Have you ever wondered what your doctor is writing as he or she is busy scratching away in your chart?  What strikes him as being important?  What does she ignore?  Or is he just drawing cartoons in the margins? (For the benefit of those readers who are actually my patients I can honestly confess that I’ve never doodled cartoons in your chart as I listen to you—my cartooning skills are simply too inadequate.)  If you were to read my hand-written notes they would go something like this: Srmfth kllmquis is hmmelsh fluthyig percquler hablehc.  My writing is no better than another doctor’s, since we all took the same “Illegible Handwriting 101” course our first year of medical school.

What’s more revealing is the final dictation that ends up in your doctor’s record.  Once she’s done visiting with you she takes to the computer keyboard (in the case of the computerized medical record) or to the Dictaphone to produce a more legible and lucid summary of your visit.  It includes the stuff you told her, her exam findings, and her impression of your medical problems.  It concludes with whatever recommendations she made to get you feeling better.  It basically summarizes her version of the interaction you two just had.

How’d you like to get a hold of that report?

Well, you may not realize this, but you’ve been able to for some time now.  Ever since Congress passed the Health Insurance Portability and Accountibility Act (HIPAA) of 1996 you’ve had legal write to not only cast eyes on your medical record but to also make amendments as you see fit.  Give it a try sometime.  March into your doctor’s office and ask to take a glance at your folder (or electronic file, as the case may be).  Odds are pretty good the clerks at the front desk will give you a funny look, but rest assured they are legally obligated to turn the whole stack of papers (or electrons) over to you.  Some offices will charge you a “processing” or “copying” fee, others will allow you to see your record only under the watchful eye of a clinic employee, and some may simply deny you access, not being familiar with a legislative change that went into effect 14 years ago.  Still, the law is on your side and you have every right to exercise your privilege.

Let’s pretend that after reading this post you decide to drive down to your doctor’s office and ask to see her most recent dictation about you.  As you stand there at the front desk and ask for your chart what do you imagine is going through the mind of the receptionist?  This patient is going to sue us.  Or, this patient is obsessive-compulsive.  Or, this patient is going to switch to another doctor.  I seriously doubt they would be thinking this patient has a rational concern about his own body, would like to be a better partner in his own healthcare, and is improving the process by educating himself. 

Nope—they’re thinking you’re nuts.

The funny thing about all this is that it rarely happens.  I can’t say for sure how many of my patients have requested access to my notes about them but I’d guess that less than 5% of them ever get the urge to check out their charts. 

Or, maybe they do, but they’re just afraid to ask.

The most recent issue of Annals of Internal Medicine contained a paper outlining the OpenNotes project:

“ ‘a demonstration and evaluation project in Massachusetts, Pennsylvania, and Washington, in which more than 100 primary care physicians are inviting their patients to read their visit notes through secure electronic patient portals.’  These clinics are taking a step beyond simply allowing their patients open access to their records upon request—they’re suggesting their patients sign in to a secure site to see every detail of their file at a moment’s notice.”

I actually really like this idea.  Maybe the reason so few people ask to look at my notes is that they’re afraid they’ll be branded as problem patients.  The OpenNotes project solves this problem by allowing patients to search their record in the comfort of their own Starbucks store without having to interact with a snoopy medical records clerk or suspicious nurse.  As a doctor, I’d never know which of my patients has dug into my most recent ramblings about them.

Several large news outlets wrote stories about this publication, including the New York Times, in which the author—a physician—expressed similar notions as my own as she described a scene where an elderly couple requested access to their charts:

When I mentioned the request to one of the nurses outside the exam room a few minutes later, her eyes grew wide.

“Oh no, you can’t do that,” she said, shaking her head. “I don’t think it’s legal.” The other doctors and nurses, attention piqued, moved closer to listen. “Send them to medical records,” she urged. “He can sign the release papers there.”

Another nurse in the growing crowd offered her own advice. “Do you know what’s going to happen if you give them a copy now?” she asked. “They’re going to start calling and e-mailing you with questions about what you wrote.”

