors causing the patient’s delirium.”
Treatment
Once the underlying problem or problems have been identified, treat those medical conditions accordingly—by administering antibiotics, fluids, and electrolytes as needed and adjusting or discontinuing medications.
However, resolution of the etiologic cause does not necessarily mean the symptoms of delirium will spontaneously resolve. These symptoms likely will require specific interventions to reorient the patient.
Encourage family members to participate in these efforts and spend as much time as possible with the patient. It may also be helpful to have family members bring in a few familiar items from the patient’s home—such as family photographs—to help calm and reassure the patient.
David Meyers, MD, hospitalist and chief of inpatient medicine at the Veterans Administration Medical Center in Madison, Wis., says: “You can use very simple modifications that really don’t take much time or effort. It’s really trying to recreate the patient’s environment and getting him or her to identify with certain things.”
To help the patient remain oriented to time and assist with disturbances in sleep patterns, staff should turn lights on and off and open and close curtains and blinds at the appropriate times. Make wall calendars and clocks visible to the patient. Try to keep the patient as active as possible during the day and minimize sleep interruptions.
Maintain as calm an environment for the patient as possible, minimizing ambient noise and activity. Place the patient in a room without a roommate if possible, close enough to the nurses’ station to facilitate close observation—but not so close that they’re disturbed by beepers, telephones, monitors, and other noises. Keep televisions at a reasonable volume and turned off when no one is watching. However, don’t isolate or abandon the patient, or let him/her spend too much time in bed. Assist the patient with mobilization several times daily.
If the patient has a vision or hearing impairment, staff and family should make every effort to ensure that the patient has access to and uses the appropriate corrective devices.4 Staff will also need to pay special attention to ensure that the patient eats appropriately, maintains an adequate fluid intake, and is assisted to the restroom regularly.
If safety concerns make it absolutely necessary to use physical restraints on a delirious patient, remember to explain all actions and instructions in clear, simple terms, using a low, calm tone of voice. Apply restraints carefully, release at frequent intervals, and discontinue as soon as possible. The patient likely will not understand why he or she is being restrained—and this lack of comprehension can worsen the patient’s fear and agitation.4,5
If nonpharmacologic interventions are not effective in controlling the patient’s agitation, physicians may prescribe antipsychotic agents and intermediate-acting benzodiazepines to immediately control an extremely agitated patient. However, some antipsychotic drugs can have anticholinergic side effects, which may aggravate delirium. Benzodiazepines can also exacerbate the patient’s delirious symptoms in the long term. Use these medications only for initial control of the patient’s behavior, and reduce and discontinue as soon as possible.
Dr. Meyers encourages consultation by a geriatrician. “The biggest consult service I utilize for suggestion of treatment options is geriatrics,” he says. “They’re very good at working with the patient and family and thinking of other behavioral and medical modifications.
“We can’t give a pill to reverse delirium. This is a shift in paradigm from what physicians are taught. In this setting, you actually want to get rid of medications and limit interventions.”
Remember to reassure patients and their families that most people recover fully if delirium is rapidly identified and treated. However, also caution them that some of the patient’s symptoms may persist for weeks or months, and improvement may occur slowly. Discharge from the hospital may be in the patient’s best interest—but the persistence of symptoms may necessitate home healthcare or temporary nursing home placement.
“In the absence of an acute medical problem, it may be preferable to get the patient to a less acute setting that can be more orienting and more therapeutic,” says Dr. Flacker.
While experts agree that it is not possible to prevent every case of delirium, knowing what puts patients at higher risk gives us the ability to reduce that risk for many patients.
In 1999, Dr. Inouye and her colleagues at the Yale University School of Medicine developed The Hospital Elder Life Program (HELP). The HELP program utilizes a trained interdisciplinary team consisting of a geriatric nurse-specialist, specially trained Elder Life specialists, trained volunteers, geriatrician, and other consultants (such as a certified therapeutic recreation specialist, a physical therapist, a pharmacist, and a nutritionist) to address six facets of delirium risk:
- Orientation. Provide daily communication and a daily schedule on a dry-erase board or chalkboard;
- Therapeutic activities. A variety of cognitively stimulating, fun activities like word games, reminiscence, trivia, or current events;
- Early mobilization. Get all patients up and walking three times a day;
- Vision and hearing adaptations;
- Feeding assistance and hydration assistance with encouragement/companionship during meals; and
- Sleep enhancement. Provide a nonpharmacologic sleep protocol, such as warm milk or herbal tea, backrub, and relaxation music.
A study of the HELP program published in The New England Journal of Medicine showed a 40% reduction in risk for delirium when these measures were applied to at-risk patients included in the study. Implementing the program cost $6,341 per case of delirium prevented. That is significantly less than the estimated cost associated with preventing other hospital complications, such as falls and myocardial infarction.
Prevention is preferable to treatment. But when delirium cannot be prevented, Dr. Inouye concludes with this advice for hospitalists: “Recognition is huge. The single most important thing that hospitalists can do for patients suffering from delirium is to know the signs and symptoms and recognize them when they occur. Earlier recognition means earlier intervention—and that is what’s in the best interest of the patient.” TH
Sheri Polley is a frequent contributor to The Hospitalist.
References
- Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med.1999 Mar 4;340:669-676.
- Rummans TA, Evans JM, Krahn LE, Fleming KC. Delirium in elderly patients: Evaluation and management. Mayo Clinic Web site. Available at www.mayoclinicproceedings.com/inside.asp?AID=4031&UID. Last accessed May 14, 2007.
- Clinical Toolbox for Geriatric Care. Society of Hospital Medicine Web site. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.
- McGowan NC, Locala JA. Delirium. The Cleveland Clinic Web site. Available at www.clevelandclinicmeded.com/diseasemanagement/psychiatry/delirium/delirum1.htm. Last accessed May 15, 2007.
- Restraint Alternative Menu. Clinical Toolbox for Geriatric Care 2004 Society of Hospital Medicine. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.
Delirium—also known as acute confusional state—is a common and potentially serious condition for hospitalized geriatric patients. It is believed to complicate hospital stays for more than 2.3 million older people, account for more than 17.5 million in patient days, and cost more than $4 billion in Medicare expenditures.1
Many experts believe the numbers may be higher because clinical staff too often automatically attribute patients’ symptoms to age-related dementia.
