Delirium in the Spotlight | Prof L.L Amila Isuru - Consultant Psychiatrist

Added: 2026-05-10

[00:00:01]Uh, good afternoon everyone and uh thank you very much for inviting me to deliver this lecture today. I'm really grateful to Anuradhapura Medical Association and uh thank you very much uh Professor Sunil Fernando for that kind and generous introduction.

[00:00:15]So today, so uh this like half an hour also I'm planning to talk about delirium. This is not a kind of a specialty of psychiatry. I mean, so anyone of us uh come across patients with delirium and so it is really important for us to uh know how to identify and manage and I'm I'm quite sure so all of you are well versed with identification, screening and management of delirium.

[00:00:42]This is just a kind of a uh update ourselves or kind of a raising the awareness. I would rather say this is kind of a raising the awareness of delirium which is really important to uh improve the outcome of patients, right? And uh so delirium I would say it's a kind of a phenotype and this is sometimes a presenting symptom of delirium. So whatever it is and if you see GI uh surgeon and some the decompensated cirrhosis can present as delirium and renal and if you say that you will see that acute renal failure and UTI can present as delirium. In parasitology if you see that the cerebral malaria can present as delirium. In medicine myocardial infarction uh the hyponatremia, hypoglycemia, so any condition can present as delirium. So the delirium is just a phenotype or just a presenting symptom.

[00:01:40]The most important thing is to identify the underlying cause.

[00:01:46]So with having that in the mind and uh so this this this is the layout. So we planning to talk about about impact of delirium and improving the diagnosis of delirium and optimizing the care and the prevention.

[00:02:01]And first I would take this we took this couple of years ago as a referral and to us a 60-year-old man was admitted to the ward for treatment of uncontrolled hypertension. Nurses observed that his behavior changed 2 days after the admission and referred to psychiatric unit for an assessment. He thought that nurses giving him poisonous medications and security personnel coming to the ward to find his details.

[00:02:30]He was escaped from the ward and found wandering on the hospital premises.

[00:02:35]Because he was just wandering and found on the hospital premises, they have referred us to us for an assessment. So you can see that mainly the psychotic symptoms. So what is the possible diagnosis here? So keep this in mind. So we'll come back to this question later on.

[00:02:56]Right. So diagnosis of delirium. So in in the medical student days we we think the diagnosis of delirium is just not knowing the time, not knowing the place, or not knowing the the month or person, not being able to identify you kind of as a doctor or nurse or someone, right? But this is So if we go by this, we'll miss a large number of patients with delirium.

[00:03:23]So it is something important for us to remind ourselves some of the features of delirium. The one possibility is the acute onset.

[00:03:35]I mean if someone on the ward notices acute behavioral change the number one possibility is delirium.

[00:03:45]>> [clears throat] >> Patient is well, suddenly changing behavior. So you need you've got to exclude the delirium, right? So, not only the patients and sometimes the friends among us, right? Sometimes the friends among us and the family members, if you notice sudden change in behavior, right? You might think that this man is crazy or sometimes having a mental illness or something like that, but if it is sudden change in behavior, it is very likely that the possibility of delirium is very likely high on the car. And so, you I mean, that is not the only possibility, but it is really important to exclude that because, for example, the patients with diabetes, one of our parent with diabetes, and if you notice sudden behavioral change, right?

[00:04:34]Talking nonsense and behaving with a odd way, if you notice that, if you do not think of the possibility of delirium, you might miss the hypoglycemia, right? If you miss the hypoglycemia, couple of hours later, the you will see a irreparable damage, and sometimes it might cause life, right?

[00:04:57]So, any change in behavior is really important to understand the possibility of delirium. And inattention, inattention is not really in the sense of not knowing the time, right?

[00:05:09]Inattention, they are very much distractable. And if you see your patients or someone is very much distractable, the one of the possibility is delirium.

[00:05:21]Actually, inattention is the cardinal feature of delirium, so that is how textbook describe it. And disorganized thinking, when we talk to the people and you will realize that they are not kind of giving right answers to what you ask, and their thought is very much disorganized, right?

