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In commemoration of Delirium Day, it is most appropriate to hear from one of the leading delirium experts, Dr. Sharon Inouye! She shares with us her professional and personal experiences with delirium in all aspects of hospitalization.
Episode Transcription
Kali Dayton
Hello! Today, March 11 is delirium day. So not in celebration, but in commemoration of delirium. This episode is of course, dedicated to delirium. ICU delirium awareness is spreading in our community. But it is also important to recognize that delirium does not just occur in the ICU, and does not just affect ICU stays.
We heard in Episode 11, that patients continue to experience delirium even throughout LTACH and SNFs stays and sometimes, even when they are home. Today, we will talk about delirium and all parts of hospitalization.
We have with us now, Dr. Sharon Inouye. She is a renowned delirium expert from Harvard University, that has been kind enough to share with us her work and experiences with delirium. Thank you so much for joining us. Oh, I’m delighted to be here. Can you tell us a little about your exciting career and your work with delirium?
Dr. Inouye
Sure, so a lot of people asked me how I got interested in working on delirium. And when I took my first job in 1985, then I was a general medicine attending physician. And so it was I was just out of my training. And it was the first time that, you know, I was responsible for a group of patients in the hospital. And I remember really distinctly the six older adults that got very confused during the course of hospitalization. And I didn’t understand it, and I saw it happen.
They were all people who came in the hospital, and were not confused when they came in. And then during the course of their hospitalization, they became very confused. And all six of them ended up not doing well. One of them died, two of them went to a nursing home, two of them went to the intensive care unit.
And I really was very distressed about this. And I asked my colleagues, my the other attending physicians, I asked the chief of my service, you know, what is it about these older people who come into the hospital and get really confused. And they all told me the same thing, different versions of, “Sharon, that just happens to older people, when they come to the hospital, don’t worry about it. You see it all the time, don’t worry about it.” And I was like, “Really?” and I couldn’t stop worrying about it.
And so after my month was done, I pulled the charts of those six patients, and reviewed them in a lot of detail. And I really became convinced that our care or medical care, the medications, we were using- the foley catheters and infections, the immobilization and the lack of sleep. On and on….I thought those things were contributing to the delirium. And when I brought that back to my fellow attendings and my Chief of Staff, it was really kind of dismissed. And so I realized, I really have to figure this out. And so that’s what launched my career in delirium, and also in geriatric medicine. So both kind of went hand in hand.
Kali Dayton
Well, now I have to ask, how did you find out? How did you figure it out?
Dr. Inouye
So the first thing after two years, I was a practicing, you know, geriatrician full time. Then I went back and did a research fellowship, where I learned how to do research, and I decided to really focus on how you recognize delirium. And I published my first article, which was on the confusion assessment method. It’s a method to identify and diagnose delirium. Then my second study was to look at risk factors and outcomes of delirium. And then my next big study and my first one funded by the NIH was how to Prevent delirium with the hospital elder Life program.
So that was really, you know, my career was to try to figure out this problem that I saw. And I was very passionate about trying to help everyone understand its importance and what we can do. That’s incredible, because I think a lot of us now do know what delirium is, I think, because of your good work. The culture has been shifting, and we’re a little more educated about it.
Kali Dayton
And yet, you mentioned your own experience with delirium. You wrote a beautiful article for the New England Journal of Medicine, about your father having delirium. Can you tell us about that experience?
Dr. Inouye
Sure. So the first thing you need to understand is that my father was my hero, and my role model, and I went into medicine, to follow in his footsteps. My father was a GP, a general practitioner in the Southern California area. And he had a huge practice. And he was very beloved and very well respected.
And what happened in the story that I relayed in the New England Journal in this, this happens when my father was 72 years old. He was on his hospital rounds, making rounds on his patients, and he collapsed during his rounds. And he was resuscitated and he had an EMI myocardial infarction or heart attack. And he needed to be rushed for emergency coronary artery bypass surgery. And following the surgery, and I was able to get to his bedside. I was in Washington, DC at the moment that that happened. I was actually sitting on an NIH study section at the moment. And I rushed back to be at his bedside, I made it there, you know, before he went into the surgery, and after he came out, and he was okay and awake and fully oriented and able to talk to me before he went in. And then after the surgery, he developed multiple complications.
