Psychiatry & Psychotherapy Podcast - Psychiatric Approach to Delirium

Episode Date: October 8, 2018

Delirium is an acute change in a person's sensorium (the perception of one's environment or understanding of one's situation). It can include confusion about their orientation, cognition or mental thinking. With hyperactive delirium, a patient can become aggressive, violent and agitated with those around them. A patient experiencing delirium can have hallucinations and hear things, they can become paranoid, and they are overall confused. A family or non-psychiatric medical staff might be concerned that the patient is experiencing something like schizophrenia. Hyperactive delirium symptoms in patients: Waxing and waning —it comes and goes Issues with concentration Pulling out medical lines Yelling profanities Throwing things Agitated Responding to things in the room that aren't there Not acting like themselves Hypoactive delirium is much more common than hyperactive delirium (based on research studies), but it is often missed because the presentation is much less dramatic. People with hypoactive delirium are confused and disoriented, but they are not expressing their confusion verbally or physically. Hypoactive delirium symptoms: Slower movement Softer speech Slower responses Withdrawn Not eating as much By listening to this episode, you can earn 0.75 Psychiatry CME Credits. Link to blog. Link to YouTube video. Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. So welcome to the podcast. I am here with Dr. Timothy Lee. Dr. Timothy Lee is the Loma Linda Residency Program Director. He is also the head of the consult and liaison services.

Those are the people that get consulted on medical patients in the actual hospital. And one of the main things that he gets consulted on is delirium. And so, Dr. Lee, how would you define delirium? So thanks for having me, David. I'm flattered to be chosen to be part of the podcast. Hopefully it's interesting. But yeah, to the question, delirium we basically think of as an acute change in a person's sensorium, which can include, you know, their orientation, their cognition or mental thinking.

But yeah, basically, in essence, in acute change in their cognition or their Sensorium. So define Sensorium? So Sensorium can involve one's perception of one's environment. So stimuli in the environment, it can involve one's understanding of one's situation, such as where one is, what the current date. is what their recent events might have been. Yeah.

So you're in the hospital. Mm-hmm. You have, let's say, a hip injury. Yeah. And you're 70 years old. Sure. And you get out of surgery. And then let's say you develop some delirium.

Mm-hmm. What would that look like? So delirium can look like a lot of different things. for simplicity's sake, we can break it down into some basic subtypes. So you think about what people mostly think about with delirium is what we call hyperactive delirium. So people with hyperactive delirium, they can become physically restless or even agitated and physically aggressive or violent towards people or, or things around them, they can become paranoid.

So they start believing, frightening, or disturbing things that aren't really true or aren't really happening. And they can start even having hallucinations where they believe or perceive either sounds or voices that aren't actually occurring in reality or visualize things. oftentimes disturbing, but sometimes just bizarre that aren't actually present in the room. So that is typical presentation of what we would call hyperactive delirium. And that's usually what you get consulted on for what? What do they usually say when they consult you? What is like you're on the phone with the cardiologist or the resident, and what do they say to you over the phone?

So they might say the patient is confused, or they might say the patient is unreasonably agitated or violence, or they might say the patient is having what they think are hallucinations. Those are common things that they'll call about. Sometimes they might be concerned that the patient has like an acute psychiatric problem, like schizophrenia or something like that. And when you arrive, if you talk to the family members, what do the family members say? So you can get a very amount of responses to the situation.

But it is a very frightening thing for a family member to see their loved one going through something like this, especially if this has never happened to them before. So oftentimes the family may be really concerned that there is something seriously wrong, which there is. But the fact that a psychiatrist gets called into the room, sometimes the family jumps to the fear that there's some acute psychiatric problem that's happened to their family member. And so our role is really to reassure them that, This is a very common thing. Of course, we're going to do an assessment and ask the family some history to try to delineate how much of this is actually a new onset confusion or psychotic symptoms that would be consistent with the delirium as opposed to some longer-term process.