Delirium is many times more likely to occur in older people.2 Because patients older than 65 account for nearly half of all inpatient days, hospitalists must be readily able to identify the signs and symptoms of delirium—as well as what factors put certain patients at an increased risk for developing delirium. Hospitalists with this knowledge and ability will be better equipped to reduce the risk for delirium in their patients and more effectively treat delirium when it occurs.
“Assuming that the patient’s confusion is a normal state for him or her, without speaking to the patient’s family or caregivers to establish the baseline mental status for the patient, is probably the biggest reason delirium is so often misdiagnosed and, consequently, left untreated,” says Sharon Inouye, MD, of the Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School.
Define and Diagnose Delirium
Delirium is a temporary state of mental confusion and fluctuating consciousness. Patients are unable to focus their thoughts or pay attention, are confused about their environment and individuals, and unsure about their daily routines. They may exhibit subtle or startling personality changes. Some people may become withdrawn and lethargic, while others become agitated or hyperactive. Some patients experience visual and/or auditory hallucinations and become paranoid.
Changes in sleep patterns are a typical manifestation of delirium. The patient may experience anything from mild insomnia to complete reversal of the sleep-wake cycle. All symptoms may fluctuate in severity as the day progresses, and it is common for delirious patients to become more agitated and confused at night.
Dementia is a chronic problem that develops over time. Delirium is acute—usually developing over hours or days. While patients with pre-existing dementia, brain trauma, cerebrovascular accident, or brain tumor are at higher risk for developing delirium, don’t automatically attribute unusual behavior in a geriatric patient to one of these diagnoses—especially if the behavioral change is sudden.
It is vital to obtain a solid history to determine the patient’s baseline mental status. The patient may not be the most reliable source of information regarding his or her normal level of cognition—particularly if he or she is beginning to show signs that may indicate delirium. Make every effort to question the patient’s family members and caregivers thoroughly to determine the patient’s normal level of functioning.
“The trick is that you have to have a nursing staff you can trust and who is attentive enough to changes in behavior—keeping in mind that they’ve only known the patient for a short time,” says Jonathan Flacker, MD, assistant professor of medicine at Emory University in Atlanta. “You have to rely a lot on the families and caregivers. You have to know whether the patient’s behavior is new or not, and sometimes that’s hard to establish.”
A simple tool nursing staff can use to monitor the patient’s mental status is the Confusion Assessment Method (CAM). The CAM is easy to use and interpret and only takes moments to complete. When staff on each shift use this tool and accurately document the results, it can help identify early changes that may indicate the onset of delirium.3
In addition to the CAM, other tools that can assist in cognitive assessment of the patient can include The Mini-Cog Assessment Instrument for Dementia, The Clock Draw Test, The Short Portable Mental Status Questionnaire (SPMSQ), The Geriatric Depression Scale, The Folstein Mini-Mental Status Exam, and The Digit Span Test.
Identify Etiology
Once the physician has determined that a patient is suffering from delirium, the challenge is to identify and treat the cause.
“It is important to remember that older folks often have atypical presentation of symptoms for medical problems,” says Dr. Inouye. “Physicians and clinical staff need to carefully consider all of the patient’s signs and symptoms, regardless of how insignificant they may seem.”
The physician can then order additional diagnostic tests based on the findings of the physical examination, which may include CBC, serum chemistry group, urinalysis, serum and urine drug screens, and possibly diagnostic radiographic studies as indicated.
Assessment must also include a careful review of the patient’s medications—possibly with input from a pharmacist. To do this, obtain a complete list of medications the patient was taking prior to admission to compare with the medications the patient is taking currently. Consider the possible effects of:
- Medications that have been discontinued;
- New medications;
- Changes in dosage;
- Possible drug interactions; and
- Possible drug toxicities that may require additional lab testing.
Pay attention to psychoactive medications the patient is taking, such as sedative-hypnotic agents, narcotics, and antidepressants. It is important to note whether the patient has recently received anesthesia or pain medications.4 It is also important to determine whether the patient has a history of alcohol or drug dependency.
“The first thing I would think if a patient is not acting right is drugs—some new drug that we’re administering or some drug that he or she is withdrawing from,” says O’Neil Pyke, MD, medical director of the Hamot Hospitalist Group in Erie, Pa. “You have to consider the possibility of side effects, drug interactions, and withdrawals. You also have to recognize polypharmacology as a major risk factor and try to curtail unnecessary medications.”
Dr. Flacker cautions that even once a problem has been identified, the physician must follow through on the complete examination and evaluation of the patient, keeping in mind that the cause for delirium may be multifactorial. “The problem is that like a lot of things in older folks, if you look for ‘the’ cause, you’re likely to be frustrated,” he says. “It’s often a combination of stressors causing the patient’s delirium.”
Treatment
Once the underlying problem or problems have been identified, treat those medical conditions accordingly—by administering antibiotics, fluids, and electrolytes as needed and adjusting or discontinuing medications.
However, resolution of the etiologic cause does not necessarily mean the symptoms of delirium will spontaneously resolve. These symptoms likely will require specific interventions to reorient the patient.
Encourage family members to participate in these efforts and spend as much time as possible with the patient. It may also be helpful to have family members bring in a few familiar items from the patient’s home—such as family photographs—to help calm and reassure the patient.
David Meyers, MD, hospitalist and chief of inpatient medicine at the Veterans Administration Medical Center in Madison, Wis., says: “You can use very simple modifications that really don’t take much time or effort. It’s really trying to recreate the patient’s environment and getting him or her to identify with certain things.”
To help the patient remain oriented to time and assist with disturbances in sleep patterns, staff should turn lights on and off and open and close curtains and blinds at the appropriate times. Make wall calendars and clocks visible to the patient. Try to keep the patient as active as possible during the day and minimize sleep interruptions.
Maintain as calm an environment for the patient as possible, minimizing ambient noise and activity. Place the patient in a room without a roommate if possible, close enough to the nurses’ station to facilitate close observation—but not so close that they’re disturbed by beepers, telephones, monitors, and other noises. Keep televisions at a reasonable volume and turned off when no one is watching. However, don’t isolate or abandon the patient, or let him/her spend too much time in bed. Assist the patient with mobilization several times daily.
If the patient has a vision or hearing impairment, staff and family should make every effort to ensure that the patient has access to and uses the appropriate corrective devices.4 Staff will also need to pay special attention to ensure that the patient eats appropriately, maintains an adequate fluid intake, and is assisted to the restroom regularly.