The doctors and nurses began clucking in agreement. “Think about it for a second, Pauline,” one doctor said with voice lowered. “Maybe they are thinking of suing you.”

There was a collective gasp from the group now gathered around me; and I could guess what they were thinking as they craned their necks to peer into the exam room where my elderly patient was busy fussing with his papers as his wife stood adjusting the canvas fishing hat on his head.

The article, and the numerous reader comments on the website, went on to speculate about the other hazards of allowing patients to rifle through their record.  What happens when a patient comes across confusing terminology or encounters some of our cryptic abbreviations and acronyms?  The phrase “This 42-year-old well-developed female with SOB” could be misinterpreted as derogatory commentary on the patient’s physique and choice in husband, rather than the intended meaning (well-developed means not malnourished, and SOB is generally translated as shortness of breath; although I have met some unfriendly spouses for whom the phrase could serve as a double entendre).

What happens when they read the part of my note where I speculate what other diagnostic possibilities might account for their symptoms?  While the patient’s SOB is most probably caused by his known emphysema, less likely possibilities could include coronary ischemia, congestive heart failure and occult malignancy.  Most people would recognize that I’m simply speculating (or, rather, doing what I was taught in medical school: developing the differential diagnosis) but some might infer that I have secret knowledge about their impending doom that I’m withholding from them.

And when they come across slight abnormalities in their testing—abnormalities that I gloss over during my visit with them—will they suspect me of indifference or poor judgment?  If I don’t explain my theories as to why their AST (a blood test reflecting function of the liver) is a point higher than the norm, will they inundate my office with phone calls and demand additional testing?

Well, these are the fears that have been expressed by doctors, nurses and some patients.  Personally, I don’t think any of them hold water.  The way I see it, these objections are nothing more than a diversion from the real concern of the medical establishment: we are afraid of giving up control. 

Ever since Hippocrates scribbled illegible medical notes (and, perhaps, little cartoon doodles) onto parchment we’ve had complete control over the documents that record the interaction we have with patients.  We’ve invested so much into our system of medical record keeping that we’ve come to believe that it belongs to us rather than the patient.  And on some level we’re still suffering from the paternalistic views of our professional forbears: the best patient is an uneducated and subservient one.

Sure, there may be some who will become confused as they read through the technical lingo of our profession, and there may be others who become fearful when they peruse the cold and relatively impersonal recounting of their health problems, but my guess is that most patients will appreciate the additional information that comes from being able to lay eyes on their record.  Those patients may also want to exert more control over how their care is provided and we may find that they become more like partners in the process rather than passive customers, a proposition that I have no objection to.

Proponents of the open access movement claim that patients who have access to a summary of their office visit will be more likely to adhere to their doctor’s suggestions, can help improve the accuracy of the record, and will ultimately develop more trust in their physician (a nice table summarizing the pros and cons of OpenNote is available here).  I’m not sure how my patients would respond to such an opportunity.  A few years ago when I was in the military we had an electronic medical note system that allowed me to immediately print a copy of the report for my patients as they left my office.  Most were politely grateful, some were indifferent, and only rarely did I get any feedback or questions about what I’d written.

Will open access be a disaster (as some people fear) or a blessing (as others hope)?  I don’t have a clue.  As for all my patients, please feel free to come take some time reading through my notes about you.  Because, to be honest, the only concern I have is not that you’ll become confused or enraged or frightened by what I’ve written about you, but that you’ll be struck with a profound and potentially dangerous attack of boredom: my notes are not really all that fascinating.  While I may wax verbose in my blog posts, my office dictations are dry, concise, and include no commentary from me about your choice in husband.

And they don’t even include cartoons.

To celebrate your 50th birthday you head to your doctor’s office to get your yearly exam. He rewards you for your diligence by poking and prodding you, sticking you with needles, and arranging for a colonoscopy (happy birthday!). He also sends you for a stress test out of concern about your strong family history of premature heart disease.

