Decoding Delirium: A Deep Dive into Standardized Care and Innovations

Podcast Transcript

Dr. James K. Stoller:

Hello, and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hello. Welcome to today's episode of MedEd Thread, an Education Institute podcast exploring enhancement of delirium education. I'm your host Dr. Tony Tizzano, Director of Student and Lerner Health here at Cleveland Clinic in Cleveland, Ohio.

Today, I am very pleased to have Dr. Anna Shapiro-Krew, Associate Program Director for Cleveland Clinic's Consult Liaison Psychiatry Fellowship and Assistant Professor of Medicine at the Cleveland Clinic Lerner College of Medicine, here to join us. Anna, welcome to the podcast.

In today's segment, we hope to explore the efforts that are underway to revisit and enhance educational strategies regarding delirium to better systematize the evaluation response to this relatively common condition.

So, Anna, if you could, help us frame the importance of what we're trying to accomplish here.

Dr. Anna Shapiro-Krew:

Hi, Tony. Thank you for having me here. I'm so happy to be here. So really, in a nutshell, delirium is what we would consider an acute brain failure. It's brought on by severe medical stress. In its most basic form, it is defined by waxing and waning cognition and attention, and this can be accompanied by changes in sleep/wake cycles and even changes in perception, such as hallucinations and emotional control.

Delirium is so important because it's caused by several different risk factors, including possible neurocognitive vulnerabilities, like dementia, severe illness, imbalances in the body, recent surgeries, infections, even medications. Some people, particularly those who have neurocognitive impairment or have had delirium before, can be predisposed.

So, the reason this is important is it's so gosh darn common.

Dr. Tony Tizzano:

Anna, particularly, I guess in a hospital setting, where you're thrust into this, usually not planned, and things are changing throughout the night, you're getting whisked off here, changing floors and units, it has to be very disconcerting for patients and may p- precipitate some of these episodes?

Dr. Anna Shapiro-Krew:

Absolutely. And we find that it is very, very common in the hospital setting. The current literature indicates that up to 30 percent of patients on regular nursing floors can struggle with delirium and up to 60 percent in the ICUs. And this is often worsened when there are longer hospital stays, the need for sitters. And there's a lot of sequelae that come from this, including prolonged hospitalizations, changes in neurocognitive function in the long term, need for more nursing home placements, and increased mortality.

And that's why, you know, as care providers, it's really essential that we can all recognize it and address it, even though it presents in different ways.

Dr. Tony Tizzano:

So, this is a lot more than saying, "Oh, you know, Mr. Jones has dementia, and this is just being exhibited in this way." It could actually be delirium, something that's precipitated on the floor. And so, if we aren't all on the same page on how to recognize that and intercede, we're a step behind.

Dr. Anna Shapiro-Krew:

Exactly. And, and the fact is delirium, because it can present different ways, can also kind of go under the radar. It has three subtypes: hypoactive, hyperactive, and mixed. I always say hyperactive delirium is really obvious one. I'm a psychiatrist. This is typically when you want me, because patients are screaming, yelling, agitated, and hallucinating.

It's the hypoactive delirium that's often the dark horse. These are patients who are often mistaken as being depressed or having failure to thrive. They're sleeping a lot. They're not participating in physical therapy. And it's really tricky at times to say, "Oh, wait. This is something else. This is not their baseline."

And then there's that mixed subtype, which is sort of the combination of the previous two. And we often see them more sedated during the day and absolutely wild at night.

Dr. Tony Tizzano:

So, it sounds like in part you might have to rely on family members to say, "What is the baseline for an individual?" and just try to compare it with where you're at.

Dr. Anna Shapiro-Krew:

Absolutely.

Dr. Tony Tizzano:

So, when it does occur, what are some of the things you can do to treat it, acutely and over a period of time?

Dr. Anna Shapiro-Krew:

Really, the most essential treatment for delirium is treating the underlying cause. I often say this is a condition where the brain and the mind follow the body. For example, if there's an infection, you treat the infection. But delirium can be multifactorial, and there are multiple risk factors like we've previously discussed, such as age, baseline neurocognitive impairment, being moved about in the hospital.

So really, in those cases, we try to address some of the modifiable causes, but we can't address all of them. So, we have to do other things. In reality, the most effective treatments, next to treating the underlying cause, is really behavioral modifications, such as maintaining circadian rhythm, making sure patients are sleeping at night, promoting mobilization and physical therapy, and of course involving families to help as advocates.