If safety concerns make it absolutely necessary to use physical restraints on a delirious patient, remember to explain all actions and instructions in clear, simple terms, using a low, calm tone of voice. Apply restraints carefully, release at frequent intervals, and discontinue as soon as possible. The patient likely will not understand why he or she is being restrained—and this lack of comprehension can worsen the patient’s fear and agitation.4,5
If nonpharmacologic interventions are not effective in controlling the patient’s agitation, physicians may prescribe antipsychotic agents and intermediate-acting benzodiazepines to immediately control an extremely agitated patient. However, some antipsychotic drugs can have anticholinergic side effects, which may aggravate delirium. Benzodiazepines can also exacerbate the patient’s delirious symptoms in the long term. Use these medications only for initial control of the patient’s behavior, and reduce and discontinue as soon as possible.
Dr. Meyers encourages consultation by a geriatrician. “The biggest consult service I utilize for suggestion of treatment options is geriatrics,” he says. “They’re very good at working with the patient and family and thinking of other behavioral and medical modifications.
“We can’t give a pill to reverse delirium. This is a shift in paradigm from what physicians are taught. In this setting, you actually want to get rid of medications and limit interventions.”
Remember to reassure patients and their families that most people recover fully if delirium is rapidly identified and treated. However, also caution them that some of the patient’s symptoms may persist for weeks or months, and improvement may occur slowly. Discharge from the hospital may be in the patient’s best interest—but the persistence of symptoms may necessitate home healthcare or temporary nursing home placement.
“In the absence of an acute medical problem, it may be preferable to get the patient to a less acute setting that can be more orienting and more therapeutic,” says Dr. Flacker.
While experts agree that it is not possible to prevent every case of delirium, knowing what puts patients at higher risk gives us the ability to reduce that risk for many patients.
In 1999, Dr. Inouye and her colleagues at the Yale University School of Medicine developed The Hospital Elder Life Program (HELP). The HELP program utilizes a trained interdisciplinary team consisting of a geriatric nurse-specialist, specially trained Elder Life specialists, trained volunteers, geriatrician, and other consultants (such as a certified therapeutic recreation specialist, a physical therapist, a pharmacist, and a nutritionist) to address six facets of delirium risk:
- Orientation. Provide daily communication and a daily schedule on a dry-erase board or chalkboard;
- Therapeutic activities. A variety of cognitively stimulating, fun activities like word games, reminiscence, trivia, or current events;
- Early mobilization. Get all patients up and walking three times a day;
- Vision and hearing adaptations;
- Feeding assistance and hydration assistance with encouragement/companionship during meals; and
- Sleep enhancement. Provide a nonpharmacologic sleep protocol, such as warm milk or herbal tea, backrub, and relaxation music.
A study of the HELP program published in The New England Journal of Medicine showed a 40% reduction in risk for delirium when these measures were applied to at-risk patients included in the study. Implementing the program cost $6,341 per case of delirium prevented. That is significantly less than the estimated cost associated with preventing other hospital complications, such as falls and myocardial infarction.
Prevention is preferable to treatment. But when delirium cannot be prevented, Dr. Inouye concludes with this advice for hospitalists: “Recognition is huge. The single most important thing that hospitalists can do for patients suffering from delirium is to know the signs and symptoms and recognize them when they occur. Earlier recognition means earlier intervention—and that is what’s in the best interest of the patient.” TH
Sheri Polley is a frequent contributor to The Hospitalist.
References
- Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med.1999 Mar 4;340:669-676.
- Rummans TA, Evans JM, Krahn LE, Fleming KC. Delirium in elderly patients: Evaluation and management. Mayo Clinic Web site. Available at www.mayoclinicproceedings.com/inside.asp?AID=4031&UID. Last accessed May 14, 2007.
- Clinical Toolbox for Geriatric Care. Society of Hospital Medicine Web site. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.
- McGowan NC, Locala JA. Delirium. The Cleveland Clinic Web site. Available at www.clevelandclinicmeded.com/diseasemanagement/psychiatry/delirium/delirum1.htm. Last accessed May 15, 2007.
- Restraint Alternative Menu. Clinical Toolbox for Geriatric Care 2004 Society of Hospital Medicine. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.
Fall Risk
The problem of falls among older adults has been recognized and studied for many years, including myriad analyses regarding assessment and prevention of falls in this population. The U.S. Census Bureau reported that there were 35.9 million people age 65 and over in the United States as of July 1, 2003. As this population increases, the specific issues pertaining to its members, including falls, must be addressed by hospitalists.
How Big Is the Problem?
The Center for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control reports that:
- More than one-third of adults 65 and older fall each year in the United States;
- Falls are the leading cause of injury deaths for older adults;
- In 2003, about 1.8 million people 65 and older were treated in emergency departments for nonfatal falls, and about 460,000 of these patients were hospitalized;
- The rates of fall-related deaths among older adults rose significantly over the past decade;
- Many individuals who fall develop a fear of falling. That may cause them to limit activity, leading to reduced mobility and physical fitness and increasing their risk for additional falls; and
- In 2000, direct medical costs totaled $179 million for fatal falls and $19 billion for nonfatal fall injuries.1
One study exploring the relationship between the mechanism of fall and the pattern and severity of injury in geriatric patients compared with younger patients concluded that falls were the mechanism of injury in 48% of the older patients (those 65 and older) included in the study compared with 7% in the younger group. Further, 32% of falls in the older group resulted in serious injury, while this was true of only 4% of falls in the younger cohort.2
Risk Assessment
When an inpatient in an acute-care hospital falls, a number of negative outcomes can occur, including a longer hospital stay and higher rates of discharge to long-term care.
Falls are associated with higher levels of anxiety and depression and loss of confidence for the patient. They lead to increased costs for patients and hospitals. Feelings of anxiety and/or guilt among staff members may follow. Ultimately, a fall can result in complaints or even litigation from patients or their families.3
Traditional methods of fall risk evaluation may not be effective for assessing the risk of falling for a hospitalized patient, regardless of the reason the patient is hospitalized. The classic risk factors are generally well recognized among physicians and clinical staff and include:
- Age 65 and older;
- A history of falls;
- Cognitive impairment;
- Urinary/fecal incontinence/urgency;
- Balance problems, lower extremity weakness, arthritis;
- Vision problems;
- Use of more than four daily medications or use of psychotropics or narcotics; and
- ETOH.
Acute illness alone accounts for approximately 10% of falls in older adults.4 Many patients suffering or recovering from acute illness may go through a transient period of increased risk for falling that needs to be recognized by physicians and nursing staff.
