Delirium: A podcast with Sharon Inouye

Eric: Welcome to the GeriPal podcast, this is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, we have a large in-studio audience today.

Alex: Large in-studio audience. We are joined by a guest host today, Lindsey Haddock, who’s one of the geriatrics fellows. Welcome to the GeriPal podcast.

Lindsey: Thank you. I’m so happy to be here.

Alex: And we are honored to have Sharon Inouye who is Professor of Medicine at Harvard Medical School and geriatrician at Hebrew Senior Life in Boston, and is an internationally famous delirium researcher among many other things. Welcome to the GeriPal podcast, thank you so much for coming.

Sharon: Thank you. I’m thrilled to be here.

Eric: And we’re very excited, we’re going to be talking about the prevention and delirium mainly, but before we get into this topic we always ask do you have a song request for Alex to sing?

Sharon: Definitely. I would love to hear the rendition of Help that you did at AGS last year.

Alex: (singing)

Eric: That was awesome. We’ll have more of that song in the end. Is there more verses?

Alex: There’s another verse.

Eric: There’s another verse. Excited to hear that. I love the CAM part.

Alex: Actually the second verse is unaltered, but as you’ll hear at the end it works well unaltered for delirium.

Sharon: It really does.

Alex: My independence seems to vanish in the haze, right?

Eric: Sharon, you are the delirium expert in my mind. When I think of delirium your name is synonymous not because you’re delirious but because you have done so much for this field. Is it okay that we kind of take a big step back and just think how did you first get interested in delirium and which this is your main research area?

Sharon: Sure. Well, it’s actually a really good question. It really stemmed out of my work at the bedside when I was just starting out. In fact, my very first attending stent which was at the VA in West Haven on the general medicine service I had a large group of patients. I was feeling very responsible for their care, and this was now over 35 years ago. On my service I had the six patients that I distinctly remember who became very confused during the course of their hospitalization.

Sharon: I was an internist on the geriatric unit. At that time, I didn’t have any formal geriatric training yet. I noticed these older people coming to the hospital, being okay, and then getting acutely confused while they were in the hospital. They ended up not doing well, these six patients. Two of them went to the ICU, two of them ended up dying. Two went to a nursing home. I turned to all my colleagues, the chief of service, and I said, “What’s going on with these older people that come to the hospital and get really confused?”

Sharon: Every single one said to me some version of, “Sharon, that just happens to older people when they come to the hospital. Don’t worry about it. It just happens.” I couldn’t stop worrying about it, and I think that sense of responsibility you have when you have your first service, so after I rotated off I pulled every chart. I made these huge graphs of everything we did to every patient every single day. Then I looked at my note about when they became confused, and I concluded that actually we had contributed to that with psychoactive medications, with Foleys and infections and immobility and all the kind of things that happen to people in the hospital.

Sharon: I went back, and I told my chief of service with my graph papers, “I really think we contributed to this confusion.” He looked at it, and he kind of nodded his head and said, “Wow.” I pointed out, “Look, we gave this Benadryl for blood transfusion, and, look, two hours later they’re really confused. We gave these high doses of opioids, and then they were zonked, and then went to the ICU with an aspiration pneumonia.” I said, “I think we contributed to this.” He said, “Well, Sharon, I think you need to give a lecture on prudent drug therapy to the residents.” I said, “Yeah, good idea. I’ll do that.”

Sharon: Then he thought that was the solution to the problem, the problem not being the delirium, the problem being the young attending who was like, “Oh, my God. We’ve got to do something.” That’s really what launched my career. Really that whole thought that this was an inevitable part of hospitalization, and it was okay for older people to come to the hospital and lose their minds, it didn’t feel okay to me. That’s what launched my career. I realized I had to go back and get research training because you know the graph papers just weren’t going to really convince anyone. That’s why I then had to learn how to do research.

Alex: Hopefully we moved the needle now due to work from you and others in this field and we realize we should worry about it. We should worry about it. We should care deeply about it. It has important consequences in patients that you cared for and we’ve all cared for I’m sure including mortality.

Sharon: That’s right.

Alex: Big, big deal.

Sharon: That’s right.

Alex: I wonder as far as getting into the topic a little bit deeper from here thinking of where to start. We sort of had a little bit of email conversation about this in advance. It seems like one place to start is who are the highest risk people. Who do we care for who’s at highest risk? What are the sort of services they’re on or procedures they’re getting or types of diagnoses they have who are our antenna should be really, really up and sensitive to delirium and we should start thinking about taking routine preventative measures?