Often, we think about some medications, but medications really are used for treatment of symptoms, such as agitation or aggression. But they're not really addressing the underlying cause, and this has been shown frequently in the literature.

And that's really where the important work of our Delirium Council comes into play.

Dr. Tony Tizzano:

So, tell us about that. I understand this is something that is in its perhaps third iteration? And what's the latest iteration look like?

Dr. Anna Shapiro-Krew:

Absolutely. So, it is the third iteration. And the goal of this council is really to bring about representatives across different specialties. They come together, and we're trying to create a standardized and common way for us as care providers to recognize, treat, and prevent delirium in our patients.

It's made up of representatives from nursing, internal medicine, critical care medicine, surgery, emergency medicine, geriatric medicine, psychiatry, and physical and occupational therapy. The reason that we have so many representatives and we're kind of crossing really a lot of different therapeutic lines is because no specialty owns delirium. It affects all of our patients, and it's all of our responsibilities to recognize and address it.

The goal of this council is really to create a common language so that we can all kinds of talk amongst each other about delirium, about strategies to address delirium when they occur in our patients.

Dr. Tony Tizzano:

Boy, it strikes me that that's really important with so many different moving parts and different areas of expertise. Having everyone on the same page when you go to discuss it or record it or explain it or tell someone else at the time of, you know, handoff can't be underestimated.

Dr. Anna Shapiro-Krew:

That's exactly it. And to be frank with you, a lot of deliriums kind of gets mixed or missed in the shuffle. So really creating this common language and also standardizing our approaches to screening, as well as standardizing our approaches to addressing treatments, optimizing things like behavioral modifications, optimizing family involvement, really expanding on those proven in the literature behavioral modifications and knowing amongst ourselves how to do it and in a very common way.

Dr. Tony Tizzano:

So, within the council, do you also have some attention being paid to information that you would give to families? Because it seems to me like, uh, I might want to know about that when I have family members in the hospital and hadn't given any thought to delirium.

Dr. Anna Shapiro-Krew:

Absolutely. And one of the beautiful things about the Delirium Council is really our focus on education, and not just education for healthcare providers, but really working on education for families so that they understand what delirium is, this waxing and waning change in attention and awareness, because it's really disturbing as a family member to see your loved one get confused, not know what day it is, get angry, have, you know, hallucinations. It's really upsetting.

And the clinic in general has made a lot of strides in empowering families and educating them. Before the pandemic, we actually had a support group for families that looked at addressing delirium and discussing what it was. And I think the goal of this Delirium Council is to really work on empowerment of families to serve as also caregivers for their delirious loved ones. And we do that through education on how the family can serve as, you know, providers of orientation, providers of comfort, explaining what's going on, regulating the circadian rhythm. All those things should really be second nature, and our goal as a council is to make that part of the care plan.

Dr. Tony Tizzano:

Excellent. So, when we look then at some of the barriers that you've encountered, you know, what have been some of the significant ones that have been more difficult than others to, to get through?

Dr. Anna Shapiro-Krew:

I mean, I think one of the biggest barriers as we're kind of working on this is really getting folks aware of delirium. It's not new. There are historic texts that document delirium.

The other issue is that a lot of people think this is something normal. They think, "Oh, well, this person just had a long hospitalization. This person is elderly. They just had surgery. This is normal that they're confused." But it's not normal. This is an acute brain failure, and this has serious consequences down the line, not just in the hospitalization, but neurocognitively in the long run.

And I think, you know, one of the other issues is delirium has so many different names and hats. It's often described as confusion, encephalopathy, ICU psychosis. I mean, if we can't agree on the name, how can we agree what it is and that we need to address it? And I think that's one of the beautiful things about the Delirium Council and really what it's done in each of its iterations, which is bring awareness to it and trying to create that common language and using that, especially in the setting of the most current and up-to-date recommendations in the literature.

Dr. Tony Tizzano:

Yeah. You know, you talk about this, and we talk about acute brain failure. And when you think of that, you know, all kinds of bad imagery go through one's head. And when we say this, "Okay, it's acute," does that mean it's also temporary, that if we can remove that underlying precipitating event that we can, in short order, or does this have a long trajectory?

Dr. Anna Shapiro-Krew:

It really depends on the patient. You know, as I mentioned earlier, the brain and mind follow the body. As we address the underlying causes, delirium should hopefully begin to resolve.

