Hospital-acquired delirium is a common problem, often not diagnosed or treated, and it's costing the nation billions of dollars in critical care and untold billions more for post-acute care.
Delirium affects up to 80 percent of intensive care unit patients older than 70, says Wesley Ely, M.D. By comparison, it impacts 10 to 15 percent of patients on medical-surgical floors. The cause of delirium is unclear, but doctors think patients sedated and on ventilators—as many are in the ICU—are particularly susceptible to the condition.
Delirium is one of the most potent predictors of length of stay and recovery time in the ICU, says Ely, a critical care specialist who founded the ICU Delirium and Cognitive Impairment Study Group at Vanderbilt University Medical Center, Nashville, Tenn. (www.icudelirium.org).
Studies show that delirium patients have hospital stays five to 10 days longer than other patients, and they're much more likely to die within six months of discharge.
"It's a huge, huge cost issue—an enormous public health problem that costs billions of critical care dollars every year," Ely says. He pegs the cost at between $3 billion and $15 billion, but adds, "that's probably a gross underestimate."
Costs don't stop at the hospital discharge door either, says Ivor Douglas, director of the medical intensive care unit at Denver Health Medical Center, one of the country's largest integrated public health systems. With 75 percent of elderly patients discharged to nursing homes, more is spent on temporary or permanent sub-acute care, he says.
"It's one thing to get someone through a severe acute illness in a hospital," Douglas says, "but for a health system with a public mission like ours, we can't just wave those people goodbye and they become somebody else's problem. We still see them."
Douglas says treatment of delirium has been scattershot at best. That's unfortunate, he says, since simple diagnostic tools quickly can spot the condition. Some assessment tools used by nurses can spot delirium in as few as 30 seconds.
"We need to look at this differently and think of it as an acute brain dysfunction," he says. "Our approach should be the same as if we had acute heart or lung failure."
Douglas and Ely are among a group of collaborators at 17 research centers around the country waiting to hear on National Institute of Health funding for a clinical study of hospital-associated delirium. They plan to approach legislators and the Centers for Medicare & Medicaid Services about Medicare reimbursing cognitive rehabilitation services, just as it now pays for cardiac or orthopedic rehab.
"This problem is only going to grow and we need to do something," Douglas says. "It's not something abstract. It's about real people—a group of people who already are our biggest responsibility."
Testing for Delirium
Clinicians can use several tools to detect and monitor delirium in the ICU. Two of the most recognized are Confusion Assessment Method for the ICU, or CAM-ICU, and Intensive Care Delirium Screening Checklist.
•ICDSC is an eight-item checklist that is tracked over the length of the ICU stay to assess delirium and monitor for changes. Conditions such as disorientation, patient alertness, hallucination and inappropriate speech are scored 1 or 0. A score of four or more indicates delirium.
•CAM-ICU comprises a handful of questions to ask the patient and can be performed at the bedside in less than two minutes. One question assesses changes in mental status from the patient's baseline. Another determines the ability to concentrate by asking the patient to squeeze the clinician's hand each time he or she hears the letter "A" when the following 10 letters are read: SAVEAHAART. A third question spots disorganized thinking by asking the patient such questions as whether a stone floats on water.
More information can be found at the Vanderbilt University Medical Center delirium website, www.icudelirium.org/assessment.html.