Hospitalisation Phenomena

When people go into hospital they expect to get better but sometimes admission to hospital is associated with a deterioration in the general condition. This is what is meant by hospitalisation phenomena.

Patients may appear to deteriorate in hospital compared with how they were in the community for a number of reasons. There may be a number of causes:

• Adverse reaction to a drug, investigation or procedure
• Hospital acquired infection e.g. MRSA
• Psychological problems e.g. delirium, loss of confidence, depression (the cause may be organic or non-organic)

Those most at risk

• Elderly patients
• Admitting diagnosis - severity of illness and duration of hospital stay also probably play a part
• Co-morbidity e.g. diabetes mellitus
• Multiple drugs/complicated regimens

The usual presentation is as an acute confusional state, also called delirium. This may be due to medications, dementia (possibly mild and formerly unrecognised), withdrawal of substances of dependence e.g. drugs or alcohol or unsuspected physical illness. See also delirium tremens.

Organic causes of delirium in hospital

• When patients are admitted to hospital they are often immobilised.
• They may have been admitted because of trauma or a stroke or are confined by the monitors in a coronary care unit.
• This can lead to physical problems such a hypostatic pneumonia, deep vein thrombosis and pulmonary embolism.
• Other causes include hypoxia and bleeding after major abdominal surgery.¹
• It is possible to anticipate who is at risk for post operative delirium.² A study of low dose pre-operative haloperidol showed that it did not prevent the condition but was associated with a shorter duration and a shorter stay in hospital.³

Drugs and delirium

Whenever there are problems of confusion or aberrant behaviour, an examination of the drug sheet should be one of the first investigations.

• Medications are often changed or started when patients come into hospital and this may be responsible for problems.
• This applies not simply to psychotropic medication but drugs for conditions like Parkinson's disease may cause confusion.
• High doses of steroids can cause psychosis.
• The role of antibiotics in iatrogenic toxicity should not be underestimated.⁴
• Hospitals are noisy and unfamiliar places at night and night sedation may be offered and this may have adverse effects both at night and into the next day.
• The reliability of the administration of medication in hospital is often less than perfect but this imperfection is usually substantially better than fluctuations of the self-administered regime at home. However, it can mean that in hospital patients are receiving higher doses than at home and this may reach toxic levels.
• Failure to sleep may be due to pain, especially after an operation. This requires adequate analgesia. If sedation without analgesia is given, such as a hypnotic benzodiazepine, this can cause acute confusion.

Unfamiliar surroundings and delirium

An elderly person may appear to be coping well at home in the familiarity of a place where they have lived for many years but when they are transported to the unfamiliar environment of a hospital, unexpected confusion reigns. There may have been a degree of dementia present that had not been appreciated by anyone as the old person was able to accommodate in familiar surroundings but when presented with something totally new they are no longer able to do so.

Delirium on the ICU

• Confusion in an ICU may be difficult to recognise, especially if the patient is intubated.
• Delirium rating scales have been validated.⁵
• Acute confusional states (delirium) occur in 10 to 60% of older patients in hospital and in 60 to 80% of patients in the intensive care unit, but they are unrecognised by the staff in 32 to 66% of cases.
• Delirium is an important independent prognostic factor in outcomes, including duration of mechanical ventilation, nursing home placement, functional decline, and death.⁶
• Recently, new monitoring instruments have been validated for monitoring of delirium in non-communicative patients receiving mechanical ventilation.
• Education of medical staff to recognise problems can reduce the incidence of acute confusion and it is hoped that will reduce the associated mortality and morbidity.⁷

Approach to a patient with delirium

• Exclude organic causes and if present treat them.
• Talk to the patient. Be kind, be patient, be reassuring. This is not the time to attempt a mental state assessment for dementia.
• If the patient is distressing others, or being inconvenient for staff, there will be a call to give sedation. This lowers the level of consciousness and may well add to confusion so caution is needed.
• The most effective policy is early discharge as stability usually returns in the familiar surroundings. However, this may not be so, especially if there is a different reason for the admission. Further, sending a confused person home too early is potentially very dangerous.
• If everything does settle down, the patient still needs to be assessed as there maybe a degree of dementia. The confused patient must not be discharged from hospital in the expectation of spontaneous recovery at home without alerting primary care to the situation.

In terms of prevention, rehabilitation of the frail elderly at home rather than in hospital may have advantages.⁸

Delirium tremens

• The problems of excessive consumption of alcohol lie not simply in the effects of high intake but in the effects of sudden withdrawal.
• The diagnosis of alcoholism is notoriously difficult and it is difficult to determine who may be consuming more than is judicious.
• This is a diagnosis that should be suspected when there is otherwise unexplained confusion in a younger person.
• Certain occupations, especially those related to the production and distribution of alcoholic drinks, are at high risk.
• In the community the person appears to have no problem because the supply of daily alcohol is uninterrupted.
• Admission to hospital stems the flow and a withdrawal syndrome follows.
• This does not usually happen in the first 24 hours and so day case surgery is usually not a risk.
• Admissions for surgery requiring longer stays or for medical reasons such as acute myocardial infarction pose a larger problem.

The florid picture of terrifying hallucinations is uncommon. The lapse of 24 to 48 hours between admission and onset should arouse suspicion. Fits can occur within 6 to 8 hours of stopping drinking. For more detail about the features of alcohol withdrawal the reader is referred to diagnosis and management of alcoholism. FBC may show macrocytosis and abnormal LFTs, especially an elevated gamma GT (but are not necessary for the diagnosis).

Management of delirium tremens

• Sedation with chlordiazepoxide is usually recommended.⁹
• Chlormethiazole should no longer be used for this condition.

Withdrawal of other substances

Other substances of abuse may also lead to withdrawal syndromes on admission to hospital. Track marks from intravenous injections are an obvious pointer if seen but may be successfully hidden or the drug may be taken by a different route e.g. inhalation of opiates, snorting of cocaine. Withdrawal from cigarettes may not produce a syndrome like withdrawal from opiates, alcohol or benzodiazepines but tobacco should probably be regarded as being as addictive as heroin.

• For those who work in hospitals it is easy to forget how frightening and disruptive it can be to become a patient.
• Illness can cause more than just the textbook symptoms and signs and this may be compounded by anxiety and sleep deprivation.
• The patient may feel loss of independence, loss of dignity and invasion of privacy.
• Talk to patients and keep them informed.
• Patients often feel disempowered so be considerate.
• The elderly person especially, may feel a loss of routine that can precipitate a crisis as adaption is limited well before overt features of dementia. Continuity of care is also important.