But if we do come to the conclusion that it seems to be. an acute delirium, then we will reassure the family that this is a very common thing, you know, that happens to even relatively healthy people in the setting of an acute illness or post-surgery or just being stuck in the hospital for a few days. It's very common for people to become confused or disoriented and to even have very dramatic extreme symptoms like this and that's not necessarily indicative of a sudden onset of a long-term psychiatric problem and hopefully it will resolve in the days to come with treatment. Yeah, yeah, I think that's good. So acute fluctuating course, waxing and waning, so it kind of comes

and goes, issues with focus, concentration, pulling out lines, yelling profanities, throwing things, getting extremely agitated, responding to things in the room that aren't there, not acting themselves. And I've actually had, you know, in an outpatient setting, a number of these patients who are kind of on the edge of the delirited. sort of spectrum where maybe later in the day they become a little bit like this. Like, you know, upstanding citizen all of a sudden has a stroke. A couple months later, they're still, they get really agitated in the afternoons,

cuss out their family, you know, very unusual behavior. And I found that educating the family can help them so much. Yeah. Because it's so scary. It's so scary. when your family member is in this state and you have no idea what's going on. Right. So that's the agitated delirium.

Tell me a little bit about the hypoactive delirium. Right. So that's kind of the opposite end of the spectrum or the second basic category that we can break delirium down into. So hyperactive, hypoactive, and then mixed, which is basically a combination of the two. But hypoactive delirium actually is much more common than hyperactive delirium based on research studies, but it's much more often missed because the presentation is much less dramatic. So people with hypoactive delirium are just as confused. They're disoriented.

They don't know what's going on. they may even internally have some misperception of their environments or the things going on around them, but they are not expressing that either verbally or in terms of their physical movement. In fact, they oftentimes are kind of slowed in their movement. Oftentimes their speech becomes softer, slower, frequency, their thought process is also slowed, so they're slowed in their responses when other people try to talk to them or ask them questions. But because they aren't presenting in such a dramatic fashion, oftentimes nurses and physicians

who, you know, are very busy and have a lot of things that they're trying to keep track of and assess for, they may actually miss the fact that the patient has some confusion and thus it doesn't come to the attention of the medical team or and of course then to the psychiatric consult service either yeah so when it does come to the attention what does the consulting physician tell you about this patient or why are they concerned about this patient. So with the hypoactive cases, definitely there's more commonly just in concern for confusion. So somebody from the team, either the physician or the nurse or the students or another

staff member has identified that the patient is confused. And so that's usually the main presenting concern. Now, sometimes also they might notice because the patient can't seem to answer the questions that the doctors are asking them, or if they're trying to consent them for a procedure, the patient doesn't seem to be able to readily relay back to them an understanding of the risks and benefits of the procedure that's being proposed. but confusion is the most common complaint you'll get in a consult like that. I also think I was looking at one study about Mayo and the consults for depression. And I think it was like 67% of the time when consulting for depression, the patient ended up having delirium. So internal medicine, you know, great internal medicine program. Their consults would be for depression.

and when doing the full evaluation, no, the patient is not depressed. They're just delirious. Yeah, you're right. That does definitely happen. And so because people with hypoactive delirium, they're withdrawn. Like you said, they're more slowed in their thought process and their speech. Maybe they stop eating as much. Those are all things that the treating team might associate with possibly.

depression. And of course, you know, it's pretty depressing being in the hospital, so that's not an uncommon line of thought to jump towards. And so if that's what they latch on to as opposed to identifying there's actual confusion or disorientation, then yeah, that may be what they report when they call us. Anything else that the family members would report to you guys, or is that something on your radar? are mostly the confusion. Yeah. I mean,

the family members may also be concerned that the patient is depressed, you know, because they can look so similar. Yeah. Yeah. I think it can be difficult as a family member as well, because once again,

it's like, what's going on with my significant other? What's going on with my mom and dad? You know, they're just not acting themselves. They're just, you know, they seem confused. They don't remember their granddaughter's name, the grandson's name, you know, different things like that. So, okay, let's say you see this patient, you have some history. How do you, what's the best evaluation tool that you use

to sort of decipher if this person is, in fact, delirious? Yeah. So common things we might do in a clinical assessment, Certainly asking orientation questions. In most branches of medicine, you focus on orientation in three dimensions. One being person, so does the patient know who they are and can they tell you their name? Second, being place, does the person know where they are? And in what detail do they know where they are?

third being time. So the date It's in our psychiatric assessment, especially for delirium, we're also concerned about a fourth dimension, which is orientation to situation. So

not only does the person know like what day, month, year it is and where they are, but do they know why they're there? Do they remember the circumstance that led to their ending up in the hospital. Do they understand what their main condition or medical issues are that the doctors are trying to treat?

