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S2D: The Symptom to Diagnosis Podcast - Episode 14: Delirium
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S2D: The Symptom to Diagnosis Podcast - Episode 14: Delirium
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2023-06-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[upbeat intro music]
DR. CIFU: I'm Adam Cifu.
DR. STERN: And I'm Scott Stern.
DR. CIFU: And here we are with another episode of S2D, the Symptom to Diagnosis podcast. We're going to go back to our original opening this week, just for a change. This podcast teaches evidence-based strategies for diagnosing common medical symptoms. Each episode is divided into four parts. We begin each episode with a case unknown to one of us. We then discuss five high yield features that help to accurately diagnose the cause of the symptom at hand.
DR. CIFU: We then return to our case before finishing up with a discussion of fingerprints, common misconceptions, our favorite pet peeves and other random pearls of knowledge pertaining to the week's symptom.
DR. STERN: Well, if I can remember properly, Adam, our topic this week is delirium, [ba-dum-bump] couldn't resist and you are the expert of the day. Do you have a case to present to me?
DR. CIFU: I do.
DR. STERN: Okay.
DR. CIFU: Because it's delirium, it's going to be very exciting.
DR. STERN: Oh, I can't wait.
DR. CIFU: Okay, so this is a healthy 70-year-old man. He presented to the hospital with acute urinary retention. A Foley was placed and he was found to have 1.2 liters of urine in his bladder.
DR. STERN: [chuckles] Oh my God.
DR. CIFU: That would be abnormal.
DR. STERN: That had to hurt.
DR. CIFU: Evaluation in the emergency room revealed a urinary tract infection, he had a white cell count of 18,000 and an AKI with a creatinine of 3.2 which was up from 1.2 about three months before.
DR. STERN: Okay.
DR. CIFU: Given all this and the fact that he lives alone, he's admitted, treated with ceftriaxone, and obviously an indwelling catheter. On admission he's actually totally with it.
DR. STERN: Okay.
DR. CIFU: Team notices nothing wrong with his mental status. On the second hospital day, he's actually doing well. He's afebrile, he has good urine output, his white count is down from 18,000 to 12,000 and his creatinine has fallen all the way from 3.2 down to 2. And the medical student sees the patients on pre-round and she thinks that he's a bit confused. But when the team goes back to see him, they notice nothing, they say--
DR. STERN: Of course.
DR. CIFU: --this person's completely normal. He discusses the events, he discusses the Cubs game that he watched on TV the previous night. And the team all looks at the medical student like, "What the hell is wrong with you?" On hospital day three, when the team sees him this time all together, the patient is awake and alert but kind of jittery, little confused, actually oriented only to person at this point.
DR. CIFU: At this point the white count's normal, creatinine is normal, he is afebrile and the rest of the electrolytes look fine. [Dr. Sterm] Well, that's an interesting story. Well, you know, it's a great case actually as these things go. I first have to give kudos to the medical student for actually noticing initially on day two that he was not quite himself and being willing to stand by that and say it.
DR. CIFU: So that's fabulous, good for her, and I'd encourage her to keep doing the same.
DR. CIFU: So you're complimenting the medical student for actually paying attention to the patient.
DR. STERN: Yes, I mean actually it sounds like she talked to him and she actually pre-rounded. Hallelujah, I'm going to just sing over here. Hearing the story though, I'm struck by a couple of things. One is the waxing and waning course. It's not a slowly progressive course like you might see if this was just simply a dementia. Nor an acute persistent course that you might see in a patient for instance, who'd had a large stroke. It's really waxing and waning a bit, so that's interesting and would really define it as a delirium.
DR. STERN: You know, and delirium has this huge differential diagnosis, infectious, metabolic, iatrogenic, toxins, trauma, endocrine and so on. And it'd be tempting initially to say, well he's in the hospital, had a UTI and that's the cause. But that doesn't make any sense because he came in sick and is getting better and why would he become delirious on day two or three after he's been treated and he seems better?
