The Dilemma of Delirium in Older Patients
Ill and hospitalized older people sometimes experience episodes of delirium, confusion, and disorientation. Often considered a transient and reversible condition, delirium in older people is still viewed by many to be a normal consequence of surgery, chronic disease, or infections.
There is mounting evidence, however, that delirium may be associated with increased risk for dementia and may contribute to morbidity and death. A recent study of 553 patients (85 years and older) found that those with a history of delirium had an 8-fold increase in the risk for developing dementia.1 The researchers also found that among the participants with dementia, delirium was associated with an acceleration of dementia severity, loss of independent functioning, and higher mortality. These findings showed that delirium is a strong risk factor for dementia and cognitive decline in the oldest patients.
Growing Momentum, Awareness
At the National Institute of Aging (NIA), and throughout the geriatric research community, momentum is building to better understand the mechanisms involved in delirium and to improve ways to recognize and treat the condition.NIA supports several clinical trials focused on finding effective drugs and protocols to prevent or reduce the impact of delirium in hospitalized older people. The goal is to identify a variety of interventions that reduce delirium for patients receiving intensive care, including the testing of supplements, pain medications, and sedatives that may alleviate delirium in pre- and post-operative patients.
“The research and medical communities are becoming more aware and interested in the impact delirium may have on the long-term cognitive health of older patients,” said Molly Wagster, MD, Chief of the NIA’s Behavioral and Systems Neuroscience Branch. “At this stage, unfortunately, there are more questions than answers. In order to treat or prevent delirium, it will be important to determine why some older people are more susceptible to developing it during hospital stays or as a result of trauma or illness.”
Attitudes About Delirium Changing
Attitudes about delirium are slowly evolving among medical practitioners, noted Joseph Flaherty, MD, of the Division of Geriatrics at Saint Louis University, who is a leading member of American Delirium Society. “As a medical student 20 years ago, I was taught delirium was completely reversible. That’s simply not the case for many older patients,” he said. “Over the past 15 years, interest has grown in identifying ways not only to reverse the condition but to prevent it from occurring in the first place.”
Dr. Flaherty said that he applauds NIA funding of delirium drug trials, but he also suggested that changes in nursing and hospital protocols today could help prevent the onset and/or reduce the severity of delirium. “Changing the hospital environment and culture to match [the needs of] the older patients with delirium or at risk for delirium is critical,” Dr. Flaherty said.
Examples of such changes include allowing hospitalized older people to sleep undisturbed between 10 p.m. and 6 a.m. so that their normal sleep cycle is less disrupted, not using physical restraints, and giving staff concrete nonpharmacologic methods to deal with agitation that may occur with delirium.2
“There are very promising, nonpharmacological methods being tested that may enable hospitals and nursing facilities to prevent, treat, and manage delirium,” he said. “For example, the new standard in ICUs is to get patients up and out of their beds within 1 to 2 days, even if they are connected to a ventilator. This reduces the number of days with delirium and time spent in intensive care.”
Dr. Flaherty said these new methods also might improve the odds that patients regain normal cognitive and physical function.3
Is the Brain Hard-Wired for Chronic Pain?
A new study has identified a potential anatomical marker for predicting who will develop chronic pain. White matter structural anomalies were discovered in the area of the brain connecting the nucleus accumbens and the medial prefrontal cortex, two areas thought to be involved with pain. The study suggests that “the structure of a person’s brain may predispose one to chronic pain,” noted Vania Apkarian, PhD, a senior author of the study, which was recently published in Pain.4 These concepts might lead to better ways to diagnose and treat chronic pain.
Dr. Apkarian and researchers at Northwestern University Feinberg School of Medicine, Chicago, conducted a study of 24 people who had recently been diagnosed with low back pain (3 months duration). The investigators conducted brain scans using a technique called diffusion tensor imaging (DTI), physical examinations, and questionnaires quarterly over the course of one year. About half of the subjects recovered at some time during the year-long study, while the other half developed chronic pain, which the researchers categorized as “persistent.”
To test the diagnostic value of the scan, the researchers asked whether the white matter differences they saw during the initial brain scans predicted whether the subjects would recover or continue to experience pain. The DTI scans were highly effective in predicting whether a patient will suffer from chronic low back pain, noted the researchers. “There was a consistent difference in white matter between the subjects who recovered and the subjects who experiences pain throughout the year,” wrote Dr. Apkarian. The team also found that the white matter of subjects who had persistent pain looked similar to patients’ known to suffer from chronic pain. They found white matter brain scans predicated at least 80% of the outcomes.
“We were surprised how robust the results were and amazed at how well the brain scans predicted persistence of low back pain,” noted Dr. Apkarian. “Prediction is the name of the game for treating chronic pain.”
The study was supported by a grant from the National Institute of Neurological Disorders and Stroke, a wing of the National Institutes of Health.
Opioid Use After Spine and Bariatric Surgery Examined
Two new studies raise concerns about the increased use of opioids long-term following surgery. Both studies found that opioid use was common up to 1 year after both spine surgery and bariatric surgery.
In the first study, researchers from the Medical College of Wisconsin reviewed data from 172 patients who underwent elective surgery for repair of the cervical spine. The investigators found that 55 patients (32%) were using opioid a year after surgery, noted Marjorie Wang, MD, MPH, who presented the team’s findings at the North American Spine Society Meeting, held in New Orleans.
The results surprised the researchers, who found that more than 70% of patients reported being satisfied with the result of their surgery. When the authors compared pre- and post-surgical use of opioids, they found that 51% of patients who were prescribed opioids prior to surgery were still taking the medications 1 year later. Moreover, among non-users prior to surgery, 18% were using opioids at the end of the study period.