COVID-19 unleashed an ongoing crisis of delirium in hospitals

Older adults have borne the brunt of the COVID-19 pandemic. While Canadians aged 60 years and older make up only 20 per cent of the population, they account for 69.5 per cent of all COVID-19 hospitalizations, and most – 91.7 per cent – of all COVID-19 deaths.

One aspect of healthcare during the pandemic that has received considerably less attention is the failure of effective delirium care.

Delirium is a sudden and distressing state of confusion that occurs in up to half of hospitalized older people. It is usually triggered by a change in health, such as an infection or surgery, and is often short-lived but can sometimes cause long-term cognitive impairment leading to an increased risk of dementia.

Fortunately, delirium can be prevented or minimized using simple strategies. Within our own health practices, we have seen the effectiveness of promoting family caregiver presence, encouraging mobility and minimizing disruptions to eating, drinking and sleeping.

In May of 2020, an opinion piece written by geriatrician Dr. Sharon Inouye in the New York Times, warned of an epidemic within the pandemic that was leaving many hospitalized older patients more vulnerable to delirium by abandoning many simple care approaches. Unfortunately, she was right.

Our study recently published in JAMA Network Open showed that the fear of a delirium epidemic was realized. We found that during the first two years of the COVID-19 pandemic, older adults admitted to Ontario hospitals experienced more delirium and were discharged home with more sedating medications compared to before the pandemic.

Disruptions to delirium prevention care caused by the pandemic are in part to blame. A shortage of staff and volunteers, visitor restrictions and infection control rules created the perfect storm of less interaction with patients and fewer opportunities to use non-drug approaches for preventing and managing delirium.

Never again should sick patients with delirium be isolated from their family.

Our study results are particularly alarming because we have made so much progress in delirium care over the last 30 years. Initiatives such as Senior Friendly hospitals, acute care of the elderly units and hospital elder life programs have flourished across Canada. In the three years preceding the pandemic, our study shows a clear trend of declining prescriptions of harmful and addictive sleep medicines given to older people after they left the hospital.

COVID-19 disrupted this hard-fought progress. Even two years after the onset of the pandemic, the number of new sedative prescriptions being prescribed out in hospitals has not returned to pre-pandemic levels.

So how do we reverse these dangerous trends?

It is likely that the fall and winter will bring a seasonal wave of viral illness such as influenza, RSV – and COVID-19, among others. Hospital and healthcare systems will soon be faced with decisions about visitor and volunteer policies in the face of viral outbreaks.

We can minimize rates of delirium by implementing policies centered on delivering dignified care, especially to older persons with cognitive impairment who cannot always advocate for themselves; renewing nationwide hospital efforts to mandate flexible hospital visitation and implement the simple and evidence-based care strategies needed to prevent and manage delirium; and addressing national staffing shortages plaguing healthcare facilities across the country and redoubling our efforts to build and sustain senior-friendly healthcare environments.

Never again should sick patients with delirium be isolated from their family caregivers.

We must return to providing the standard of care for older people that reduces delirium and minimizes sedating drugs. We owe it to our aging population to provide the kind of humanistic care that helps older adults leave hospitals with their independence and cognition intact.

Dr. Reppas-Rindlisbacher is a geriatrician at Sinai Health and University Health Network and a PhD student at Women’s Age Lab at Women’s College Hospital.

Dr. Nathan Stall is a geriatrician and clinician scientist at Sinai Health and Women’s Age Lab at Women’s College Hospital.

Dr. Paula Rochon is a geriatrician and the founding director of Women’s Age Lab at Women’s College Hospital.