Unlocking the Mysteries of Delirium

What is delirium and how should we handle it?

EdwardMarcantonio_FlyerLast month, Edward Marcantonio, MD, MS, the IOA’s most recent visiting scholar and professor of Medicine at Harvard Medical School*, offered some answers to these questions during his lecture at the University of Pennsylvania.

In the 1980’s, as he was just beginning his career in the medical field, Dr. Marcantonio was taught that it was essentially “normal” for older people to go a little crazy – or “bonkers” as he calls it – during their hospital stay. The belief was that there really was not much that could be done about it, but if the symptoms became overly bothersome, prescription medications such as haloperidol or diazepam — drugs commonly used for mental or psychiatric disorders — would “take care of it.”

Today, while we are much better at recognizing what delirium actually is – and understanding that it is not “normal” – there is still some confusion across disciplines in the terminology used to identify this condition. Delirium is often referred to as acute confusional state, altered mental status, subacute befuddlement, or postoperative psychosis.

Regardless of what term is used, the diagnosis of delirium, or any of the other aforementioned names, is characterized by confusion, restlessness, and a disturbance in attention and awareness that develops acutely and tends to fluctuate. Delirium is typically referred to as one of two types—prevalent delirium or incident delirium. Prevalent delirium is when the condition is present and observed at the time of hospital admission and incident delirium develops during the hospital stay.

Delirium is even more common than most people realize. According to Dr. Marcantonio, it is experienced in 30-40% of medical inpatients over 70 years old, 15-50% of surgery patients over 70 years old, and at least 75-80% of intensive care unit patients over 18 years old.

In his line of research, Dr. Marcantonio focuses on two main aims: 1) improving delirium identification at the bedside and 2) understanding the pathophysiology of delirium and its association with dementia.

Improving delirium identification at the bedside

Because symptoms of delirium can come and go and vary in severity, identifying it can be quite a challenge. “When I got started in the field there were a number of studies that sent research teams out doing gold standard delirium assessments and then compared that to what was diagnosed in clinical care and it turned out that less than 50% of cases were recognized,” said Dr. Marcantonio.

In the 1990’s, the Confusion Assessment Method (CAM) was developed to help detect delirium in patients. The CAM looks at four key features: 1) acute change/fluctuating course, 2) inattention, 3) disorganized thinking, and 4) altered level of consciousness. In order to officially diagnose delirium according to the CAM diagnostic algorithm, the patient must be experiencing both features 1 and 2, in addition to either 3 or 4. While recognizing these features as signs of delirium can produce a successful diagnosis, there still needed to be a standardized way to identify these features in the patients. With this in mind, Dr. Marcantonio developed a series of methods and assessments for detecting delirium – some taking as little as 30 seconds to administer.

Learn more about these assessments in Dr. Marcantonio’s full lecture starting at 0:20:28:
Full lecture

Understanding the pathophysiology of delirium and its association with dementia

Although a variety of situations, such as dehydration, visual or hearing impairment, immobility, and sleep deprivation, can increase the chances of developing delirium, current research suggests that one of the strongest risk factors – aside from aging – is dementia.

One emerging hypothesis is that delirium may represent a state of neuroinflammation. It is believed that this neuroinflammation could be the link between delirium and dementia and if this theory is confirmed, it could have some very important therapeutic effects for both conditions.

Learn more about the link between dementia and delirium in Dr. Marcantonio’s full lecture starting at 0:40:05:
Full lecture

Although we have come a long way over the years to better understand delirium, there is still much work left to do. The ultimate goals are to establish effective and efficient assessments of delirium as a part of daily hospital vital sign checks and to develop pathophysiologically-based treatments to improve the short and long-term outcomes of this condition.

To view the full lecture, click here.

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* Dr. Marcantonio is also the Section Chief for Research in the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center (BIDMC).

 

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Delirium and Aging

screen-shot-2016-11-10-at-10-41-51-amDelirium, a medical condition characterized by acute confusion, disorientation, or other mental health disruptions that affect thinking and behavior, affects nearly 7 million hospitalized Americans annually. While this condition can occur at any age, it mainly affects individuals 65 years or older and is often misdiagnosed as dementia.

As stated in an article originally published by Kaiser Health News and shared by Next Avenue, “while delirium and dementia can coexist, they are distinctly different illnesses. Dementia develops gradually and worsens progressively, while delirium occurs suddenly and typically fluctuates during the course of a day.” Particularly susceptible patients are those on ventilators or being heavily sedated in intensive care units, as well as those recovering from surgery.

“After an older adult undergoes anesthesia, they can often experience postoperative delirium,” explained Lee A. Fleisher, MD, chair of Anesthesiology and Critical Care at Penn, in a recent Penn Medicine News Blog on postoperative delirium and the uncertainties of anesthesia. “Patients in this state may hallucinate, they may forget why they are in the hospital, or have difficulty communicating or understanding what is going on around them.”

However, delirium can also result from something as simple and easily treated as a urinary tract infection.

According to research published in 2009 and referenced by Next Avenue, an estimated 40% of delirium cases are actually preventable; yet, the underlying cause is still unknown.

With all of this in mind, health care professionals, government agencies, and related nonprofit organizations gathered at the American Society of Anesthesiologists’ Brain Health Summit to discuss, among other topics, the postoperative risks of delirium and delayed cognitive recovery and whether or not they are significant enough to include in consent and patient education materials. They also considered ways to reduce the risks and to increase research funding.

The Penn Medicine News Blog says that “while the Summit provided some direction and tactics for industry leaders to act upon, there are still other options that can be explored and implemented to advance learning, protect patients, and uncover the uncertainties around anesthesia and postoperative delirium.”

“Encouraging patients to follow a balanced diet and exercise regularly in the lead up to surgery, allowing patients to bring mementos and family photos to their hospital room after surgery, even asking families and caregivers to keep a close eye on small declines in patients’ cognitive function preoperatively – simple things like the patient not being as sharp as he or she once were – may help clinicians properly prepare for patient care, and may help patients readjust after surgery and avoid postoperative delirium,” Fleisher said. “While these have not been scientifically proven to help, we think that even the smallest measures may make a difference for patients who are coming out of anesthesia.”

To learn more about delirium and aging, join the Institute on Aging on Tuesday, April 18, 2017 for our Visiting Scholars Series lecture by Edward Marcantonio, MD, SM.

Dr. Marcantonio is the Section Chief for Research in the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center and Professor of Medicine at Harvard Medical School. His research concentrations focus on delirium and cognitive function.

For more information, visit: www.med.upenn.edu/aging/events


Photo credit: news.pennmedicine.org/blog