Recognizing the Clinical Features of Delirium can Save the Lives of the Hospitalized Elderly

Nariman Malik, BSc

Confusion in the elderly is a common problem. Its onset may be acute or chronic and progressive in nature. Confusion may be a symptom of delirium or dementia but it may also be associated with psychoses and affective disorders, in particular major depression.¹ This article focuses on delirium, one of the most common and frequently unrecognized causes of confusion in the elderly.

Delirium is a syndrome of disturbed consciousness, attention and cognition or perception, which develops acutely, fluctuates during the course of the day, and is a direct physiologic consequence of a general medical condition.^2-4 Delirious patients may also have psychomotor and emotional disturbances. In most cases, delirium is reversible upon treatment of the underlying medical condition.¹ Currently, a great deal of attention is being focused on this condition because of the huge impact it has on patients and their families, as well as on patient care costs. Delirium is a phenomenon that is common in hospitalized patients, and is associated with high morbidity and mortality rates, and significantly extended lengths of hospital stay.⁵

The incidence of delirium increases progressively after the fourth decade of life.

A. Mark Clarfield, MD

I had almost been convinced by Mrs. C. that her friend Sarah, after 50 years of friendship, had actually turned on her. On the surface, the story presented by my patient, who appeared well-groomed and intelligent, was certainly quite believable. I had read far more incredible tales in the Toronto Globe and Mail.

Apparently, the friendship between the two ladies went back many years. They had been born in the same little poverty-stricken Jewish shtetl (farming village) in Poland just after the turn of the century. They had both moved to Montreal where they married and brought up their respective families. The two ladies and their families shared summer holidays "at the lake," as well as their children's birthdays, baseball games and graduation celebrations and weddings.

Later in life, after both were widowed, the two women moved into separate but adjacent apartments in a subsidized seniors' home. They exchanged keys so that each could look after the other's apartment when the need arose.

It was just last year, my patient informed me, "that of all people"; Sarah had started stealing from her. First it was just little things, such as a quart of milk. But lately, as the stakes got higher and jewelry began to go missing, my patient became concerned. She confronted her friend Sarah who "blew her stack.

Christopher B. Overgaard, MSc, MD

Atrial Fibrillation and Elderly Patients
Atrial fibrillation (AF) is by far the most common cardiac arrhythmia, and is most prevalent among the elderly. One large study found that 70% of all patients with AF were between 65 and 85 years of age.¹ Many underlying conditions have been associated with the development of AF, including diabetes, hypertension, pulmonary disease, thyrotoxicosis, cardiomyopathy, and nonspecific conduction defects; the AF patient population is, therefore, a heterogeneous one.² Regardless of underlying cardiac pathology, this arrhythmia is associated with a doubling of mortality and is a very significant health issue for elderly patients.

AF occurs through the propagation of random waves of intra-atrial reentry, with many macroreentrant circuits moving throughout the atrial muscle.³ This chaotic pattern results in a random irregular rhythm, a significant decrease in stroke volume and cardiac output, and the risk of thrombus formation due to atrial stasis. Systemic embolization from an atrial clot is considered to be the most devastating, albeit potentially preventable, consequence of this disease process.²

Atrial Fibrillation, Stroke, and Bleeding Risk
Elderly patients with atrial fibrillation are at a fourfold higher risk of suffering a stroke than the age-matched general population.

Tracey Tremayne-Lloyd, BA, LL.B,
Tremayne-Lloyd Partners
Toronto, Ontario

More than just the catch-phrase of the day, 'Living Wills' appeared to be the answer for increasing patient control in end-of-life decisions, and a much sought-after solution for an aging population (but one that is increasingly sophisticated about treatment options). The issue of Living Wills was explored in the May/June 1998 edition of Geriatrics and Aging in an article entitled 'Living Wills Ease Patient's Fear' by Lawrence J. Papoff (please see our web site www.geriatricsandaging.com for this article). Recent research has demonstrated that the Living Will is an instrument well-liked by physicians and patients for its capacity to empower patients with independence when facing a life-threatening condition, but it is still surprisingly under-used. It is important for physicians treating geriatric patients to be aware of the extent to which Living Wills can be incorporated into their practice, and to consider their role in educating patients about the issue.