The impact of pharmacology on a patient’s risk for falling is widely recognized. Patients who take four or more medications are generally considered to be at increased risk. Certain medications, including diuretics, anti-hypertensives, tricyclic antidepressants, sedatives, and hypoglycemics are known to increase an individual’s risk for falling. An October 2004 CDC-funded study by researchers at Johns Hopkins University (Baltimore) concluded that the short-term risk of single and recurring falls may triple within two days after a medication change.5 A patient hospitalized for an acute illness or injury is likely to have had a recent and significant change in the medications he or she is taking, thereby at least temporarily increasing that individual’s risk for falling.
The environmental hazards of the hospital room can’t be overlooked when assessing a patient’s risk for falling. The patient is in an unfamiliar setting—often with informal restraints in place, including IV tubing, feeding tubes, pulse oximeters, and catheters. These obstacles make it more difficult for the patient to maneuver and present opportunities for tripping.
All these things—individually or combined—can increase the chances of falling, even for a patient who at first glance doesn’t appear to be at risk.
Stephen Shaw, MD, medical director of Community Hospitalists in Cleveland, says that while falls assessment tools can be helpful, it would be difficult to outline a foolproof assessment form.
The physician must keep in mind the fact that falls prevention is multifactorial; it may be difficult to attribute the patient’s fall(s) to any single reason. “Any vigorous falls assessment program has to have a comprehensive approach,” he cautions. “Medications, attention to vision limitations, and his or her ability to feel in the dark in their surroundings all have to be taken into consideration.”
The Hospitalist’s Role
When a patient is admitted for injuries resulting from a fall or from an illness that may have been diagnosed as a result of a fall, consider acute conditions first. Also remember that falling is a symptom; understanding why the patient fell is the first step to prevention—both while the patient remains in the hospital and following discharge.
One of the first things the hospitalist must do to reduce patient falls effectively is to study risk assessment and prevention of geriatric falls. A study published in the Journal of Hospital Medicine in January/February 2006 (“Is There a Geriatrician in the House? Geriatric Care Approaches in Hospitalist Programs”) identifies the need for collaboration between hospitalists and geriatricians to better address the issues specific to hospitalized older adults. This collaboration combines the geriatrician’s expertise regarding the elderly patient’s unique needs and considerations with the hospitalist’s expertise regarding specific acute care situations.6
Heidi Wald, MD, MPH, assistant professor, Division of Health Care Policy and Research and General Internal Medicine at the University of Colorado in Denver and primary author of the Journal of Hospital Medicine study, says numerous things can be done to reduce the risk of inpatient falls, beginning with identifying patients at high risk for falling. This can be done by assessing the classic risk factors intrinsic to the patient, while keeping in mind the risk factors that could be mediated by the acute illness.
Risks created by the environment can be fairly easily addressed, according to Dr. Wald. Lower beds as far as they will go, with the wheels locked. Don’t use upper and lower bedrails simultaneously (this reduces the chance of a patient being caught between the two). Cut down on the use of restraints—both formal and informal.
Because many falls result from patients trying to get to the bathroom, Dr. Wald advises scheduled toileting, with the staff regularly assisting the patient to the bathroom. If a patient cannot ambulate to the restroom independently, ensure that a urinal or a bedpan is nearby and readily accessible to the patient.
Dr. Wald also advises utilizing the expertise and skills of those clinicians most familiar with the patient: the nursing staff. The nurses who have daily contact with the patient are in the best position to provide information regarding changes in the patient’s mental status, ability to ambulate, response to medications, compliance, and other factors that may increase the risk for a fall.
“The bottom line of any quality initiative will often fall to the nurses’ assessment,” says Dr. Shaw. “The front-line caregivers for fall assessments are our nurses.”
A Multidisciplinary Approach to Prevention
Drs. Wald and Shaw both stress the importance of a multidisciplinary approach to prevention of falls (both in hospital and following discharge). A patient who has already fallen—or one identified to be at risk for falling—can be offered a great deal of support and guidance pending discharge. And discharge planning can begin literally at admission.
It’s Dr. Shaw’s practice with at-risk patients to involve physical and occupational therapy (as well as social workers) in the patient’s care right from the beginning. Those individuals are then in a position not only to perform a thorough assessment of the patient but also to begin working on ways to reduce the patient’s risk following discharge. As Dr. Shaw points out, the hospitalist has access to resources the patient’s primary-care physician generally does not, and those resources should be utilized to full advantage.
Physical therapy can offer rehabilitative interventions, including transfer, gait, and balance training; strength and range-of-motion exercises; and habituation exercises for vestibular problems. Occupational therapy can offer the patient instruction on simplifying tasks and on performing everyday activities safely. Social workers can assist the patient with finding educational and assistive resources. All disciplines can be involved in home safety evaluations, patient and family education, and the procurement of assistive and adaptive equipment, such as ambulation devices, grab bars, handrails, raised toilet seats, and so on.
When all of these healthcare providers are involved in the patient’s care from the beginning and can coordinate discharge planning as a team, a more well-rounded and comprehensive plan for prevention of falls can be formulated. This team approach also offers a more accurate view of whether the patient is capable of returning home with or without help or if placement in a rehabilitation or long-term care facility may be more appropriate.
Involve the Patient
Once an at-risk patient has been identified, communicate that risk to everyone involved with the patient’s care, including the medical staff, the family, and the patient. “Patients have a certain degree of risk-taking behavior, and they won’t necessarily ask for help,” says Dr. Wald. “Part of that is that they’re not willing to admit that they need help.”
Patients need to be reminded that they are or have recently been sick—that’s why they’re in the hospital in the first place. She says patients and caregivers must be attuned to the fact that as patients begin to feel better and stronger and become more mobile, their risk for falling will go up before it starts to come down.
If a patient remains resistant to asking for or accepting assistance, Dr. Wald suggests finding out what the patient’s barriers are and trying to get around them. “Try to get people to admit that they have a problem,” she advises. “A lot of times, the barriers aren’t rational, so rationalizing isn’t always effective.”
She offers the example of a patient who resists the idea of using a walker. Sometimes simply demonstrating how much more quickly the patient can get around using the walker may do the trick.
Dr. Shaw adds that a certain level of sensitivity is required when approaching a patient who is in denial regarding his or her limitations. It may be necessary to ask a second physician or nurse to lend credibility by explaining to the patient again that he or she may have needs that didn’t exist previously. He cautions, however, that if his patient remains in denial about his or her limitations, he does not hesitate to engage the family. “If the patient is discharged home, it’s going to be the family who will be the policemen and watchdogs,” says Dr. Shaw.