A slightly abnormal treadmill test leads to a slightly abnormal nuclear imaging stress test, and before you know it you’re in with a cardiologist discussing the need for a cardiac catheterization. Your health is otherwise very good and you have absolutely no symptoms that would suggest any significant coronary artery narrowing—in fact, you’ve been vigorously exercising faithfully for several years and feel pretty good about your level of fitness.

You leave the office a little uncomfortable about being told you need an invasive procedure when your health is doing so well, but you let them set a date and time for your study. You relate all this to a friend of yours who suggests that you try to find another doctor for a second opinion.

Do you do it? Do you tell your cardiologist so that he can send his nuclear study results to the new doctor? Do you tell your primary doctor, who, after all, has a good enough relationship with the cardiologist to have sent you to him in the first place? Will your doctors be offended? Will your insurance cover the cost of the second opinion?

Patients don’t ask for second opinions very often. I know of no statistics that can tell us how frequently patients seek the advice of a second physician, but I’d guess it’s pretty uncommon. Most patients are probably pretty satisfied with the care their provider recommends (otherwise they’d have switched to another doctor already) and don’t feel that another opinion is necessary. Of those who feel unease with their doctor’s recommendations, most probably just swallow their personal misgivings and proceed with the suggested therapy.

A select few will seek a second opinion and most of them will likely feel pretty uncomfortable about it. As an example take this article, for example, written by a doctor about other doctors he knows who also happened to be patients:

“When I went for a second opinion, my internist got mad,” a physician with lymphoma recently told me. “As if I were his lover and had cheated on him.”

As a cardiologist, I’ve been the “second opinion” on many occasions (although I can’t know how often my patients leave my office and head elsewhere for another opinion). In most instances, the patient didn’t necessarily feel that the recommended testing or therapy was wrong, they just felt uncomfortable with the entire doctor-patient interaction. Most people don’t come to me saying “My doctor said I needed surgery X, but I know that surgery X is not the right surgery for me.” Rather, it’s more like this: “My doctor said I needed surgery X, but I feel like he didn’t really listen to me when I was telling him about my symptoms and I’m just worried that he’s recommending surgery without hearing the full story.”

My experience is supported by studies on the subject that show that people who seek second opinions do so mainly because of a dissatisfaction with the quality of dialogue they experienced with the primary consultant. In some ways this makes it even harder for patients initiate the move to another doctor, since it signals that the doctor and the patient are not matching up well—kind of like telling your prom date that you had fun but you don’t want to see her again. It would be easier if it were a simple case of suspected incompetence: “Your foot hurts? Nothing that cardiac catheterization can’t cure.” Advice from that type of doctor is easy to abandon.

Will your doctor be offended if you go elsewhere for another consultation? I hope not. He or she should understand that you as a patient must feel comfortable with the care you’re receiving and getting a second opinion may help you achieve that goal. I certainly don’t mind if my patients ask to get input from another doctor; in fact, if I sense that a patient or family member is uncomfortable with the plan I am offering I will suggest that they consider seeking advice from another doctor. There are a couple other cardiologists in town—in other practices—who are regular recipients of my referrals for another opinion. I find it extremely helpful to have a different doctor lay eyes on a patient’s case and offer alternatives.

You may be surprised to learn how often we doctors seek informal second opinions on our own patients. We frequently sideline our partners to have them cast eyes on the chart of a patient with a particularly challenging problem. We have routine conferences where we discuss clinical dilemmas and review study images. Once or twice a week someone in my practice will send out an e-mail asking for others in the group to provide an opinion on a challenging echocardiogram. I think most doctors have a pretty healthy understanding of their own limitations (at least I hope so).

Insurance companies will commonly pay for you to see another specialist. Medicare even mandates that some diagnoses be confirmed with a second opinion. I called an account representative at my insurance company who told me that I can get a second opinion anytime I want and that it would be billed as a standard office visit. “What about a third, fourth, or fifth opinion?” I asked. “Sure,” she said, “as many as you’d like” (although the nice lady on the other end of the phone probably thought that one psychiatric opinion would suffice).