Do they understand what the doctors are proposing to treat them with? So those among other things are common factors that we try to assess for as part of the fourth dimension of orientation. So that's a common thing that we, including the assessment, we're also looking at their short-term memory as well as long-term, but specifically to test short-term memory, we might ask them to repeat a few words back to us, like a list of three words that we give them. And then after asking a few other questions,

roughly three to five minutes later, we'll ask them to see if they still remember those three words. So there's memory. Concentration is an important thing that we assess for. So we're looking at their ability to focus and concentrate on a unfamiliar task to them. So I'll often ask the patient if they can tell me in reverse order the months of the year or the days of the week as a way to test their concentration. Oftentimes, I'll also try to assess their visual spatial ability, which can often be impaired when they're confused, as well as their ability to plan or map things out. So the way we often do that with patients who are physically able to write or draw is we'll do what's called a clock draw test.

So we will draw on a piece of paper a large circle for them. I'll ask them to draw the numbers on the face of a clock. So that is where the visual spatial ability comes into play. How well can they actually space out the numbers on the face of the clock? And you can pick up subtle impairments or difficulties that way. and if they do a reasonable job with that, then we will ask them to actually draw the hands on the clock to indicate a specific time.

The standardized time for that test is to ask them to draw the hand so it indicates 10 minutes past 11. So those are common things that I'll routinely do in assessing a person's cognition and mental states and trying to screen for possible delirium or dementia. As far as like standardized assessment tools, the ones probably most commonly used would be the mini mental status exam. Another one that's frequently used these days is called a Montreal cognitive assessment.

And those are both standardized screening tools intended to screen for either delirium or dementia. Yeah. When I cover for you, the first thing I have the residents do is pretty much every new patient, have them do a clock draw, have them do spell world backwards or countdown from 21 by 3. I often will see with delirious patients, they still know their name. They still know where they're at. A lot of people don't know the date. Sure. but the focus and concentration tasks are completely gone. Yeah. And the clock draw, I've never seen a normal clock drawing from a delirious patient.

Yeah, it would be, I'd say possible, but atypical or unusual. And yeah, oftentimes we will get consults, you know, and the consulting physician, believe that the patient is not delirious because they can roughly tell them their name, their location, and the month and year. But that alone doesn't necessarily mean that a person isn't confused. So doing some of those other tests can identify maybe subtler forms of confusion that would still be consistent with delirium. Yeah, I remember having a discussion like that.

with an ER doctor once, and I pulled out the clock draw of the test, or the patient had done, and it was a very, very poorly done clock drawing. And the attending was like, oh, okay. All right, we'll get, we'll admit the patient. Okay, so you have that basic assessment. You have the fluctuating course. You have parts of the mental status examination with issues of focus and concentration. As you go about your assessment, I'm thinking probably the next biggest thing to think about is why they're delirious. Yeah. So let's start at the head and go down the body. Okay. And think of all the reasons why someone might be delirious. Because I think when I was a medical student, that was the most systematic way to think about.

delirium. Okay. Okay. So what are all the things that could cause delirium just from inside the skull, the head? Okay. So yeah, this exercise, obviously we're going to leave out some things because the potential differential diagnosis is as far and wide as you can imagine. But things I would think about in terms of central nervous system or in the brain issues, certainly you'd be concerned for a stroke. You might be concerned for a hypertensive emergency, possibly an infection or meningitis, trauma that might cause, like even subtle or minor bleeds can cause increased pressure in the brain, which can lead to confusion. That's good. Yeah, the stroke thing, and when someone finds a really confused patient,

they often forget to check strength in both arms and both legs. Yeah. Have the patient smile, things that you could do. And so sometimes people will miss the stroke. for the head injury. You know, with a head injury, you can have concussion. You can have loss of consciousness, but then you can also have damage that after the concussion leads to a delirious type of picture.

