Helping to Prevent One Patient's Delirium Experience

"We know delirium is very important to prevent because of how impactful an experience it is on people."

June 28, 2018
by Sandra Gordon for ASA

“The hospital is on fire!”

Several years ago, Karin Neufeld, M.D., M.P.H., clinical director of psychiatry at Johns Hopkins Bayview, a state-of-the-art medical center on a 130-acre suburban campus in eastern Baltimore, received a distressing phone call from the husband of a good friend. For privacy purposes, we’ll call the friend Joan Doe. Joan’s husband was calling, desperate for Neufeld’s guidance.

Joan, a seasoned and experienced academic who was in her late 70s, had just had surgery for spinal stenosis. “It was relatively brief surgery and she came out of it looking quite well,” Neufeld says. But that night, when Joan was back on the inpatient unit, she began frantically trying to get the nurses’ attention and calling her husband and adult children at their homes. Joan couldn’t smell smoke or see flames, but she was convinced the hospital was on fire and that she and everyone would perish if they didn’t evacuate, Neufeld says. “I don’t know what to do,” Joan’s husband had said.

Fortunately, in the days following her surgery, Joan gradually began to improve and was soon discharged. But she was still quite fearful about what had happened to her. “She said it was the most terrifying experience of her life,” Neufeld says.

Nine months later, Joan required surgery again for an unrelated condition. She worried that her delirium would recur. “We worked with her anesthesiologist and tried to minimize all the things that might be associated with producing delirium as much as possible,” Neufeld says, including:

  • Reducing or avoiding drugs that increase the incidence of delirium during surgery.
  • Trying nonpharmacological approaches for delirium prevention. For example, Joan’s daughter was allowed to stay with her overnight so she could help reorient her mother in the hospital during recovery.
  • Getting Joan up and moving around early on after surgery. “It’s very important for brain function,” Neufeld says.
  • Regulating Joan’s sleep-wake cycle by minimizing daytime napping. At night, Joan’s room was dark and quiet, with minimal interruptions, to promote sleep.

The results? “Joan didn’t have any problems with delirium after her second surgical experience. She came out of the O.R., I saw her and she was completely oriented and attentive and knew exactly what had happened,” Neufeld says. In fact, in the past seven years since her first and only postsurgical experience with delirium, Joan has continued working and hasn’t had any problems with delirium or long-term cognitive issues. Joan is well into her 80s now and received several professional awards because of her lifelong accomplishments. She has no evidence of dementia.

“We can’t be certain what prevented her delirium, but we know that it is very important to prevent because of how impactful an experience it is on people, just as her case illustrates,” Neufeld says. “People don’t want to be confused for any period of time.”

Preventing postoperative delirium may also help preserve cognition. “We know from literature that the more episodes of delirium people have, the more likely delirium can make somebody’s overall cognition worse,” Neufeld says. Overall, preventing delirium takes a multidisciplinary approach. “Collaborations are really important, getting people together to see the importance of it,” Neufeld says. But the payoff is comprehensive. “We’re continuing to investigate and understand delirium. But we know that all the things we need to do prevent delirium are good care indicators. When people start caring about delirium and teams start working towards its reduction, care really improves.”

Read on for more about what teams at Johns Hopkins Bayview are doing to prevent postoperative delirium.

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