DR. STERN: And similarly, the AKI is getting better and so although that can push someone over the edge that doesn't really make sense either. You mentioned his sodium and his electrolytes and presumably his sugar were normal. So although hypo- and hypernatremia can occur in the hospital and hypo- and hyperglycemia can occur in the hospital, that doesn't sell me either. So I think we have to really notice the fact that it occurred in the hospital, and what is that telling us?
DR. STERN: And I guess I would think about two big categories. One would be, boy, is it iatrogenic? Are we giving him something like, is he getting stuff to sleep every night? And it's just throwing him off and he needs his med list reviewed in great detail.
DR. CIFU: One of those PRN meds that ends up being [a two eight hour thing?]
DR. STERN: You know he's getting Ativan or he's getting something that's just throwing him off. Narcotics for pain for his Foley, you know, something. The other possibility though, or the other thing that strikes me is he's jittery. And you know, most delirious patients they're more commonly delirious and depressed or lethargic than they are anxious and jittery. And so that sounds like some sort of hyped up state. And that would make me think about actually alcohol withdrawal in his age group.
DR. STERN: In a younger age group, I might think about a patient taking something illicit in the hospital. But in this age group, he's at day three, maybe drinks more at home than anybody wanted to talk about. Maybe nobody asked the question about how much he drinks. And now he's withdrawing because we don't serve whiskey in the hospital. I wish we could have a margarita now and then, but that doesn't happen.
DR. STERN: So I guess alcohol would be top of my list, and iatrogenic would be second.
DR. CIFU: Okay. It's good to hear you talk through all that, I've obviously got some stuff to teach you so--
DR. STERN: [chuckles] Well, good. But I won't remember it because I'm demented already. So we're going to take a deep dive and now you can educate me and tell me what I have wrong. And I think you've told me this before, and I just can't remember. So go ahead.
DR. CIFU: Okay. You've really beat that joke to death.
DR. STERN: Sorry, I'll stop that now.
DR. CIFU: Okay, so five key points for diagnosing delirium. Point one I always think about is that there's a very, very, very simple framework but a really extensive differential diagnosis. So remember, we're talking about acute mental status change, so we're not talking about chronic mental status change. I think to the internist, chronic mental status change is basically dementia, but clearly there are other things. Acute mental status change that is fluctuating, and Scott, you mentioned this, mental status change that sort of waxes and wanes, that's probably delirium, that's kind of the definition.
DR. CIFU: Acute mental status change that is not fluctuating, we call it acute confusional state. And this might be delirium, but it also might be a whole bunch of other things. Infections, stroke, toxin exposure, hypoglycemia, a whole bunch of things. And so an acute confusional state can really only be called delirium if the other causes are ruled out. Okay?
DR. CIFU: And if the other causes are ruled out, or maybe you find a cause for delirium while other causes of, you know, brain injury have been ruled out, then you can say, okay, this is delirium as well.
DR. STERN: Well, clarify that for me and the audience. So you said you can only diagnose an acute delirium if the other causes of a persistent acute confusional state are ruled out.
DR. CIFU: Right.
DR. STERN: That would seem to
DR. STERN: suggest that everyone who comes in with a delirium though needs to have all those things ruled out and I know you don't think that, so--
DR. CIFU: No, definitely not. So there are a lot of people like-- put yourself in the emergency room.
DR. STERN: Go ahead.
DR. CIFU: There are a lot of people who are in the emergency room that through a history or through observation, you will recognize that this is delirium, that this person has waxing and waning mental status change and probably they have an easily identifiable cause for that delirium.
DR. STERN: Got it.
DR. CIFU: Okay?
DR. CIFU: Then there are other people who are just out, and you're like, "What the heck is wrong with those people?" And these are the people who are admitted with delta-MS.
DR. STERN: Right.
DR. CIFU: And so a lot of times,
DR. CIFU: this is what the emergency room docs are incredible at. That person is going to get a head CT, they're going to get electrolytes. They're going to get a tox screen, they'll probably get an LP. They're going to get the whole evaluation to say, you know, what's happened to this person's brain, why do they have this acute confusional state? And very often what happens is they find nothing but they do find out, oh, look, they have pneumonia. They have a urinary tract infection.
DR. CIFU: They have an acute MI, something which is causing this delirium.