Sharon: Right. Again, really, really good question to know who are the patients you really need to pay close attention to. You want to think about your vulnerable older adults. For instance, if someone has cognitive impairment at baseline, if they have vision and hearing impairment, if they have multi-morbidity, if they have underlying renal or hepatic insufficiency that will cause them not to be able to metabolize drugs well, those are all things that place people at high risk. You also asked about settings. Definitely things like major surgery with general anesthesia, that could place a person at very high risk. Also, other high risk areas that you want to think about are the intensive care unit where people are obviously very ill, but also are being exposed to a huge number of medications and procedures and sleep deprivation and so forth. The palliative care setting as well, very high rates of delirium.

Sharon: I think if you look at the NICE guidelines out of the UK that are the sort of latest standard in the field as well as the American Geriatrics Society Guidelines, they identify the high risk patients as those age 70 and older, anyone who has underlying cognitive impairment, admitted for a hip fracture and then with multi-morbidity. Those are the key things. They say any one of those, but others say two or more put people at high risk.

Eric: How important is it to identify risk versus… I’ve given a couple of talks on delirium. When we talk about, which we’ll talk about soon, about what preventative measures do we have in place, people say, “That just… Good medicine? Shouldn’t we be doing this for everyone who comes to the hospital? Should it just be limited to those people who are at high risk?”

Sharon: Right. My argument is it should be everyone, but because a lot of times resources are limited or staff time is limited, you can help prioritize to the even higher risk patients. I agree with you. I feel like these types of prevention programs should be in the place for all older adults, even some may argue for all adults period. It’s expensive and time consuming for staff in some cases.

Alex: Lindsey, it’s hard to think of a patient that we’ve seen in this time — we’re working on palliative care right now currently –who’s over 70 years old who doesn’t meet one of those criteria.

Lindsey: That’s exactly right. Yeah. That’s all of our patients.

Alex: It’s a huge swath of hospitalized older adults.

Sharon: That’s true. You’ve seen quite a bit of delirium I would wager on the palliative care service?

Lindsey: Absolutely. Every day.

Sharon: Yes.

Eric: Are there any risks of screening? Should we just be doing this right away?

Sharon: So there are risks to screening. I’m really glad that you asked that because I have found when hospitals approach me asking or saying, “We want to make delirium a quality target for our hospital. What can we do?” I always start saying, “Not just screening.” Because most of them just want to put into place a screening program, and then that’s it. The problem is that… To give you a real world example. The Netherlands mandated screening in all of their hospitals I think about four or five years ago. It became required on every shift at admission, and on every shift people had to undergo a delirium screening.

Sharon: What they found was that the rate of antipsychotic prescription in the hospitals throughout the Netherlands went up four to five fold.

Alex: Oh, no.

Lindsey: Wow.

Sharon: Yeah. I was recently reaching out to the person who presented that work at the IAGG meeting last year to find out if they had published that result and also if there was any follow up as to outcomes of the patients with the five-fold increased risk of antipsychotics because as you know from the literature antipsychotics often worsen the clinical outcomes for persons with delirium. They are not routinely recommended. The risk for screening is if you don’t have a system set up and a workforce that’s educated to know what to do if delirium is identified, then unfortunately what happens is sort of these automatic things. If a nurse comes to a trainee and says, “Listen, this patient has delirium, see my CAM score, it’s positive,” they’re just going to go, “Well, okay, what do you do for delirium?” Well let’s prescribe Haldol or Olanzapine or something without knowing that the first steps are you need to really diagnose it, put into place non-pharmacologic strategies.

Sharon: And also screening it’s almost too late because the most effective thing for delirium is prevention. By the time someone screens positive, it’s too late in that chain of events. It should have been that all the stuff was in place before then. That would be the ideal. That’s the danger to screening for me. I think it’s that systems feel they’re doing something, and that’s what they’re going to target as their delirium effort, but it’s too little too late rather than building systems that will prevent the delirium from occurring. If you have those systems built, then really you should rarely have to get a screen positive for delirium. You know if it really works.

Eric: What are some of the proven systems that we can put in place to decrease the risk?

Alex: Help.

Sharon: Yes. It’s the song.

Alex: That’s right.

Eric: We should sing to more patients?

Sharon: Yes.

Eric: Music therapy.