Nowadays you can even get a second opinion without leaving the comfort of your own home. Sites such as the Cleveland Clinic’s MyConsult allow you to tap the brains of their doctors with the ease of the “phone a friend” option on “Who Wants To Be A Millionaire?” The only drawback—as clearly spelled out on the site’s disclaimer page—is that insurance won’t pay a cent of the $565 it costs to initiate the service.

A couple of years ago CNN posted a list of 5 diagnoses that call for a second opinion: “when the diagnosis is tricky, the procedure is risky or has permanent consequences, or when there are less-invasive alternatives.”

1. Heart bypass surgery
   
2. Hysterectomy
   
3. Pregnancy termination for fetal abnormality
   
4. Surgery for varicose veins
   
5. Treatments for brain tumors

I can’t say that I know much about the manifold treatment options for brain tumors or varicose veins, but I do know something about cardiology. In that light, here’s my list of clinical scenarios where there are many treatment options and for which you should seek a second opinion if you don’t feel comfortable with your doctor’s suggestions:

1. Cardiac catheterization when you have no symptoms (as in the example at the beginning of this post)
   
2. Surgery for valvular heart disease, especially involving valve leakage (regurgitation)
   
3. Rhythm control or surgical treatment of atrial fibrillation
   
4. Hypertension resistant to numerous medications
   
5. Pacemaker for lightheadedness or fainting in the absence of clear evidence of slow heart rate
   
6. Pacemaker for slow heart rate in the absence of symptoms of lightheadedness or fainting
   
7. Any treatment regimen consisting mainly of branded (rather than generic) medications
   
8. Routine use of expensive “screening” testing in the absence of symptoms

Bear in mind that I’m not recommending that anything on the above list is wrong or inappropriate—there are many situations where such testing or therapy is warranted. It’s just been my experience that overly aggressive therapy occasionally accompanies these particular clinical scenarios.

In summary, you should never hesitate to seek a second medical opinion if you are uncomfortable with the recommendations your doctor makes, particularly when you are being asked to undergo invasive testing or therapy and especially if you feel that you and your doctor haven’t enjoyed a level of communication that satisfies your concerns.

This last week the newspapers reported on yet another chapter in the story of Dick Cheney’s ongoing struggle with heart disease.  The former vice president was admitted to George Washington Hospital in June for “chest pain” and has now announced that he underwent surgical placement of a heart pump.

Mr. Cheney’s long-running saga of cardiac issues reads more like an exhaustive treatise on cardiovascular disease than a personal biography.  He suffered his first heart attack in 1978 at the tender age of 37 and with that gave up his longstanding smoking habit.  Just ten years (and two heart attacks) later he underwent coronary artery bypass surgery.   Since that time he’s had at least one more heart attack, episodes of unstable angina, two percutaneous interventions (angioplasty and stents), congestive heart failure (CHF), peripheral arterial aneurysm repair, atrial fibrillation, and the placement of a defibrillator.  I now almost need to consult my cardiology textbooks to conjure up any heart ailments he hasn’t had.  Let’s see . . . as far as I can tell he’s yet to develop Chaga’s disease or peripartum cardiomyopathy.

The former veep is now the proud owner of a HeartMate II ventricular assist device (VAD), a small machine that serves as an accessory pump in the chest to relieve pressure on his ailing heart.  Requiring an open thoracotomy (“cracking the chest”), the $100,000 VAD has proven quite effective at dramatically improving patients’ symptoms and extending their lives to the point where they can undergo cardiac transplantation.  Recent published studies also suggest that the device can serve as a stand-alone therapy (referred to as “destination therapy”) for CHF rather than just a bridge to transplant, and there are many reports of patients doing so well with the VAD that their own heart has the ability to heal to the point that the device can be removed.

