How to better treat delirium in hospitals: A Q&A with expert Dr Valerie Page

Dr Valerie Page

Seriously ill patients can suffer extreme confusion, or delirium, which predicts slower recovery, long-term memory problems, and early death.

One in ten hospital patients experience delirium. Much more common in the elderly and critically ill patients in intensive care units (ICU), the confusion is distressing and often accompanied by frightening hallucinations, distorted reality, and paranoia.

Patients may develop delirium as a result of their illness, or from problems that develop in hospital or from the treatment. In fact, surgery, infection, or similar trauma, are major risk factors for delirium, as are drugs commonly used in ICUs, such as sedatives.

Dr Valerie Page from the Department of Surgery and Cancer at Imperial College London, and critical care consultant at West Hertfordshire Hospitals NHS Trust, studies delirium and explores potential avenues of treatment and prevention for those at risk.

Caroline Brogan interviewed Dr Page about her recent work.

Why is it so important to prevent and treat delirium?

Delirium is very common in patients admitted to ICUs, as they are generally critically ill and therefore undergo treatments that increase the chance of delirium, such as surgery.

People who suffer delirium typically have worse outcomes and take longer to recover from their conditions, and patients stay longer on ventilators and in hospital. Patients are often left with long-term cognitive impairment, which is similar to a mild dementia that they often don’t recover from, regardless of age.

How do we usually treat delirium?

Unfortunately, all the drugs we currently use to treat delirium can in fact make the condition worse. We therefore try to treat specific symptoms. For example, we may give antipsychotics such as haloperidol to a patient who is agitated because of hallucinations and delusions, to keep them safe. Other clinicians use tranquilisers or sedative drugs, but the downside to this is that they can often make the confusion worse.

Can you take me through your recent research?

My research group recently proposed that statins, commonly used to lower cholesterol levels, might help to reduce delirium.

We already know that inflammation in the brain contributes to delirium, and we know that statins reduce inflammation and can indeed cross into the brain via the bloodstream. With this in mind, we proposed for the first time that statins might help to reduce the length or severity of the syndrome.

We assigned 142 critically ill hospital patients with delirium to receive either the statin, simvastatin, or placebo at Watford General Hospital.

We found that during treatment, the group receiving statins spent the same amount of time in delirium or coma, with the same severity of symptoms, as the placebo group. We concluded from this that statins have no positive effect on delirium or associated coma.

Based on these findings, amongst others, it seems that best way to help patients is by preventing delirium in the first place, and to work with medics and families to help reduce confusion and disorientation.

How can you prevent delirium before it occurs?

Prevention is better than cure, and fortunately we know the risk factors for delirium and can therefore target those at risk. These include those who are older, in ICU, or have certain infections, as well as other conditions such as early dementia and immobility.

The main way to offset the risk is to encourage movement, even for patients on ventilators. This can include anything from helping patients to move their limbs, to going for a gentle walk. More active ways to prevent delirium include getting the patient out of bed early in the morning, and installing bicycles that can be used in bed.

Maintaining routine and reducing disorientation also helps. This means that we ensure patients have eyeglasses and hearing aids, and are able to see a clock from their bed. Leaving patients to sleep at night also helps, so we discourage too many nursing interventions during this time. We do, however, suggest using low lighting to reduce disorientation when waking at night.

It’s also important to identify and treat any physiological causes, such as infection, very quickly, and to make sure patients are not on any unnecessary medications that could cause or worsen delirium.

How do you include families in caring for their loved one, and how does this help to reduce delirium?

The family support project, which has shown success in North America, reduces the distress felt by partners, family members, carers, and close friends of those affected. We find that easing their concerns ultimately helps patients.

We enable this change by educating family members about the patient’s illness and treatments, as well as by resolving misunderstandings, offering support, and encouraging open communication with doctors.

Including families in patient care reduces feelings of helplessness and improves morale. They often help with combing hair, bathing, applying hand cream, giving foot massages, and assisting with walking and other movements where possible.

Dr Page's family support project encourages more patient-family interaction

This approach has great potential to reduce patients’ agitation, meaning they would require less sedation and ultimately suffer less delirium.

What are the next steps for your work?

So far, we’ve only been able to see the family support project in action in North America, so I am keen to now test how feasible it would be to use it in the NHS.

We will also continue to study the effects of different drugs, for example sedatives, on delirium.

“Evaluation of early administration of simvastatin in the prevention and treatment of delirium in critically ill patients undergoing mechanical ventilation (MoDUS): a randomised, double-blind, placebo-controlled trial” by Dr Valerie J Page et al, published 19 July 2017 in The Lancet Respiratory Medicine.

Listen to a podcast interview between Dr Page and The Lancet Respiratory Medicine. 

Dr Page has also published a book on delirium in critical care.