But in patients who have more vulnerabilities, in patients who have had longer lengths of delirium, and in patients who, you know, frankly aren't being mobilized, aren't, you know, maintaining a good sleep/wake cycle, are on multiple medications that can cause confusion or delirium, that this can have long-term consequences.

And I think that's another important educational piece that we all really need to get on board with, which is just because you leave the hospital doesn't mean that these long-term effects haven't had an effect on the brain.

Dr. Tony Tizzano:

So, empowering families and really educating them is a critical step, because when they go home, the likelihood that they're going to have someone who is knowledgeable around these concepts about delirium is probably unusual.

Dr. Anna Shapiro-Krew:

And it's essential. I mean, the literature demonstrates that when families are involved in multidisciplinary cares, patients have less time delirious and a lower morbidity and mortality. Not to mention that family members acutely, while patients are hospitalized, can serve as really care providers to reorient patients, keep them awake, keep them focused, and keep them participating in physical and occupational therapy, which also has a tremendous impact on their overall health and wellness.

And it's really our goal as the council that this really becomes second nature across all of our specialties so that we're all working with families, working with patients, optimizing these behavioral modifications, and trying to minimize the sequelae of a delirium.

And it's tricky. I mean, each council has used the best literature that they've had at the time. But times are changing, and our knowledge of delirium is changing. And the pharmacologic interventions we thought were important and that we've often frankly got in, stuck in the weeds with among specialties are really being shown to be more treatment of symptoms, not underlying cause. It's really these behavioral changes that the Delirium Council is trying to push forward while we try to herd the cats of multiple specialties and multiple providers.

Dr. Tony Tizzano:

Oh boy. That's an understatement. So, you know, what efforts are being made? I listen to this, and I begin to think, Anna, how critical is it that we get in on the ground floor for medical students, nursing students, students in the health sciences to recognize this? Because oftentimes, you know, they're the people who are trying to get something accomplished. Occupational health, physical therapy that, you know, we don't oftentimes think of being on point for this, but they may be some of the first people to see this.

Dr. Anna Shapiro-Krew:

And that's exactly it. And frankly, you know, it's so funny, Tony, because I was thinking about my own e- medical education, and I kept thinking, "Did they teach me about delirium in med school?" I don't know if they did. I just remember kind of learning about it as I went through training and getting more and more invested.

And these are the boots on the ground for this. I mean, our nursing staff are the ones who are evaluating the patients with our standardized screening tools. Our medical students are usually the first to be interviewed. And our occupation and physical therapists, I mean, they're essential to recovery.

So really, the goal should be early education and intervention with these groups so that everybody is comfortable with what delirium is, how do I see it, how do I recognize it?

Dr. Tony Tizzano:

Sure. And this is stretching it a bit, Anna, but you could even have housekeeping. If they knew that this existed, they see that patient every day and all of sudden they're seeing a mental status change. Where does it begin and end?

Dr. Anna Shapiro-Krew:

Yeah.

Dr. Tony Tizzano:

So, what do you see on the horizon?

Dr. Anna Shapiro-Krew:

One of the things that the council is really focused on is definitely tools, like, for example, a delirium risk calculator, something that we can use for when a patient, you know, walks through the door that could predict their risk of becoming delirious. So, we can intervene early and often.

The literature also indicates that there are, you know, theories regarding changes in neurotransmission based on, you know, the underlying causes that cause the different presentations of delirium. Likely we can eventually use that information to adjust treatment strategies. But as a field, our real goal is to just continue with the literature and keep following what the experts are saying and adjust and grow and be flexible. I think that keeps us on the cutting edge.

Dr. Tony Tizzano:

Excellent. Well, we've covered a lot of ground. Are there any other comments or questions that I didn't pursue that you would feel are important for our listeners to know?

Dr. Anna Shapiro-Krew:

I don't think so. I think that the biggest thing I would like our listeners to know is, again, to reiterate, just because it's common doesn't mean it's normal and to serve as advocates for their loved ones and our patients when there is a sudden change in someone's neurocognitive state.

Dr. Tony Tizzano:

Yeah.

Dr. Anna Shapiro-Krew:

That's not normal.

Dr. Tony Tizzano:

Well, I really appreciate your efforts at, at creating, uh, awareness, and we thank you so much, Anna. This has been a very interesting episode of MedEd Thread. To our listeners, thank you very much for joining, and we look forward to seeing you on our next podcast. Have a wonderful day.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, SoundCloud, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread, and please join us again soon.