He developed congestive heart failure, atrial fibrillation, he had complete kidney failure, multiple, multiple problems, and he developed delirium. And so at by this time, when my father was 72, I had already been researching delirium, working on delirium, thinking about delirium day and night for 15 years, as I’ve already mentioned to you. And so I was considered, you know, an expert in the field.
And I spent my days and nights at my father’s bedside, trying to work with every team that was taking care of them, to let them know he was delirious, to let them know that I didn’t think he was tolerating this medication or that medication. And, you know, he was very sensitive to this other medication. And what happened were several things my father was taken care of, by at least five different subspecialty consultation teams. So his primary team was cardiac surgery, and cardiology. And then he also had the GI team involved gastroenterology, because he had a very upset stomach and was an eating and was having some nausea, and he had abnormal liver function tests, in pancreatic enzymes, both indicating that there were things going wrong there.
You know, the renal team, the kidney team was following him about his kidney failure, and he didn’t need to be dialyzed. He developed an infection at an intravenous site, and that was managed by the infectious disease team. You know, they have the nutrition team seen him, he had really bad diabetes. So the endocrine team was seeing him. And what happened was all of these teams were prescribing different medications. And he wound up being on a med list of like 20 different medications, many of which were different medications for the exact same thing. And many of them had delirium inducing potential. And here my dad was very delirious and the teams weren’t really recognizing it.
They were very dismissive towards me and they were not willing forms about delirium and not well informed about the medications and it was completely uncoordinated. And I couldn’t speak to everybody fast enough. And the consequence was, I really couldn’t impact very much on my father’s care. And so that just really made me realize that this problem of delirium, it’s really complicated, and we have a lot of understanding of it now, but we’re not going to be able to impact on it unless our healthcare system is coordinated, and the members communicate with each other.
And until everyone knows about what delirium is and what you need to do. And I just realized, we had a long way to go. And, of course, this happened to my father, quite a number of years ago now over 10 years ago. But things haven’t changed that much. From what I’ve seen myself, I’m working in a lot of different hospitals. And just the response to my article has been overwhelming. And I’m hearing very similar stories to my father’s, at least from 100 Different people already. So I know, it’s still a huge problem. It’s touched a chord with people. And so I hope that I can continue to work to try to make things better in terms of delirium prevention in the hospital.
Kali Dayton
Yeah, I think, um, you know, in the ICU, we see it very clearly. I mean, it’s very profound when it happens. So I think there’s been a big push to recognize it, and a little bit of push to prevent it. I don’t think we have any real connection to what it ultimately means for a patient. I think we see it as an acute problem. But you mentioned that it took your father a year to recover. Why and what was that like?
Dr. Inouye
Yeah, it took a very long time for him to recover.
His mental and cognitive functioning actually cleared up, I would say within a few weeks after he got home. I’m sure there were, you know, more subtle things, but at least the the flagrant delirium resolved within weeks. But what happened, you know, as a result of the delirium, and he had been very agitated during some parts of his delirium.
And he had also been very lethargic and immobile and other parts. And what happened is because it was so prolonged, is that he got severely deconditioned, and very functionally impaired, he had a lot of trouble walking, initially, he got very short of breath, and is very weak, he did lose a lot of weight as well during the hospitalization.
And so really the recovery process just to get back his way, and his strength, and his energy, and his intolerance, and his focus, all of that really took a good year for my father to recover. And, you know, it’s just so dramatic that before in the after the delirium because here you had a practicing physician, who looked, you know, 20 years younger than his stated age.
And then within just, you know, the month that he was in the hospital or three weeks, to come out in this state of, you know, just looking 20 years older than his stated age, you know, and it did take that full year to get back so that he could return to his practice part time. But I have to say that he never got 100% back to where he was before. And he said that often as well.
So it just really set him back. And, you know, I really believe and I’ve seen this in my own patients and in in others that if you can prevent the delirium and that downward spiral in terms of functioning that people can recover so much more quickly and so much better after a major surgery, or a major illness.
Kali Dayton
Yeah, you spoke a little bit about that prevention in your article, or at least you mentioned that you suspected that your father’s delirium was preventable. Can you speak to that?
Dr. Inouye
Yeah, sure. Yeah, I really do believe that it was preventable. If you look at the literature on delirium, at least half the cases that are seen or felt to be preventable, both from my clinical experience as well as from the reported literature.
