Below is a loosely edited partial transcript of the live conversation recently held with Dr. J.J. Rasimas, MD, PhD and Ariel Mintz, MD. Dr. Rasimas discussed the causes, prevalence and treatments for delirium and why this is a condition that should matter to all of us. Refuat Hanefesh holds monthly live conversations. Our next live conversation will be 4/22/18 at 830pm est with Bari Mitzmann discussing her experience with perinatal depression. Previous and upcoming conversations can be found on our Live Conversation Page. Please subscribe to ensure you do not miss out on future live conversations and the opportunity to ask questions live.
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Delirium: The Secret Killer
Refuat Hanefesh: As we were advertising this live conversation, it became clear that many people don’t know what delirium is. Why should we be concerned about this topic?
Dr. Rasimas: Our bodies do a lot to defend our brains and keep them functioning well. So when a physical illness affects thinking and behavior, it means that illness needs to be taken very seriously. In fact, the illnesses that cause delirium are almost always potentially life-threatening, and delirium itself increases the risk that people will not recover because it gets in the way of the necessary treatment.
RH: With that said, can you please briefly describe what delirium is?
DR: Delirium is a syndrome that looks like mental illness, but shows up in people who are physically sick. A useful way to think about it is the idea of “Acute Brain Failure”. You may know people who have had heart failure or kidney failure, meaning that what we expect of those organs is no longer working properly. Well, a person with delirium doesn’t think or act or understand what is going on around them the way we normally expect them to. And the cause of that set of problems is an underlying diagnosis, not of a mental illness, but a serious medical condition.
RH: So you’re telling me this is not a mental illness. Who is responsible for treating it?
DR: Delirium is in the Diagnostic and Statistical Manual of Mental Disorders, largely because the symptoms that it produces are the sort that psychiatrists are experts in recognizing. But it is important that all kinds of doctors, especially those who work in hospitals and emergency rooms, can recognize it too. That’s because definitive treatment is going to require expertise from outside of psychiatry.
RH: How can you tell if someone is delirious? Do all people with delirium look the same?
DR: There are some things that are common to all delirious people. But sometimes when people suffer this kind of attack on their brain, they react with anxiety or agitation out of confusion. Other times, the sickness itself saps them of so much energy that they are mostly lethargic and don’t interact much at all.
RH: What are the visible signs?
DR: Delirium makes it hard for people to stay awake and pay attention, even when important things are going on. They often have problems getting good sleep at night and then can’t help but sleep intermittently during the day — their normal day/night patterns get messed up. Also, they have memory problems, particularly with remembering things that are new since the time they got sick. One of the scariest things is seeing, hearing, and feeling things that aren’t real and then not knowing how to make sense of it all, sometimes having irrational fears. They often don’t understand things told to them, so they can be hard to reassure. And they also don’t communicate in reasonable ways. It’s hard for them to follow what is going on around them. Sometimes even choosing what to eat or whether to have a shirt on or off is impossible for them to decide.
RH: What causes delirium?
DR: A long list of different kinds of medical problems can cause delirium. Everything from lung problems that decrease the amount of oxygen that gets into the blood and to the brain to major infections that travel around the body and cause problems for a number of different organs, including the brain. Other causes include out of control diabetes, a new cancer, and exposure to environmental toxins like lead, carbon monoxide or other gases.
RH: Tell us more about the medical risks and what medications increase risk.
DR: Medications that interfere with clear thinking are the ones that increase risk. These include some anti-anxiety drugs, some recreational drugs, and a number of medications we use for other conditions but affect brain function. Having an episode of delirium makes recovery harder and usually keeps people in the hospital longer.
RH: How commonly does it occur?
DR: It’s hard to quote a useful number for each possible cause. But in general, about a quarter of people who end up sick enough to be admitted to the hospital experience delirium at some point in the course. Some studies suggest that as we approach the end of life, depending on the specific incurable illness that is leading to death, the rates of delirium are 75 to even 90 percent.
RH: Who is at greatest risk for delirium?
