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Researchers estimate delirium affects up to 60% of people over age 75 living in long-term care and up to 50% of those in hospital. Signs and symptoms of delirium usually begin over a few hours or days and caregivers are often the first to notice changes in their loved one. Would you recognize the signs? Listen as host Ian Gillespie learns about delirium from St. Joseph's geriatrician Dr. Alishya Burrell.
Welcome to the DocTalks Podcast, a conversation on what’s new and relevant in the world of Canadian medicine and hospital health care. Join us for each episode, as we interview physicians, patients and caregivers to dive deep into what it’s like to treat and live with some of today’s most common health challenges. Hosted by Ian Gillespie.
Note: The content of St. Joseph's DocTalks Podcasts is for informational purposes only. The material is not intended for and should not be used as a substitute for direct medical advice from a licensed health care practitioner.
The DocTalks Podcast - Delirium w/ Dr. Alishya Burrell
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[00:00:00] Ian Gillespie: Welcome to The DocTalks Podcast, a conversation on what's new and relevant in the world of Canadian medicine and hospital healthcare. I'm your host, Ian Gillespie and I'm here to ask the questions and find the answers you need to know. We wanna help our listeners know how to prevent and detect illness and how to navigate our healthcare system.
Be sure to subscribe to The DocTalks Podcast to stay up to date on new episodes and follow us on Twitter at St. Joseph's London, or visit sjhc.london.ca/podcast. Hello, I'm Ian Gillespie, and welcome to The DocTalks Podcast, brought to you by St. Joseph's healthcare, London. Today's episode, we're talking about delirium, a little known condition that can affect people of all ages for a variety of reasons. According to the Cleveland clinic, 60% of those 75 and older in nursing homes are at risk of delirium as well as about 25% of individuals with cancer.
But what is it? How do you recognize it? And how is it treated? Today to help us sort out some of the answers to those questions, I'm talking with geriatrician, Dr. Alishya Burrell, and she's a geriatrician in the specialized geriatric services program at St. Joseph's Parkwood Institute here in London. She was trained as an internal medicine physician at Western university before specializing in geriatrics.
And she's also an assistant professor in the division of geriatric medicine at Western University. Dr. Burrell, thanks for joining us today.
[00:01:53] Dr. Alishya Burrell: Thanks for the invitation.
[00:01:54] Ian Gillespie: So, delirium, first of all, it kind of sounds like an Alfred Hitchcock film or something. And I actually, actually there is a movie, I looked it up. There was a horror movie made in 2018 called Delirium, but that's, uh, seems totally irrelevant. and I also, when I. You really, frankly, the only thing I've really ever heard was delirium Tremon or the DTS, which is obviously of course, connected with alcohol and withdrawal treatment.
So just for our purposes, what can you tell me? And I know there's various types and it's, it's never as simple as we think, but what is delirium?
[00:02:26] Dr. Alishya Burrell: Absolutely. It's funny because we do use it kind of in our day to day conversation, someone will say, I feel delirious and things like that. So it is something that comes up in conversation. But often we don't talk about the real diagnostic criteria, and what do we actually mean when a physician says it?
So delirium is incredibly common and is a sudden change in thinking particularly affecting our ability to focus on things that fluctuates through time and is usually triggered by something. That's my most high level description of it, I would say. And I'm sure we'll get into more details.
[00:03:02] Ian Gillespie: Okay. And, and I understand though, there are obviously different types of delirium. I'm just looking here at my handy dandy notes. There is hyperactive, hypoactive and mixed. Can you, guide us through those a little bit?
[00:03:14] Dr. Alishya Burrell: Absolutely so delirium um, the different types depend on how a patient is actually presenting with their delirium symptoms. So some people tend to have more of a hypoactive presentation, so it's a lot more kind of drowsiness. If someone's in hospital, they're, they're just not as interactive. They might be, sleeping peacefully through the day. That's a type of delirium that we actually tend to under recognize as healthcare professionals. it's important for family members, you know, to, to think about it. The second type is that hyperactive, that tends to be the patient is, more agitated, maybe they're having hallucinations, delusions, something scary is happening.