Now, I have to add the caveat that in the ICU setting, and at the end of life, these are perhaps settings where delirium may not be as preventable, because of the burden of, you know, overwhelming illness in your settings. And very often to the medications you have to use, you know, there’s no question they have to be used in that setting. It’s not necessarily preventable. So I do want to add that caveat.
But in my father’s case, and focusing on that case that I know very, very well, I really do believe that the delirium could have been prevented. If the polypharmacy was addressed and reducing the use of the multiple psychoactive medications that he was started on, if his nutrition had been addressed.
If he was, if his mobility had been addressed, if the catheter could have come out sooner, if his sleep wake cycle could have been addressed, you know, I think just with these things, it could have made a huge, huge difference. And also, the other thing is that my father kept saying this, as he felt very out of control, he didn’t feel like anybody was communicating with him. You know, he was a physician, he knew everything that was going on, even while he was delirious, he still could understand everything. My father was a brilliant, brilliant man.
He felt like, you know, people were treating him as if he wasn’t human. And so I think that that really fed into it. I was there, and everyone was talking to me. And I said, no, please talk to my dad. And so there were things very much there as well about communication, treating the individual, as an individual, as an important person, even if they’re confused, right, you still communicate with them, you let them know what was happening.
And so I just felt that, you know, if there had been someone coordinating his meds and mobilizing him, and doing relaxation, and communicating with him and making sure he slept during the night and not waking him up every 30 minutes. I think it would have been quite a different outcome for him. So that, you know, I really believe that we, you know, the, the doctors may say, “Oh, well, that’s 2020 hindsight.” But you know, I’ve done that for other patients, I’ve done those things and have been able to prevent delirium. And so I do believe it could have been done.
Kali Dayton
It’s almost like all the elements to a patient’s cares, like this is really a “multilevel Symphony or Orchestra”. There’s so many participants, so many things to consider. But someone has to be the conductor. Someone has to see the end from the beginning, which is the perspective you had for your own father. But that wasn’t…. there was no conductor at the facility, helping do the big picture goals for him, correct?
Dr. Inouye
That’s right. That’s right. And I think that’s, that was really the point of the article is that there has to be coordination of care. There has to be someone in charge or someone coordinating the care or even if it’s a level playing field, everyone wanting to communicate with each other and making sure that everyone is working towards the same goals and and I think it it can be done. I think it can be done.
Kali Dayton
I love that. You bring in such a human element to it. He had a long problem list. But in the end, he was your father. He was a renowned physician with this capacity that deserve to be fought for and preserved.
Dr. Inouye
That’s right. That’s right. And I think that’s really, you know, that the person, the patient always needs to be at the center of our care. What they want and what they need, you know, needs to be at the center of our care at the center of the universe. And I think if the teams never lose sight of that, then, you know, we will do okay with how we care for patients.
Kali Dayton
That plays so much into what we’ve been discussing on the podcast, because even patients in the ICU on mechanical ventilation deserve to be seen as human treated as human. I have been discussing a lot about how we can let them be awake, avoid delirium, and then they can communicate with us and have their needs and wants known. But that is equally applicable to when they leave the ICU. Their journeys not done yet.
Dr. Inouye
That’s exactly it.
Kali Dayton
I love it. And you have done some incredible work with developing a program to address delirium. Can you tell us about your HELP program?
Dr. Inouye
Sure. So HELP stands for the Hospital Elder Life Program. And really, it was originally modeled after the Child Life program that was up in many hospitals. And it was up at Yale New Haven Hospital where I was at that time. And it was a wonderful program of coordinated child centered care that was done on the pediatric service at the hospital. And it was designed to keep the child at the center of the care and really to meet their needs, both medically and psychosocial Lee as well into prevent complications.
And so those were the principles with which I initially conceptualized the hospital elder Life program. And yes, it was originally designed to prevent delirium. But it turns out if you prevent delirium, you also prevent functional decline, you prevent falls, you shorten the length of stay, you reduce costs of care, you prevent rehospitalization, and you provide better overall care?
Kali Dayton
Hallelujah,
Dr. Inouye
Like no surprise, right?
Kali Dayton
Right.
Dr. Inouye
Delirium is, you know, just one of the if you focus around that, you will provide better care.
Kali Dayton
Kind of like delirium that first domino.
