Scott Webb (Host): Delirium is a serious sudden change in brain function that causes severe confusion, trouble focusing, and shifts in awareness. And my guest over the next two episodes is going to help us to understand delirium and how Salinas Valley Health is working to prevent and treat delirium. And joining me for these episodes is general surgeon Dr. Atul Jani.

This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. Doctor, it's nice to have you here today. We're going to talk about delirium and what that is and what that means and how you help folks. So, let's just start maybe with the most obvious one. What is delirium? Why does it happen? And maybe what are some of the common causes?

Dr. Atul Jani: So first of all, thanks for having me. And I think it's a very important subject, because many people don't realize how often it does happen to hospitalized patients and how dangerous it can be. I've kind of developed a little educational mantra for delirium. I think delirium is dangerous and disabling and deadly and deserves detection and diagnosis.

And kind of going through that, you can kind of see that it's an important subject. It's a medical condition that causes sudden and severe confusion in individuals. It can sort of be thought of as acute brain failure. Just like you can have acute heart failure, you can have acute brain failure, and it's just as emergent and urgent a condition as heart failure can be. There are specific definitions. You know, in psychiatry, they go through a diagnostic and statistical manual of mental disorders. That's kind of like their Bible.

And their definition is that it requires a disturbance in attention, which means that the patient is not focusing anymore. The patient is not able to concentrate well. And it's an awareness, and it's also a problem with awareness, and it develops acutely, fairly quickly, and it fluctuates. So in the morning, they might be fine. In the afternoon, they're delirious. We can see it soon after they're admitted. Sometimes they're admitted with that problem. Other times, as a general surgeon, I can see it after they've had major surgery.

Host: Okay. Yeah, because I was going to ask you, how does it present and maybe does it present differently or exactly how does it present, let's say, postoperative?

Dr. Atul Jani: There's actually two different types of delirium, and the most common type is the type that's missed the most unfortunately. Because the common type, which is hyperactive, that's the one we often hear about or see about or see on television where the patient's, essentially out of control. They're pulling out their lines. They're yelling. They're trying to get out of the hospital. They're essentially what we think of as a delirious patient. And that only happens about 25% of the time. Seventy-five percent of the time, it's what we call hypoactive, and you might come in to see the patient after surgery, and they might just be very quiet, maybe sleeping most of the day, just staring at the wall, not really focusing on anything.

But since they're so quiet, we think they're just resting after surgery, and nursing staff might want to leave them alone so they can rest. What's actually happening is they're delirious, and that needs to be diagnosed so that can be treated or at least attended to so that it doesn't get worse and it doesn't cause long-term problems.

Host: Yeah, because I was thinking about the signs and symptoms. And for a layperson like me, someone just kind of hanging out looking at the wall wouldn't, for me, seem like a sign of delirium. But clearly, learning from you today, it is. So, let's just talk through the signs and symptoms of one or both types.

Dr. Atul Jani: So for hyperactive delirium, the patient is clearly agitated. They are usually feeling a little bit concerned about their surroundings. They are not sure where they are, why they're there in the hospital. They can also be a little bit combative. They might, as I said, start pulling out all their lines, their IV lines, trying to get up out of the bed, trying to get out of the hospital, and that tends to be the squeaky wheel gets all the grease. So, that's the one where we can rally around the patient and make the diagnosis earlier and then try to treat it.

The hypoactive one is the one that's more difficult. Often, even family feel that the patient is just resting. And so, nobody's understanding that the patient internally is going through a lot of stress and developing delirium.

Host: Yeah, it's very interesting. It makes you wonder, what do we do if we notice the signs of either or both? But if we notice these signs in a loved one, but we're not in the hospital and we're not experts, what do we do?

Dr. Atul Jani: First thing is to make sure that the patient's safe and that the patient is in an environment that's comfortable for them. So, just as we do in the hospital at home, there should be family around them. They should have their usual things that allow them to connect with their surroundings, which would be if they use a hearing aid, that they have the hearing aid, it's working. If they use glasses, that they have their spectacles and they can see what's going on around them. If they are unfamiliar who's around them, that they have family or friends, that they know that are surrounding them.

And then, finally, it's best to then contact their healthcare provider to tell them what's going on. If they're hyperactive, obviously that's the time when you worry and you call your healthcare provider, or you might even call an ambulance to take the patient to the hospital, because you don't know what's going on. And that's a prudent thing to do also, because we'll talk more about what can be the causes for delirium that can be life-threatening.