[00:05:40]And if you see their the the brain is compromised to some extent, especially in old age people, so their information processing is very much slowed down. Information processing is very much slowed down. And in the context of dementia or something Parkinson's disease or something like that. And if you see this the disorganized thinking in the context of slowed down information processing. So that is again if that is on top of the cognitive impairment that if the again the possibility of dementia high on the card. And disorientation, memory impairment. So long-term memory impairment is not a delirium. But if you see a patient who is having a good cognition and all of the sudden if you realize that patient is very much forgetful and that is one of the possibility. And actually one of the post-operative patient referred to us the thinking of the possibility of dementia after the surgery, right? So we found out that patient is having just hyponatremia, right? So if you kind of a just a superficially assess the patient and kind of a given the label as hyponatremia, patient would would succumb to hyponatremia, right? So that is the importance of kind of a having a detailed assessment for delirium, screening for delirium. Another one is perceptual disturbances. So this is uh one of the common thing the patients with delirium are perceptual disturbances like visual hallucinations, auditory hallucinations, and tactile hallucinations. They are become very much paranoid about people around, so that is one of the things.

[00:07:27]And the psychomotor agitation and psychomotor retardation. So psychomotor agitation, you just imagine a patient is got very agitated in the context of psychosis or whatever thing in the in the medical casualty or surgical casualty in the the the ward people may not be able to manage that.

[00:07:44]Among the many other urgent cases need to be attended, right? So, that is something really important think about the possibility. Other one is retardation. So, on the ward this patient is not disturbing anyone, right?

[00:07:58]When you wake up the patient to give medication or food, you realize that patient is disoriented a bit, right? So, if you did not detect this hypoactive delirium, so patient will silently pass away, right? Because there is a significant underlying cause when uh someone presented with delirium. So, hypoactive delirium is the mortality is very high not because of anything else, we do not detect that.

[00:08:27]And the altered sleep wake cycle, so this is typical textbook things we The other important thing is patient experience of delirium.

[00:08:38]So, most of the time we struggle in the medical ward, surgical ward, neurology, whatever the things, the patients are can be very much disturbed, right? So, you can't comprehend what is going on.

[00:08:50]And patients with deli- delirium, they are frightened, they are very much anxious about the surrounding.

[00:08:57]Right? So, if you look at some in there enough and more videos in the YouTube about the patient experience. One of the patient around 1:00 a.m. in the morning called her wife his wife saying that there are a lot of bombs set inside the wall and at any time they will go off. I'm going to die in a couple of hours. I just calling you to say goodbye, right?

[00:09:23]The wife wife was telling that she she couldn't made up her mind what to say, just to say I mean no, you will be all right or just to say thank you for the last 50 years if that is the the right?

[00:09:36]So, I mean so, that is the thing. So, in the morning when they go and assess the patient, patient was delirious. There was no bomb risk or anything like that.

[00:09:44]So, that kind of uh the paranoia is uh can be seen in patients with delirium.

[00:09:51]So, it is they see very strange animals, they see very strange things, they see people are trying to get getting at them, and they they see uh the the doctors with stethoscope to strangle them and things like that.

[00:10:07]So, these perceptual disturbances and paranoia is real to them.

[00:10:13]So, that is something so, in that context, if we if we do not understand this patient experience, and if we treat them kind of a bit of a rough way saying that don't do this and that.

[00:10:28]They will get really scared.

[00:10:31]Right? They'll be very helpless, right?

[00:10:33]So, that is something really important to understand the patient experience in the management of the delirium.

[00:10:41]And this is in cultural way also, you might have heard in uh in good old days, our grandparents says that the hell, something like that. I'll buy it to you and let you buy it to you and let you buy it to you and let you buy it to you and let you buy it to you and let So, before the death, he might have had hypoglycemia, hyponatremia, UTI, or something. So, he might have seen those things.

[00:11:19]So, so this very likely the uh visual hallucinations in the context of delirium, right? So, when you are delirious, though your mortality is very high. When you see it is very likely that you die in couple of years. Right?

[00:11:34]Yeah.

[00:11:36]So, first the impact of delirium. So, why we need to be really aware of this condition? Why we need to really screen the delirium? Right? So, delirium so, it if it happen, so, there is eight time risk of developing dementia, which is irreversible condition.

