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Clinical Consultation: Delirium: A Critical Diagnosis for Every Member of the Rehabilitation Team
During the course of rehabilitation, a 78-year-old man presented with immobilization and deconditioning that began 15 days after surgery for a left-sided total hip arthroplasty. His relatives also revealed that he had suffered a severe depressive mood, including fear of falling, within the past 3–4 days. Episodes of agitation, sleep disturbance, decreased attention, confusion, and hallucinations, especially at night, were also present. Accordingly, his rehabilitation process had been affected unfavorably. The medical history was otherwise unremarkable.
Results from a cognitive evaluation of the patient (during the day) were normal except for disorientation in regard to time. Physical examination revealed painful and limited movement of the left hip joint. His neurological evaluation was unremarkable. Laboratory evaluations—including a complete blood count and liver and renal function tests; erythrocyte sedimentation rate; urine analysis; and urine, blood, and gaita cultures—were all normal. Overall, the patient was diagnosed as having delirium. After reassuring the patient and relatives about the diagnosis, the physician began treatment with trazodone HCL 50 mg/day and recommended modifying the room to provide sufficient day-night lighting, installing a calendar and clock to help the patient be aware of time, having family photographs available to the patient for personal orientation, and removing extra objects from the room to decrease disturbing sensory input. On the seventh day of the control visit, the patient was observed to improve significantly (with increased voluntary participation during rehabilitation and decreased agitation). On day 35 of his hospital stay after complete recovery, the patient was discharged. He could ambulate independently by using a walker and trazodone treatment was stopped.
Delirium (acute confusional state) is a mental disorder with acute onset, altered consciousness, fluctuating disease course, and disturbances in cognition with decreased ability to maintain attention. Although it is the most common complication among hospitalized elderly people, especially following a major operation, 84%–95% of cases are generally overlooked by health professionals (American Psychiatric Association, 2000; Thomas et al., 1988). Although this may be related to the physician’s lack of familiarity with delirium (Gustafson et al., 1998), it may also be due to the variability of symptoms as well as the concomitance of etiologic factors further challenging the scenario.
Various assessment tools can help confirm the diagnosis of delirium. For example, the Confusion Assessment Method for Intensive Care Unit is an instrument that is a brief and easy-to-use evaluation for both physicians and nurses (McNicoll et al., 2005). Four individual features are assessed: (a) change in baseline mental status or fluctuation in the past 24 hours, (b) inattention, (c) disorganized thinking, and (d) altered level of consciousness. Delirium is present when both features a and b or either feature c or d are positive (Truman & Ely, 2003). In addition, complete history taking, physical examination, laboratory evaluation (for metabolic causes), infection work-up, and review of the medication list are important for diagnosis and management (Robinson & Eiseman, 2008). Delirium is commonly misdiagnosed as depression, dementia, and the physiological aging process, but can be distinguished from these disorders by the short onset of its signs (especially attention and confusion)—typically a period of hours or days—and their variability throughout the day (Torpy, Burke, & Glass, 2008).
The management of delirium requires optimizing both preventive measures and pharmacologic treatment. Specific interventions that have been shown to reduce delirium include orientation to the surroundings and care team members, uninterrupted nighttime sleep, early mobilization, and optimum vision and hearing. These protocols have been shown to reduce the incidence, duration, and total episodes of delirium (Inouye et al., 1999). Regarding prognosis, several studies have found associations between delirium and poor prognosis for functional recovery, increased mortality, increased length of hospital stay, increased institutionalization following discharge, and increased incidence of dementia (Dolan et al., 2000; Lundström, Edlunds, Bucht, Karlsson, & Gustafson, 2003; Marcantonio, Flacker, Michaels, & Resnik, 2000; Torpy et al., 2008).
In our case, the patient had impaired attention and disorganized thinking along with agitation and altered level of consciousness. In addition, major surgery, immobilization, and possibly insufficient pain management were predisposing factors. Certainly, delirium affected the rehabilitation process unfavorably. Therefore, during treatment, we explained to the patient’s relatives that the self-perpetuating cycle of immobilization-delirium needed to be broken (i.e., room and lighting modifications) and recommended trazodone for sleep hygiene. As members of the rehabilitation team, nurses play an important role during a patient’s stay in the hospital because close contact with the patient and the family is of paramount importance.
By highlighting the favorable outcomes that can be achieved with prompt management (Beresin, 1988; American Psychiatric Association, 1999), we are able to remind all members of the multidisciplinary rehabilitation team of the importance of being aware of delirium, particularly for elderly patients, to avoid the types of complications encountered in this case and to ensure that patients quickly regain functionality during rehabilitation.
About the Authors
Levent Tekin, MD, is an assistant professor in the department of physical medicine and rehabilitation at Gülhane Military Medical Academy HaydarpaÅŸa Training Hospital in Istanbul, Turkey.
Levent Özçakar, MD, is an associate professor at Hacettepe University Medical School, department of physical medicine and rehabilitation in Ankara, Turkey, and at Gülhane Military Medical Academy HaydarpaÅŸa Training Hospital, department of physical medicine and rehabilitation in Istanbul, Turkey. Address correspondence to him at email@example.com.
Ahmet Turan Isik, MD, is an associate professor at Gülhane Military Medical Academy, department of internal medicine, division of geriatrics in Ankara, Turkey.
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