When a nurse in the orthopedic unit asked her new post-operative patient where she was, the response had a pleasant ring: “I’m at a spa.”
But that answer sent the nurse straight to the phone. She called Kathleen Turner-Hubbard, MS, NP, and asked her to come to the D-ground unit. In a hurry.
A specialist in caring for elderly patients, Turner-Hubbard is a geriatric nurse practitioner trained to quickly spot the sudden changes in mental status that signal the onset of the sudden, severe confusion known as delirium. She knows the hospital “triggers” that can bring on fluctuations in behavior: blood loss during surgery, anesthesia, pain medications and anti-anxiety drugs, infections, dehydration, IV lines and catheters, as well as being immobilized for an extended period of time.
Turner-Hubbard also knows that some patients with delirium can become agitated, incoherent and combative, while other, so-called “pleasantly confused” patients—like the “spa” woman who had undergone a major orthopedic procedure—can appear lethargic and apathetic. “We look for patients who were fine yesterday, and suddenly, today, they don’t know where they are or what day it is.”
Nationwide, an estimated 30 percent of all hospitalized patients over age 65 develop delirium. In intensive care units, the percentage is closer to 80. But in spite of the prevalence of symptoms, delirium often isn’t recognized, or is mistaken for dementia. “And you can get delirium on top of being demented,” Turner-Hubbard explained. “You can have a little memory problem, and then you get a urinary tract infection and you’re really confused, especially if you’re 80.”
When she responded to the phone call from the orthopedic nursing unit, Turner-Hubbard learned that the 75-year-old patient had been successfully managing arthritic pain for years, taking only Tylenol. According to her friends, the woman had been alert and active before coming to Stanford Hospital & Clinics. But after surgery, they said, she’d starting having hallucinations, seeing people who weren’t in the room. Nor could they make any sense of what she was saying.
“She had narcotics on board for her pain, and her surgeon had also prescribed Ativan, a powerful benzodiazepine, for the anxiety he’d observed,” Turner-Hubbard said after reading the patient’s chart.
She called the surgeon and suggested that the Ativan was enough to “tip” the patient’s brain chemistry and bring on delirium. “So he took away the Ativan and cut back on her pain meds,” Turner-Hubbard said. “And when I went to see her the following morning, she was completely fine.” The woman was able to leave the hospital on the scheduled discharge day.
It was another successful case of delirium identified and treated quickly. “Delirium can persist, and you can have cognitive decline over time,” Turner-Hubbard added. “Which is why we want to get to them early.”
Turner-Hubbard was hired six months ago by the hospital’s Aging Adult Services to develop a “delirium project.” Guided by clinical psychologist Rita Ghatak, PhD, director of geriatric health services and Aging Adult Services, and working closely with medical director Yusra Hussain, MD, Turner-Hubbard is designing the project to help nurses identify patients with delirium and intervene on their behalf—say, by recognizing the drugs that can cause problems for elderly patients.