[00:11:55]Right? And there's a the as I discussed, the patient distress and the caregiver distress.

[00:12:03]More than anything else, distress to the the health care team.

[00:12:09]So, likewise, in the middle of the casualty day, how you can manage this?

[00:12:13]Right? So, the causes huge distress to everyone. And 20% mortality in 3 months time.

[00:12:21]Right? And 20% do not go back to the baseline.

[00:12:25]Right? All these meta-analysis findings tells us that 20% do not go back to the baseline.

[00:12:31]And the health care cost. In Sri Lanka, we haven't kind of systematically evaluate the health care cost for the delirium, but in developed countries, they have evaluated like millions of dollars and long-term cost the health care and the long stay in the hospitals and the lot of other expenses.

[00:12:53]Right.

[00:12:54]So, it is clear that delirium has to be prevented.

[00:13:00]Right?

[00:13:01]The most important thing is delirium is most of the time delirium can be prevented.

[00:13:07]Right?

[00:13:08]So, one in eight cases of delirium preventable according to the systematic analysis. And most of the causes of delirium are modifiable.

[00:13:18]For example, you get a patient with renal failure, acute renal failure on the ward. Patient having diarrhea, something like that. Patient get dehydrated. So, patient can get delirious, right? And so, dehydration is one of the commonest cause of The pain is one of the commonest cause of delirium in old age. Constipation, UTI, hypoglycemia, hypernatremia, fever, any infection, right? So, it is really important for us to be aware of this condition, have a high index of suspicion, right?

[00:13:53]Another important thing is causes of delirium are multifactorial.

[00:13:58]That is one of the important thing. So, we think patients with UTI develop delirium because of the UTI. You treat the UTI, you you close the case.

[00:14:09]But, it's not only the UTI. There can be fever can cause in delirium. There can be dehydration causing delirium. This can be pain, quality pain causing delirium, right? So, likewise, so when you identifying identifying something, right? That is not the cause of delirium. There can be so many other causes of delirium that can be multifactorial.

[00:14:34]Actually, research has found out that this is one of the causes of long-lasting delirium. So, you think because of delirium, you treat with that antibiotics and you leave the case, but patient continuously experience delirium.

[00:14:50]Right.

[00:14:52]The prevention of delirium.

[00:14:54]Now, this is the delirium. So, delirium management and uh prevention, these are not rocket science. Very simple things we can do. We can save many lives, right?

[00:15:06]Prevention of delirium. So, out of these things, what is the most important thing to prevent the delirium?

[00:15:15]So, research has shown across the globe the most important thing to prevent delirium outside the patient.

[00:15:23]That is staff education.

[00:15:25]Educate and raise the awareness of delirium and do systematic analysis systematic screening of delirium.

[00:15:34]So this is the most important thing.

[00:15:37]We need to be real are we educating our staff on delirium?

[00:15:43]Right?

[00:15:44]So this is something really important.

[00:15:46]This is the most effective thing. This doesn't cost anything, right? So this is our response one of our responsibilities to educate our staff.

[00:15:55]Not only the doctors, nurses and other staff just to notice the change in behavior.

[00:16:00]And then doctors try and identify the cause of delirium.

[00:16:05]Right? So this is the something most important one. So we we actually thought of kind of a doing the with the medical wards and the our geriatric team do about the educate about the delirium in the hospital setting.

[00:16:22]Right.

[00:16:24]And improving the diagnosis of delirium.

[00:16:28]So internationally there a lot of research they have shown that up to 60% of cases of delirium are under detected in medical setting.

[00:16:38]I'm sure in Sri Lankan setting is this is much higher. 60% of cases are not being detected.

[00:16:46]You you can understand what would happen to this 60% of patients.

[00:16:50]The fate of the 60%. Their individual suffering, their family suffering, long term mortality and the morbidity and everything.

[00:17:02]Right.

[00:17:03]So why do we miss diagnosis of delirium?

[00:17:07]Right?

[00:17:08]Then the number one thing is lack of awareness.

[00:17:12]So this is the case across the the job categories in healthcare system.

[00:17:20]The doctors, nurses, specialists, and other supportive staff, and everyone.

[00:17:24]So, this is lack of awareness identified as a major problem not only in Sri Lanka, in other countries as well. And lack of systematic systematic screening.