Kimby N. Barton, MSc
Assistant Editor,
Geriatrics & Aging

This past month, the Ontario Medical Association governing council and the Provincial Government of Ontario ratified a comprehensive four-year agreement, which will pave the way for the trimming of $50 million annually in medical services from OHIP. In a telephone referendum that took place May 3 to May 10th, 66% of OMA physician members who took part across Ontario voted 'yes' to the agreement (in total 10,603 members voted, a number that represents less than half of the OMA's total membership). The number of Ontarians over the age of 65 has increased by 31% in the past decade and per capita seniors utilize up to five times more health services than the rest of the population. The new agreement is designed to address some of the issues resulting from the need to allocate sufficient resources to treat this aging population.

The agreement provides for a 1.95% increase in physician billing this year and a 2% increase to be implemented in each of the next three years. It also raises thresholds by $10,000, allowing family doctors to bill up to $330,000 a year and specialists up to $410,000 before discounts on their billings kick in.

The parties have also agreed on several initiatives to enhance delivery of needed services to patients and to provide physicians' incentives motivating them to deliver those services. Some of the initiatives include changes to the Schedule of Benefits with respect to home care application, home care supervision, complex care of the elderly and after-hour premiums. Specifically, a 20% premium ($10.30) will be added to the general assessment code for services provided to patients who are 75 years of age or older. This general assessment premium can be charged only once per patient per year. Physicians who submit a home care service request form to the Community Care Access Centre (CCAC), or who provide information in response to an inquiry from CCAC staff can charge a Home Care Application fee ($16.50) or a Home Care Supervision fee ($10.40). Changes have also been made to the Schedule of Benefits for the after-hours premium codes. Physicians may charge a premium for visiting hospital inpatients, for visiting a patient's home or a multiple resident dwelling and for making a special visit to a long-term care institution. Exact fees for these services are listed in Appendix B of the Agreement.

The Agreement has not met with universal acceptance. A release from the Coalition of Family Physicians (COFP) states that the agreement has merely guaranteed that "for the next four years family physicians will fall further behind inflation". The number of allowable non-emergency visits per month to patients in long-term care facilities and chronic hospitals (complex continuing care) were left unchanged. The allowable number of visits was cut in the last agreement and this is a problem for nursing home physicians. There are also concerns amongst specialists and advocacy groups about the possible delisting of several services. "What it means is $50 million less in health-care spending," says Ray Foley, execu- tive director of the Ontario Association of Radiologists. It is rumoured that optometry, physiotherapy, and audiology tests will no longer be insured. If the committee decides to delist hearing tests it means that patients who require audiology testing are going to have to pay for it themselves. Since many patients who visit optometrists and audiologists are senior citizens, it is apparent that improving geriatric care in one area may result in deficiencies in other areas. If you have any comments about the new deal and how it affects your practice, please email us at geriatrics@ribosome.com.

Dr. Michael J. Taylor

With the rapid progress in medical knowledge and technology over the past several decades, caring for patients with terminal illness has become increasingly challenging to both individual physicians and to the profession of medicine as a whole. In addition to keeping abreast of an ever-growing body of palliative care literature, physicians caring for terminally ill patients must often make management decisions that are difficult because outcomes, such as the impact on quality of life and the potential to increase patient survival, are hard to predict. The resulting uncertainty combined with the fear and anxiety experienced by physicians, patients and families facing terminal disease, often presents obstacles to effective communication among all parties. Furthermore, in busy inpatient and outpatient settings, the palliative needs of terminally ill patients may be overlooked by physicians who are trained to focus on the prevention and cure of disease, but are ill-equipped to meet the challenges of attending to a patient's spiritual and psychosocial 'end-of-life' needs. The following article examines some of the current deficiencies characterising the care of the terminally ill, and highlights a number of the obstacles to overcoming these deficiencies through a brief survey of some of the literature that addresses this complex issue.