Sharon: That is true. That can be part of a delirium prevention. The Hospital Elder Life Program is a very well tested strategy, cost effective for prevention of delirium. What HELP involves is first and foremost a trained interdisciplinary team that comes to help older persons throughout hospitalization it really is to create a system that focuses on prevention. But there are some protocols that you put into place with the HELP program. The most important ones are mobility, so making sure people get up and walk three times a day at least if possible and that they have orientation and therapeutic activities. That’s just a fancy word for enjoyable, cognitive stimulating activities that keep people engaged with the environment.

Alex: Do you mean watching the TV right in front of them in the hospital bed?

Sharon: Not a TV. Really things like reminiscence activities, current events, reading activities where you discuss it. We had really fun… I’m trying to think of some of the activities that I’ve heard people really enjoy. We had these really old time photos of actors, actresses and then different old time cars and clocks and washboards and things. Then you would just have a reminiscence about that. We would write prompts to ask people about on the back of the photo. They would allow people to really reminiscence about the actor or the actress or the item. Have they ever seen one? Have they ever used one? Did they ever have an experience with it? It’s really fun and enjoyable but also keeps people engaged in reality.

Sharon: And then a variety of games, music therapy, pet therapy could be part of that. Really what you’re trying to do is keep people engaged in time and place, socializing, keeping them in the present. They can think back to the past, but pulling them to the present. That can really help. We also do feeding, hydration, vision and hearing adaptations and making sure staff know how to communicate with patients who have vision and hearing impairment, and sleep. We try to do a non-pharmacologic sleep protocol.

Alex: What is that?

Sharon: That’s a glass of warm milk or herbal tea, not chamomile because I think chamomile interferes with Coumadin. It has to be something like peach spice, something like that. An herbal tea. Relaxation music or sounds and a back rub or a hand massage.

Alex: Sounds great.

Sharon: It’s very relaxing.

Eric: Who’s doing all of these things? Is the nurses? I’m guessing it’s not the doctors.

Sharon: It’s not the doctors. At many HELP sites it’s trained volunteers. So many, many HELP programs utilize trained volunteers. That’s not true at all hospitals. In some hospitals it is the nurses incorporating things as part of their routine or the aides. Some places have multi staff like PT aides who will do the mobility, and then they may have… Some places actually have massage therapists that come in on the night shift as volunteers to do the massage. There’s different ways that hospitals solve it. HELP does provide training on doing all those kinds of interventions, which has been very successful.

Alex: That’s terrific.

Eric: Going back to when you were an intern and the chief said, “Oh, let’s talk about medications,” is there a component around proper medications and medication debridement?

Sharon: Yes, yes. That is another very vital and important part of HELP is to do regular medication reviews. That interdisciplinary team will meet at least twice a week to go over ideally upon admission and then on an ongoing basis reviewing all the meds, making sure we don’t have Beers Criteria meds. These are medications that the American Geriatrics Society puts out the Beers Criteria, just recently updated as you probably know in 2019. On it they utilize what’s called potentially inappropriate medications for the elderly. Obviously, many of the meds we have to use, but they let you know that there could be safer versions of that class of meds that for instance might be less anticholinergic. If you have to use an antidepressant for instance, please choose one with the least toxic potential.

Lindsey: Sharon, I love hearing about your vision for what hospitalization should look like for all patients but especially our vulnerable older adults. I’m also thinking about the constraints that we sometimes practice in and how a lot of our listeners may not have the HELP team or this interdisciplinary team. I’m wondering what would you recommend to maybe individual providers? Are there small things they could do if they’re not lucky enough to have this whole team of resources?

Sharon: That’s a really good question, really good to think about what we can do already on our own as well as hopefully work to building systems that could integrate this. I think that there are a lot of things that individual practitioners can do. Even as you write your admitting orders, please rather than… I know a lot of times clinicians tell me they don’t know if someone’s safe to ambulate. They’ll put bed rest or clearance from PT rather than trying to screen. My rule of thumb… One thing we do in the HELP program is try to train every nurse so they feel comfortable knowing if a patient can walk. Chances are if the patient was walking up until they came to the emergency room, and they didn’t break their hip or something, that they can still walk later that night when they’re in the hospital.

Sharon: A lot of patients may be at risk for falls, but those patients… I know that the instinct right now is, “Oh, we got to put them in bed with the bed rolls up and a bed and chair alarm.” I know you did a whole show on bed and chair alarms, which I love, and I play for my students. That is exactly not what you want to do with someone who maybe at falls risk. You do want them to continue to ambulate regularly and you want to make that possible and safe for them. It’s actually the opposite. What I like to ask practitioners to do is please actually write a mobility order.