Maybe they're striking out at caregivers. It's really out of their usual behaviors and that's a delirium type that we tend to not miss. Because it's more in our face. And then there is also this mixed picture where patients can kind of actually go in between the hypoactive and hyperactive. So there might be a period where they're really striking out and really agitated, and then maybe they get some medication for that, and then they're really drowsy. So we can kind of flip back and forth between the two types.
[00:04:28] Ian Gillespie: And you were referring to of course, well seniors and, and aging patients. Who does it affect? Is it, is it mainly older adults and individuals?
[00:04:37] Dr. Alishya Burrell: So delirium can affect anyone. So anywhere from pediatrics up into older adults. We talk about it more with older adults, just because it is more common in the pediatrics world, which of course is not my, my specialty, but I do know that say in the intensive care unit um, with pediatrics, you can still see delirium.
So we're not talking only about the care older adults, but, but I will focus on older adults since that's what I know best. Uh, but so it can happen in anyone. And there's certain risk factors that make us more susceptible. So it's often things that make our brains more susceptible. So as we age things like dementia, put us at higher risk of delirium. Sensory impairment,
so if we have a hard time seeing or hearing we're at higher risk. if there's alcohol misuse, there's a higher risk of delirium medical conditions and just being very, very sick. So the sicker you are the higher risk of, uh, delirium.
[00:05:33] Ian Gillespie: Right. Huh? And. How long does it last? I mean, it's a temporary condition. Is that right?
[00:05:40] Dr. Alishya Burrell: That's a really good question. And something that comes up quite frequently. So delirium is something that is in theory, temporary and in theory, reversible. Sometimes though I think we need to be careful of how we sell how quickly it can improve though it, because deliriums so complicated that it's not like we just treat that little infection and the symptoms go away just like that.
Sometimes it does take longer. Um, So when I'm counseling family members on this, uh, in the hospital, you know, there are cases where it, it improves over the next few days as we treat the triggers, but there's also times where it takes weeks, months more recently, the evidence has shown that it can last
six months to a year in rarer cases. And some people actually never get all the way back up to where they were before. Some people have a little bit of a cognitive decline afterwards. So we do have to think about that in our more frail kind of susceptible patients.
[00:06:33] Ian Gillespie: Right. Do, do you have an idea? Can you gimme a number? Can you quantify it somehow about what's the percentage of the population that are sometimes affected by delirium?
[00:06:42] Dr. Alishya Burrell: So it depends where you're receiving care, where the patient's receiving care and what they have essentially. So, um, usual medical, inpatient ward, we're talking about a quarter of patients can have delirium. In surgical patients, and these are all older patients, in surgical patients, it can be about half and in the intensive care unit, it's actually up to 75% that can have delirium.
So the sicker you are, the more likely.
[00:07:04] Ian Gillespie: So. We'll we'll talk about some of the, the triggers and causes, but maybe we should again, talk about some of the symptoms that people experience. I've got a huge list here. I'll just tick through a few of them, an inability to stay focused on a topic being easily distracted, poor thinking or cognitive skills, uh, difficulty speaking or recalling words, difficulty reading or writing, seeing things that don't exist.
I E hallucinating. Can you talk a little bit about some of the some of the symptoms of delirium? How do we recognize it in an individual what do we see in a patient who's experiencing delirium? What are some of the symptoms and signs of it?
[00:07:42] Dr. Alishya Burrell: Hmm. So some of the first more obvious ones are those cognitive ones, the first ones that you mentioned. So it's that kind of confusion that's worse than usual or new confusion. Sometimes that's hard to tease apart from dementia, so we can kind of talk about that a little bit afterwards, but so it's confusion and it's really that ability to focus on something.
So they, a patient might seem distractable that they can't kind of focus on what you're talking about. Maybe they're kind of looking around the room, picking at things, kind of focused on something odd in the room. So we'll see that, and that's kind of that memory cognition. Then there's these perceptual abnormalities, which is what you were getting at with the, maybe seeing things and hearing things.
Those can be kind of simple things like thinking, you know, that their mother is in the room and that someone who's already passed away or it can be really distressing things. And I think that's where some of that, you know, that horror movie about delirium comes in, you know. That it can be really awful.