Dr. Inouye
Exactly. That’s exactly right. And the secret of how is it uses a interdisciplinary team, and that’s so important. So nurses, physicians, social workers, nutritionists, pharmacists, the whole team, assisted by skilled volunteers, and that’s unique to the health program, we train volunteers, and I’ll tell you about what they do in just a minute. But we target delirium risk factors in the program.
And so what are those risk factors that we target so there are cognitive impairment or any degree of memory impairment when someone comes to the hospital in mobility, sleep deprivation, vision and hearing impairment, dehydration and nutrition, and polypharmacy, and so you can see all those themes, you know, that were there with my father as well. One thing that I didn’t mention is my father was severely hearing impaired and that actually happened during that hospitalization from a gentamicin toxicity before they realized how bad his kidneys were.
Yeah, and so they knocked out his hearing as well. And that I’m sure contributed as well to the delirium because it was very acute onset. But what we do is we target each of these risk factors, and we have trained volunteers who help with things like orienting communication, letting people know what’s happening that day, giving them their schedules, during therapeutic activities, and that’s a fancy word for really fun, games, activities, whatever the person loves to do. We try to make it happen for them. So if they love to read, we get reading materials we get magnifiers we get good lighting.
If they love to do crossword puzzles, we get that crossword puzzle for them. If they like arts and crafts, we do that if they like animals, we have the pet therapy, people come by if they like music, or they play music, or they like to listen to music, do all those things. And so that’s what we mean by therapeutic activities. And the volunteers help with that three times a day.
And then for immobility, we get them up in walking three times a day, if they’re not allowed to walk, then we have exercises that we do three times a day, we got them off of their immobilizing equipment. So Foley catheters, you know, we get those out as soon as possible. If they are on oxygen, then we try to get them a portable oxygen tank so they can walk around.
We do everything we can to try to assure they can be mobile while they’re in the hospital. And patients love being up out of bed it just to make you feel human and in control, there’s nothing like being able to get up and go for a walk up and down the home.
For sleep deprivation, we tried to do a unit wide noise reduction strategy. So we try to work with the nurses on the unit to see what we can do about creating a quiet environment for sleep. And I tell you, the nurses can be so creative, and we try to help them. So I know on one floor, we got silent, kill crushers, there are such a thing, and got beepers for all the nurses so they could turn off the overhead page. And if on one unit, they had these vital signs board that were metal, and they clicked into a metal rack, and it was so noisy, so every time they record the vital signs, there would be this unbelievable clacking noise. And all we had to do was provide them with some soft folders and stuff.
So it was the least expensive, near miraculous solution. And so we did all kinds of things like that we got, you know, earplugs, we got noise cancelling headsets, we got all kinds of things that the nurses came up with. And, really and then we also offered a non pharmacologic sleep protocol. And so that’s a fancy word for a glass of warm milk, or both tea relaxation music in the background, or a hand and foot massage. And I can tell you that the patients love our protocol, and it’s very, very effective. And it reduced the use of sleep medications by over half. And so we had massage therapists that came in at evening and night shift, who were volunteers to do this protocol for our patients, but they also trained the nurses on doing that kind of therapeutic massage.
And so that was really exciting. And then for vision and hearing impairment, we provide vision and hearing aids and we teach the staff how to communicate with vision and hearing impaired patients. For dehydration and nutrition. We train our volunteers so they can push oral fluids and they can also assist at meal times. And then with polypharmacy. We work with the pharmacists to do medication reviews. Our nurses do it too. We provide all the nurses with a little pocket card of 10 medications to avoid that are very bad for older adults. They carry that with them. If they see patients on those meds, they alert our health team.
And we also have the pharmacists do a review of all the medications for interactions for those that may be contributing to delirium and suggesting alternatives that we could consider. So that’s the health program in a nutshell, and it is up and running in several 100 hospitals around the world. And it you know, I continue to see studies published some of them I participate in many of them I don’t, but showing the effectiveness of help all around the world. And so that’s been really exciting. It really works. It’s a program that really really works.
Kali Dayton
Wow, that sounds like a dream. How would a hospital even start implementation of the health program?
Dr. Inouye
Yes. So if you go to our website, it’s www.hospitalelderlifeprogram.org. So the hospitalelderlifeprogram is all one word with no spaces. Or you can just put hospital elder Life program into your browser and look for the hospital elder Life program or because when you put hospital elder life programming, you’ll see hundreds of sites from the individual hospitals that have set up their own programs, those are all wonderful, but they won’t be able to guide you step by step through the process. So go to the main www.hospitalelderlifeprogram.org.
