#375 Delirium in the Hospital featuring Dr. Esther Oh

January 9, 2023 | By Adam Barelski

In this episode you will learn to master delirium in the hospital!  We discuss preventing, recognizing, and managing this common and dangerous condition.  We are joined by delirium expert and President of the American Delirium Society, Dr. Esther Oh @EstherOh_MDPhD (Johns Hopkins University)

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Credits

• Produced, Script, Show Notes: Adam Barelski MD 
• Infographic & Cover Art: Edison Jyang; Sarah Phoebe Roberts
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP; Adam Barelski MD   
• Reviewer: Molly Heublein MD
• Showrunner: Matthew Watto MD, FACP; Paul Williams MD, FACP
• Technical Production: PodPaste
• Guest: Esther Oh MD, PhD

Sponsor: Panacea Financial 

Visit panaceafinancial.com to open your free account. 

CME Partner: VCU Health CE

Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner, Picks of the Week*
• Case 1 from Kashlak: hypoactive delirium
• Definition of delirium
• Delirium vs. encephalopathy vs. dementia
• Delirium assessment tools
• Prevention of delirium
• Discharging patients with delirium
• Case 2 from Kashlak: hyperactive delirium
• Antipsychotics
• Working up etiologies of delirium
• Treatment/management pitfalls
• Outro

Delirium Pearls

1. Delirium is a clinical syndrome and it is NOT just dichotomous (either present or absent). The severity and duration of delirium matter for long-term clinical outcomes.
2. Delirium is associated with ongoing brain inflammation and neuronal damage, and increases rates of dementia, functional decline, and institutionalization. 
3. Up to 30-40% of delirium can be prevented with multicomponent prevention strategies. Behavioral strategies may help reduce severity and duration even when delirium is present.
4. There are several tools to help identify delirium, including the CAM, 4AT, and the ultra-brief CAM, but ultimately it is a clinical diagnosis.
5. The etiology of delirium is usually multifactorial and requires a thoughtful clinical evaluation.  Don’t just check the UA until it becomes abnormal. 
6. There is no evidence that antipsychotics help to prevent or treat delirium.  In general, avoid antipsychotics unless patient or staff safety is at risk.

Delirium Show Notes 

Defining delirium

Delirium is a clinical syndrome characterized by an acute disturbance in the domains of attention and cognition. It may be called “altered mental status,” “acute confusional state,” or “encephalopathy.” Delirium is different from dementia. Delirium is an acute condition, whereas dementia is chronic. Telling the difference between delirium (acute) and dementia (chronic) often requires family member collateral. Inattention is a key hallmark of delirium, but is often absent in dementia. 

Delirium can be distressing for patients and family members. Dr. Oh tells family members that when their loved one becomes delirious, that means they cannot think very clearly, they cannot pay attention, and they are not aware of their environmental surroundings. 

Dr. Oh notes that at the center of delirium is a “vulnerable brain,” and older patients with pre-existing neurocognitive disease are at highest risk. However, Dr. Oh also notes that everyone is potentially at risk for developing delirium depending on the degree of the insult, even previously healthy adults who experience a major illness or injury.  

We should NOT think about delirium as a dichotomy (delirium present or absent), but rather consider the severity and duration of the delirium. According to Dr. Oh, reducing the severity and duration of delirium can shorten the damage done to the brain and may improve long-term outcomes (Richardson 2021).

Recognizing Delirium

Recognizing delirium can be challenging if the patient’s cognitive baseline is unknown. Family members often help identify mental status changes, which can help clinicians identify delirium. There is an initiative in Canada called “This Is Not My Mom” to raise awareness of delirium. 

Confirming a diagnosis of delirium is ultimately a clinical decision. There are several useful tools to evaluate for delirium, including the Confusion Assessment Method (CAM) (Inouye 1990) and 4AT.  These tools are also available from the American Delirium Society.  

There is also an “ultra-brief” version of the CAM (UB-CAM), which is distilled down to two questions, which test for awareness and attention: 

1. What day of the week is it? 
2. Can you recite the months of the year backward starting with December?

You can download an app for UB-CAM on your phone (currently available only for iOS; an app for Android is in development). 

[Note: When using the UB-CAM app, the assessment ends for those who screen negative based on the two questions (delirium negative). For those who screen positive based on the two questions, the app will allow administration of additional 3DCAM items using a skip pattern to complete a quick CAM-based delirium assessment.]

