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As a hospitalist, you are in a unique position to notice changes in your hospitalized patients. This frontline perspective can be used to improve inpatient attention and care, and differs from primary care, where a clinician might only see a patient once or twice a year, and subtle, gradual changes may be missed, said George Cao, MD, MBA, a hospitalist at the University of Vermont Medical Center in Burlington and assistant professor at UVM’s Larner College of Medicine.
But in the hospital, Cao said even small shifts — like becoming less active, eating less, or changes in personality — can become much more obvious.
“As hospitalists…we see patients throughout the day, in different situations, and often end up spending more time with them over the course of a week than their primary care provider might in a year,” Cao explained. “This gives us a real advantage in picking up on subtle changes in mental awareness.”
These assessments can also be evaluated with the benefit of daily labs, frequent bedside interactions, and 24–hour observations.
With older adults, Cao said it’s important to go beyond just what’s in the chart.
“I always start by reviewing notes from the primary care provider and previous admissions, but some of the most valuable insights come from talking with family and close friends to get a true sense of the patient’s baseline — how they usually think, move, and interact,” he said.
Why to Watch for Declining Mental Awareness
Declining mental awareness in the inpatient setting is often a sign of an underlying problem — whether that’s a reversible medical condition, unrecognized dementia, or the development of delirium, Cao said.
“On the inpatient side, I pay close attention to more than just memory loss,” he said.
Changes in how patients function day–to–day, shifts in their behavior, or even something as simple as not wanting to get out of bed can be early signs of an aging mind or untreated psychiatric issues, he noted.
“Of course, we always rule out infections and medication side effects, but I also look for other reversible causes like thyroid problems, electrolyte imbalances, low oxygen, pain, urinary retention, constipation, and nutritional deficiencies,” Cao said.
Of note, delirium is the most common cause of sudden mental status changes in the hospital, and “it’s easy to miss if you’re not looking for it.”
He summarized that classic signs are an acute and fluctuating course with changes in alertness, but added there are other red flags too: disorientation, hallucinations, changes in sleep patterns, sporadic unsafe behaviors, mood swings, and changes in activity level, whether that’s agitation or just being unusually quiet.
By combining what he notices bedside and what is learned from the medical record (and from the people who know the patient best), Cao said he’s able to catch these changes early, identify the underlying cause, and work toward the best possible outcome.
“One of the main interventions is providing mental stimulation,” he said.
Why Mental Stimulation Is So Vital
Mental stimulation of the patient is critical to recovery and may prevent prolonged illness, said Meghana R. Medavaram, MD, associate director of consultation liaison and emergency psychiatry at Montefiore Medical Center’s Weiler Hospital in New York City. “Keeping a patient active both physically and mentally can help prevent deconditioning and risks of prolonged immobility,” she said.
It’s important to note that when patients are out of their familiar routines, away from their usual environment and people, and their sleep is fragmented, this can make them even more vulnerable. Keeping patients mentally stimulated during their hospital stay can help maintain their attention, orientation, and a healthy sleep-wake cycle — all things that are easily thrown off in the hospital, Cao said.
“These disruptions hit the pathways that control attention, wakefulness, and the sleep–wake cycle. That’s when you see attention drifting, orientation fading, and circadian rhythms unraveling, especially at night, which is why “sundowning” is so common, Cao said, referring to the syndrome where older adults or people with dementia experience behavioral changes in late afternoon or evening. “Mental stimulation is critical in the hospital because when the brain isn’t active and gets disoriented, it becomes an easy target for delirium.”
He said delirium often develops in older adults when acute stressors like inflammation, low oxygen, metabolic imbalances, or sedating medications disrupt the brain’s arousal systems and networks, especially in older adults.
Therefore, Cao said, encourage your patients to be more engaged during the day through conversation, activities, or regular reorientation. “This supports the brain networks that help prevent inattention and confusion, which are the hallmarks of delirium. Daytime stimulation also helps build up the natural drive for nighttime sleep, so patients are less likely to nap during the day and be awake and disoriented at night.”
To support this, it’s helpful to schedule medications during waking hours instead of around–the–clock dosing that interrupts sleep, and to cluster nighttime care activities to minimize disturbances, Cao explained. Ensuring patients have their glasses, hearing aids, and familiar routines, along with encouraging mobility and hydration, further protects against delirium and supports patients’ cognitive health during hospitalization. “These same principles are just as important in outpatient subacute rehab settings and at home, so it’s essential to take home these strategies after discharge,” he said.