DR. STERN: So if it's fluctuating and we're clear about that, we're clearly in the delirium category. And if it's persistent, then we have to rule out those other causes first. I got it, okay.
DR. CIFU: So that's sort of the simple framework. And when you see this in the Symptom to Diagnosis textbook, it's the most pathetic algorithm you've ever seen because it's like two or three branch points. But then when you go to differential diagnosis, the differential diagnosis of delirium is, I don't know, expansive, infinite, whichever word you want to call because in the right person basically anything could cause delirium.
DR. STERN: In the right person, we're going to come back to this actually, right? Because that's a big-- That little parenthetic comment is really important.
DR. CIFU: Right, it would be hard for it to get me delirious with an illness, it would be a little bit easier to get you delirious with an illness.
DR. STERN: [chuckles]
DR. CIFU: And it would be much easier to get someone 15 years older than you delirious.
DR. STERN: Right.
DR. CIFU: Okay?
DR. STERN: Well, I'm not going to agree to your underlying premise but the more poorly functioning the brain, the easier it is to get delirious. All right, what's your second key point?
DR. CIFU: Okay, second key point is diagnosis. Okay? And all I can sort of say about diagnosis is use the Confusion Assessment Method, the CAM. It's a diagnostic tool, there are four points. You need point one and two and either point three or four. So point one, the change in mental status needs to be of acute onset and fluctuating course. Kind of obvious, right? That's delirium.
DR. STERN: Okay.
DR. CIFU: Point two, so you need both point one and point two, is inattention. So when you talk to the patient, the patient needs to have difficulty focusing attention. So the patient will be easily distractible, having trouble keeping track of what is said, and that counts as inattention. Okay? And everybody you see with delirium is going to have this. And then you need one of these two other points, disorganized thinking, and so disorganized thinking is incoherent thinking, rambling thoughts, irrelevant conversation, unclear or illogical flow of ideas, rapid unpredictable switching from subject to subject.
DR. CIFU: So inattention is the person has trouble sort of keeping track of what it says, while disorganized thinking is just kind of being all over the place.
DR. STERN: Got it.
DR. CIFU: Then the last one is altered level of consciousness. And this is where maybe, I don't know, I wouldn't correct you because I think you're right. Most of the time when we see someone who's got an altered level of consciousness from delirium, they're kind of out of it. Right? They're sleepy, they're stuporous, whatever. But actually you will see people who are delirious who are just like, wound up.
DR. STERN: Right. I mean, certainly some people get very upset about not understanding what's going on.
DR. CIFU: Right. And I think, every intern or at least every medicine intern let's say, has been called to see a patient who's delirious and the patient is climbing the wall saying, "Someone stole my money, I need to call 911," those kinds of things, and that person is certainly not lethargic.
DR. STERN: Well right, and hence the paradoxical effects sometimes of benzodiazepines. Right? They get them a little bit confused and then the confusion actually agitates them rather than calms them down.
DR. CIFU: Excellent.
DR. STERN: Okay, and your third point?
DR. CIFU: Okay, so third point is maybe one that needs a little bit of explanation and this is, I think the thing that's a little bit surprising is that delirium is often, or I would actually say usually, persistent. So we've all had patients who come in with delirium. We hear that, "Oh, you know, grandma is wonderful, she's the nicest person in the world, she's completely with it, she tells stories about her childhood," and she's completely out of it.
DR. CIFU: And she's got a terrible urinary tract infection. And you're like, "I can't believe this person is usually with it." And then after 24-48 hours of antibiotics and fluid, she is completely normal. Okay? And that's sort of the picture of delirium. But the fact is that the majority of people when they have an illness and especially a severe delirium, they take a while to come back.
DR. CIFU: And some people really never get back to their baseline after a bad episode of delirium. And this is at least really important for discharge planning because sometimes someone comes in and even though you've treated their urinary tract infection, their pneumonia, their cellulitis, they may not be ready to go right back home to independent living where they came from.
