Older adults who experienced delirium in the emergency department (ED) followed by intense physical or occupational therapy had shorter subsequent periods of delirium, Vanderbilt researchers recently reported.
“Our finding was that older hospitalized patients who received more intense PT and OT had a shorter delirium duration. This finding is similar to what has been observed in ICU studies,” said Jin Ho Han, M.D., an associate professor of emergency medicine at Vanderbilt University Medical Center.
Han’s study is one of the first to assess the effects of PT and OT as a treatment for delirium in ED patients who are subsequently admitted.
Problems Ahead
“Delirium affects 10 percent or more of older patients in the ED and 40 percent or more of older patients in the hospital, but there is no universally accepted treatment,” Han said.
“Delirium often leads to ‘the spiral,’ where a person loses the ability to take care of themselves.”
“We all agree that patients who develop it lose the ability to function independently, lose their cognitive abilities, and are ultimately robbed of their ability to live a good and productive life.”
The condition is dangerous, often preventable, and linked to higher medical costs and increased morbidity and mortality, Han added.
“Delirium often leads to ‘the spiral,’ where a person loses the ability to take care of themselves. They often get sick, and get delirious again, leading to more deterioration.”
Some Overlooked
Delirium takes different forms, which researchers are starting to categorize.
Marked by various types of alterations to attention, consciousness, and cognition, delirium reduces a person’s ability to focus and sustain or shift attention. It develops quickly and fluctuates during the day.
The diagnosis is often missed, Han says, especially in the hypoactive type in which a patient is sluggish. The hyperactive type involves restlessness and agitation.
“Loss of physical function and muscle strength are typically associated with a loss of cognitive function, so exercise is an important aspect of maintaining brain health,” Han said.
A lack of physical activity, such as sitting in a hospital bed all day, degrades muscle strength.
“If you lay in bed and do nothing, you lose muscle mass. You end up leaving the hospital weaker than when you entered it,” Han said. “This loss in muscle mass is accelerated in older adults who haves a low physiological reserve to begin with.”
Patient Challenges
Engaging a patient with delirium in PT or OT can be challenging for the therapists involved. Their willingness to persevere and adapt to individual patient needs and abilities varies widely, often tied to the therapist’s depth of experience.
Another practical challenge involves an ongoing shortage of physical and occupational therapists to meet the needs of the aging population.
Planning Required
A medical order for PT or OT may be written quickly yet still take several days to implement. Along with a lack of therapists, not all are trained to take on a patient in the throes of delirium.
“Delirious patients are confused and often have difficulty understanding or following instructions,” Han said. “Some patients may be too sleepy. It’s a lot easier to wait for the delirium to clear up before initiating PT or OT.”
“It’s about not ignoring them; it’s about figuring out what they can do.”
However, it is possible to make some strides in patients with delirium, he added.
For the hypoactive type, it may be helpful to get them out of bed and open the curtains to bring in sunlight prior to the session. The therapist can start small. Just having the patient stand up and sit down in a chair is a plausible first step.
“It’s about not ignoring them; it’s about figuring out what they can do,” he said.
Protocols for administering PT and OT in patients undergoing delirium are not yet formulated, but Han is working toward this goal.
Secondary Analysis
In his current analysis, Han used data gathered between March 2102 and November 2014, initially for use in the DELINEATE Study (Delirium in the ED and Its Extension into Hospitalization: Effect on 6-month Function and Cognition), which found 77 percent of patients’ delirium to persist into hospitalization.
“We reviewed the records to record the amount of PT patients obtained and what was done,” Han said. “We also recorded when the patient received PT or OT for the first time.”
The researchers analyzed the experiences of 130 older patients (median age 76 years) who presented at Vanderbilt’s ED.
Eighty-eight percent of the study participants were white, and 62 percent were women. Funding was provided by the National Institute on Aging.
A median total of 75 minutes of PT and OT was received by patients in the study, and the median time from prescription to initiation of PT/OT was two days.
Intensity of the therapy was defined as the percentage of time patients spent engaged in PT or OT sessions. Although greater intensity was significantly associated with less overall delirium, a delay in initiation of therapy was not.
“We also want to see if more aggressive and intense PT and OT improves their long-term function and cognition.”
Han plans to do a larger study to confirm the findings and consider other aspects of the condition.
“We also want to see if more aggressive and intense PT and OT improves their long-term function and cognition, which is often lost in frail, older patients after they leave the hospital,” Han said.