I don't know if you would consider that like post-TBI or delirium. Do you often diagnose delirium in a TBI patient after? the TBI or how do you work that through in your own mind? Yeah, that's trickier because if you're talking like a post-concussive syndrome, you might be thinking more in terms of actually like a more persistent process or even like a cognitive impairment or what some people... Hardware. You have like a hardware and then you have a software issue. Delirium is more of like the software.

Yeah. To some degree. So with the TBI patients, though, I see that they are more apt to get delirious. That's true. They're more commonly delirious and you really need to optimize their brain functions so that they do not get delirious. Yeah. In my Sensorium part one, two, and three early on, I really go through this and kind of how do I optimize these types of patients? Because I see these in the outpatient.

I see these in the intensive outpatient partial program that I run for people with medical issues. is they have a TBI, they get months away from the TBI, but they're still on meds that are causing them to have a more, a lower level of brain function, which causes them to be more delirious. And it could be a hypoactive nature. So it's good that we discuss that. When you think about medications and how they affect the brain,

what are the biggest classes of medicine? medications that you always screen for when you're doing a delirium workup? So anything that has antichulnergic side effects, and there's a wide list of medications that have anticholineric side effects, definitely sets up the brain for risk of delirium by suppressing acetylcholine. So after an excess of dopamine in the brain, a deficiency of acetylcholine is thought to be probably the second most important imbalance in the brain that can cause confusion. So Benadryl is a common one.

Anti-allergy medications can do that. A lot of pain medications commonly have anticholinergic side effects. Our psychiatric medications, especially some of our antipsychotic medications, can commonly cause antichotic side effects. cholergic tricyclic antidepressants especially if the levels

are too high and sometimes if the breakdown of these medications is impaired in some way then that can cause an increase in like a tricyclic

which would cause an increase in the anticholinergic side effects and those people can get confused yeah benzodiazepines yes would be the next big category benzos

and other GABA-urgic agents, so sedative or asleep pills, especially like Zolpidem or, sorry, Ambien or Lunesta, those class of medications can commonly cause confusion through their effect in the GABA system, slightly different from the anticholandric effects, but equally common. I remember having an argument with a physician on another team about not giving ad-a-van to this patient. And the other physician was convinced that this would actually help because the patient is agitated. You give ad-a-van and they calm down. Yeah. Can you explain to someone who believes that why that's not the case in this?

Sure. So it definitely can calm them down. Now, sometimes it doesn't calm them down. Actually, sometimes benzos like Ativan can make the patient more agitated because they are more confused, but they're not sedated. So they actually act out even more or become even more aggressive. But even then the patient said it does calm them down, it's mostly through sedating effects. and they're actually more likely to get confused. So even though they're calmer, they are more confused.

And so you may actually be shifting from what might seem like a hyperactive delirium presentation to more of a hypoactive delirium presentation. One example that's useful to think about is alcohol withdrawal. So patients who are going through severe alcohol withdrawal, A very standard, you know, long-time approach is using benzodiazepines like Aduvan or Librium or Valium to manage the alcohol withdrawal because they kind of act on the same receptors that alcohol does and thus kind of replaces the alcohol, so to speak. So it can keep the alcohol withdrawal symptoms at bay. but they actually end up in a confused state.

So you're treating them with the benzodiazepines after 72 hours, which is typically the kind of crisis phase for onsets of severe alcohol withdrawal symptoms. They're past that risk phase, but you're left with a patient who is confused and not able to, appropriately respond, manage, and thus they stay in the hospital longer because they're not able to function and go back to their home environment. So in that case, Ativan would be helpful? It calms them down, but the trade-off, which is unhelpful, is that they're more confused. Okay.

So is there a solution to that? So the solution is to really focus on treating the delirium. And I think for the sake of time, we won't go into alternative methods of treating alcohol withdrawal using non-benzodiazepine methods. Oh, come on. Let's do it. Sometimes they do like a Maltinato up at Stanford. He's doing like Galapentin or. Yeah.