DR. STERN: That's really a good point. And I think part of the reason for that, and you can correct me if you disagree, of course, is a healthy young person who gets very sick, they have to be incredibly sick to get delirious. You know, their brain is organized enough that despite a massive insult they're still thinking clearly. And so I think it's a marker of an early, either an early dementia or some cognitive disarray that predisposes those people to delirium.
DR. CIFU: Right, I think that's true. I think that's true. Though, I had an episode of delirium.
DR. STERN: You did? From what?
DR. CIFU: When I was, I think 11 at summer camp, I got a really high fever, got really sick. I remember they called the doctor into the infirmary to see me. I remember them asking me where I was from. And I thought I was being funny and said, Indiana. They gave me aspirin--
DR. STERN: [chuckles]
DR. CIFU: --and I put the aspirin on my forehead because I think I thought it was ice. And I like vaguely remember all this and then I kind of was out. And then I woke up at some doctor's office.
DR. STERN: Do you know how high your fever was? I bet it was pretty high. I mean, there's no doubt with enough of an insult--
DR. CIFU: Right.
DR. STERN: --people get delirious.
DR. STERN: But the elderly, it's often like you say, UTI we wouldn't expect either of us with an uncomplicated UTI to be delirious.
DR. CIFU: Right. I obviously recovered perfectly from that.
DR. STERN: Well, we could debate that later. Okay, your fifth point.
DR. CIFU: Actually, we're up to the fourth point.
DR. STERN: Sorry.
DR. CIFU: So fourth point is evaluation. And this kind of comes from what we just talked, so anything, anything, anything can cause delirium. And so you just have to figure out what caused it. So generally you're going to do a good history, you're going to do a good physical exam, basic lab tests, you know, comprehensive metabolic panel, CBC, chest X-ray, UA, even EKG, if you haven't found anything because interestingly in the oldest patients, patients over 80, 10% of MIs actually present as delirium which is sort of amazing.
DR. STERN: 10%?
DR. CIFU: 10%. - That's really scary actually.
DR. CIFU: And then as you mentioned, alcohol use. Right? Which maybe is a separate entity. Right? We think about delirium tremens rather than just delirium but whatever, it all looks the same. Right? Do not - at least routinely and I'll get to this later - do not feel like everybody who's delirious needs a CT, an LP and EEG, or certainly a neurology consult.
DR. STERN: I think you and I have had this discussion about CTs, LPs and EEGs 100 times because my natural inclination being a Nervous Nellie if you will, was always to do too much. And I think that's a really important point about figuring out who needs those things and who really doesn't.
DR. CIFU: I seem to remember the three words, suck it up, coming out of my mouth.
DR. STERN: [chuckles] I wouldn't be surprised. I don't remember, but that's the truth, not a joke. All right, go on, the final point.
DR. CIFU: And fifth and final point is you can actually prevent delirium. There have been some great studies on this, I think Sharon Inouye was the first who really worked on this and has done some amazing stuff. So the sort of independent predictors that are "reversible" are cognitive impairment, sleep deprivation, immobility, visual and hearing impairment and dehydration or hypovolemia. And so all of those you can intervene on.
DR. CIFU: So cognitive impairment, how do you intervene on cognitive impairment? You work on orienting the person. Right? You let them know what day it is, what time it is, whether it's daytime, nighttime, you write on the whiteboard today is Tuesday and your nurse is Todd, and you actually make sure you change that every day so it's not Tuesday for their whole hospitalization.
DR. CIFU: Sleep deprivation, let the people sleep. You don't need 4:00 a.m. labs, let them get a good night's sleep. Immobility, have physical therapy work with them or go back to see them in the afternoon. And when you're usually around with them, get them up, walk them around the hall. Visual and hearing impairment, don't lose their glasses, get their hearing aids from home.
DR. CIFU: And hypovolemia, make sure you're keeping them hydrated, and make sure you're keeping them as afebrile as possible.
DR. STERN: Those are really good points. And we really do have to attend to that or we're going to have a lot of unnecessary adverse effects. All right. Well, with all that, we've got this 70-some odd year-old fellow who got delirious in the hospital, let's get back to him and what happened?
