Dr. Christina 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 (WCH). Dr. Nathan Stall is a geriatrician and clinician scientist at Sinai Health and Women’s Age Lab at WCH. Dr. Paula Rochon is a geriatrician and the founding director of Women’s Age Lab at WCH.
Much has been said about one of the great tragedies of the pandemic: that vulnerable older adults have borne the brunt of COVID-19. 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 the vast majority – 91.7 per cent – of all COVID-19 deaths in the country.
But one aspect of health care during the pandemic that has received considerably less attention is the failure of effective delirium care, even though it disproportionately affects the same demographic that was let down over the past three years.
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 one’s health, such as an infection or surgery, and is often short-lived. However, it can sometimes cause long-term cognitive impairment leading to an increased risk of dementia. Sedating medications can make things worse.
Fortunately, delirium can be prevented or minimized using simple strategies. Within our own health practices, we have seen that a variety of interventions that don’t require drugs – including promoting family caregiver presence, encouraging patients to move while in hospital, and minimizing disruptions to eating, drinking and sleeping routines – have reduced the incidence of delirium and prevented falls, while decreasing length of stays and reducing the need for institutionalization.
But doctors had warned that the hospital conditions created by the COVID-19 pandemic would disrupt delirium prevention care and produce an epidemic within the pandemic. Restrictions on visitor access to prevent viral spread led to patients feeling socially isolated; stressed and under-resourced medical staff had to wear face-obscuring protective equipment and minimize their visits to patients’ rooms, which increased their reliance on drugs to manage delirium. “If you could design a health care system that would generate delirium, you would design exactly the system we have with COVID-19,” Dr. Sharon Inouye wrote in The New York Times in May, 2020.
And our study, recently published in JAMA Network Open, showed that fears of a delirium epidemic were realized here in Canada. 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 with before the pandemic. It was a perfect storm.
Our study results are particularly alarming because we had made so much progress in delirium care over the past 30 years. Initiatives, such as senior-friendly hospitals, units specifically for the acute care of the elderly, 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 after the onset of the pandemic, the number of new sedatives being prescribed after hospital stays has not returned to prepandemic levels.
We need to reverse these dangerous trends, especially since 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 health care 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 centred on delivering dignified care, especially to older persons with cognitive impairment who cannot always advocate for themselves. We also have an opportunity now to renew nationwide hospital efforts to mandate flexible hospital visitation and implement the simple and evidence-based care strategies needed to prevent and manage delirium. Addressing national staffing shortages plaguing health care facilities across the country and redoubling our efforts to build and sustain senior-friendly health care environments should also be a priority.
Health care providers can also recommit ourselves to this mantra: 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 care that helps older adults leave hospitals with their independence and cognition intact – and do whatever it takes to ensure they receive high-quality care.