[00:17:35]So, in other geriatric units, and so, most of the time they screen for delirium. In in our setting, because of very heavy case load and patient turnover and everything, this is not happening.

[00:17:47]Right?

[00:17:47]Other important thing is presentation simulates symptoms of mental illness.

[00:17:53]Right? So, we think delirium is not being oriented.

[00:17:57]But, commonly, they present as a symptom of mental illness. They just pass it to a mental health care team. Right? But, delirium is a medical emergency. Okay?

[00:18:08]And so, they might be very paranoid and hallucinating and agitated, disturbed behavior, very difficult to contain on the ward. Right? So, they present as symptoms of mental illness.

[00:18:20]Right? They overlap with other psychiatric diagnosis like people think this is the possibility of because of this memory problem, acute memory problem. People think that this is dementia or something. Right? Or depression or something. Right? The other one is the hypoactive delirium.

[00:18:37]The patients are very much withdrawn, not talking, but you see patient is delirious. Right? And so, because of this reason, the delirium, the hypoactive delirium is actually the commonest cause of delirium commonest subtype of delirium. Right?

[00:18:53]So, most of the time the hyperactive hypoactive and mixed and the more than 40% of time in Sri Lanka and other countries, it is hyperactive delirium. That is why it is missed quite a lot. There's a very interesting joke running and so, they think that in the medical team, they think the the delirium is a psychiatric the the condition and the psychiatrist think that this is a medical condition, right? Then delirious patient think that where am I belong, right?

[00:19:22]Then delirious patient thinks where I should I be managed, right? So actually the management so that is what we all practice in in the teaching hospital Anuradhapura. This is we realize with the medical team and surgical team. So we psychiatric team go and see the patient and medical team identify the underlying cause whatever the brain tumor or hypernatremia, hypoglycemia, UTI they they treat that. So we treat the we do the behavioral management and the psychiatric symptoms. So that is how it's been managed. So it is more of a collaborative work. This is a medical emergency.

[00:19:59]Right.

[00:20:01]So if you look at the the first question I asked after the case scenario, so what is the most likely diagnosis?

[00:20:10]Now I change the question if I change the question, you might have thought that there could be kind of more than one question here. More more than one right answers here. It's like uh SBA.

[00:20:23]But if I change the question, what is the most important diagnosis needs to be excluded in this scenario?

[00:20:31]Now there are you get only one answer.

[00:20:36]You agree?

[00:20:38]It is delirium, acute medical emergency.

[00:20:42]Right?

[00:20:44]Okay.

[00:20:45]So this is we did uh recent research one of the post MD dissertation and uh among 233 patients in our hospital, the prevalence in medical wards it's 20.3%.

[00:21:00]And prevalence in general surgical wards it's 11.5%. You can see that one in five people over the age of 60 in medical boards are having delirium.

[00:21:12]Right. So, we we miss quite a lot of patients with delirium.

[00:21:16]And one in 10 patients or older adults in surgical wards are having delirium. So, we again miss quite a lot of patients with delirium.

[00:21:25]And in our hospital, the hypoactive delirium is 40.5% and hyperactive delirium is 33.3% and mixed type is nearly 25%.

[00:21:39]Right.

[00:21:41]And implications of misdiagnosis of delirium. So, we can see that in our setting in the country and globally, we miss the diagnosis of delirium. So, what are the implications? So, you can see that huge distress to the patient, family, health care team, right?

[00:21:59]Increased mortality.

[00:22:01]They're not been coming back to cognitively to the baseline. Risk of dementia which is irreversible, right?

[00:22:08]And the health care cost.

[00:22:10]Right?

[00:22:12]If you miss the diagnosis of delirium, so there can be a [clears throat] lot of reversible causes.

[00:22:17]Right? So, like hypoglycemia, hypernatremia, UTI, very simple ones, right? You might miss the possibility of getting the patient back to normalcy completely. You might miss that opportunity. So, that is why we call it as a kind of a presenting symptom. Delirium is a presenting symptom. It is really important to pick it up. And so, if you miss, there can be a permanent consequences.

[00:22:46]Right.