DR. CIFU: Okay, so the team really did a very good job on this guy, looked him over closely, repeated labs. They actually had not gotten labs that day because they felt like this guy is on-demand he's probably going to be ready to leave. And actually labs all looked good, his CBC had continued to improve, his comprehensive metabolic panel was fine. They listened to lungs, sounded good, they actually looked at the culture results and found that his organism that was in his urine was actually sensitive to the antibiotic he was on.
DR. CIFU: So they felt very comfortable about that. They checked his oxygen, saturation was fine. He had no reason to retain CO2, has got no COPD or sleep apnea, anything like that. And what was striking is during this evaluation although he was afebrile, his pulse which had even at his sickest been in the 80s and 90s, was 120. And his blood pressure was in the 160s, the guy did not have a history of hypertension, and actually when he first came in, his blood pressure was a little, as the young ones would call, soft, running in kind of the 110s, 120s.
DR. STERN: So it's sounding more and more like withdrawal, frankly, you've ruled out a lot of the-- they did a good job of ruling out some of the common causes in the hospital, and he clearly sounds hyperadrenergic, for some reason.
DR. CIFU: Right. So it was tough because this is a man, he was widowed, he lived alone. There wasn't a whole lot of secondary sources but the team was able to get in touch with a friend who turned out, interestingly enough, to basically be a drinking buddy. And he'd stopped drinking, you know, 24-36 hours before he came in, because he was feeling crappy from his urinary tract infection.
DR. CIFU: And so he was sort of right on the perfect place as far as withdrawal.
DR. STERN: Well, it's really interesting and one of the reasons I always press that we have to get an alcohol history on everyone because this is when you see withdrawals it's people who are sick and come in, and can't be drinking anymore. So kudos to the medical student for noticing that he was confused, not so much kudos for nobody noticing that he was drinking routinely at home, but okay.
DR. CIFU: Right. And actually, you know, the question was asked in the emergency room. Do you drink? And what do you think was documented?
DR. STERN: I don't know.
DR. CIFU: Social alcohol--
DR. STERN: Oh, social alcohol.
DR. STERN: I love that. You know, I just got to say, when you take an alcohol history you have to do it correctly. And one thing I always ask people when they say they have a drink a night, is what does that look like? And I recently had an 80-year-old woman. Something about her struck me as though she might be drinking too much, I'm not quite sure what that was. And she said, "I have a drink at night." And I said, "How do you make that?" And she showed me the size of a glass and basically it was an eight ounce glass, and she said, "I put some ice in it and I fill it with vodka." So every night she's having six to seven shots of vodka.
DR. STERN: Well, you know..
DR. CIFU: It's a big gulp.
DR. CIFU: One of my favorite attendings, a person who sort of taught me the most I think during residency, Dr. Booker Bush, he always pushed really hard to say, "What do you drink and how often do you buy it?"
DR. STERN: Oh, interesting! Right.
DR. CIFU: How big are the bottles of vodka? How often do you have to go to the liquor store? All sorts of ways to maybe getting around people's hesitancy which I thought were really excellent questions.
DR. STERN: You know, another pearl, we can put this in the pearls later but I'm going to say now is if people act very uncomfortable when you ask them about alcohol, you should notice that because it's not illegal, it's not a crime, most people don't think of it as a socially illicit substance. And if people don't like it, it's telling you something.
DR. CIFU: And maybe if you think about the old CAGE questions. Right?
DR. STERN: Right.
DR. CIFU: Have you cut back?
DR. CIFU: Do you get annoyed when people ask about drinking? Do you ever feel guilty about your drinking? You know, maybe that gets into that. [PE] is obviously eye-opener. I always think eye-opener must be the most specific.
DR. STERN: [chuckles] That it has to be. Yeah, I try to avoid those. Okay, so let's go on then to-- we'll come at the end to what happened to him?
DR. CIFU: [chuckles] No, we treated him.
DR. STERN: It's life-threatening, as you know.
DR. CIFU: It is life threatening, so he was started-- We used the CIWA scale, we assessed the degree of his withdrawal. He did need low dose benzodiazepines, his CIWA scale was high when we first checked. We also gave him a little bit of a beta blocker. We were worried about the guy, old, tachycardic, hypertensive. And actually the withdrawal turned out to be mild. He was, I would say, somnolent but arousable for about 48 hours, as we got him to the right place on the benzos and then slowly withdrew them.