A Family Member or Friend May Help
Hospitalists can suggest straightforward ways to encourage families and friends to keep patients engaged during a hospital stay. Visits and chats can go a long way as conversations are incredibly grounding, Cao said. Other methods could be bringing in favorite foods or snacks, a phone chat or video call, or even showing prerecorded video messages. “These can be effective. Patients respond well to seeing and hearing familiar faces and voices, even if it’s just on a screen,” Cao said.
Beyond that, he said, activities such as watching and discussing the news, reading aloud, using tablets for games, watching movies, doing crossword puzzles, knitting, reminiscing, and playing word games can also be mentally stimulating for patients.
In addition, safe exercises/activities that patients can do in bed — with advice from physical therapy and occupational therapy — are beneficial, Medavaram said. “These often include gentle range–of-motion activities,” she said.
Share Importance of Mental Stimulation With Patients and Caregivers
If a hospitalist wants to motivate patients to keep their minds active, the framing should be simple, positive, and tied directly to their goals of getting better and getting home, said Medavaram. She provided this script suggestion:
“One of the best ways to help your recovery isn’t just taking your medicine, it’s keeping your mind active. When you’re in the hospital, it’s easy to spend the day lying in bed and staring at the TV in your room, but that can make your brain slow down and even cause confusion. Simple things — like reading, talking with visitors, doing puzzles, listening to music you enjoy, or telling a nurse about your favorite memories — can keep your brain sharp. Staying mentally active helps your thinking stay clear and can even help you get home sooner. Think of it like physical therapy for your brain.”
A version of this article first appeared on Medscape.com.
As a hospitalist, you are in a unique position to notice changes in your hospitalized patients. This frontline perspective can be used to improve inpatient attention and care, and differs from primary care, where a clinician might only see a patient once or twice a year, and subtle, gradual changes may be missed, said George Cao, MD, MBA, a hospitalist at the University of Vermont Medical Center in Burlington and assistant professor at UVM’s Larner College of Medicine.
But in the hospital, Cao said even small shifts — like becoming less active, eating less, or changes in personality — can become much more obvious.
“As hospitalists…we see patients throughout the day, in different situations, and often end up spending more time with them over the course of a week than their primary care provider might in a year,” Cao explained. “This gives us a real advantage in picking up on subtle changes in mental awareness.”
These assessments can also be evaluated with the benefit of daily labs, frequent bedside interactions, and 24–hour observations.
With older adults, Cao said it’s important to go beyond just what’s in the chart.
“I always start by reviewing notes from the primary care provider and previous admissions, but some of the most valuable insights come from talking with family and close friends to get a true sense of the patient’s baseline — how they usually think, move, and interact,” he said.
Why to Watch for Declining Mental Awareness
Declining mental awareness in the inpatient setting is often a sign of an underlying problem — whether that’s a reversible medical condition, unrecognized dementia, or the development of delirium, Cao said.
“On the inpatient side, I pay close attention to more than just memory loss,” he said.
Changes in how patients function day–to–day, shifts in their behavior, or even something as simple as not wanting to get out of bed can be early signs of an aging mind or untreated psychiatric issues, he noted.
“Of course, we always rule out infections and medication side effects, but I also look for other reversible causes like thyroid problems, electrolyte imbalances, low oxygen, pain, urinary retention, constipation, and nutritional deficiencies,” Cao said.
Of note, delirium is the most common cause of sudden mental status changes in the hospital, and “it’s easy to miss if you’re not looking for it.”
He summarized that classic signs are an acute and fluctuating course with changes in alertness, but added there are other red flags too: disorientation, hallucinations, changes in sleep patterns, sporadic unsafe behaviors, mood swings, and changes in activity level, whether that’s agitation or just being unusually quiet.
By combining what he notices bedside and what is learned from the medical record (and from the people who know the patient best), Cao said he’s able to catch these changes early, identify the underlying cause, and work toward the best possible outcome.
“One of the main interventions is providing mental stimulation,” he said.
Why Mental Stimulation Is So Vital
Mental stimulation of the patient is critical to recovery and may prevent prolonged illness, said Meghana R. Medavaram, MD, associate director of consultation liaison and emergency psychiatry at Montefiore Medical Center’s Weiler Hospital in New York City. “Keeping a patient active both physically and mentally can help prevent deconditioning and risks of prolonged immobility,” she said.
It’s important to note that when patients are out of their familiar routines, away from their usual environment and people, and their sleep is fragmented, this can make them even more vulnerable. Keeping patients mentally stimulated during their hospital stay can help maintain their attention, orientation, and a healthy sleep-wake cycle — all things that are easily thrown off in the hospital, Cao said.
