Scott Webb (Host): Today in part two of our series on delirium, we're going to learn about how this serious condition is diagnosed and the role that the Delirium Prevention Program at Salinas Valley Health plays in preventing delirium in patients. And I'm joined again by Dr. Atul Jani. He's a general surgeon with Salinas Valley Health.

This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. Dr. Jani great to have you back on. Let's pick up where we left off last time and talk about how you diagnose delirium.

Dr. Atul Jani: We have different methods to risk stratify patients if they're at risk for developing delirium, especially if they're in the hospital and they've had a major operation. And then, we have ways to help diagnose it through different strategies after they're hospitalized or after they've had their surgery.

And nursing and other ancillary services can be helpful, and even family members can be helpful in identifying what could be going on, whether it's delirium or something else. The assessment tools that are used in the hospital, for instance, at SVH, we decided on different tools that are easy to remember that nursing staff can do. Some are done in the ICU, some are done on the regular floors. There are instruments or tools that nursing staff can ask the patient questions to evaluate their condition and help decide whether they're possibly having delirium, and then calling the physician or healthcare provider to see if they are actually in delirium.

The ones that are done for predictive, as either as an outpatient or once they're admitted to the hospital, can help the physician decide whether they're at risk. And then, we can start to employ our tools at the hospital to hopefully prevent delirium from occurring because treatment of delirium is very difficult. There's no FDA-approved medication to give. It can be a long-standing problem.

So, prevention is actually the best means in order to think about this problem. And up to about 40% of patients, who would eventually develop delirium, we can prevent that by employing simple methods, they're not high-tech, they're not flashy, they're things that you can do at home and in the hospital to reorient the patient and make sure that they're grounded and decrease the chances of them developing delirium. Because once it happens, it's really difficult to treat and get them through it.

Host: Yeah, that was going to be my follow-up, was asking you if it's possible for this to be a permanent condition. And it sounds like it can be challenging to treat, you know, if it's not prevented. So, give us a sense, like, are some folks just always dealing with delirium or is it possible to cure it per se?

Dr. Atul Jani: We can break them out of it over time, but it can be very difficult, and sometimes it can morph into issues such as dementia or other permanent mental conditions. So, most of the time that they have delirium in the hospital, it'll hopefully resolve within a number of days.

And then, the patients that go home, a number of them will have persistent delirium. But over time, it should improve. A sort of small percentage of the time, it can be permanent, or it can develop into other permanent mental conditions. The 45% or so of patients that leave the hospital still with delirium are the ones that have a really severe case of delirium. You can have mild or moderate or severe cases, and the ones that tend not to do well are the ones that have real severe cases that are hard to treat in the hospital and are hard to get you through.

In order to recognize it, you talked about different ways to try to recognize it. And mainly, it's a patient that's confused or disoriented. They have difficulty understanding where they are, what their surroundings are. And so, for those patients, family, friends, and, the staff at the hospital can continually reorient the patient, tell them where they are, the date and time, and things like that. If it's fluctuating, sometimes doctors will be on rounds in the morning, and the patient will be fine. And then, later in the day, it's only family that notices that they're different. And so, it's nice to have family or friends with the patient most of the time if they're at risk for developing delirium or have delirium to help orient the patient and also tell the hospital staff what's going on.

Host: Yeah.

Dr. Atul Jani: They might have mood swings, anxiety, agitation, might even be depressed. And usually, their sleep cycle is disrupted. And so for those things, we like to employ strategies at the hospital to make sure that we're not ruining their circadian rhythm, that they know what day it is, and they know that it's night. And like I said, it's non-pharmacologic treatment that is mostly used to help patients get through this.

Host: Any recommendations for loved ones, taking care of loved ones who are suffering from delirium, regardless hypo, hyper, you know, they're caring for them at home? What's your best advice?

Dr. Atul Jani: I'm hoping that hopefully, you know, most of it has resolved before they've left the hospital. But for those patients that have developed it at home, like for instance, if a patient comes to the hospital and develops delirium, about 50% of those had some element of it when they were at home. And then, the rest of it developed it in the hospital.

