In an interview on the Rusk Insights on Rehabilitation Medicine podcast, Jonathan H. Whiteson, MD, assistant professor of rehabilitation medicine and vice chair of clinical operations, spoke about encephalopathy and delirium in complex cardiopulmonary rehabilitation patients:
It’s very important that we recognize that encephalopathy and delirium are common following an admission to a hospital with a cardiac or a pulmonary event. One third of post-cardiac surgical patients and up to 80% of patients managed in an ICU setting with complex heart and/or lung disease will have cognitive disturbance consistent with encephalopathy and/or delirium. Oftentimes, these are older individuals, and they may have had some pre-existing cognitive decline that’s not always recognized. Pre-existing dementia magnifies the impact of encephalopathy and delirium as evidence by an increased mortality rate within one year after discharge.
I think one of the most important things that we’ve done at Rusk is educate our colleagues— ICU, surgical and medicine physicians, nursing staff, therapists—and discuss the impact on discharge planning. If a patient is living alone, and now they’re confused and don’t remember if they’ve taken their medications or how to manage themselves, they’re at increased risk of medical decline and readmission.
Recognizing the very significant impact of encephalopathy and delirium, every single one of our patients who is admitted onto our acute inpatient rehabilitation floor will undergo a thorough cognitive screen. Our psychologists, occupational therapists, social workers, nurses and PTs constitute our mental health team, where we’re purposefully looking for cognitive issues. We’ll interview not just the patient but family members as well, and really look for the clues to see if there were any pre-existing cognitive decline, what’s changed in the hospital, how significant the decline in cognition has been. We also look for communication deficits as these are closely linked. Ruling out hearing and vision deficits that can contribute to confusional states is also crucial.
So if somebody does have confusion, agitation, memory issues while on the cardiac and pulmonary rehabilitation unit, we manage them like a patient with brain dysfunction and try to reduce external input and stimuli. We make the environment consistent and quiet, lower the lighting, try and reduce the noise input and try to add consistency back into the pattern of daily care. We use memory aids like notebooks, provide a list of medications, and encourage patients to go over these lists as we are handing out medication from the nursing staff. Daily routines are repeated so that we can establish a cognitive pattern in all of our patients.
Helping patients and care givers become aware of cognitive issues can be upsetting to the patient and caregiver. Emotional support is critical to acceptance of safety plans both on the rehabilitation unit and in the transition to the home environment. Working with caregivers to ensure that home supervision is adequate is essential for longer term outcomes.