The page filled me with dread: “Your elderly patient is confused, getting out of bed, and threw her entire dinner tray at a nurse just now.” Because this morning my patient was polite and appropriate, the now-angry, dinner-splattered nurse means only one thing: delirium.
Delirium is one of the most difficult problems for hospitalists to manage, in part because our management of delirium is often learned on the fly during residency and early years of practice. This post-hoc approach toward delirium misses the most important aspect of treatment: Prevention.
Interventions like early mobilization, environmental interventions, careful oversight of drugs, hydration protocols, and reinforcing the day/night cycle are crucial. Unfortunately, few hospitals can provide these resources or the trained multidisciplinary team with geriatrics expertise to administer them. The result is that delirium occurs more frequently than it should, and hospitalists often face a patient who is a risk to themselves or others.
In this situation, antipsychotics (APs) are often prescribed. However, long term use of APs by elders is highly discouraged by many organizations, including the Society of Hospital Medicine, because of risks like cardiac events (e.g., QT prolongation), stroke, extrapyramidal symptoms, falls, somnolence, and increased mortality in older patients with dementia.
One unanswered question regarding the use of APs is whether starting the medications in the hospital results in long-term use. To answer this, we performed a retrospective study of 300 elderly hospitalized patients who were treated for the first time with APs during their hospitalization. Of these 300 patients, 10% died during that first hospitalization, and almost half (48%) remained on APs at discharge. We found that most of the prescriptions were to treat delirium ( J Hosp Med. 2014 Dec;9[12]:802-4. doi:10.1002/jhm.2277 ).
In a more recent study, we looked at outcomes for patients discharged from Baystate Medical Center (Springfield, Mass.) on APs. Within a year of discharge, 40% of these patients were readmitted at least once and approximately two-thirds were still taking the same APs on which they had been discharged ( J Hosp Med. 2016 Apr 6. doi: 10.1002/jhm.2585 ). Thus, if I start my patient described above (who threw the dinner tray) on an AP today, she is very likely to be readmitted the next year still taking that same medication. Starting an AP in the short term can lead to the very thing we have been warned against: long-term use of an AP in an elderly person.
Even more striking than the continuation rate was the incredibly high 1-year mortality rate. Of the 260 patients discharged from the original admission on an AP, one-third had died at the 1-year mark. This group of patients had a wide range of diagnoses, but nearly as many died as if they all had stage IV heart failure. Because most had an agitated delirium at the time of AP prescription, these findings suggest that onset of in-hospital delirium should trigger a closer examination of the patient’s current burden of illness, prognosis, functional and cognitive status, treatment options, and goals of care.
Prevention is key
Our study also supports the prevention of delirium as the most important strategy to improve patient outcomes. Since conducting this study, Baystate Medical Center has implemented an “ACE” (Acute Care for Elders) pilot project and will soon open a full ACE unit. This unit, which employs many of the behavioral interventions described above (early discharge planning, drug oversight, team-based care, early mobilization, optimizing vision and hearing, sleep-wake cycle preservation, and hydration) has resulted in declines in both delirium rates and use of APs. Use of restraints has been virtually eliminated.
Our ACE program was a combined effort between geriatrics, hospital medicine, nursing, pharmacy, and others, but hospitalists often lead acute care quality improvement (QI) initiatives, and are superbly positioned to champion programs like ACE, NICHE (Nurses Improving Care for Health System Elders), and HELP (Hospital Elder Life Program) to benefit this vulnerable population.
Some important questions about AP use remain unanswered. First, there is very limited clinical trial evidence that APs actually improve outcomes in patients with delirium. Second, our study fails to answer one all-important question: does long-term AP use increase mortality in elders? Prior studies are largely retrospective, and results have been mixed.
Our study highlights the difficulty of teasing apart the baseline risks of the patients, the risk of the medications themselves, and confounding variables. There may be an association between APs and death, but it is quite possible that patients who require APs are simply at higher risk of death independent of the drugs’ effect; this confounding by indication cannot be adjusted away.
This leaves hospitalists in a difficult position. At Baystate Medical Center, hospitalists have opted to focus on prevention, but when delirium occurs, some patients are still treated with APs. Clinicians reserve the medications for patients who are suffering and fail to respond to nonpharmacologic interventions or are a risk to themselves or others. Still, Baystate plans to reduce use even in this population by instituting behavioral response teams to devise nondrug care plans, and hospitalists are encouraged to avoid discharging patients on APs.
Finally, even though patients who require APs may lack a clear terminal diagnosis, we encourage clinicians to recognize that delirium should prompt a discussion of prognosis and clarification of values, goals, and realistic treatment options.
Dr. Loh is a fellow at the James Wilmot Cancer Center, University of Rochester (N.Y.) Medical Center. Dr. Brennan is chief of geriatrics and post-acute medicine at Baystate Medical Center, Springfield, Mass. Dr. Lagu is an academic hospitalist in the Center for Quality of Care Research at Baystate Medical Center.