DR. CIFU: And 48 to 72 hours later, he was really fine. And the guy actually ended up going home and did great, had a follow-up visit two days later, it was really good.
DR. STERN: And I'll just point out the obvious which is had it not been picked up, had this been picked up 24 hours later, he might've been in full blown delirium tremens and then that's a real crisis.
DR. CIFU: Could have been a disaster.
DR. STERN: Okay, good. So that's good for him. Do you know if he quit drinking? [both chuckle]
DR. STERN: Probably not.
DR. CIFU: [chuckles]
DR. STERN: All right, let's go on to fingerprints, common misconceptions and pet peeves, and random pearls of knowledge. Adam, fingerprints.
DR. CIFU: Sure, so I think I already stated this but the Confusion Assessment Method. Positive Confusion Assessment Method has a positive likelihood ratio of 12.3. And what's really important about the Confusion Assessment Method is that we should use it because it's both sensitive and specific. We as doctors are a very specific diagnostic tool for delirium, right?
DR. STERN: Right.
DR. CIFU: When we say someone's delirious, we know it, we're not terribly sensitive, and multiple studies which have looked at doctors identifying delirium in the emergency room, our sensitivity is about 30%. [Dr. Sten] Well, it's interesting because my fingerprint is similar, only about dementia. And so the Mini-Mental Status Exam is very specific for dementia at 8.5 and I suspect that the same thing's true for doctors and dementia.
DR. CIFU: We miss, in a standard primary care visit, dementia all the time because people can be very social and have great speech and language abilities but still have some pretty severe dementia. As a matter of fact, I saw someone just recently who seemed totally coherent, normal conversation, his wife was in the background, shaking her head saying, "No, there's something wrong." And I said to him, "Who's the president now?" And he said, "Biden," and I said, "Who was the president two months ago?" And he couldn't remember Trump.
DR. CIFU: Yeah, yeah.
DR. STERN: All right, so--
DR. CIFU: That might be a good thing.
DR. STERN: [chuckles] That might--
DR. CIFU: I should just add so, both the Mini-Mental Status Exam and the MoCA, the Montreal Cognitive Assessment, they're interesting because they test multiple things obviously. And there are very small parts of those which are really specific for dementia. Right? I mean, like the clock draw is remarkable. But, moving on.
DR. STERN: All right, so misconceptions.
DR. CIFU: So misconception, again, I'm probably underlining one of my five key points. I think it is a misconception that delirium requires an exhaustive workup and that's because the differential diagnosis of delirium is essentially infinite. But really the diagnosis is usually obvious. Right? It's what's bringing the person into the hospital is making them delirious. Right? Or the person's here because they're delirious but very quickly you find out what the underlying problem is.
DR. CIFU: The hard part is often I think being satisfied with that diagnosis because mental status change worries everybody. Right? It freaks out the family. It generally even worries the, I don't know, maybe less experienced members of the team because you've got that loss of humanity in the person. And it takes a long time to adapt to, you know, this person has a urinary tract infection, they're delirious.
DR. CIFU: We have to concentrate on treating the urinary tract infection, the delirium will take care of itself. It may take a long time, it never totally gets better but we can't really do anything about that.
DR. STERN: And my point would just be to agree with you, frankly, I mean, it took me a long time to feel comfortable to the point where I didn't feel everybody who's delirious who came to the hospital needed a head CT scan. And so I'm sure I did thousands of CT scans unnecessarily and I'm more comfortable with that now.
DR. CIFU: Yeah.
DR. STERN: Okay, so let's turn then to pet peeves.
DR. CIFU: Okay. I love this.
DR. STERN: All right.
DR. CIFU: So my biggest one, and I've written things about this in the past is, "the patient is a poor historian." Okay? And I'll tell you why this gets to delirium. First of all, you, the doctor, you are the historian. The patient's not the historian. The patient is just providing you, the historian with the raw data to write the history. Okay? So how does this relate to delirium? It's because often patients who are labeled as being poor historians are actually delirious.