Alex: Great idea.

Lindsey: I love that idea.

Sharon: Out of bed to chair, and please walk three times a day minimum. Rather than ad lib or bed rest that we specify activity.

Sharon: The other thing is as you’re writing the med order list, please be aware or I hope many hospitals have in place now little cheat sheets or even things that come up as you enter the orders about Beers Criteria meds. So if that’s not something available at the hospital, maybe that’s something that could be advocated for. They would get an automatic warning if they’re prescribing a Beers Criteria med.

Sharon: Being attentive if they’re vision or hearing impaired. There are a lot of ways the room can be set up or making sure the family is bringing in the hearing aids and the dentures. There’s a lot that we can do about that. Ordering supportive services if they’re needed. If they do need a walker, then please get the PT in to do the walker, get them up and walking. Start all the different therapies that hopefully should be in place for good holistic care. There’s a lot we can do.

Lindsey: That’s really helpful. I love the idea of writing a mobility order and that we can feel really safe to do that as clinicians if the patient was just walking a few hours before admission.

Sharon: That’s right.

Eric: Then from a systems standpoint, HELP program or Acute Care for the Elder ACE units, it sounds like there’s a lot of more overlap than I thought there was between the two. Is that right?

Sharon: Yes. HELP programs in ACE units are extremely complementary. There is quite a bit of overlap. In fact, of our HELP programs across the country, many are in place in hospitals that also have ACE units. The ways that they’re complementary is that an ACE unit is one targeted unit on a hospital, which is wonderful, and the staff there are often very well trained in how to care for older adults. There’s often many similar protocols in place to what we have in HELP.

Sharon: The problem is that the staff aren’t always able even on an ACE unit to do things like the ambulation three times a day, the non-pharmacologic sleep protocol, the hearing and vision adaptations, all the things that HELP is designed to do. They love it when there’s volunteers available to help with that. The other thing is that the HELP program tends to be hospital wide. It is a way to kind of spread the influence of the ACE unit throughout the organization, and it really does help HELP if there is a home base with this kind of geriatric expertise. Because believe it or not some hospitals… some of our HELP programs don’t have geriatricians or geriatric nurse practitioners or even that sort of well spring of geriatric expertise, but they’re trying to do a HELP program without that. That’s another way that the ACE/HELP combination really strengthens both programs.

Eric: Let’s say I’m now totally convinced I want to start a HELP unit, do I just read one of your articles and kind of make it up as I go or is there a resource that I could go to?

Sharon: Definitely. We do have a central HELP office right now and we have a website. If you just Google hospital elder life program, or you put in hospital elder life program all one word dot org, you will get to our website. There’s Google groups where you can reach other HELP sites for questions. We have training materials on the site. I have a really exciting announcement that everyone will hear very soon. HELP is now going to be taken over the American Geriatrics Society.

Eric: Oh, wow.

Lindsey: Wow.

Sharon: We’re having an all day HELP conference. It’s actually our second one. It’s a full day preconference at the American Geriatrics Society meeting, and the American Geriatrics Society will soon be developing a whole very robust program where HELP sites can become official HELP sites and have CMEs and CEUs for staff training. We’ve developed a set of 14 training modules that are going to actually make it much easier to set up a HELP program because it will actually walk you through that process.

Sharon: That is all available, but right now it comes to you as a 120 page manual that you have to read. This way, it’s actually going to be these training modules that are really nicely done and that people can go through. There’s a pretest and a post test. You’ll get credits for hours spent in the training, and it’s going to be official and really I think make the program what it should be.

Eric: Let’s say we’ve done all this stuff. We got HELP and ACE, we got geriatricians, and we’re getting them up three times a day, and they’re delirious now. Is this when I jump to the antipsychotic and just call it a day? I just read an article in JAMA Psychiatry. It was a, I’m seeing these all over the place, network meta-analysis that said, “The best treatment is a benzodiazepine.” Should I just load people up with benzos?

Sharon: No, please don’t do that. I think, yes, there were a lot of problems with that network meta-analysis. We should say that up front. I think those are not best practices and not accepted in the field. I think there’s plenty of evidence that particularly benzos should be reserved for alcohol or benzo withdrawal related delirium. In other forms of delirium, they should not be the first line choice.