These, these things that we're seeing and hearing and that what the patient experiences changes, how we treat it. So we would kind of look for those distressing kind of hallucinations and delusions. And then other symptoms, it really depends on whether it's that hypoactive kind or the hyperactive kind.
So it may be that drowsiness and just fatigue or it might be actually aggression, violence striking out, pulling at tubes, pulling at lines which is more can be really distressing for families to see.
[00:09:05] Ian Gillespie: Wow. So what are, again, again, it's I always ask these simple questions and the answers of, I know beforehand are never simple. What are some of the causes of delirium?
[00:09:20] Dr. Alishya Burrell: So how I think about it is that there's these risk factors. So we talked about those risk factors. So this is already a person that's a little bit susceptible, and then there's these triggers. So I think of triggers as the things rather than a cause, because often it's not just one thing. And that's what makes it difficult.
Often there's multiple triggers, particularly in hospital contributing to this delirium. Um, We teach medical students to think of it as like an acronym D.I.M.E.S. But so there's all of these things. So drugs medication changes, um, new medications, withdrawing from medications. is infections.
So any type of infection can actually trigger a delirium. M is for metabolic. So it's all of these abnormalities, maybe the liver isn't functioning well. Maybe the kidney's not functioning well. That can be a trigger. E is environment. Um, And that's actually. everything we do in hospital is a trigger.
Really. It's the waking up people for 3:00 AM, blood work. It's, you know, the wrong date being written on the wall and you don't have a window. And you know, you don't have a clock and there's overhead announcements in the middle of the night. And it's, it's this environment that is really difficult to have normal sleep patterns.
Also in an environment, I kind of put in having a catheter, having all these tubes and drains connected to you because how is that helping with sleep and getting moving? And then S is structural. So it's things like a heart attack, a stroke, a seizure, not all older adults present kind of the classic way with some of these things.
Sometimes it's delirium is actually the first thing we see.
[00:10:54] Ian Gillespie: Wow. And so again, with such a variety of triggers, I'm, sure that there are variety of treatments. Can you talk a little bit about some of the treatments?
[00:11:06] Dr. Alishya Burrell: I would say first that what we try and do is prevent so prevention is number one, if we can. So we try and, manage those environmental factors. Have a patient with a window, have family members coming in, have familiar items in the room, things like that. We try not to start medications that are bad for older adults because we know that can trigger a delirium.
So a lot of what we do in hospital is trying to prevent. Because once a delirium has started, it's actually a little bit difficult to treat. There's actually zero, no medications that have evidence for treating delirium. Mostly what we do is these non-medication things, and we treat all of these triggers.
We try and find each and every trigger and fix it and hope that the delirium improves.
I should mention, cuz I, I said there was no medications for delirium, but I should say that sometimes we do have to reach for medications for delirium. So in the setting where the patient is experiencing those more scary hallucinations or delusions, we will sometimes have to reach for medications, even though they're not really evidence based.
So we will sometimes start things like antipsychotics in that setting. Knowing that, you know, antipsychotics can, can worsen delirium can increase our risk of falls. They have a lot of potential side effects, but if we're seeing a lot of really distressing delusions or hallucinations or aggression where someone could get hurt we do sometimes have to reach for those medications and incorporate that into our treatment.
And then hopefully taper off of it quickly as, uh, as things improve
[00:12:42] Ian Gillespie: I see. So right. looking at the drugs, trying to treat an infection. What about metabolic? How do you, how would you handle that?
[00:12:50] Dr. Alishya Burrell: So you would look for all of the metabolic causes. So we would, you know, check the thyroid, the liver, the kidneys, the vitamin levels, and fix each of those. You know, if they're in severe kidney failure, we have to treat that and figure out what's causing it. So you're looking for each cause and trying to manage each one.
[00:13:07] Ian Gillespie: Right. And then environment of course, would be removing, well, I guess you can't stop the announcements at 2:00 AM in the hospital, right? But trying to lessen those annoyances and distractions and disruptions,
[00:13:18] Dr. Alishya Burrell: and there are certain hospitals that are better at this. I, I think in Europe you know, there are some things called delirium units where they actually try and, you know, have it dark at night and have the nursing station not be lit and loud. So some of those kind of small. That we're not always good at, in acute care hospitals.