“These disruptions hit the pathways that control attention, wakefulness, and the sleep–wake cycle. That’s when you see attention drifting, orientation fading, and circadian rhythms unraveling, especially at night, which is why “sundowning” is so common, Cao said, referring to the syndrome where older adults or people with dementia experience behavioral changes in late afternoon or evening. “Mental stimulation is critical in the hospital because when the brain isn’t active and gets disoriented, it becomes an easy target for delirium.”
He said delirium often develops in older adults when acute stressors like inflammation, low oxygen, metabolic imbalances, or sedating medications disrupt the brain’s arousal systems and networks, especially in older adults.
Therefore, Cao said, encourage your patients to be more engaged during the day through conversation, activities, or regular reorientation. “This supports the brain networks that help prevent inattention and confusion, which are the hallmarks of delirium. Daytime stimulation also helps build up the natural drive for nighttime sleep, so patients are less likely to nap during the day and be awake and disoriented at night.”
To support this, it’s helpful to schedule medications during waking hours instead of around–the–clock dosing that interrupts sleep, and to cluster nighttime care activities to minimize disturbances, Cao explained. Ensuring patients have their glasses, hearing aids, and familiar routines, along with encouraging mobility and hydration, further protects against delirium and supports patients’ cognitive health during hospitalization. “These same principles are just as important in outpatient subacute rehab settings and at home, so it’s essential to take home these strategies after discharge,” he said.
A Family Member or Friend May Help
Hospitalists can suggest straightforward ways to encourage families and friends to keep patients engaged during a hospital stay. Visits and chats can go a long way as conversations are incredibly grounding, Cao said. Other methods could be bringing in favorite foods or snacks, a phone chat or video call, or even showing prerecorded video messages. “These can be effective. Patients respond well to seeing and hearing familiar faces and voices, even if it’s just on a screen,” Cao said.
Beyond that, he said, activities such as watching and discussing the news, reading aloud, using tablets for games, watching movies, doing crossword puzzles, knitting, reminiscing, and playing word games can also be mentally stimulating for patients.
In addition, safe exercises/activities that patients can do in bed — with advice from physical therapy and occupational therapy — are beneficial, Medavaram said. “These often include gentle range–of-motion activities,” she said.
Share Importance of Mental Stimulation With Patients and Caregivers
If a hospitalist wants to motivate patients to keep their minds active, the framing should be simple, positive, and tied directly to their goals of getting better and getting home, said Medavaram. She provided this script suggestion:
“One of the best ways to help your recovery isn’t just taking your medicine, it’s keeping your mind active. When you’re in the hospital, it’s easy to spend the day lying in bed and staring at the TV in your room, but that can make your brain slow down and even cause confusion. Simple things — like reading, talking with visitors, doing puzzles, listening to music you enjoy, or telling a nurse about your favorite memories — can keep your brain sharp. Staying mentally active helps your thinking stay clear and can even help you get home sooner. Think of it like physical therapy for your brain.”
A version of this article first appeared on Medscape.com.
As a hospitalist, you are in a unique position to notice changes in your hospitalized patients. This frontline perspective can be used to improve inpatient attention and care, and differs from primary care, where a clinician might only see a patient once or twice a year, and subtle, gradual changes may be missed, said George Cao, MD, MBA, a hospitalist at the University of Vermont Medical Center in Burlington and assistant professor at UVM’s Larner College of Medicine.
But in the hospital, Cao said even small shifts — like becoming less active, eating less, or changes in personality — can become much more obvious.
“As hospitalists…we see patients throughout the day, in different situations, and often end up spending more time with them over the course of a week than their primary care provider might in a year,” Cao explained. “This gives us a real advantage in picking up on subtle changes in mental awareness.”
These assessments can also be evaluated with the benefit of daily labs, frequent bedside interactions, and 24–hour observations.
With older adults, Cao said it’s important to go beyond just what’s in the chart.
“I always start by reviewing notes from the primary care provider and previous admissions, but some of the most valuable insights come from talking with family and close friends to get a true sense of the patient’s baseline — how they usually think, move, and interact,” he said.
Why to Watch for Declining Mental Awareness
Declining mental awareness in the inpatient setting is often a sign of an underlying problem — whether that’s a reversible medical condition, unrecognized dementia, or the development of delirium, Cao said.
“On the inpatient side, I pay close attention to more than just memory loss,” he said.
Changes in how patients function day–to–day, shifts in their behavior, or even something as simple as not wanting to get out of bed can be early signs of an aging mind or untreated psychiatric issues, he noted.