After discharge, following up with the patient can make a big difference in patient compliance. The time following discharge to the home can be confusing for the patient, and he may be overwhelmed with changes in routines, medications, and activities. Dr. Shaw’s organization calls the patient three to four days post-discharge to verify that the patient understands the discharge instructions, to answer questions the patient may have, and to confirm that prescriptions have been filled and that follow-up appointments have been made with the primary-care physician. He notes that although this simple follow-up phone call takes little time and effort, it has improved patient satisfaction immensely.
Quality and Prevention Initiatives
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2007 National Patient Safety Goals for hospitals includes the following goal: “Reduce the risk of patient harm resulting from falls” (Goal 9).
The requirement for this goal is the implementation of a fall reduction program, followed by evaluation of the effectiveness of the program. Drs. Wald and Shaw agree that, because of the nature of what they do, hospitalists are in an ideal position to spearhead the movement to assess the reasons a patient may have fallen and the risk for future falls—both in the hospital and following discharge—and to synthesize that data to create comprehensive falls prevention programs in their hospitals.
Because hospitalists are on-site 24 hours a day, seven days a week, they are usually first responders when a patient falls and can best evaluate the reasons for the fall and track outcomes. “We’re in an ideal position to create protocols for what to do once a patient does fall in the hospital and [to] evaluate the fall and the incident,” Dr. Wald says. “This is a great quality improvement project because the data are already being collected.”
Dr. Shaw concurs. “Hospitalists are the quality assessors that are in the trenches,” she says. “The hospitalists are really the clinicians most familiar with the strengths and weaknesses of any institution.” TH
Sheri Polley is a medical journalist based in Pennsylvania.
References
- Centers for Disease Control and Prevention. Falls among older adults: an overview. CDC Web site. Available at: www.cdc.gov/ncipc/factsheets/adultfalls.htm. Last accessed March 13, 2007.
- Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001 Jan;50(1):116-119.
- Oliver D, Daly F, Martin FC, et al. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing. 2004 Mar;33(2):122-130.
- Nnodim JO, Alexander NB. Assessing falls in older adults: a comprehensive fall evaluation to reduce fall risk in older adults. Geriatrics. 2005 Oct;60(10):24-28.
- Centers for Disease Control and Prevention. CDC fall prevention activities: research studies. CDC Web site. Available at: www.cdc.gov/ncipc/duip/FallsPreventionActivity.htm. Last accessed March 13, 2007.
- Wald H, Huddleston J, Kramer A. Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs. J Hosp Med. 2006 Jan;1(1):29-35.
The problem of falls among older adults has been recognized and studied for many years, including myriad analyses regarding assessment and prevention of falls in this population. The U.S. Census Bureau reported that there were 35.9 million people age 65 and over in the United States as of July 1, 2003. As this population increases, the specific issues pertaining to its members, including falls, must be addressed by hospitalists.
How Big Is the Problem?
The Center for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control reports that:
- More than one-third of adults 65 and older fall each year in the United States;
- Falls are the leading cause of injury deaths for older adults;
- In 2003, about 1.8 million people 65 and older were treated in emergency departments for nonfatal falls, and about 460,000 of these patients were hospitalized;
- The rates of fall-related deaths among older adults rose significantly over the past decade;
- Many individuals who fall develop a fear of falling. That may cause them to limit activity, leading to reduced mobility and physical fitness and increasing their risk for additional falls; and
- In 2000, direct medical costs totaled $179 million for fatal falls and $19 billion for nonfatal fall injuries.1
One study exploring the relationship between the mechanism of fall and the pattern and severity of injury in geriatric patients compared with younger patients concluded that falls were the mechanism of injury in 48% of the older patients (those 65 and older) included in the study compared with 7% in the younger group. Further, 32% of falls in the older group resulted in serious injury, while this was true of only 4% of falls in the younger cohort.2
Risk Assessment
When an inpatient in an acute-care hospital falls, a number of negative outcomes can occur, including a longer hospital stay and higher rates of discharge to long-term care.
Falls are associated with higher levels of anxiety and depression and loss of confidence for the patient. They lead to increased costs for patients and hospitals. Feelings of anxiety and/or guilt among staff members may follow. Ultimately, a fall can result in complaints or even litigation from patients or their families.3
Traditional methods of fall risk evaluation may not be effective for assessing the risk of falling for a hospitalized patient, regardless of the reason the patient is hospitalized. The classic risk factors are generally well recognized among physicians and clinical staff and include:
- Age 65 and older;
- A history of falls;
- Cognitive impairment;
- Urinary/fecal incontinence/urgency;
- Balance problems, lower extremity weakness, arthritis;
- Vision problems;
- Use of more than four daily medications or use of psychotropics or narcotics; and
- ETOH.
Acute illness alone accounts for approximately 10% of falls in older adults.4 Many patients suffering or recovering from acute illness may go through a transient period of increased risk for falling that needs to be recognized by physicians and nursing staff.
The impact of pharmacology on a patient’s risk for falling is widely recognized. Patients who take four or more medications are generally considered to be at increased risk. Certain medications, including diuretics, anti-hypertensives, tricyclic antidepressants, sedatives, and hypoglycemics are known to increase an individual’s risk for falling. An October 2004 CDC-funded study by researchers at Johns Hopkins University (Baltimore) concluded that the short-term risk of single and recurring falls may triple within two days after a medication change.5 A patient hospitalized for an acute illness or injury is likely to have had a recent and significant change in the medications he or she is taking, thereby at least temporarily increasing that individual’s risk for falling.
The environmental hazards of the hospital room can’t be overlooked when assessing a patient’s risk for falling. The patient is in an unfamiliar setting—often with informal restraints in place, including IV tubing, feeding tubes, pulse oximeters, and catheters. These obstacles make it more difficult for the patient to maneuver and present opportunities for tripping.
All these things—individually or combined—can increase the chances of falling, even for a patient who at first glance doesn’t appear to be at risk.
Stephen Shaw, MD, medical director of Community Hospitalists in Cleveland, says that while falls assessment tools can be helpful, it would be difficult to outline a foolproof assessment form.