DR: The “Acute Brain Failure” analogy helps to answer this question. With heart failure, the people most likely to have an acute episode are people who already have heart disease. Similarly, with delirium, people who already have a disease or established problem with brain functioning are more likely to suffer delirium when they get sick. Those conditions include dementia, epilepsy, a previous head injury or stroke, significantly low IQ, and age. Older people are more likely to have delirium than younger people; though, it does occur even in the youngest of children. Having a surgery that involves getting anesthesia is also a risk, even if it’s an elective procedure and the person wasn’t really sick at all beforehand.
RH: Is it preventable? Can we do anything in our day-to-day life to help ourselves avoid it?
DR: Well, obviously there are some diseases we get that we just can’t control. And of course, we can’t stop the aging process. But there are some things that keep brains healthier to protect against delirium if we are to have a serious medical problem. That includes regular exercise, which is the best prevention strategy known for Dementia. Protecting our heads when we get that exercise in the form of bicycle helmet use and protective equipment in contact sports is a good idea. So is taking good care of our blood pressure and blood vessels with a healthy diet and medications, if needed. Also, avoid abusable drugs and excessive consumption of alcohol, since they can cause lasting damage to the brain.
RH: Can delirium be predicted?
DR: Unfortunately, it really can’t in most cases. People who have had delirium before and are getting sick from the same kind of problem that produced delirium in the past does make it more likely they will experience it again. I can predict that if you use a large amount of cocaine or synthetic marijuana or other drug, it will happen reliably. But otherwise, we have screening measures in place in all hospitals to try to make sure we catch delirium as early as possible, so we can do something about it.
RH: When someone gets sick, can we do anything to reduce the risk of delirium?
DR: It is helpful to give doctors a good accounting of all the medications and chemicals someone has in their lives so we know what to watch out for and avoid bad interactions that can affect the brain. Having familiar faces visit the hospital can help. Frequently reminding someone in simple terms where they are, what has happened to them, and what to expect next is reassuring and helps their brains process the situation better. We also emphasize keeping lights on during the day with some level of stimulation and as much physical activity as can be managed. Making things quiet and restful to promote sleep at night is crucial. It can be hard to keep the chaos of being in the hospital from contributing to the risk, but this should be our goal.
RH: What are the medical treatments?
DR: The most important treatment for someone with delirium is to fix the medical problem that set it off. Without that, the risk for bad outcomes stays high, and delirium usually doesn’t go away. When the delirium itself causes major problems, we sometimes will use medications to make sure people don’t hurt themselves or someone else out of confusion. We also use antipsychotic medications to treat the distress caused by misperceiving what is going on. Other medications can keep people calm during these difficult times but can perpetuate the cycle of confusion, so we try to use caution. If we can, we rely on reassurance and patient, sensitive human care to carry through.
RH: Are there long-term consequences that result from delirium?
DR: Even after recovery, although we think of delirium as reversible, some people can have problems with their thinking being less efficient than it was before they got sick. The recovery back to routines of daily life can be slow, even if the physical recovery seems complete. And, to focus on mental health for a minute, having delirium increases the risk that during the months, even up to years after the time in the hospital, people can have serious problems with depression, anxiety, and even PTSD from the experience of delirium.
RH: Can we do anything after delirium to reduce these risks?
DR: There aren’t any results of research or clinical experience that tell us there are medication treatments that prevent the long-term problems. But in the hospital, putting together a kind of “diary” of the experience has actually been shown to really help a lot. It may seem like a time that you or the sick person may not want to remember at all, but losing our memory for stressful times is actually worse for our sense of well-being. Keeping track of what has happened day by day and reviewing it with patients when they are awake helps them make sense of the experience and probably makes depression and PTSD after recovery less likely.
RH: Based on those risks, does it make sense to preemptively treat illnesses such as anxiety, depression or PTSD, or should individuals who developed delirium be followed more closely after discharge from the hospital?
DR: Both of those suggestions make sense. We’re not certain about the size of the effect, but having treatment in place – especially social support – for people who already have a mental illness does make it more likely that delirium will be less problematic. And we certainly think it is important to screen for problems with mood, anxiety, cognition, and overall social and occupational functioning in the weeks and months following a hospitalization where delirium was an issue.
- Delirium: The Secret Killer – A Live Conversation Transcription - March 26, 2018