Sharon: I think the way that delirium should be managed after it occurs is first and foremost you need to figure out what the underlying causes are. Generally, there’s one or two or three or more things contributing. You want to address those features first. You want to educate the family, the patient, and the staff that while these things are being addressed the patient is going to be delirious, and here are some approaches to use to try to manage that. There’s actually a very nice video put out about the TADA Method, T-A-D-A Method, about how you deescalate an agitated patient. It’s designed for the long-term care setting, but it’s absolutely wonderful just how you do the communication, how often it centers around a device or an IV or a tube that’s really agitating the person. Then what happens is it escalates, and they wind up needing to be physically restrained at least one arm or both arms. Then that leads to more agitation and then you get into this crisis situation where you have to prescribe the pharmacology.

Sharon: Really what we want to try to do is avoid that escalation. Really it takes a lot of training to be able to do that because it is frightening. The patient is frightened. The nurse is frightened. The family is frightened. We all get kind of caught up in that. Our natural reaction is to want to sedate the patient. I think if everyone can remain calm and then try to deescalate as you can see in that TADA video, which is very nice, and try to get through that time and really educating the family to get through that time, it can really make all the difference.

Sharon: One thing that I learned from Meera Agar who is a palliative care expert out of Australia… She deals in palliative care with people who are in agitated delirium all the time. She said that actually the fact that we assume that patients and families really would rather themselves or their loved one be sedated rather than agitated, she said that that’s actually untrue in qualitative studies that have explored that. That patients a lot of times would rather be awake and alert even if agitated rather than sedated at all times but especially at the end of life when every moment is so precious, and they would rather be in that state rather than sedated.

Eric: Is it true looking at all the studies of really any pharmacological therapy, when it does help it mainly helps by just sedating folks actually not reversing the underlying delirium? Is that right?

Sharon: That’s absolutely true.

Eric: I think that was the issue with the network meta-analysis is that it was positive for benzos mainly because benzos do a good job of sedating folks at high enough doses.

Sharon: Correct. All of our current drug treatments for delirium treat it by sedating. We don’t yet understand enough about the pathophysiology of delirium to really be able to do definitive targeted treatments that will limit the pathophysiology. That’s where we need to get, but unfortunately we’re not there yet.

Alex: Can we just do quick hits? Really quick.

Sharon: Yes.

Alex: All right. Thirty seconds or less. What do you think about the term “terminal delirium”?

Sharon: I dislike that term. I’d much rather say delirium at the end of life, and we need to separate that delirium is inevitable as a part of death and is okay as a part of death. They concur highly, but the important thing is that delirium even at the end of life is treatable and reversible in 50% of cases. We still have to look for the dehydration, the urinary retention, the constipation, the easily treatable thing that could be contributing. So that’s why I think it’s important for us to have a different terminology.

Alex: Last lightning round question. Many patients in hospice, many hospices use benzodiazepines, Haldol, antipsychotics like water for the patients near the end of their life. Not all, but many it’s common practice. Somebody is agitated delirium at home to give them those medications. Thoughts about that common approach?

Sharon: Yes. Well, of course, comfort is key. I don’t at all want to say… There are very appropriate situations where we must do that for comfort and for safety. One spin on it that Meera Agar again has alerted me to is that because of this realization that many patients actually don’t want to be sedated and would like to tolerate some pain and some agitation in order to be alert, there is a movement to actually gain informed consent for sedation at the end of life. I think that’s actually… Even if it’s not like a strict informed consent, I feel like having that discussion is really important to know what the patient’s preferences are and the family’s preferences. If the alertness is something that’s so important to the patient and the family, then I think we really need to honor that. We really need to honor that. That’s just what I want to advocate for.

Eric: Great quick hits. We’re coming up at the end of our time. Sharon, I really want to thank you for joining us.

Alex: Thank you so much.

Lindsey: Thank you.

Eric: It was absolutely fabulous. I learned a lot. I learned a lot about HELP, and I think we have a little bit more of that song. Maybe?

Alex: I’m hoping that there will be some help with the song at the very end. When I sing please, please help me, they’ll be a “help me,” or something like that.

Lindsey: We’ll do our best.

Alex: (singing)

Eric: That was wonderful. Sharon, again, thank you very much for joining us. I want to thank everybody else for listening. We look forward to having you listen to us … I forgot how to end our podcast Alex.

Alex: Next week.

Eric: Next week.

Alex: Thanks, folks. Bye.