The physician must keep in mind the fact that falls prevention is multifactorial; it may be difficult to attribute the patient’s fall(s) to any single reason. “Any vigorous falls assessment program has to have a comprehensive approach,” he cautions. “Medications, attention to vision limitations, and his or her ability to feel in the dark in their surroundings all have to be taken into consideration.”
The Hospitalist’s Role
When a patient is admitted for injuries resulting from a fall or from an illness that may have been diagnosed as a result of a fall, consider acute conditions first. Also remember that falling is a symptom; understanding why the patient fell is the first step to prevention—both while the patient remains in the hospital and following discharge.
One of the first things the hospitalist must do to reduce patient falls effectively is to study risk assessment and prevention of geriatric falls. A study published in the Journal of Hospital Medicine in January/February 2006 (“Is There a Geriatrician in the House? Geriatric Care Approaches in Hospitalist Programs”) identifies the need for collaboration between hospitalists and geriatricians to better address the issues specific to hospitalized older adults. This collaboration combines the geriatrician’s expertise regarding the elderly patient’s unique needs and considerations with the hospitalist’s expertise regarding specific acute care situations.6
Heidi Wald, MD, MPH, assistant professor, Division of Health Care Policy and Research and General Internal Medicine at the University of Colorado in Denver and primary author of the Journal of Hospital Medicine study, says numerous things can be done to reduce the risk of inpatient falls, beginning with identifying patients at high risk for falling. This can be done by assessing the classic risk factors intrinsic to the patient, while keeping in mind the risk factors that could be mediated by the acute illness.
Risks created by the environment can be fairly easily addressed, according to Dr. Wald. Lower beds as far as they will go, with the wheels locked. Don’t use upper and lower bedrails simultaneously (this reduces the chance of a patient being caught between the two). Cut down on the use of restraints—both formal and informal.
Because many falls result from patients trying to get to the bathroom, Dr. Wald advises scheduled toileting, with the staff regularly assisting the patient to the bathroom. If a patient cannot ambulate to the restroom independently, ensure that a urinal or a bedpan is nearby and readily accessible to the patient.
Dr. Wald also advises utilizing the expertise and skills of those clinicians most familiar with the patient: the nursing staff. The nurses who have daily contact with the patient are in the best position to provide information regarding changes in the patient’s mental status, ability to ambulate, response to medications, compliance, and other factors that may increase the risk for a fall.
“The bottom line of any quality initiative will often fall to the nurses’ assessment,” says Dr. Shaw. “The front-line caregivers for fall assessments are our nurses.”
A Multidisciplinary Approach to Prevention
Drs. Wald and Shaw both stress the importance of a multidisciplinary approach to prevention of falls (both in hospital and following discharge). A patient who has already fallen—or one identified to be at risk for falling—can be offered a great deal of support and guidance pending discharge. And discharge planning can begin literally at admission.
It’s Dr. Shaw’s practice with at-risk patients to involve physical and occupational therapy (as well as social workers) in the patient’s care right from the beginning. Those individuals are then in a position not only to perform a thorough assessment of the patient but also to begin working on ways to reduce the patient’s risk following discharge. As Dr. Shaw points out, the hospitalist has access to resources the patient’s primary-care physician generally does not, and those resources should be utilized to full advantage.
Physical therapy can offer rehabilitative interventions, including transfer, gait, and balance training; strength and range-of-motion exercises; and habituation exercises for vestibular problems. Occupational therapy can offer the patient instruction on simplifying tasks and on performing everyday activities safely. Social workers can assist the patient with finding educational and assistive resources. All disciplines can be involved in home safety evaluations, patient and family education, and the procurement of assistive and adaptive equipment, such as ambulation devices, grab bars, handrails, raised toilet seats, and so on.
When all of these healthcare providers are involved in the patient’s care from the beginning and can coordinate discharge planning as a team, a more well-rounded and comprehensive plan for prevention of falls can be formulated. This team approach also offers a more accurate view of whether the patient is capable of returning home with or without help or if placement in a rehabilitation or long-term care facility may be more appropriate.
Involve the Patient
Once an at-risk patient has been identified, communicate that risk to everyone involved with the patient’s care, including the medical staff, the family, and the patient. “Patients have a certain degree of risk-taking behavior, and they won’t necessarily ask for help,” says Dr. Wald. “Part of that is that they’re not willing to admit that they need help.”
Patients need to be reminded that they are or have recently been sick—that’s why they’re in the hospital in the first place. She says patients and caregivers must be attuned to the fact that as patients begin to feel better and stronger and become more mobile, their risk for falling will go up before it starts to come down.
If a patient remains resistant to asking for or accepting assistance, Dr. Wald suggests finding out what the patient’s barriers are and trying to get around them. “Try to get people to admit that they have a problem,” she advises. “A lot of times, the barriers aren’t rational, so rationalizing isn’t always effective.”
She offers the example of a patient who resists the idea of using a walker. Sometimes simply demonstrating how much more quickly the patient can get around using the walker may do the trick.
Dr. Shaw adds that a certain level of sensitivity is required when approaching a patient who is in denial regarding his or her limitations. It may be necessary to ask a second physician or nurse to lend credibility by explaining to the patient again that he or she may have needs that didn’t exist previously. He cautions, however, that if his patient remains in denial about his or her limitations, he does not hesitate to engage the family. “If the patient is discharged home, it’s going to be the family who will be the policemen and watchdogs,” says Dr. Shaw.
After discharge, following up with the patient can make a big difference in patient compliance. The time following discharge to the home can be confusing for the patient, and he may be overwhelmed with changes in routines, medications, and activities. Dr. Shaw’s organization calls the patient three to four days post-discharge to verify that the patient understands the discharge instructions, to answer questions the patient may have, and to confirm that prescriptions have been filled and that follow-up appointments have been made with the primary-care physician. He notes that although this simple follow-up phone call takes little time and effort, it has improved patient satisfaction immensely.
Quality and Prevention Initiatives
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2007 National Patient Safety Goals for hospitals includes the following goal: “Reduce the risk of patient harm resulting from falls” (Goal 9).
The requirement for this goal is the implementation of a fall reduction program, followed by evaluation of the effectiveness of the program. Drs. Wald and Shaw agree that, because of the nature of what they do, hospitalists are in an ideal position to spearhead the movement to assess the reasons a patient may have fallen and the risk for future falls—both in the hospital and following discharge—and to synthesize that data to create comprehensive falls prevention programs in their hospitals.