The pump itself is a fascinating marvel of engineering.  The VAD sits inside the chest and draws blood from the left ventricle of the heart through a large diameter tube.  A magnetically driven corkscrew mechanism serves as the pump and allows the device to function with only one moving part, decreasing the likelihood of malfunction over time.  The blood is then propelled into the base of the ascending aorta and continues on to the rest of the body.  Check out this interesting video from the manufacturer’s website for a graphic illustration.

Now here’s the fascinating part.  The VAD cycles blood to the aorta in a continuous fashion.  As you may have already surmised from inspection of your own body, the pump most of us were born with propels the blood in a pulsatile manner, resulting in the familiar pulse found in the wrist, neck and elsewhere.  Here’s what Wikipedia has to say about this design:

“A side effect is that the user will not have a pulse, or that the pulse intensity will be seriously reduced, and will need to carry documentation saying that the lack of a pulse does not mean that they are dead.”

While I’m normally quite fond of the reliability of Wikipedia in the realm of medicine, I was a little skeptical about the whole issue of documentation.  I would have thought that the owner of this type of device could be taken at their word that they are still alive and would not need to produce some type of written verification.  I can imagine that late night comedians could have a field day with this tantalizing bit of information about Mr. Cheney, a man many left-leaning pundits already accuse of being among the undead.

In order to clarify the purported need for proof-of-life I reached out to an expert on the matter.  Dr. Mohammed Quader is a cardiothoracic surgeon who has long been a member of the heart transplant team at the Nebraska Medical Center and is someone who has implanted a number of these fascinating pumps.  He told me that these patients are indeed lacking in the usual arterial pulse but appear to function remarkably well despite the aberrancy.  It turns out that the presence of pulsation is not necessary to normal physiological function and that blood flow at the level of muscles and organs is non-pulsatile anyway (the oscillations of systolic and diastolic pressure become dampened as blood progresses from large elastic vessels like the aorta and brachial artery to the small arterioles and capillaries).

Since the presence of a pulse is requisite for the use of a sphygmomanometer (blood pressure cuff) a nurse or medical technician would have to use a Doppler probe in order to determine the patient’s mean arterial pressure.  Dr. Quader states that patients are not actually required to carry around the documentation cited by Wikipedia, but that the patient and their family members are educated about the lack of pulse and can pass this information along to emergency medical providers.

One of the current limitations to the existing devices relates to their supply of electricity during normal function.  While the device Mr. Cheney owns will be encased in his rib cage he will still have a power cord connecting the VAD to an external battery source.  Patients need to carry with them the battery needed to power the device as well as a back-up battery to employ the moment its needed—losing power to a VAD is a slightly more serious problem than having a cell phone battery go dead.

The power cord itself is a source of some of the difficulty with the VAD as it serves as a conduit for bacteria to potentially enter and infect the space occupied by the device.  This problem will likely be remedied in the not-to-distant future by technology that enables wireless transmission of electrical energy from a battery pack outside the skin to the implanted VAD without the need for a cord.

My personal experience with the device is limited to a solitary patient of mine who recently received a HeartMate II and whom I saw in my clinic a couple of weeks ago.  She suffers from dilated cardiomyopathy and has had declining health over the course of the last few months despite my best efforts.  I sent her to the Nebraska Medical Center to be listed for heart transplantation and as her condition worsened the transplant doctors decided to offer her the VAD.  Her quality of life improved dramatically after she received the device and she is now back to a fairly healthy level of daily activity.  I admit it was a little spooky listening to her chest and not hearing the familiar lub-dub that accompanies most of my living patients.  She remains on the cardiac transplant list but should do quite well for the foreseeable future.

Others have done well with such devices for several years. The longest surviving owner of a VAD was one Peter Houghton, a psychotherapist and author who received an early-generation device in 2000 and went on to live 7 more years with the same device during which time he completed a 91 mile charity walk, published two books, lectured widely, hiked in the Swiss Alps and the American West, flew in an ultra-light aircraft, and traveled extensively around the world.