So Dr. Jose Maldonado up at Stanford University. He is presence of the delirium society. and has done a lot of research. I should have him on. If he's on, that would be amazing. Please reach out to him. I would love you on.

Yeah, I would love to hear that if he'd speak with you. I've heard about six hours of his lectures. He's amazing. Yeah, absolutely. But yeah, so he would propose, because of this problem, you know, sure you can mask the alcohol withdrawal, but you end up with a confused, delirious patient. he would propose that it actually makes it a lot more sense, both practically speaking and from a pathophysiology standpoint, to treat the alcohol withdrawal with non-benzidazapine agents, such as anticonvulsants, which have effects on the NMDA system and also will prevent seizures.

So like valporeic acid or gabapentin, and then using other agents. for the hypertension or tachycardia such as clonidine. Clonidine, yeah. Yeah. Yeah, and I'll try to dig up one of his articles on that to put in the resource library. Great. And I'm going to put up Dr. Lee's two lectures as well, if you let me. Sure, that's fine.

He has one on hypoactive delirium and one on delirium that we're kind of pulling stuff from. So, okay, so we have the patient. And we've talked about a couple medications that can make things worse. Benadryl or anticholinergic medications, benzodiazepines, barbiturates, sedatives, any other classes of medications that sort of right away jump to your head when you are kind of evaluating the patients? Pain medications for sure can cause confusion in other ways. There's a delicate balance because you also need to treat their pain because uncontrolled pain can also cause confusion or delirium. But those are the common things as far as like pharmaceuticals.

And then of course any other drugs like illicit drugs or alcohol certainly can put a person at risk for becoming acutely confused. Yeah. Okay, so moving down from the head. Okay. Let's get into the chest or the neck. I guess we could go to the neck. Anything from the neck that could cause a delirium? Mainly be thinking about like trauma.

You know, so anything that might, you know, cause bleeding or other circulatory problems or something like that would probably be what would cause an acute delirium. Yeah. Thyroid. So the thyroid gland in the neck. Okay. So imbalances in the thyroid or parathyroid hormones certainly could cause a person to become confused or delirious. I also think of like cancer. Can cancer cause a delirium?

That's tricky. In and of itself, I'm not sure. Cancer can certainly cause other sequelae or physiological sequela in the body that could cause delirium. or yeah, but just having a cancerous tumor in and of itself that's not in the brain, it's harder to make that association. So people with cancer who have sarcopenia, you know, who have a lot of weight loss, who have a lot of muscle loss, those people are more, and then let's say they get another little infection on top of it. So usually it's multi-factoria, multiple things going on.

or if they're on like a lot of chemo and radiation, you know, that can influence sensorium as well. I was recently at a strength training conference and one of the guys that trains in their gym has stage four cancer and continues to strength train, you know, lifting really heavy weights and continues to gain weight. And his thing was like, well, as long as I'm gaining weight,

I'm not going to die. And most people with cancer die of, you know, the muscle wasting, the protein malnutrition, and then the complications of having the disease. So that's something to think about. Okay, let's get into the chest. So anything in the chest that jumps out, common issues that cause delirium? Yeah. So anything with the heart and lungs.

So take the heart, you know, certainly a heart attack. Not pumping enough blood to the brain. Yeah. So anything that interferes with the circulation, the ability of the blood to reach the extremes of the body, anything like a traumatic injury to the heart may result in swelling or bleeding within the heart or in the kind of paracardium, the sacs surrounding the heart. So all that congestive heart failure,

which is basically when the heart is too weak to adequately pump blood, that can certainly set a person up for delirium. And if you think about the lungs, probably the most common thing that can cause a delirium, especially in the hospital setting is a aspiration pneumonia. So somebody is, you know, tired, they're sick, they're lying down for most of the day, which is really unusual. It's not too difficult to imagine swallowing something, either just secretions or if they, you know,

try to swallow some fluid or a piece of food. and it goes down the wrong way into their windpipe rather than down their throat into their stomach. Any minor thing like that, which can frequently happen, can result in inflammation and thus an infection in the lung, and that's a very common cause of delirium. Other things certainly can happen in the lungs. So cancer of the lungs or traumatic injury that results in air entering the lung region, which shouldn't be there, things like that. Yeah. I would say with the aspiration pneumonia, I'm glad you brought that up. You know, if someone gets intoxicated, they have less control over there, you know, what goes up, what pipe.