[00:22:47]So, management of delirium. So, in any setting, the understanding patient experience is really important.

[00:22:54]Right? So, understanding patient experience is really, really important.

[00:22:59]Because the patient might see this patient as a nuisance, right?

[00:23:04]Troublemaking person on the board. But if you really look at the patient experience, patient is really frightened. They're really scared to death.

[00:23:15]Right? So, it is very unfortunate that sometimes the patients with terminal illness in their like the last couple of hours they're suffering a lot because of the delirium, right? So, when I underwent the surgery once in Kalubowila, there was a the SIDU and also there's myself and there's another the patient and the that patient is very much renowned chemistry teacher in Colombo. And so, after the post-operative surgery, he was very much delirious and he's really scared of me.

[00:23:49]Really scared of me. The myself and only him and there's also one of my friend called Anand is a very good psychiatrist and he tried his best to kind of a reorient them and reassure and talk to the doctors and everything.

[00:24:03]They just came and give him diazepam in the morning. So, they might have increased my analgesics as well. So, I fell asleep and when I wake up in the morning, so because of nuisance you call the nurses and this patient is being you needs your support and help, right?

[00:24:18]And the in the morning it is very unfortunate that the patient passed away. Right? So, you can see that last couple of hours in his life, right?

[00:24:28]Lived in extreme fear, anxiety, and terror, right? So, this should not happen if if the the staff kind of a keen enough.

[00:24:38]I'm I'm not I That was a major surgery.

[00:24:40]I think the mortality is very high.

[00:24:42]Uh the but they might have find a kind of a reversible cause. So, that is the importance of the identifying the delirium, the patient experience, which is something really important.

[00:24:55]Right?

[00:24:57]So, when it's come to the management the there are two things. One is non-pharmacological and pharmacological So, if you look at the evidence, if you look at carefully the evidence the the methodological rigor of the studies and the the meta-analysis and systematic analysis, so you have only the effective evidence for non-pharmacological management.

[00:25:22]Right.

[00:25:22]So, non-pharmacological management is the one we have evidence. Right.

[00:25:30]The So, that is something really important. In non-pharmacological management, if you look at you don't need an expert. Right. Again, if you can teach your staff about the non-pharmacological management of delirium, right, just reassure the patient, right, saying that so your mind is playing trick on you, right. So, this is not the reality. You you ground the patient, reassure the patient reorient the patient. Right. So, that is very helpful. Identify the reversible underlying cause and things like that.

[00:26:01]That is very helpful and that is what is most important.

[00:26:05]And pharmacological management, so you will see if you look at the research carefully, there's no evidence for pharmacological management. Right. The most of the time we treat the patients with pharmacological [clears throat] pharmacological we treat the patient.

[00:26:19]Right.

[00:26:20]So, pharmacological management is has to be low dose and shortest duration of time.

[00:26:30]The you use pharmacological management only to reduce the harm. It's just a harm reduction.

[00:26:38]It does not alter the cause of delirium.

[00:26:41]It does not shorten the cause of delirium. It does not treat the cause of delirium or it does not kind of a shorten the duration of delirium.

[00:26:51]In fact, pharmacological management can worsen the delirium. So you know that organic brain disorders, if you use antipsychotic medication, it can increase the conditions like neuroleptic malignant syndrome and other things, right? So that is something really important to understand. Use your pharmacological management sparingly.

[00:27:15]Right. So these are the most effective and evidence-based interventions for delirium. So you can see that. So anyone can do these kind of things, right?

[00:27:29]Modify Modify patient's surrounding.

[00:27:31]Patient you give some the the cues to understand what time of the day is it, right? And the the sunlight, the clock and things like that. And reassuring environment the because patient sees lot of things are threatening. You just reassure the patient, right? So they they are delirious and they have hallucinations and illusions, but they can be reassured. So that is the most important thing. So you put the kind of photograph of their children and wife or family or something the the familiar to them just to ground them, right? And improve vision and hearing, which is very very important. And proper environmental cues, manage pain, early mobilization. And that is one of the best evidence for post-surgical delirium. Management of post-surgical delirium. Early mobilization.

[00:28:22]Prevent the delirium, right? And improve sleep and reorientation the patient and consistent care.