The hypoactive type, it's the same thing if it's not so much of an emergency to you, but internally it might be an emergency to the patient. Contact the healthcare provider or bring them to the hospital so that can be worked up to see what might be the causes for them to tip into delirium.

Scott Webb: Yeah. Yeah, I wanted to ask you, we focus more on the causes. Like, this is just something that can happen to older adults, or is it genetics, family history? Like, how does this happen?

Dr. Atul Jani: In the medical field, we like to use acronyms. And the one that's good for this one is actually delirium, the word delirium. And you use each letter to try to figure out and diagnose what the etiology is for the problem.

So, D would stand for drugs, because there's lots of medications that can cause delirium. It could be new medications that the patient has just been prescribed. It could be increased doses. It even can be over-the-counter medications, because even a drug such as Benadryl can lead to delirium in patients who are a little bit older. More often we see delirium in older patients. It can occur in younger patients, but the risk is higher when you're over the age of 60 or 65. And as you get older and older, the risk even increases.

E stands for electrolyte disturbances. Maybe the patient is dehydrated. Maybe there is electrolyte imbalance, maybe even a thyroid problem.

L actually stands for lack of drugs. So, some patients are on medications chronically. And then when they enter the hospital, those medications aren't renewed so that they're actually going through withdrawals from medications that they take at home regularly. It could be pain medicine, it could be sedatives. And then, some patients are in so much pain that they're not getting enough medications. It's a lack of analgesics or pain medicine to help them, and that can tip them into delirium. The more other medical problems you have, it takes less and less to tip you over into delirium and vice versa. You might only have a few medical problems, but you have so many stressors from your present illness that that can tip you into delirium, even if it's an operation or major operation afterwards, they can develop delirium.

The I stands for infection. So, we work up sources of infection that could be causing the delirium, such as a urinary tract infection or a pneumonia or infection in the skin. Those are more common causes of delirium if the etiology is infection, and we can see that more often in older patients.

R stands for reduced sensory input. We talked about maybe they didn't bring their glasses or eyeglasses or their hearing aids or portable amplifier with them to the hospital, and now they're sort of isolated and they get stressed and then develop delirium.

The next I is something going on in the brain, intracranial disorder, such as maybe they're having a stroke, maybe they have a tumor, maybe something else is going on in their brain, and we work that up.

The U stands for urinary and fecal disorders. Patients who are older can have problems emptying their bladder, and maybe their bladder is full, and that's tipped them into delirium. So, we work that up to see if that's the source, or maybe they've haven't had a bowel movement for a while, they're severely constipated or what we call fecal impaction, and that needs to be treated.

The M can be myocardial and pulmonary disorders, which means they could be having heart problems or lung problems leading to them having delirium. It can mean anything from a heart attack, abnormal rhythm, heart failure, maybe their blood pressure's low, maybe they've got COPD from smoking and now that's worse and they can't breathe well. And those are the kind of things that we look into to develop a differential diagnosis. And once you treat the problem, then hopefully their delirium will improve.

Host: Right. Yeah. And gaining an understanding here today of the different types of delirium and what may be the causes, I guess makes me wonder, is this something that comes on rather quickly or slowly? Like, how fast does delirium develop in most folks?

Dr. Atul Jani: Unfortunately, it can develop fairly quickly. It can be a matter of hours or days after a stressful event such as a surgery. And then, it can last for days on end after that until we've treated the problem. good percentage of the time, 45% of the time, patients leave the hospital with still some element of delirium, and that can even last for months or be permanently disabling.

Host: Right. Yeah, we talked earlier about what we should do if we're at home and we recognize the signs of hyper or hypo in a loved one or maybe even a friend. But when is it an emergency situation?

Dr. Atul Jani: Well, interestingly enough, this is considered an urgent or emergent situation whenever it's diagnosed or whenever it's appreciated. And if it's a friend or family member or even at home, they should contact their primary or their healthcare provider or if not, just take them to the local emergency room to get evaluated, because the underlying causes could be life-threatening.

Host: And next time, we'll talk about how delirium is diagnosed and more. Thanks so much.

Dr. Atul Jani: All right. Thank you.

Host: And to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor, or family member. And subscribe, rate and review this podcast, and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.