So those people tend to get the aspiration pneumonia's. the pneumonia in general, I would say, like even viral pneumonia's and elderly people can cause delirium. So that takes like something that could be short-lived. Like maybe that would have only lasted a week. But now you put a delirium on top of that, and now they're in the hospital for 10, 20 days, sometimes, you know? Yeah.

It's like super hard to take care of these people. Yeah, so lungs, just, yeah, I was thinking about with the CHF, I had a case of this recently, where you're not pumping enough blood to the brain. So maybe, you know, before you had a pretty sharp person. Yeah. Maybe they were 10 years away from getting any sort of dementia. But now it's like, it's kind of like it takes what little brain function they have

and makes it that much harder for that brain to function. Okay, so we got the heart cavity. I'm sure there's other things that are missing, by the way, but we're just going to keep going. Yeah. Let's go down to the stomach, the abdominal cavity. So you think of all the major organs in your abdominal cavity. Pancreas, so pancreatitis, very common to end up with delirium.

So that's when the pancreas gets inflamed, releases all these, you know, things that normally break down food are now in the circulatory system. Yeah, I think of like a little old lady with urinary tract infection. Sure. Lady because, you know, urethro is much shorter than men. They tend to get more urinary tract infections. And, you know, that can just set them off the edge. Something that simple.

So we always, always ask for a urinalysis, like immediately when there's a question of confusion. because it's just so common. And, yeah, even I'm sure you've had conversations with physicians. I've had conversations with physicians who are arguing about, well, the urine infection is mild, and that's the only identified medical problem. And they're pretty incredulous when we try to insist that even something as simple as that could cause confusion. But it definitely does. remember a patient who was treated not too long ago. She was in the ER. She was confused.

She'd taken a few extra benzodiazepines. I think she was trying to get some sleep. But the next day, she was up on the medical floor and she was very awake compared to the previous day when she was just sleepy, very awake, very paranoid. cussing up a storm and basically wouldn't engage in any kind of reasonable back and forth conversation and kicked us out of the room

and the only identified abnormality on her test was this urine infection and so the hospital doctor was very convinced that this must be an acute schizophrenia or an acute mania. But we stood our ground and we gave her some intravenous Hal Dahl. And the next day,

she was totally back to herself. So that was kind of gratifying to see. And those are really rewarding situations when you can get someone back to their normal state so impressively and in a quick fashion. One thing that I think is important to understand is, if you're a primary care physician listening to this, is it's very rare to have a new onset schizophrenia later in life. Yeah, anything like late 30s and upward, it's unusual. It's unusual. So it's very, very, very rare to have a 50-year-old with a new onset, you know, psychosis

that's caused by schizophrenia or bipolar. So historically, just the age and the onset and getting the collateral. We don't always have collateral, and, you know, ER physicians are very busy, and so they don't always have that information, but that can be very helpful. Right. Yeah. Any, gosh, okay, so abdomen, groin. Groin area.

Yeah, and so. If you think about the groin, you're thinking about besides the urine infection, you might think about cancers that can result in confusion. Back tracking from there, just thinking about the urinary system, the kidneys. So any alteration or impairment in kidney function definitely is a setup for a delirium. in the vast majority of cases. So you're talking about like the kidneys actually being able to filter out the toxins

of the body? Do these two kidneys work? What is their creatinine function? You know, are they in the normal range? Are they able to get rid of these toxins? And the liver's the same way. We haven't really touched on like... Right.