[00:28:30]So because patient the there's a processing abnormality in processing of information, so in one shift, you can allocate one nursing officer to attend the patient, right? Then the patient will not misinterpret the information. the consistent care.

[00:28:50]Right.

[00:28:51]So, coming back to pharmacological management, right? Not a substitute for non-pharmacological management. Right?

[00:28:57]So, we all know we all are busy. We find it difficult to kind of a deliver non-pharmacological management, but it takes just 5 minutes. Right?

[00:29:06]If you can get one of the nursing officer trained and it is it is not a rocket science. It's very easy to train anyone. Even the supporting staff member can do this, right? And if you train your staff adequately and you can do that.

[00:29:19]Right?

[00:29:20]Only use for harm reduction.

[00:29:23]If patient is very much disturbed, right? Why do I use pharmacological management most of the time if patient is delirious patient is and they restrain right? So, you can see that such a frightening person, anxious and scared person, if you have tied the patient to the bed you can imagine patient experience what it is, right? So, that is where you can manage the you can use the pharmacological management just to contain the behavioral problems. No evidence to improve outcome.

[00:29:57]Treat underlying cause, speeding the recovery. Pharmacological does not cause shortening of the duration of delirium.

[00:30:05]So, this is the this is based on research and meta-analysis and everything and so, this is one of the important things I want to discuss with you. Well, I'm sure you all know this and just remind and refresh our knowledge.

[00:30:21]This is the updated medical knowledge.

[00:30:25]Right.

[00:30:27]Again, pharmacology can cause worsening or inciting delirium.

[00:30:32]And use the lowest dose for shortest period of time.

[00:30:37]Right. So, we know some antipsychotic medications, benzodiazepine, antiepileptic medication, and propofol.

[00:30:45]Right.

[00:30:46]So, antipsychotic medications, there are the the side effects on its own like QT prolongation, worsening the delirium, right? So, benzodiazepine, they use some analgesics like morphine as well.

[00:31:00]They're just to contain the behavior, right?

[00:31:04]It does not change the outcome.

[00:31:07]The the dexmedetomidine, I can't pronounce this. So, this is the latest one. This has some kind of evidence in ICU delirium. And so, this is alpha-2 agonist given as infusion.

[00:31:20]And benefits include anxiolytic, analgesics, hypnotic, anti-agitation properties, lighter sedation compared to alternatives like propofol. Side effects are primarily hemodynamic.

[00:31:33]The bradycardia, hypertension, rebound hypertension, and things like that.

[00:31:37]This is yet to get the FDA approval, but out of other medication, this I'm I'm not sure whether it's available in the Yeah. Yeah, okay. Right. So, this is uh one of the newer medications which has lesser side effects.

[00:31:54]Right.

[00:31:55]So, okay, I'm on time. And uh so, few take-home messages.

[00:32:00]Delirium is under recognized and under treated.

[00:32:04]And cost of delirium is huge at personal level, family, health care team, and the government. Health care cost is huge.

[00:32:13]Delirium is multifactorial in etiology.

[00:32:15]If you think it is UTI, there can be other causes of delirium as well. The main stay of management is non-pharmacological management, right?

[00:32:24]Mainstay of management is non-pharmacological. Educate your staff to do the non-pharmacological management which is the most effective one. The pharmacological management do not have an evidence-based and use it with extreme caution.

[00:32:40]The most important thing is educate, educate, and educate your medical team on prevention of delirium.

[00:32:48]So, this is the most important thing. In the prevention of delirium, the systematic screening is something really important. Raising the awareness among the the the medical professionals really again important and understand that the the delirium is just a presenting symptom. There can be a lot of underlying causes and causes are multifactorial, right? So, in fact, so there's the in addition to that the study that there are two other current studies are going on. We will do a study one and the the for the screening. So, we validate the tool to our culture to detect delirium, to give the the our health care staff to increase the detection of delirium. There are two the 4AT and CAMs. The tools we are validating in Anuradhapura. So, so we are more than happy to work with in our mental health team. We are more than happy to work with the medical, surgical, or whatever the specialty to manage the patients with delirium. And if you think we can help out to educate your staff about the management of delirium and raising the awareness and things like that.

[00:33:55]Thank you very much.