[00:13:36] Ian Gillespie: Wow. And then, sorry again, one of the triggers, you said the, the last one on your acronym, D.I.M.E.S. Was structural. How, how would you deal with that trigger?
[00:13:44] Dr. Alishya Burrell: Similar to metabolic, we, we really just go on a search and see, is there something we're missing, you know, is this older adult that's presenting with delirium, you know, not expressing any other clear symptoms, are we missing something like a heart attack or a stroke? So we go looking for these things and you know, again, you would treat whatever you find.
[00:14:06] Ian Gillespie: Right. Right. And does delirium cause any lasting damage to the patient's brain?
[00:14:13] Dr. Alishya Burrell: So. There are poor, like there are bad outcomes that come with delirium, which is why we care about them. So delirium patients are at higher risk of dementia. So similar to what I was saying with not every patient gets all the way back up to where they were before. Sometimes there are lasting kind of changes in cognitive impairment.
Whether that is a new is getting closer to a dementia diagnosis or not. It depends on that patient and how well they were before. So there, there can be lasting changes. We also know that patients with delirium just do more poorly in hospital. So they're at higher risk of poor outcomes. Things like falls, institutionalization, having to go to long term care not being able to make it back to independent living where they were before.
They're at higher risk for those things.
[00:15:01] Ian Gillespie: I'm, I'm glad you mentioned dementia. as I understand it, so delirium can be part of dementia, is that right? But it's sometimes separate from that, you can experience delirium and not be, uh, suffering from dementia?
[00:15:14] Dr. Alishya Burrell: Right. So there are two separate things, both that involve cognitive changes. Dementia. You can have both separately though, so you can have dementia and it is a risk factored for delirium. You can have delirium and not have a diagnosis of dementia. Where it gets a bit foggy and difficult sometimes for, especially for the medical team is in a patient with dementia coming in with delirium where you have to tease apart,
is this a change? Are they different from their usual self? And you know, as we see the improvement, how far off of the usual baseline are we?
[00:15:47] Ian Gillespie: So it's kind of a real detective, some detective work here to figure out, to diagnose someone and, and diagnose the causes. Right? I mean, is that, am I right about that?
[00:15:58] Dr. Alishya Burrell: Absolutely. That's I that's the part I of delirium care that I really enjoy. We do consults as geriatricians in acute care for patients that have developed delirium under all of the Different surgical specialties medical specialties, and these patients are presenting with delirium and someone needs to take a step back and think, okay, what are the, the multiple triggers that are potentially contributing to this and how do we fix each of these up?
And sometimes those triggers are smaller things like constipation or not emptying the bladder fully or pain. So some of those things we just don't think about being significant medical problems. But as when a geriatrician comes in, we say this matters in an older adult, who's experiencing delirium.
[00:16:39] Ian Gillespie: What what got you interested in delirium?
[00:16:42] Dr. Alishya Burrell: I have always enjoyed, like I said, enjoyed those consults. It is like a bit of a mystery. You also can make a huge difference. I find I make a huge difference when I'm taking care of these patients because families are terrified when they're seeing their loved one, go through a delirium I've experienced this with my own family.
Actually, my grandfather had a horrible delirium and um, watching your own family member have delirium is very different from just the knowledge of it. So, and I think the biggest thing. If we don't use the word delirium, caregivers think that this is the new baseline. They think that their loved one has dementia because that's the only word they know for memory changes.
So they're panicking. So when I come in and can explain, you know, this is what we're dealing with, these are the many triggers, these are the things we're gonna try and fix up and we'll see how they do. And we'll support you through this. It makes a huge difference just to have that knowledge and the power to know what their loved one is going through.
[00:17:38] Ian Gillespie: right. Wow. Yeah, it must be satisfying though, to see if you can, can you recall instances where someone you've you've removed you you've eliminated the delirium from a patient.
[00:17:48] Dr. Alishya Burrell: Oh, absolutely. We have it all the time, where patients, you know, a few days after will be back to their usual selves. They won't, they often won't recall it. So. It's often quite foggy. There's some really interesting actually there's some really interesting artwork if you Google like delirium artwork by patients where they've painted their experiences of delirium and some of them are very dark and scary.
So for the most part they don't remember, but they have these little glimpses of, of these horrible things happening. That's really hard to hear as a caregiver or, or even a, a healthcare practitioner.
