As a newly trained attending physician, I vividly remember several patients who became extremely confused during their stay at the hospital. They were disoriented, and had problems with attention and memory. I realized that something was wrong. What was causing their confusion? They were all older adults and had been admitted for different conditions such as congestive heart failure, pulmonary disease, and cancer.
Every single physician I spoke with, including the Chief of Medicine said, “Don’t worry about it. The confusion is normal in older adults. We see that all the time. They will get better.” But I noticed that these patients actually ended up doing worse. I spent hours reviewing their medical charts, examining their treatment, and tracking when they became confused. In fact, I came to realize that aspects of the care we gave them during hospitalization—medications, procedures, sleep deprivation, and immobilization— were contributing to their confusion.
When I was a young physician in the 1980s there was very little in the medical literature on delirium, a serious medical condition that presents as sudden confusion or an abrupt change in mental status. At that time, no one really understood what it was, how to diagnose it, or which patients were vulnerable. Delirium and geriatric medicine are extremely important areas for scientific investigation and innovation, but receive little attention from funders and researchers—something I wanted to change.
My goal was to shed light on delirium, spread awareness of the clinical signs of the condition, and make a difference in geriatric care. My first step towards this goal was to develop the Confusion Assessment Method (CAM) to give clinicians a way to identify delirium quickly and accurately in both clinical and research settings. Since its development, the CAM has become the most widely used delirium instrument worldwide because of both its strong validation results as well as its ease of use. The CAM instrument has been used in over 5,000 original articles to date, and has been translated into over 16 languages.
We now know that delirium is a common, costly, life-threatening yet potentially preventable condition. Each year, more than 12 million older Americans develop delirium, and the condition costs the nation more than $164 billion in healthcare costs. Long-term consequences of delirium include increased risks of death, dementia, and prolonged disability. As a result of my work, acute confusion in older adults is no longer considered “normal” and every clinician is aware of the serious adverse effects associated with delirium. Delirium is now included on the curriculum of every medical and nursing school in the country.
Over the past 25 years, my research has focused on the prevention of delirium and cognitive and functional decline in older hospitalized patients. This commitment has brought about system-wide interventions aimed at improving health care quality for older adults. One such example is the Hospital Elder Life Program (HELP), an evidence-based model of hospital care that is designed to prevent delirium and improve health care outcomes for older persons. HELP prevents cognitive and functional decline in older patients while maintaining their dignity and respect. Recently, a HELP-trained nurse related: “We just got a letter from a patient's family complimenting the program, just saying how exceptional it was and the fact that their mother stayed both physically and mentally active."
IFAR has long been an innovator in cognitive aging and ways to optimize brain health, and I established the Aging Brain Center at IFAR in 2005 to continue this mission, by working to advance research on cognitive and physical functioning in older adults following delirium. Currently underway, the Successful Aging after Elective Surgery (SAGES) study—an $11 million project funded by the National Institutes of Health—examines how surgery and hospitalization may lead to a series of events in which older adults develop difficulties in thinking, functioning, and memory. SAGES is one of the largest studies of its kind and investigates risk factors of delirium and its long-term impact on patients. The results of our work aim to find ways of helping older adults successfully recover after surgery, avoid complications from hospitalization and surgery, and maintain their cognitive abilities—ultimately improving the quality of life for older adults.
Most recently, as a member of the Institute of Medicine of the National Academies I took part in a committee that wrote an important report that will have a significant impact on practice and policy for older adults, “Cognitive Aging: Progress in Understanding and Opportunities for Action.” This report addresses the concept of cognitive aging, its impact on public health, and the actions the nation needs to take to better understand and maintain the cognitive health of older adults. In addition to important policy recommendations, the report offers advice to older adults that promotes cognitive health by highlighting the areas of exercise, diet, delirium prevention, and prudent use of medications.