While I don’t foresee Mr. Cheney spending too much time in the Alps he’ll probably recover from this episode as quickly and gracefully as he has from nearly everything else.  And, despite his lack of heartbeat, I don’t imagine he’ll miss a beat as he resumes his usual cantankerous vexing of the current presidential administration and liberal pundits.

Now, whatever you do, don’t get too excited, anxious, worked-up, or fretful about this post.  It is, after all, only words on paper (or pixels on a computer screen, as the case may be).  Words cannot really hurt you—unless, of course, you’re hit on the head by a falling sign.  So, take a deep breath, relax and focus on your happy place.  Ready?  OK, here we go.

Two studies came out in this week’s issue of the Journal of the American College of Cardiology that link anxiety early in your life to heart disease later on.  The first was a meta-analysis of 20 studies among populations around the world that included the experience of nearly a quarter million individuals.  The authors were able to tease out of this large database a statistic that shows that anxious people are a quarter to a half more likely to suffer coronary disease or cardiac-related death than their calmer counterparts.

Even more compelling is a clever longitudinal evaluation of nearly 50 thousand young Swedish military conscripts reporting for duty between 1969 and 1970.  Each 18-to-20-year-old male was given a thorough physical and completed an exhaustive questionnaire.  If any of them gave answers that suggested any depression or anxiety (who could be anxious about joining the Swedish military in 1970?  It wasn’t exactly a hotbed of battlefield activity in those days.) they went on for a thorough evaluation by a psychiatrist.  Thanks to the magic of socialized medicine the researchers tracked the health course of all these individuals for 37 years and were able to determine who among them developed heart disease.  Among the cohort of enlistees with a clinical diagnosis of anxiety the risk of developing coronary disease in the ensuing decades was over two-fold higher.

On the surface you might object to the findings of these studies with the argument that inherently anxious people tend to smoke more and exercise less, but your objections wouldn’t hold.  Thanks to the large numbers in both of these studies the authors were able to factor in variables such as exercise and use of tobacco, and the relationship between anxiety and heart disease remained strong.

Possible explanations for the link between these two common disorders tend to all invoke the elevated level of catecholamines (adrenalin and noradrenalin) frequently demonstrated in jittery people and how these “fight or flight” hormones can have an insidious deleterious effect over time.

Anxiety itself is a bothersome enough problems without introducing yet another misery to accompany what is clearly a sometimes debilitating disorder.  Already, anxious people are afflicted with “considerable suffering, disability, and impaired quality of life,” according to the University of California, San Diego psychiatrist Joel E. Dimsdale, M.D., in an accompanying editorial.  He goes on:

“The lifetime prevalence of anxiety disorders is approximately 28%.  Their impact on global functioning is roughly akin to that of low back pain or leg ulcers.  When anxiety coexists with depression, the corresponding impact on quality of life is even worse, along the lines of the impact of chronic obstructive pulmonary disease.”

The unknown factor in all of this is whether treatment for anxiety can ameliorate its long-term effect on coronary disease.  If you’re an emotionally wound-up nervous wreck but do your daily tai chi and yoga, eat all your healthy vegetables, take your prescribed anxiolytic medication, and become one with the universe, will you be able to cut your risk of heart disease back to the level of the rest of us calm people?  Or is your fate sealed the moment you are officially labeled with “anxiety disorder?”  We can’t know, and we may never know.  To figure this out we’d need to organize and fund a long-term controlled study comparing treatment to no treatment in thousands of anxious volunteers over the course of several decades—a prospect that no one is willing to take on.

So now, dear readers, if you’ve managed to stay calm throughout your perusal of this brief report, you’ve got nothing to worry about.  If, however, this revelation fills you with apprehension and dread then I offer you my sincerest apologies and take full responsibility for triggering anxiety and its lasting effects on your heart.  Schedule yourself an appointment with a cardiologist in, say, 20 or 30 years, then just sit back and try to relax.

