The Long-Lasting effects of Delirium: Tammy Hshieh, Ed Marcantonio, & Thiago Avelino-Silva

Delirium is probably the single most common issue I see in clinical practice as a palliative care consultant for our hospital's very geriatric population. I would say that only about half the time we are consulted has the team consulting us recognized that the patient has delirium. I would guess that about 25% of the time there is an obvious culprit or set of culprits that lead to resolution of the delirium, e.g. for one recent patient, sedating meds used for behavioral issues in a patient with dementia.

In today's podcast we focus primarily on the long term effects of delirium on cognition. There's a major debate in the field as to whether delirium itself is the cause of accelerated cognitive decline, or does delirium merely unmask underlying vulnerability and frailty. We try not to get confused (see what I did there) as we puzzle out this mystery: hospitalization is associated with worsening cognition, but does rehospitalization explain the worsening cognition observed in older adults with post-operative delirium?

Our guests Tammie Hshieh, Ed Marcantonio, and Thiago Avelino-Silva are experts in delirium research and address:

• What is delirium, is it "brain failure" as Ed wrote in the NEJM in 2017?

• What are the mechanisms of delirium?

• Are debates over which delirium screening tool is best in the hospital productive or counter-productive? Get ready for a fantastic breakfast cereal analogy

• What did Tammy and colleagues find when studying the 5 year course of post-operative delirium and impact on cognition, did rehospitalizations as a marker of frailty explain the cognitive decline (the unmasking hypothesis)? Article in JAMA Internal Medicine

• The answer is no, and Thiago's commentary and explanation helps explain why this is important, and demonstrates that delirium itself predisposes to future cognitive decline. He also helps us understand transient vs enduring impacts of delirium.

• What evidence do we have about the relationships between frailty and delirium?

• What can clinicians do about delirium and do interventions have any impact? Ed's classic trial published in JAGS found that proactive geriatrics consultation in hip-fracture reduced delirium by over one-third. 

• The CMS Age Friendly Health System measure and delirium assessment

And I get to play "Where is my mind?" The Pixies were highly influential on Nirvana, one of my favorite bands from high school, and if you listen to the original you can hear it in the