“Of course, we always rule out infections and medication side effects, but I also look for other reversible causes like thyroid problems, electrolyte imbalances, low oxygen, pain, urinary retention, constipation, and nutritional deficiencies,” Cao said.
Of note, delirium is the most common cause of sudden mental status changes in the hospital, and “it’s easy to miss if you’re not looking for it.”
He summarized that classic signs are an acute and fluctuating course with changes in alertness, but added there are other red flags too: disorientation, hallucinations, changes in sleep patterns, sporadic unsafe behaviors, mood swings, and changes in activity level, whether that’s agitation or just being unusually quiet.
By combining what he notices bedside and what is learned from the medical record (and from the people who know the patient best), Cao said he’s able to catch these changes early, identify the underlying cause, and work toward the best possible outcome.
“One of the main interventions is providing mental stimulation,” he said.
Why Mental Stimulation Is So Vital
Mental stimulation of the patient is critical to recovery and may prevent prolonged illness, said Meghana R. Medavaram, MD, associate director of consultation liaison and emergency psychiatry at Montefiore Medical Center’s Weiler Hospital in New York City. “Keeping a patient active both physically and mentally can help prevent deconditioning and risks of prolonged immobility,” she said.
It’s important to note that when patients are out of their familiar routines, away from their usual environment and people, and their sleep is fragmented, this can make them even more vulnerable. Keeping patients mentally stimulated during their hospital stay can help maintain their attention, orientation, and a healthy sleep-wake cycle — all things that are easily thrown off in the hospital, Cao said.
“These disruptions hit the pathways that control attention, wakefulness, and the sleep–wake cycle. That’s when you see attention drifting, orientation fading, and circadian rhythms unraveling, especially at night, which is why “sundowning” is so common, Cao said, referring to the syndrome where older adults or people with dementia experience behavioral changes in late afternoon or evening. “Mental stimulation is critical in the hospital because when the brain isn’t active and gets disoriented, it becomes an easy target for delirium.”
He said delirium often develops in older adults when acute stressors like inflammation, low oxygen, metabolic imbalances, or sedating medications disrupt the brain’s arousal systems and networks, especially in older adults.
Therefore, Cao said, encourage your patients to be more engaged during the day through conversation, activities, or regular reorientation. “This supports the brain networks that help prevent inattention and confusion, which are the hallmarks of delirium. Daytime stimulation also helps build up the natural drive for nighttime sleep, so patients are less likely to nap during the day and be awake and disoriented at night.”
To support this, it’s helpful to schedule medications during waking hours instead of around–the–clock dosing that interrupts sleep, and to cluster nighttime care activities to minimize disturbances, Cao explained. Ensuring patients have their glasses, hearing aids, and familiar routines, along with encouraging mobility and hydration, further protects against delirium and supports patients’ cognitive health during hospitalization. “These same principles are just as important in outpatient subacute rehab settings and at home, so it’s essential to take home these strategies after discharge,” he said.
A Family Member or Friend May Help
Hospitalists can suggest straightforward ways to encourage families and friends to keep patients engaged during a hospital stay. Visits and chats can go a long way as conversations are incredibly grounding, Cao said. Other methods could be bringing in favorite foods or snacks, a phone chat or video call, or even showing prerecorded video messages. “These can be effective. Patients respond well to seeing and hearing familiar faces and voices, even if it’s just on a screen,” Cao said.
Beyond that, he said, activities such as watching and discussing the news, reading aloud, using tablets for games, watching movies, doing crossword puzzles, knitting, reminiscing, and playing word games can also be mentally stimulating for patients.
In addition, safe exercises/activities that patients can do in bed — with advice from physical therapy and occupational therapy — are beneficial, Medavaram said. “These often include gentle range–of-motion activities,” she said.
Share Importance of Mental Stimulation With Patients and Caregivers
If a hospitalist wants to motivate patients to keep their minds active, the framing should be simple, positive, and tied directly to their goals of getting better and getting home, said Medavaram. She provided this script suggestion:
“One of the best ways to help your recovery isn’t just taking your medicine, it’s keeping your mind active. When you’re in the hospital, it’s easy to spend the day lying in bed and staring at the TV in your room, but that can make your brain slow down and even cause confusion. Simple things — like reading, talking with visitors, doing puzzles, listening to music you enjoy, or telling a nurse about your favorite memories — can keep your brain sharp. Staying mentally active helps your thinking stay clear and can even help you get home sooner. Think of it like physical therapy for your brain.”
A version of this article first appeared on Medscape.com.