I read an interesting article in the NY Times the other week regarding a phenomenon I’ve seen over and over in hospital intensive care units.  The report, published June 20, 2010, claims that nearly one third of patients over the age of 70 will experience some degree of delirium during a hospital stay, especially if they spend any time in the ICU.  With our current population pushing the curve of age distribution farther to the right we will be seeing more geriatric patients admitted to hospitals and with them more frequent cases of delirium.

A reasonable definition of delirium would be as follows (courtesy of medical-dictionary.com):

“An acute, reversible organic mental disorder characterized by reduced ability to maintain attention to external stimuli and disorganized thinking as manifested by rambling, irrelevant or incoherent speech. There is also a reduced level of consciousness, sensory misperceptions, disturbance of the sleep wakefulness cycle and level of psychomotor activity, disorientation to time, place or person and memory impairment.”

The key words in the definition that differentiate delirium from chronic mental illness or dementia are acute and reversible.  If you indulge yourself at a college frat party and strip to your skivvies for a night of dancing on the furniture, you’d be classified as delirious (since you’d presumably be of sound—although embarrassed—mind once the alcohol effect wears off).  A patient with Alzheimer’s, whose symptoms may include those in the definition cited above, would not be classified as delirious since the manifestations are neither acute nor reversible (typically).

To give you an idea what some of these patients are experiencing, allow me to cite the NY Times story:

No one who knows Justin Kaplan would ever have expected this. A Pulitzer Prize-winning historian with a razor intellect, Mr. Kaplan, 84, became profoundly delirious while hospitalized for pneumonia last year. For hours in the hospital, he said, he imagined despotic aliens, and he struck a nurse and threatened to kill his wife and daughter.

Justin Kaplan thought himself besieged by “thousands of tiny little creatures,” he said, “some on horseback, waving arms, carrying weapons,” during his bout with hospital delirium last year.

“Thousands of tiny little creatures,” he said, “some on horseback, waving arms, carrying weapons like some grand Renaissance battle,” were trying to turn people “into zombies.” Their leader was a woman “with no mouth but a very precisely cut hole in her throat.”

Attacking the group’s “television production studio,” Mr. Kaplan fell from his hospital bed, cutting himself and “sliding across the floor on my own blood,” he said. The hospital called security because “a nurse was trying to restrain me and I repaid her with a kick.”

My experience with hospitalized elderly people is similar.  I’ve seen patients who believe that long-dead relatives or ghostly strangers are roaming their hospital rooms.  Patients have told me of animals around their beds and scenes from their childhood being replayed before their eyes.  Many will simply become confused and disoriented.

And these are the more benign variety.  Some patients suffer impressive levels of paranoia, insisting that the doctors and nurses are out to kill or imprison them or that family members are conspiring to eliminate them.  They’ll refuse to take medication, fight back anytime a nurse or aide approaches, and yell out or become belligerent in the darkest hours of the night.

These episodes are not without their consequences.  As pointed out in the NY Times article, delirious patients tend to end up with longer and more complicated hospitalizations than lucid individuals.  I saw a patient last week who suffered a heart attack at an outside hospital and underwent a relatively uncomplicated angiogram.  While he was recovering from the procedure he became confused and agitated, whereupon his doctors responded by sedating him to the point that he aspirated and developed respiratory failure.  He spent a week on the ventilator—a week that would have been spent in the comfort of his home had it not been for his acute delirium and the treatment provided.

Family members become appropriately concerned when they see grandma or grandpa “going nuts” and want to know the cause.  Here are a few possibilities:

• Pain medications often accompany a stay in the hospital and can wreak havoc on an elderly patient’s level of coherency.  Older people tend to metabolize narcotics and sedatives more slowly, resulting in an excessive accumulation of the active chemical in the patient’s body.  Other drugs—even those we don’t typically think of as sedating—can significantly impair clear cognition in susceptible geriatric patients.  A good example is diphenhydramine (Benadryl) with its potent anticholinergic effect.
  