That's the other major organs. So, you know, alcoholic liver cirrhosis or hepatitis or other things that are causing issues with the liver, such as a gallbladder inflammation, which is very close to the liver that can all result in confusion or delirium. Now, when you think of a liver being dysfunctional, there's the acute dysfunction and the prolonged dysfunction. So acute dysfunction, I tend to think of, you know, your AST, your ALT are very elevated.

for chronic dysfunction your platelets are low and your albumin is low. Anything else that you have on that? Billy Rubin. Sure. Billy Rubin tends to be elevated in the chronic dysfunction. The albumin is the protein that floats throughout the blood that binds to things. that's made by the liver, so that gets pretty low if you have chronic kidney, or sorry, yeah, chronic liver disease.

One of the things I think about is hepatic encephalopathy. So this is someone with cirrhosis of the liver, chronic damage of the liver, and they get confused. Do you differentiate this at all, hepatic encephalopathy from delirium in general, or are these two and the same thing to you? It's the same. So there's a lot of different words for what we consider delirium. So some people would say encephalopathy. Some people will say delirium. Some people might say like ICU or intensive care unit psychosis is another term because delirium and confusion happens so often in the intensive care unit setting. because of the severity of the medical issues that the patients are dealing with.

And the environment is a lot more hectic, and there's a lot more noise and external stimuli going on. Do you treat? Some people also use brain failure would be another term people use. Do you treat hepatic encephalopathy different from a delirium, for example, like an agitated delirium caused by a urinary tract infection? I guess to that, I would say, treatment of. any delirium really foundationally involves treating what you think is the underlying issue. So certainly with hepatic encephalopathy, whatever interventions, pharmacological or otherwise, that you can employ to improve the liver function or maintain liver function will help.

but that is like so like a UTI then you won't give an antibiotic to treat the urinary tract infection and that should help with the delirium oftentimes by the time that we get involved those things have been done you know our colleagues are on top of it they're treating the underlying cause but the confusion's not improving so at that point they're often asking us to get involved, one, to figure out whether there might be another cause that they haven't thought of, but two, to think about if it's just that the delirium is not improving, even though the underlying condition is improving or has resolved, do we give additional treatment for the delirium? Most commonly would be an antipsychotic to treat a delirium.

But that is an important point to bring up is that just because you treat a delirium, you treat the initial cause of the delirium doesn't mean that the delirium will automatically resolve along with it. So like your UTI, for example, they've treated it with antibiotics for three to five days. They're pretty convinced that the infection is resolved or controlled, but that doesn't necessarily mean that the confusion will necessarily resolve immediately. Yeah. What have you seen in terms of how quickly does a hypoactual... or hyperactive delirium resolve? A reasonable time frame might be after like three to five days of treatment.

Okay. Sometimes you'll get a much more dramatic, quicker response like the lady I mentioned a few minutes ago. Sometimes it's a lot more prolonged and refractory. I've had patients we've had to treat for weeks for their delirium, even though the underlying condition was stabilized. before their mentation finally started to improve and get back closer to normal. That brings up another important point, which is, as we mentioned at the beginning, assessments for confusion can often be varied in terms of the tests that people will do.

Some are more thorough than others. But the point I want to bring up is that just because a person's confusion seems to be improving, and on a superficial level, they seem to be back to normal functioning cognition, doesn't necessarily mean that their delirium has completely resolved and that they don't still have some underlying cognitive impairments that are somewhat more subtle. So there are longitudinal studies that have looked at patients' cognitive functioning days, weeks, months after they've been treated for a delirium and release from the hospital and identified that they do have ongoing cognitive impairment and they're not back at their baseline cognition. So that's something important to keep in mind is that delirium, even though it may look like it's improved very quickly, there can be insidious or underlying cognitive issues that are still present.

And so it's important to be fairly conservative in terms of how quickly you taper them off the antipsychotic medication that you use to treat the delirium, rather than just stopping it immediately when they're discharged from the hospital. Very good. You know what? I'm thinking we're going to have to have you back on to do treatment and the nuances of treating delirium. Okay. Going through the different antipsychotics, going through the different other treatments, talking about maybe, you know, how the hospital can prevent delirium.

Dr. Lee, it's been a pleasure. Thank you for coming on. Likewise. Time's flown a lot faster than I thought it would. All right.