Lilia Malkin, MSc

Sleep is a necessary physiologic break that gives the human body the opportunity to relax and revitalize itself. Unfortunately, getting "a good night's rest" frequently proves challenging, particularly for the elderly. As many as twenty-five percent of otherwise healthy older adults complain of chronic sleep difficulties.^1,2 When seniors with medical and/or psychiatric co-morbidity are taken into consideration, the proportion of the elderly who suffer from chronic insomnia and excess daytime somnolence may actually exceed fifty percent.³ Since adequate sleep makes a substantial contribution to one's quality of life, it is important to determine the etiology of a sleep disorder, so that the primary sleep problem and/or the underlying condition may be treated appropriately. This article will discuss the physiologic changes in the sleep pattern of healthy older adults, common geriatric sleep disorders, as well as assessment and treatment strategies for insomnia in the elderly.

Sleep Changes in Healthy Elderly
Aging is associated with a multitude of physiologic alterations in healthy seniors, and sleep is no exception. Age-related sleep changes occur apart from primary sleep disorders, or medical and/or psychiatric conditions.

Options Range From Pills to Hand- and Battery-Operated Pumps

Joyce So, BSc
Co-author:
Sidney Radomski, MD, FRCSC
Urology, Toronto Western Hospital

Erectile dysfunction (ED), the persistent inability to attain or maintain a sufficient penile erection for sexual intercourse in at least 50% of attempts, afflicts more men and with greater severity as they age. A quarter of men who are 65 years of age struggle with erectile dysfunction, while more than half of 75-year-olds and 65% of 80-year-olds, experience difficulties with sexual function. Although age is the greatest risk factor associated with ED, it is not considered to be a part of the normal aging process. Physicians should encourage patients and their partners to discuss this problem so that appropriate treatment can be initiated.

Because ED often comprises both organic and psychogenic components, manage- ment of this problem can address both medical and psychological causes. The management of medical causes of ED includes oral therapy, intracavernosal injection therapy, intraurethral therapy, vacuum constriction devices, surgical options including penile prostheses, and various preparations of testosterone for men with diagnosed testosterone deficiency.

In March 1998, the Food and Drug Administration (FDA) approved sildenafil (Viagra), in the United States as the first oral medication available for the treatment of erectile dysfunction in men. Soon after, it was also approved for use in Canada.

Somatization Disorder: General Approach & Management

Dr. A. Abdulla, BSc, MD, LMCC, CCFP, DipSportMed

"Doctor I feel like vomiting, there is pain in my arms and legs, I am always exhausted, cannot catch my breath, have difficulty swallowing, and have a poor memory." This is the worst way to start with your first patient on Monday morning, but it really happened to me about a week ago. Normally, I would try to see whether Mrs. B. had any other complaints but somehow I felt compelled to just go with the first six.

This article deals with a fairly common condition called somatization disorder (SD). It fits into a category of unusual conditions, like body dysmorphic disorder, hypochondriasis, conversion disorder, and somatoform pain disorder, collectively called somatoform disorders. Most physicians will rarely see these conditions; however, SD is very common. Studies cite that more than fifty percent of patients presenting to a primary care center with vague ill-defined symptoms have SD.^1-3

Definition
Somatization disorder involves multiple, ill-defined symptoms, stemming from a number of organ systems. The symptoms described by patients do not fit any classical patterns of typical medical conditions.

Miriam Vale, B. Journalism

Like girl scouts, doctors should always be prepared to help families cope with grieving for the death of a loved one. The physician's support is needed when he or she introduces the option of palliative as opposed to curative care. For the patient and family, palliative care is the acknowledgement that managing pain and improving quality of life are the most appropriate goals as the patient nears death. This change in care strategy can be difficult for everyone involved. This article focuses on helping the family cope with the dying process of a loved one with an incurable illness.

Family physicians can make an immense difference in helping families cope with grieving. When a loved one has a terminal condition and the family knows that death is imminent, family members will often grieve before the death occurs (this is known as anticipatory grief), consequently losing precious time with their relative.

Anticipatory grief is not necessarily a bad thing as it may help the family deal with the upcoming loss. In some cases, anticipatory grief allows family members to sort out certain feelings toward their loved one (getting emotions off their chests, so to speak) before he or she dies so that there are no regrets afterwards. Because anticipatory grief often forces family members to face the reality that death will occur, they are more likely to start dealing with practical issues before it is too late to get the patient's input.