• Illness tends to affect older patients differently than the rest of us.  I’ve always been impressed with how a problem as simple as a bladder infection can trip a debilitated nursing home patient into an incoherent stupor.  Medical students learn very quickly to screen for simple infections when older patients are admitted for confusion.
  
• Being in the ICU is a bit like being on the Las Vegas strip at midnight (and, no, I’m not referring to the revealing nature of the hospital garb)—the lights are always on, the pumps and monitor beep incessantly, and alarms sound for every physiological aberration from the norm.  Doctors, nurses and technicians enter the room randomly at all hours with stethoscopes, needles, and x-ray equipment.  Night and day become theoretical concepts to a patient who drifts in and out of non-restorative, interrupted sleep.  This deprivation of normal diurnal cycle—a staple of combat interrogators eager to “break” a captive—can degrade a patient’s mental lucidity to the point of psychosis.
  
• Older patients with early or borderline dementia can often function in their normal environment without family members suspicious of the beginnings of mental impairment.  At home, in their usual daily routine, there is nothing that challenges their ability to perform the simple tasks expected of them.  Put them in a hospital, however, with a constant turnover of new faces and unexpected stresses, and what appears to be a new case of delirium is nothing more than the unmasking of dementia.  (It should be noted that patients who suffer hospital delirium are more likely to develop dementia at a later point—an association that underscores the idea that the stress of the hospital simply unveils early dementia in these individuals.)
  
• Other, random things can impair a patient’s ability to hold on to reality: they change rooms, sometimes in the middle of the night; their glasses and hearing aids are placed in closets and drawers, leaving the patients in effective sensory deprivation; they can be left isolated from the usual company of known family members and friends; they suffer sleep deficiency, eat strange foods, are overheated or chilled—even the interruption of usual bowel patterns add to the mix of ingredients that bake up a potpourri of confusion and hallucinations in their heads.

What can be done about this?  The first and most obvious step is to recognize it for what it is and not overreact to it.  Family members shouldn’t get too anxious about what they perceive as “craziness” on the part of grandpa—in nearly all cases the patients return to normal once they are back in a less disruptive environment.

We doctors need to try to resist the reflexive use of sedatives or antipsychotics in patients with mild cases of delirium.  Rather, we should expend the effort to sort out what type of environmental, medical, or pharmacological trigger is to blame for the change in mental status, then try to rectify it.

Finally, hospital personnel should do all they can to stabilize the environment for geriatric patients.  Numerous facilities have adopted the Hospital Elder Life Program (HELP), a method of patient care that aims to prevent the development of delirium “by keeping hospitalized older people oriented to their surroundings, meeting their needs for nutrition, fluids, and sleep and keeping them mobile within the limitations of their physical condition.”  Their website has numerous suggestions that are simple, easy to implement, and have been scientifically tested and validated.

I’ll conclude this post with a final anecdote:

On my first call night as a new medical intern my resident and I were called to the coronary unit to help calm an older patient who had become disruptive.  He had a history of mild dementia and had already begun to annoy the unit staff by performing a series of a cappella renditions of old show tunes at the top of his lungs.  We were called only when he began carrying on about bats flying around his hospital room.  He had become a little more anxious and seemed to be perseverating on the subject to the extent that his performance playlist now consisted only of songs about flying rodents.

We wrote for some haloperidol (at the time, a medication on the short list of any new intern) and headed back to our call room.  Within minutes we received a panicked call from the nursing station: get back here immediately.  When we arrived we were greeted by the muffled panting of nurses as they huddled under the nursing station desks and the anxious hands pointing up into the air.  Around the corner flew a bat, swooping in and out of the open rooms of the ICU.  Before the night was done more than a dozen bats were apprehended, all of which appeared to have entered the hospital by an open window in the room where our demented, operatic patient was now resting blissfully.

The moral of the story?  Close the windows to the ICU if the belfry of the 100-year-old building across the street is undergoing construction.

Well, at least that’s one moral.  Another would be to take a close look at a newly delirious patient before reaching for your prescription pad and try to find the root cause.  Maybe they aren’t as crazy as they look.