And so, the ones that are at home, contacting your healthcare provider, seeing who they can be referred to, and if it's a serious situation, consider admission to the hospital to get it worked up. For chronic conditions, that's best when you speak with your healthcare provider and see if they need help with mental conditions, which would be out of my scope of practice, but would be understood by primary care providers and psychologists and psychiatrists.

Host: Right. As you say, the goal is to not send folks home while they're delirious, while they're suffering from delirium. But if loved ones have to help them, and treat them, obviously, there's still some assistance available. And speaking of that assistance, I wanted to ask you more about the Delirium Prevention Program at Salinas Valley Health, what you're doing there, how you're helping folks and families and all that.

Dr. Atul Jani: Just a little history behind the program, during actually the pandemic, with everyone locked down and under a lot of stress, I was noticing that some of my patients were developing delirium, but we didn't really have a program to assess that and then help patients get through it.

So, we developed a task force at the hospital, a delirium task force, which is multidisciplinary. So, we had physicians, nursing staff, ancillary services such as physical therapy, occupational therapy, pharmacy, lab, everyone get involved and helped to develop this pathway. And we finally developed a pathway where we had risk assessment done, which was usually done either admission to the hospital or in patients that were having surgery, we would have them evaluated in our preoperative outpatient center that they would go to before the operation, or once they were admitted, they would be evaluated.

And that would be mostly by nursing. They'd have a risk assessment tool, the tool that we use in the hospital. We have a couple of different tools, but one is called—the acronym is AWOL, A-W-O-L, and that's screening that's done, before the patient develops any delirium, just to risk assess them.

The A stands for age. So, the older the patient, the higher the risk that they might develop delirium. We used an age of 80 at that time, but we're probably going to go down to an age even lower of 65. Because although all patients are at risk, it's mainly around the age 65 and older that your risk increases. And that's mainly because as patients get older, a lot of these issues, at least the theory behind the development of delirium, is that it's an issue with neurotransmitters that get to the brain or inflammation in the brain. And that barrier between your bloodstream and your brain, or the so-called blood-brain barrier, gets a little bit more leaky as you get older and just that's a natural process of aging.

And so, the W, we ask the patient to spell the word world, W-O-R-L-D, or that translation into their native language, such as Spanish, it would be mundo, and ask them to spell it backwards and see if they are able to do that or maybe there's some confusion there.

We also assess their orientation, if they know where they are, person, with who they are, where they are in the hospital, which floor, if they happen to know what city and state they're in.

And then, finally, the L kind of stands for ill. The nursing staff decides how ill they are, and they add up all these parameters. And if they have a high enough score, then they're considered to be at risk for developing delirium in the hospital. And then, we put them on a specific program where we try to prevent the delirium, such as one of the programs is called sunrise-sunset protocol, where we do things—and these are things that can be done at home also. But we do things such as make sure the daytime, the shades are up, the lights are on, patients are getting up and walking around, that they have enough water to be properly hydrated, that they're eating enough food and they're getting adequate nutrition.

We talked about that they're able to use the bathroom. We try to prevent them from sleeping in the day and then waking and staying up all night. So, we want to prevent them from napping in the daytime. We talked about them having hearing aids and glasses and that they engage in conversation, which would be really good if family or friends were visiting them or staying with them. And that they are oriented by hospital staff as to the time of day and where they are. We don't want them to be tied down because that increases the risk for worsening problems with delirium. And that we review the medications, and pharmacy helps with that to make sure there's not any meds that they're taking that could be worsening or predisposing them to developing delirium.

There's a specific order set that the nurses then will ask the physicians to start, which uses most of these orders to help nursing staff take care of these patients. And then, we finally, as I said, promote that they have a companion with them constantly, maybe in shifts. The family can stay with the patient in a private room to keep them oriented, and then encourage the family to bring in pictures that the patient likes of families or their animals or something so that they can stay grounded.

And then, at nighttime, we want them to go to sleep at a proper time, turn the lights off, bring the shades down, that they, not have any caffeine after twelve noon, that the television and all the devices and iPhones and everything are off so that they're not staying up all night and getting disoriented.

Host: Well, it's been great having you on these Delirium episodes. Very educational. I appreciate your time, expertise, everything. 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.