Because hospitalists are on-site 24 hours a day, seven days a week, they are usually first responders when a patient falls and can best evaluate the reasons for the fall and track outcomes. “We’re in an ideal position to create protocols for what to do once a patient does fall in the hospital and [to] evaluate the fall and the incident,” Dr. Wald says. “This is a great quality improvement project because the data are already being collected.”
Dr. Shaw concurs. “Hospitalists are the quality assessors that are in the trenches,” she says. “The hospitalists are really the clinicians most familiar with the strengths and weaknesses of any institution.” TH
Sheri Polley is a medical journalist based in Pennsylvania.
References
- Centers for Disease Control and Prevention. Falls among older adults: an overview. CDC Web site. Available at: www.cdc.gov/ncipc/factsheets/adultfalls.htm. Last accessed March 13, 2007.
- Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001 Jan;50(1):116-119.
- Oliver D, Daly F, Martin FC, et al. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing. 2004 Mar;33(2):122-130.
- Nnodim JO, Alexander NB. Assessing falls in older adults: a comprehensive fall evaluation to reduce fall risk in older adults. Geriatrics. 2005 Oct;60(10):24-28.
- Centers for Disease Control and Prevention. CDC fall prevention activities: research studies. CDC Web site. Available at: www.cdc.gov/ncipc/duip/FallsPreventionActivity.htm. Last accessed March 13, 2007.
- Wald H, Huddleston J, Kramer A. Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs. J Hosp Med. 2006 Jan;1(1):29-35.
The problem of falls among older adults has been recognized and studied for many years, including myriad analyses regarding assessment and prevention of falls in this population. The U.S. Census Bureau reported that there were 35.9 million people age 65 and over in the United States as of July 1, 2003. As this population increases, the specific issues pertaining to its members, including falls, must be addressed by hospitalists.
How Big Is the Problem?
The Center for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control reports that:
- More than one-third of adults 65 and older fall each year in the United States;
- Falls are the leading cause of injury deaths for older adults;
- In 2003, about 1.8 million people 65 and older were treated in emergency departments for nonfatal falls, and about 460,000 of these patients were hospitalized;
- The rates of fall-related deaths among older adults rose significantly over the past decade;
- Many individuals who fall develop a fear of falling. That may cause them to limit activity, leading to reduced mobility and physical fitness and increasing their risk for additional falls; and
- In 2000, direct medical costs totaled $179 million for fatal falls and $19 billion for nonfatal fall injuries.1
One study exploring the relationship between the mechanism of fall and the pattern and severity of injury in geriatric patients compared with younger patients concluded that falls were the mechanism of injury in 48% of the older patients (those 65 and older) included in the study compared with 7% in the younger group. Further, 32% of falls in the older group resulted in serious injury, while this was true of only 4% of falls in the younger cohort.2
Risk Assessment
When an inpatient in an acute-care hospital falls, a number of negative outcomes can occur, including a longer hospital stay and higher rates of discharge to long-term care.
Falls are associated with higher levels of anxiety and depression and loss of confidence for the patient. They lead to increased costs for patients and hospitals. Feelings of anxiety and/or guilt among staff members may follow. Ultimately, a fall can result in complaints or even litigation from patients or their families.3
Traditional methods of fall risk evaluation may not be effective for assessing the risk of falling for a hospitalized patient, regardless of the reason the patient is hospitalized. The classic risk factors are generally well recognized among physicians and clinical staff and include:
- Age 65 and older;
- A history of falls;
- Cognitive impairment;
- Urinary/fecal incontinence/urgency;
- Balance problems, lower extremity weakness, arthritis;
- Vision problems;
- Use of more than four daily medications or use of psychotropics or narcotics; and
- ETOH.
Acute illness alone accounts for approximately 10% of falls in older adults.4 Many patients suffering or recovering from acute illness may go through a transient period of increased risk for falling that needs to be recognized by physicians and nursing staff.
The impact of pharmacology on a patient’s risk for falling is widely recognized. Patients who take four or more medications are generally considered to be at increased risk. Certain medications, including diuretics, anti-hypertensives, tricyclic antidepressants, sedatives, and hypoglycemics are known to increase an individual’s risk for falling. An October 2004 CDC-funded study by researchers at Johns Hopkins University (Baltimore) concluded that the short-term risk of single and recurring falls may triple within two days after a medication change.5 A patient hospitalized for an acute illness or injury is likely to have had a recent and significant change in the medications he or she is taking, thereby at least temporarily increasing that individual’s risk for falling.
The environmental hazards of the hospital room can’t be overlooked when assessing a patient’s risk for falling. The patient is in an unfamiliar setting—often with informal restraints in place, including IV tubing, feeding tubes, pulse oximeters, and catheters. These obstacles make it more difficult for the patient to maneuver and present opportunities for tripping.
All these things—individually or combined—can increase the chances of falling, even for a patient who at first glance doesn’t appear to be at risk.
Stephen Shaw, MD, medical director of Community Hospitalists in Cleveland, says that while falls assessment tools can be helpful, it would be difficult to outline a foolproof assessment form.
The physician must keep in mind the fact that falls prevention is multifactorial; it may be difficult to attribute the patient’s fall(s) to any single reason. “Any vigorous falls assessment program has to have a comprehensive approach,” he cautions. “Medications, attention to vision limitations, and his or her ability to feel in the dark in their surroundings all have to be taken into consideration.”
The Hospitalist’s Role
When a patient is admitted for injuries resulting from a fall or from an illness that may have been diagnosed as a result of a fall, consider acute conditions first. Also remember that falling is a symptom; understanding why the patient fell is the first step to prevention—both while the patient remains in the hospital and following discharge.
One of the first things the hospitalist must do to reduce patient falls effectively is to study risk assessment and prevention of geriatric falls. A study published in the Journal of Hospital Medicine in January/February 2006 (“Is There a Geriatrician in the House? Geriatric Care Approaches in Hospitalist Programs”) identifies the need for collaboration between hospitalists and geriatricians to better address the issues specific to hospitalized older adults. This collaboration combines the geriatrician’s expertise regarding the elderly patient’s unique needs and considerations with the hospitalist’s expertise regarding specific acute care situations.6
Heidi Wald, MD, MPH, assistant professor, Division of Health Care Policy and Research and General Internal Medicine at the University of Colorado in Denver and primary author of the Journal of Hospital Medicine study, says numerous things can be done to reduce the risk of inpatient falls, beginning with identifying patients at high risk for falling. This can be done by assessing the classic risk factors intrinsic to the patient, while keeping in mind the risk factors that could be mediated by the acute illness.