The etiology of delirium is usually multifactorial. When working up delirium, Dr. Oh recommends a thoughtful clinical evaluation, metabolic work-up (CBC, CMP, urinalysis), and review of current medications. Even necessary medications can be optimized—ensure they are properly renally adjusted and at lowest doses necessary. Neuroimaging, EEG, and LP are usually unnecessary, but may be considered in severe, protracted cases. TSH, vitamin B12, and folic acid are not typically needed to work-up delirium (rather, they are more commonly checked in the evaluation of dementia). 

Consequences of delirium

Why does delirium matter?

First, the level of patient distress may be dramatic. Dr. Oh recommends the article COVID-19 Is a Delirium Factory from The Atlantic to understand how distressing delirium can be for patients.

According to Dr. Oh, delirium occurs in one older adult every five minutes.  It is associated with functional decline, higher mortality, institutionalization, and incident dementia.  Newer studies are finding that the pathogenesis of delirium is ongoing inflammation and neurodegeneration in the brain. For example, Dr. Oh notes that delirium is associated with elevated biomarkers of neuronal damage, such as neurofilament light (NfL), which is typically found in traumatic brain injury and dementia (Casey 2020). The recent DECIDE study found that episodes of delirium increase the risk of future cognitive decline and dementia, and more severe delirium episodes were associated with worse outcomes (Richardson 2021). 

Prevention of delirium

Approximately 30-40% of delirium can be prevented (Inouye, 1999; Marcantonio, 2001). Delirium prevention is everyone’s responsibility and should be part of the hospital culture. The key prevention strategies are multicomponent interventions (bundles) with the following items (Oh, 2018):

1. Orientation activities (e.g. update the board with the correct date and staff names) 
2. Providing activities to engage the patient
3. Oral fluid repletion
4. Early and safe mobilization
5. Vision and hearing assistance (use pocket-talkers; speak in a low, deep voice and rephrase if patient does not understand)
6. Sleep enhancement (e.g. earplugs, quiet environment, lighting)
7. Infection prevention
8. Pain management
9. Minimizing psychoactive medications

Discharge Recommendations

Per Dr. Oh, the decision about discharging patients who have stable delirium is nuanced. Delirium may take weeks to fully resolve. In her expert opinion, if you are confident you have worked up all possible etiologies and removed offending medications, patients may be safe for discharge. Some patients may need to discharge to a rehabilitation facility. However, discharging a patient home to a more familiar environment with close follow up may have additional benefits (if these patients have the necessary support in place from families and home services).  

Hyperactive vs. Hypoactive Delirium

Hypoactive delirium is more common (75% of cases) than hyperactive delirium (25% of cases) and is often under-recognized (van Velthuijsen 2018). Dr. Oh refers to hypoactive delirium as “quiet delirium,” and notes that patients may just appear to be sleeping.

Hyperactive delirium may be much more obvious, as patients can become agitated or combative. In these cases, de-escalation is important. Strategies include re-directing patients and trying to change the subject that is causing distress. Often patients with cognitive impairment have difficulty communicating and expressing what they want. Additionally, patients may become agitated because they do not have enough activities to occupy them. Dr. Oh recommends trying to optimize the environment by avoiding loud noises and commotion. Try to connect patients with family members, either in person, on a screen, or with pictures. She recommends having a patient safety attendant (sitter) to help reorient the patient.

Antipsychotics

Current evidence does not support the use of antipsychotics for the treatment (Nikooie, 2019) or prevention of delirium (Oh, 2019). However, per Dr. Oh, if patient or staff member safety is at risk, pharmacologic treatment may be needed. She would recommend quetiapine, olanzapine, or risperidone in these cases, based on formulation, dosing, and side effect profile. Quetiapine generally has the least anti-dopaminergic activity, followed by olanzapine, then risperidone. Oral dissolving tabs (olanzapine) and oral liquid solution (risperidone) may be useful formulations.

Links

1. The Emperor of All Maladies (book by Siddhartha Mukherjee MD)
2. Management Time: Who’s Got the Monkey (article by William Oncken, Jr. and Donald L. Wass )
3. Healing: Our Path from Mental Illness to Mental Health (book by Thomas Insel MD )
4. Creative Confidence (book by Tom Kelley and David Kelley) 

Goal

Listeners will prevent, recognize, and manage delirium among hospitalized patients.

Learning objectives

After listening to this episode listeners will…  

1. Define delirium and contrast it with other causes of altered mental status.
2. Detect delirium among hospitalized patients using validated assessment tools.
3. Distinguish between hyperactive and hypoactive states of delirium.
4. Describe nonpharmacologic strategies to prevent delirium.
5. Review the evidence behind pharmacologic interventions for delirium.
6. Develop an approach to management of patients with delirium.

Disclosures

Dr. Oh reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Barelski AM, Oh ES, Williams PN, Watto MF. “#375 Delirium in the hospital”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list January 9, 2023.