Prevention of hospital-induced delirium was an important part of my job responsibilities in the last 10 years of my career in elder services. I understood the risk factors and was familiar with the nonpharmacologic interventions one can use with a hospitalized elder to prevent or alleviate delirium.
Then, in November 2018, I found myself to be that hospitalized elder. I spent five days in the ICU and three days in a cardiac step-down unit following a convergent hybrid cardiac ablation and a left atrial appendage occlusion.
I knew that delirium is common in the ICU and is often associated with poor outcomes. Prior to hospitalization, I expected to spend only one day in the ICU; when I realized I would be there for a few days, I decided to create my own “care plan” to stave off delirium and its adverse outcomes.
On the plus side, I was one of the healthier patients in the ICU; I was not intubated and, although I felt a little hazy, I did not have chronic cognitive loss. But I did have several well-known risk factors for delirium:
- over 65 years of age
- recent anesthesia—my procedures were done on two consecutive days, thus twice the exposure
- in the ICU—its intense and disorienting atmosphere can contribute to confusion
- steroid—Schreiber and colleagues (Critical Care Medicine, 2014) found patients were 52% more likely to develop delirium if they had been treated with steroids the previous day, as I had
- low food intake—a combination of irritation from surgical intubation and a case of thrush made eating and swallowing difficult
My private rooms with large windows on both units gave me a good start, affording me the quiet needed for rest and the stimulation and time orientation provided by a view to the outside world. Each room also had a whiteboard that was updated on each shift. Delirium is a gradual disconnecting from reality—continual reminders, especially of people, place, and time, are essential to maintaining orientation.
Inouye and colleagues (Lancet, 2014) emphasize that patients in the ICU need cognitive stimulation and socialization. The intervention can be any activity that keeps the mind active, even a simple conversation. I had several visits from family daily.
I decided to focus on creating lists in my mind. I repeatedly reviewed the names and birth dates of my 25 grandchildren—a significant mental challenge that reminded me how truly blessed I am. I also tried to remember the names of classmates in the two small elementary schools I attended in the 1950s.
There were two very stressful nights in the ICU. Every time I closed my eyes, I felt like I couldn't breathe. My nerves felt like overly taut violin strings that were vibrating out of control. In the end, it wasn't medication that calmed me down; it was a caring nurse who took the time each night to talk me through these dark moments.
Nurses are incredibly busy, but the following are some practical strategies they can use to prevent delirium in the ICU, particularly with older patients:
- Extend a conversation beyond “What is your full name and date of birth?” Stopping to engage the patient in a meaningful way, even briefly, can provide a crucial sense of orientation.
- Ensure the whiteboard is updated in large print with day, date, year, and names of care providers.
- Check that the patient has glasses and hearing aids. It is difficult to remain engaged if one can't see or hear properly.
- Watch for subtle changes in cognition and behavior. Family members can be invaluable partners in this endeavor.
The word “delirium” comes from the Latin, meaning “off the plowed track.” This implies that one can be guided to stay on the track or to get back on track. You could be that compassionate guide.