Hospitalization increases chances of poor outcomes in Alzheimer’s patients
■ Physicians should work to decrease risks of dementia by providing a sense of time and ample sleep, and encouraging family involvement, a new study says.
Staying in a hospital can be a difficult and unsettling experience for anybody, but it can be especially problematic for dementia patients — who have a harder time coping in unfamiliar surroundings.
Hospitalization of individuals with Alzheimer’s disease greatly increases their risk of adverse outcomes, such as institutionalization, mental decline or death, according to a June 19 Annals of Internal Medicine study. The risk is amplified for those who develop delirium during an inpatient stay. Knowing this, Alzheimer’s experts recommend that physicians try to keep people with the disease out of the hospital. When such patients are hospitalized, physicians should work with other medical staff to help keep patients oriented and avoid medications or procedures that can contribute to delirium.
“Hospitalization of people with Alzheimer’s has a lot of challenges that come with it,” said Sharon A. Brangman, MD, past president of the American Geriatrics Society. “You have a strange environment. You don’t feel well, and you have all of these different people coming at you with many different things.”
The risk of being hospitalized is three times greater for the 5.4 million Americans with the disease than for those without it. In a three-year period, up to two-thirds of individuals with the disease will end up as an inpatient, and nearly half are hospitalized two or more times, said Tamara G. Fong, MD, PhD, lead study author and assistant professor of neurology at Harvard Medical School in Boston.
In addition, the aging of the population means an increased incidence of the disease. The number of people with Alzheimer’s is projected to go from 5 million to 15 million in the next 30 to 40 years, said Ralph Nixon, MD, PhD, chair of the Alzheimer’s Assn.’s Medical and Scientific Advisory Council and professor at New York University School of Medicine.
“This is an underrecognized and underappreciated problem that is going to get much, much worse,” he said. “The number of people who are going to be in the hospital and have these kinds of adverse outcomes is going to increase.”
For the study, researchers reviewed 15 years of medical records for 771 Alzheimer’s patients. Of those, 367, or 48%, were hospitalized, and a quarter, or 194, developed delirium.
All patients who were hospitalized were more prone to institutionalization or death within one year of hospitalization, but the risk was greatest for those who also developed delirium, the study said.
“The evidence is pointing to the fact that delirium can be a very serious condition with significant consequences,” Dr. Fong said.
Creating familiarity in the hospital
Multiple factors can trigger delirium, including medications, immobilization, medical procedures, and the reasons behind hospitalization — such as an acute infection, Dr. Fong said.
The problems may be compounded by the fact that many people with Alzheimer’s can’t communicate well. Physicians and other health professionals should be aware of how best to approach Alzheimer’s patients and ways to diagnose and prevent delirium, said Dr. Brangman, professor and chief of geriatrics at State University of New York Upstate Medical University.
“We have a huge need to educate our health care work force,” she said.
For example, some things can be done to make sure the patient has a more peaceful environment, such as allowing them to sleep through the night, providing a sense of time, and ensuring that their basic needs are met.
“A person with Alzheimer’s may not be able to say they are hungry, have to go to the bathroom or are in pain,” Dr. Brangman said.
Physicians should be proactive about trying to create an environment that reduces the risks of delirium or disorientation for patients, Dr. Nixon said. Providing familiar objects like calendars and clocks can help keep patients oriented.
Some patients with Alzheimer’s may have additional challenges if they have decreased sensory perception. If patients require hearing aids or glasses, the physician should make sure they have those items, he said.
Physicians should speak without using a lot of medical jargon and encourage family and friends to stay and provide comfort to the individual whenever possible. They should assess the patient’s mental capabilities, and be sure to include them in discussions about their care if they are able to contribute, Dr. Brangman said.
Doctors also should minimize use of medications that might contribute to confusion, such as certain sedatives and anti-anxiety medications, Dr. Nixon said.
Dr. Fong said more research is needed to determine whether interventions to try to avoid hospitalizations or strategies to prevent delirium can reduce the risks of poor outcomes in these patients.
“Ultimately, we hope that the [study] findings can teach us how to provide better care for patients with AD,” she said. “If we can show that delirium prevention can delay cognitive decline and improve the outcomes for patients with AD, this may be a far more effective treatment than the current drug treatments that are available.”