And there you will find on the website, there is a link called How to Start a health program or how to learn more about health. So go to that one, and it’ll walk you through the process. Now I do need to say two things that help is now going to be administered through the American Geriatric Society. And we’re very, very excited about that. So the American Geriatric Society is a nonprofit organization to advance on geriatric care throughout the US and throughout the world. And they will be administering the health program. And so the advantage of that is there’s going to be much more support to start a program. And there will be a process and a team to walk interested people through the process.
And we do have a conference coming up in end of April or early May. That’s with the American Geriatric Society. And they will be announcing the partnership and they have a whole help conference plan there. And then they will have a charge for the program to become a Help site. But it is modest. And I think it’s going to be well worth the investment for any site that wants to be able to set up the program. The program does require, you know, a champion at the psi and really dedication, because you do have to build this interdisciplinary team.
You have to change, change business, as usual at the site. So it does require some time and some investment. But I think it’s well worth it. And, you know, many, many programs, in hospitals around the world have kind of built their improved care for older adults around the health program. And so it really helps you to do that as well.
Kali Dayton
That is so exciting. And I will put all of those links to those resources on the website on the blog, associated with the podcast. So that will be directly accessible to anyone that’s interested and wants to start being the champion in their hospitals to help bring this change. It’s amazing to think that those those interventions can ultimately change patient outcomes. Is there anything else there any last thoughts of what you would share with bedside caregivers?
Dr. Inouye
Sure. So a couple of things, that messages I really like to get out there are that delirium can be a scary experience for caregivers. And I know even when I been an expert in delirium, had to experience it with my father. It was very frightening. And so I do want to acknowledge that. But I also want to empower families. I want to empower family members to learn about the condition to learn about delirium. There is so much family members can do to help with the identification of delirium, and about its prevention and its management. And really being the conduit through which you can let the healthcare teams know about the delirium. So often, it’s the family members who recognize that their family member has changed, that they’re not themselves that they’re not right. And I just want to empower family members to bring that to the attention of their clinicians.
Clinicians, I have to say by and large now are much more aware of delirium, then what I experienced with my father more than 10 years ago, I think the word has gotten out. I think, though, that family members do need to bring it to their attention, they need to advocate for the clinicians to pay attention to a, they could say, “Do you think this could be the medications? Do think there are things we could do like get them more mobile, get them up into a chair? Is there anything we need to look at?”
And if they go to the HELP website, there is a section for caregivers and family members. And under there, we have a document that’s called “What you can do tips to reduce risk.” And so just look at that it provides some helpful tips for family members to know when they have a family member or a loved one going to the hospital, or if major surgery is planned, they may want to look at that printed out, you know, just be prepared, be aware.
And there’s a lot of information for family members on the HELP website that can help them be more knowledgeable about delirium about what it is, about what they can do. And I think knowledge is one of the ways that, you know, we can be less scared, and we can help ourselves, cope with the situation.
And be prepared, you know, for what might happen. And I don’t want to give the message at all that people should avoid the hospital or should avoid surgery if their doctors are recommending that that is not the message to take away from this not at all.
And I would never have wished you know that my father didn’t undergo the surgery that was that saved his life, obviously. But what I do want to say is be prepared, be knowledgeable, be there to help you, your family member. And, you know, ask questions and be an advocate. And so that’s the message that I hope I can give to family members as well as letting them know there’s a lot of information available for them on the website.
Kali Dayton
Such good points. I feel like I could do a whole episode and probably will, on family involvement in the process and even prevention of delirium. I kept instinctively looking for the like button, but I couldn’t find it. You had so many great points and valuable insights and I’m so grateful for you coming on and I don’t know if it’s called a celebration of delirium day, really nothing to celebrate, but commemoration of the Delirium day so thank you so much.
Dr. Inouye
Thank you so much, Kali. And I really look forward to the launch of your podcast in world delirium day. Thank you so much.
Kali Dayton
Thanks for all you do.
Transcribed by https://otter.ai
Resources Referenced:
https://www.nejm.org/doi/full/10.1056/NEJMp1910499#.XjtPogfHcFU.twitter
https://help.agscocare.org/https://www.hospitalelderlifeprogram.org/
https://www.hospitalelderlifeprogram.org/
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