DR. CIFU: So don't miss this. Because if you think about the things we talked about in the Confusion Assessment Method, inattention, disorganized thinking, wow, that'd be tough to get a history from those people. And so if you're having trouble getting history from somebody, you're like, "God, this isn't making sense," just stop, take a step back and say, "Huh, might the problem be that this person's delirious, and that's why I'm not getting a good history?"
DR. STERN: That's really good. So you use it as a diagnostic tool, essentially, the fact that you're frustrated. And you know, what that reminds me of is oftentimes when patients come in with eight or ten problems and they're jumping from thing to thing, and they're making you crazy, it's actually a sign that they have an anxiety disorder and you use that as information, not just get aggravated. It's very similar. Right?
DR. CIFU: I guess, shall we use the countertransference term? But it's important to use, as you say, you know, use your own reactions to patients as a diagnostic tool--
DR. STERN: Right.
DR. CIFU: --because I think it's very different for everybody but there are certain patients, certain concerns which affect us in ways. And if you can get good at recognizing that, I think it's probably hard to determine the exact test characteristics of Scott Stern feeling aggravated--
DR. STERN: [chuckles] Maybe not so much. [both chuckle]
DR. STERN: All right. Well, mine is actually considering delirium as a diagnosis rather than a symptom. And this is not just delirium, but there are many entities where people say, "Oh, they have X and Y," and it's not a disease and you need to figure it out. If someone comes in confused and delirious, boy, if you think you're done then, you should give up your degree and go home, because if you haven't figured it out, that patient's going to have a bad outcome.
DR. STERN: And that's true, whether for delirium it's true for chronic fatigue, it's true for anemia, you need to figure these things out. But that's why we're here to help you.
DR. CIFU: All great points. All great points. I think about that a lot with chronic abdominal pain. It takes a long time and a lot of workup until you could feel comfortable just saying, this is chronic abdominal pain.
DR. STERN: Absolutely, for sure.
DR. CIFU: My last pet peeve, I got a second pet peeve here and we we've talked about this but I wanted to throw out a little bit of data. It's the sort of overuse of CT scans, LPs, EEGs in people who have delirium. So, I think generally-- and let me step back and say, remember, this is not people with acute confusional states where these may play a role. These are people who are clearly delirious have waxing and waning mental status, have a medical cause of that.
DR. CIFU: So a CT is really looking for a stroke. So CT might be reasonable in a patient with an acute confusional state with no apparent cause, but in waxing and waning delirium, a stroke is a rare cause. Okay? About 7% actually in some studies or in one study that I found on this. And most of those people, 97% of that 7% actually have a focal neurological exam.
DR. CIFU: Okay? So you should be able to tell it. LP necessary if the person has fever, change in mental status, and not an otherwise localizable cause. EEG, what the hell are you looking for with EEG? EEG is basically, I guess, looking for like non-convulsive seizures and then postictal states. A. that's incredibly rare, generally at least during a non-convulsive seizure you're going to have eye findings that you can go on.
DR. CIFU: And lastly, neurology consult. I guess we can ask the neurologist listening to this podcast. Neurologists don't want to see this, it's a medical problem. It's not a neurology problem.
DR. STERN: Right, we should all be able to do this, absolutely. So mine is--
DR. CIFU: You have another one?
DR. STERN: I have another pet peeve actually which is the "the exam is non-focal," which makes me want to put a bullet in my brain. What does that mean when the exam is non-focal? Does that mean you walked in the doorway and the person was alive? Does it mean they looked at you? Does it mean you saw one limb move and you thought it was okay? I mean, if someone's delirious and they have a hemiparesis, you are in a completely different situation.
DR. STERN: So you need to examine the patient, even if the patient can't cooperate a lot. Do their cranial nerves look like they're intact? Can they actually move all of their extremities? Is there anything that suggests focality to that? You have to at least do those minimum things before you just say that the exam is non-focal.
DR. CIFU: Someday, I'm going to bribe one of your interns--
DR. STERN: [chuckles] Can't wait.