Risks created by the environment can be fairly easily addressed, according to Dr. Wald. Lower beds as far as they will go, with the wheels locked. Don’t use upper and lower bedrails simultaneously (this reduces the chance of a patient being caught between the two). Cut down on the use of restraints—both formal and informal.
Because many falls result from patients trying to get to the bathroom, Dr. Wald advises scheduled toileting, with the staff regularly assisting the patient to the bathroom. If a patient cannot ambulate to the restroom independently, ensure that a urinal or a bedpan is nearby and readily accessible to the patient.
Dr. Wald also advises utilizing the expertise and skills of those clinicians most familiar with the patient: the nursing staff. The nurses who have daily contact with the patient are in the best position to provide information regarding changes in the patient’s mental status, ability to ambulate, response to medications, compliance, and other factors that may increase the risk for a fall.
“The bottom line of any quality initiative will often fall to the nurses’ assessment,” says Dr. Shaw. “The front-line caregivers for fall assessments are our nurses.”
A Multidisciplinary Approach to Prevention
Drs. Wald and Shaw both stress the importance of a multidisciplinary approach to prevention of falls (both in hospital and following discharge). A patient who has already fallen—or one identified to be at risk for falling—can be offered a great deal of support and guidance pending discharge. And discharge planning can begin literally at admission.
It’s Dr. Shaw’s practice with at-risk patients to involve physical and occupational therapy (as well as social workers) in the patient’s care right from the beginning. Those individuals are then in a position not only to perform a thorough assessment of the patient but also to begin working on ways to reduce the patient’s risk following discharge. As Dr. Shaw points out, the hospitalist has access to resources the patient’s primary-care physician generally does not, and those resources should be utilized to full advantage.
Physical therapy can offer rehabilitative interventions, including transfer, gait, and balance training; strength and range-of-motion exercises; and habituation exercises for vestibular problems. Occupational therapy can offer the patient instruction on simplifying tasks and on performing everyday activities safely. Social workers can assist the patient with finding educational and assistive resources. All disciplines can be involved in home safety evaluations, patient and family education, and the procurement of assistive and adaptive equipment, such as ambulation devices, grab bars, handrails, raised toilet seats, and so on.
When all of these healthcare providers are involved in the patient’s care from the beginning and can coordinate discharge planning as a team, a more well-rounded and comprehensive plan for prevention of falls can be formulated. This team approach also offers a more accurate view of whether the patient is capable of returning home with or without help or if placement in a rehabilitation or long-term care facility may be more appropriate.
Involve the Patient
Once an at-risk patient has been identified, communicate that risk to everyone involved with the patient’s care, including the medical staff, the family, and the patient. “Patients have a certain degree of risk-taking behavior, and they won’t necessarily ask for help,” says Dr. Wald. “Part of that is that they’re not willing to admit that they need help.”
Patients need to be reminded that they are or have recently been sick—that’s why they’re in the hospital in the first place. She says patients and caregivers must be attuned to the fact that as patients begin to feel better and stronger and become more mobile, their risk for falling will go up before it starts to come down.
If a patient remains resistant to asking for or accepting assistance, Dr. Wald suggests finding out what the patient’s barriers are and trying to get around them. “Try to get people to admit that they have a problem,” she advises. “A lot of times, the barriers aren’t rational, so rationalizing isn’t always effective.”
She offers the example of a patient who resists the idea of using a walker. Sometimes simply demonstrating how much more quickly the patient can get around using the walker may do the trick.
Dr. Shaw adds that a certain level of sensitivity is required when approaching a patient who is in denial regarding his or her limitations. It may be necessary to ask a second physician or nurse to lend credibility by explaining to the patient again that he or she may have needs that didn’t exist previously. He cautions, however, that if his patient remains in denial about his or her limitations, he does not hesitate to engage the family. “If the patient is discharged home, it’s going to be the family who will be the policemen and watchdogs,” says Dr. Shaw.
After discharge, following up with the patient can make a big difference in patient compliance. The time following discharge to the home can be confusing for the patient, and he may be overwhelmed with changes in routines, medications, and activities. Dr. Shaw’s organization calls the patient three to four days post-discharge to verify that the patient understands the discharge instructions, to answer questions the patient may have, and to confirm that prescriptions have been filled and that follow-up appointments have been made with the primary-care physician. He notes that although this simple follow-up phone call takes little time and effort, it has improved patient satisfaction immensely.
Quality and Prevention Initiatives
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2007 National Patient Safety Goals for hospitals includes the following goal: “Reduce the risk of patient harm resulting from falls” (Goal 9).
The requirement for this goal is the implementation of a fall reduction program, followed by evaluation of the effectiveness of the program. Drs. Wald and Shaw agree that, because of the nature of what they do, hospitalists are in an ideal position to spearhead the movement to assess the reasons a patient may have fallen and the risk for future falls—both in the hospital and following discharge—and to synthesize that data to create comprehensive falls prevention programs in their hospitals.
Because hospitalists are on-site 24 hours a day, seven days a week, they are usually first responders when a patient falls and can best evaluate the reasons for the fall and track outcomes. “We’re in an ideal position to create protocols for what to do once a patient does fall in the hospital and [to] evaluate the fall and the incident,” Dr. Wald says. “This is a great quality improvement project because the data are already being collected.”
Dr. Shaw concurs. “Hospitalists are the quality assessors that are in the trenches,” she says. “The hospitalists are really the clinicians most familiar with the strengths and weaknesses of any institution.” TH
Sheri Polley is a medical journalist based in Pennsylvania.
References
- Centers for Disease Control and Prevention. Falls among older adults: an overview. CDC Web site. Available at: www.cdc.gov/ncipc/factsheets/adultfalls.htm. Last accessed March 13, 2007.
- Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001 Jan;50(1):116-119.
- Oliver D, Daly F, Martin FC, et al. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing. 2004 Mar;33(2):122-130.
- Nnodim JO, Alexander NB. Assessing falls in older adults: a comprehensive fall evaluation to reduce fall risk in older adults. Geriatrics. 2005 Oct;60(10):24-28.
- Centers for Disease Control and Prevention. CDC fall prevention activities: research studies. CDC Web site. Available at: www.cdc.gov/ncipc/duip/FallsPreventionActivity.htm. Last accessed March 13, 2007.
- Wald H, Huddleston J, Kramer A. Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs. J Hosp Med. 2006 Jan;1(1):29-35.