[00:18:20] Ian Gillespie: Wow. And one, one of the other, I mean, you were talking about family members I have a family member who elderly, who has late night terrors, will scream out very, very vivid dreams and so forth. Would that, might that be delirium?
[00:18:35] Dr. Alishya Burrell: Yeah. So it's a good, great question. There are a lot of sleep disorders that people that kind of look a little bit like delirium, but what those tend to be kind of consistent. And they don't, they're not associated with a trigger. And they're not new. So that's, those would be the things that would kind of differentiate them from delirium.
There's a lot of sleep disorders, like very vivid dreams and things like REM behavior disorder, people with Lewy body dementia can get that and just other sleep disorders. So, and those are normal sleep disorders.
[00:19:07] Ian Gillespie: Can delirium occur to a patient after they've left a hospital setting, i
[00:19:12] Dr. Alishya Burrell: I think if, if a caregiver or family member was noticing new symptoms of delirium after, their loved one is has returned home. I would say they actually have to worry about something new happening. It would make me think that, you know, either a new medication change. They have a new infection, I would say there's been a change,
and that actually would justify going back to hospital or reaching out to a healthcare provider to see, you know, what could be causing, what is that trigger that has caused this new change? There shouldn't be new delirium after a hospital stay kind of in the normal course.
[00:19:47] Ian Gillespie: right. And what's the general path for someone, a family member who just suspects, who sees some of the symptoms that we've talked about and sees a family member showing symptoms of delirium. What, what do they do? What should they do?
[00:19:59] Dr. Alishya Burrell: So number one is reaching out to, the primary care physician would be the go-to kind of point person. The second thing is really looking for, especially I, I coach My patients, caregivers, my patients with dementia because they're at risk for delirium. They're at risk for behavior changes too, with any, with any changes in their environment.
They're at risk for kind of those same triggers impacting their behaviors. So I coach them to kind of look for, is there something that's changed? Could the patient now be constipated? Are they having problems with their urination? Do they have signs of an infection? To kind of watch out for those things? Some of those things we can manage at home you know, we can get the bowels moving better.
Small things like that, but if it's infection or something like that, we have to reach out to our, our physician team and get it treated. This is kind of like an emergency for the brain, right? We talk about you know, we talk about heart attack, being a, a sign that there's something going on with the heart, delirium is a sign that there's something going on with the brain.
So it is still an emergency. And it does warrant reaching out to healthcare providers, or even if going to the emergency room.
A very common initial presentation to the emergency room is actually delirium. So it's delirium that's developed at home. The family is saying my loved one is not who they usually are. They're more confused than usual, or they're never like this.
They're usually perfectly cognitively intact and this is new. What's going on. So that, that first presentation, even to the emergency room is delirium. So it, and it's developed at home. So that's very.
[00:21:26] Ian Gillespie: And so Dr. Burrow, what, what, how does you, how do you go about it? If, if you notice some of these symptoms, some of these changes, uh, in a patient in say long term care, what, should the family member do? Obviously bring it to the attention of the, the staff there, I guess, would be the first step.
[00:21:42] Dr. Alishya Burrell: Absolutely. I think it's really important because family and caregivers they know their loved one best. So they're gonna recognize these changes maybe earlier than the staff. Um, And this goes for long-term care. And even in a hospital stay delirium can develop in the middle of a hospital stay.
So, um, if a caregiver sees these changes, reaching out first to the, the nurse covering the ward and kind of saying, you know, I'm noticing this. And then that can escalate from there to, to the care team, to really look for, for potential triggers and, uh, recognize delirium.
[00:22:14] Ian Gillespie: Okay. That's great. Thank you for joining us today, Dr. Burrell.
[00:22:18] Dr. Alishya Burrell: Yeah, no problem.
[00:22:22] Ian Gillespie: That's it for this episode of The DocTalks Podcast.. Thanks for joining us and join us next time when we'll continue our conversation on what's new and relevant in the world of Canadian medicine and hospital healthcare.. Be sure to subscribe and follow us on Facebook and Twitter @stjosephslondon.. For more resources and details about today's topic, visit sjhc.london.o.ca/podcast. Until then stay healthy.