DR. CIFU: --and what they're going to say is that the alcohol history revealed social drinking, the exam was non-focal, the rectal exam was deferred. And I'm trying to think what else--
DR. STERN: [chuckles] And we didn't do orthostatics.
DR. CIFU: And we didn't do orthostatics. And I would just be sitting there watching your head explode.
DR. STERN: [chuckles]
DR. STERN: All right, we should go to pearls.
DR. CIFU: Okay, here's a fast one.
DR. STERN: Go on.
DR. CIFU: Don't forget alcohol use.
DR. CIFU: Withdrawal is common. It's one of the worst things to miss with delirium. I have no data on this, but I think that the more you see it, the easier it gets to identify because alcohol-related delirium is pretty stereotypic and you get a sense of what people look like when they're withdrawing. But depending on where you practice and what your patient population is like, you may or may not have a lot of experience with this.
DR. STERN: I guess, what I would just add to that is, if you do see alcohol withdrawal, you need to get somebody in the room who really knows how to manage it. And you need to stay at the patient's bedside because it's not easy to manage actually.
DR. CIFU: Right, right.
DR. STERN: My clinical pearl is we've alluded to this, but when you see people are delirious, you need to suspect even if they haven't been previously diagnosed that there might be an underlying dementia. They might not go back to normal. But even if the family has said the person's okay, oftentimes they've missed the fact that there's processes going on. So you should just be alert.
DR. CIFU: Terrific, and it's one of the reasons to underline the Confusion Assessment Method. Right? Because if you miss delirium and say, send people home from the emergency room, send someone home to independent living, it might be a disaster and it might be a disaster because there's a bad underlying problem, or it might be a disaster because they're unable to care for themselves anymore.
DR. STERN: Totally.
DR. CIFU: I guess my last clinical pearl is just about treatment, you know, we focus a lot, I think appropriately, on treating the underlying cause of the delirium. Right? You're treating the disease which is causing the symptom of delirium, but sometimes delirium itself needs treatment. Right? When you see that person in the middle of the night who is you know, climbing up the walls, who's maybe somewhat violent with the staff, who's trying to call 911, sometimes that needs to be treated.
DR. CIFU: And we often, as physicians, sit there calmly with the patients, talk to them, talk them down and then like go back to our call room and the nurses are like, "This isn't going to last."
DR. STERN: Right.
DR. CIFU: Five minutes later the person's climbing the walls again. So sometimes you need to use a neuroleptic, something like haldol, and sometimes you need to use a benzodiazepine.
DR. STERN: So when you talk about medications, let me just explore that with you for a minute before we end, so I'm often leery of benzodiazepines in these patients because I'm not sure that it's not going to add to their confusion. So I've tended to lean more towards very low doses, like you mentioned, of antipsychotics. Do you know, does the literature help us with this?
DR. CIFU: I'm not sure the literature helps us that much.
DR. STERN: What do you do then?
DR. CIFU: I usually go with antipsychotics first, but I have to say, in more emergency settings with a really agitated patient, I will use benzodiazepines as well. You can mix haloperidol and Ativan in the same syringe and give it as an IM dose if it's really an emergency. Because, you know, it's a chemical restraint. Right? Rather than a physical restraint which-- Is that better? Probably. Who knows?
DR. CIFU: I think it's a difficult issue.
DR. STERN: And just to make clear for the audience. I mean, benzos alone are safe. I'm only worried they're going to get more confused. You know, when we hear about deaths from benzodiazepines, it's them being mixed with other sedatives.
DR. CIFU: Right, right. We hope you found this episode of the Symptom to Diagnosis podcast useful and a bit enjoyable. A reminder that the cases that we discuss are drawn from our clinical experiences but, because protecting patient privacy is part of our oath, we never discuss actual patients and most cases are composites. As a reminder, out textbook Symptoms to Diagnosis: An Evidence-Based Guide takes a much deeper dive into how to think about and reason through the diagnosis of medical presentations.
DR. CIFU: The book is available in print, on your handheld device, and in a new fully searchable mode via the Access Medicine website available worldwide from McGraw Hill. The music for this, the S2D Podcast is courtesy of Dr. Maylyn Martinez. [upbeat outro music]