Phil:
Hey, everybody!

All this season, we’ve been talking about life with Alzheimer’s and dementia, featuring perspectives from society, health systems, the patient and the caregiver.

There’s a pretty natural question that gets posed after all of that, though, which is “what can I do to protect my brain and reduce my risk?”.

While there’s no way to completely prevent Alzheimer’s, there are some good habits and behaviors that we’ve found can reduce your risk, and possibly protect your memory.

This episode, we’re going to talk about deliri a neurological condition that may have a link to memory loss.

Welcome to The Problem. I’m your host, Phil Lofton.

[THEME]

Meet Heidi Lindroth, a fellow at the Regenstrief Institute, and a Critical Care nurse.

Heidi Lindroth:
I decided to take that leap, go from a bedside nurse to becoming a nurse researcher.  About the second year of my position as a bedside nurse.  the first year I, you know, as a trainee I was a resident, I saw a lot of delirium and I was really struck by how much these people were suffering and how we were really not able to help them. And it also struck me that a lot of the reason why or behind why we weren’t able to help them is because we didn’t know why delirium happened and we really didn’t have the tools readily available at the bedside at that time to prevent and manage those symptoms and really alleviate that suffering. I felt the best way to be able to help answer that question and to help patients recover or, and maybe not even experience it at all and prevent it, was to go into research and really learn how to ask the right questions and try to find the right answers.

Phil:
Heidi, along with several researchers at the Indiana Center for Aging Research at the Regenstrief Institute, studies a condition called delirium.

Delirium is one of those words that gets thrown around enough that you may not know it’s an actual medical condition, but it’s a very specific type of brain condition that can have serious effects.

Here’s Sikandar Khan, a regenstrief scientist and ICU doctor.

Sikandar Khan:
Delirium is characterized by a change in the mental status of the patient. There is a fluctuation in their level of consciousness and how awake they are. There’s also inattention; they are not able to hold their attention on a task or shift their attention such as you and I can. And there’s also a lot of disorganized thinking. What we see in the intensive care unit, is a form of brain failure where the brain is simply not functioning as it normally does.

Delirium is something that affects more than 7 million hospitalized patients every single year.

It’s associated with hallucinations, inability to think clearly, and a lack of awareness of the environment. It’s sometimes called ICU psychosis or sundowning, and for patients and their families, it can be really traumatic.

During my talk with Dr. Lindroth, I asked her what it was like to see delirium in her patients.

Heidi Lindroth:
It looks awful. It’s horrible. I think when people, like as a bedside nurse in that perspective, it, you feel so helpless because you know, this person is going through something that you aren’t sure if you can help them through it. And I think sometimes when in, like when you’re at the bedside, at the frontline, it’s, it’s hard to remember that sometimes the simplest thing goes the furthest. And so like that reassurance or holding that patient’s hand or just simply being there and explaining in detail what you’re going to do or what’s happening can have a huge impact on that person.  and that, that perspective has been formed by talking to patients after they’ve experienced delirium and how utterly terrifying it was.  I think as a researcher, through my dissertation, I had a number of, participants or people that I, they were in my research study, which I’m always gonna be grateful for. And they really opened up to me and shared what their experience was like.  And that is why I am so dedicated and passionate to finding a solution, cause they should not have gone through, like they went to surgery, because they needed to have something fixed. And, unfortunately, they ended up with a worse outcome because they experienced delirium which should have been prevented in my mind.

So I think that is, it’s very heartbreaking and I think for a family, what I’ve seen is that family members kind of seem to be bewildered after, like during they’re terrified and like frightened because their loved one may not know who they are, where they are. They’re completely different person.

They might be saying things and doing things that just are completely uncharacteristic of them and they have no idea what it is because no one talks about it before, after, during the hospitalization, which is really unfortunate. And I think it’s something we need to change and we’re working towards that.  there’s a lot of great work being done, but I think afterwards it’s kind of a, a sense of,  it’s not, I would call it somewhat remorse, but it’s kind of like, almost like bewilderment.

Like, “What was that and what does it mean now for our future and how, how do, how do I help, help that person, my loved one, get through that experience and recover from it?”  and the more I talk to people about delirium and kind of describe what it’s like, eh, so many people have had a relative or a friend or themselves have gone through delirium and just really didn’t know what it was. And sometimes people are really embarrassed by how they acted, which is very sad.

Phil:
Yeah. It sounds like there’s this huge dissonance between, you know, knowing how your loved one or knowing how your, you as a person would act in a given situation and then hearing verifiably that that was not how things shook out during your stay. That’s gotta be really, really hard to reconcile.

Heidi Lindroth:
Yeah. Yeah. From the people I’ve spoken to, it sounds like it’s very difficult to reconcile cause it sounds like you feel embarrassed, you know, you’re embarrassed because that isn’t you, that isn’t how you would react or, or treat people. But yet you’re being told that you did and you don’t remember that. Like, you have your own reality that you remember and that’s the hallucinations and the vivid dreams and that reality that you are experiencing in your brain. But you don’t remember the reality that everyone else experienced when they were interacting with you.

Phil:
The causes behind delirium are just as confusing as the hallucinations it can cause, and in a lot of ways, we’re still early in the process of understanding the condition, but we know how it starts.

Heidi Lindroth:
So delirium is a type of an acute brain failure that is precipitated by an acute event. And so that acute event can be anything from surgery to an infection to a trauma, like a motor vehicle accident. And it really is dependent, you know, we don’t know why delirium happens. We’re still looking into that.

So we don’t understand the biology behind it.  We’re making progress, but we’re not there yet. But what we are coming to understand is that it’s an interaction between someone’s vulnerability going in to that event. So how many risk factors they have, you could also say. And for example, someone who is an older adult who maybe has some comorbidities like diabetes and maybe they aren’t as physically fit and they have some memory impairment, they are at a higher risk for delirium and they need a s, they would require a smaller precipitating event. So like a urinary tract infection or maybe a smaller back surgery, and that might stimulate delirium in that person versus someone who’s young, healthy, no comorbidities, and they’re really physically fit, no memory issues. They would require a really large precipitating event or insult, like a real large surgery or a big motor vehicle accident to experience delirium.

Phil:
Once someone suffers delirium though, they might be at higher risk for developing dementia later on in life.

Sophia Wang is an Indiana University School of Medicine researcher who’s leading the way in exploring the potential link between dementia and delirium.

Sophia Wang:
I think one of actually the really exciting things is that in the field of Alzheimer’s, we’re beginning to start to,   do testing to see whether someone’s got deposits of C beta amyloid, the protein associated with Alzheimer’s.

Now there’s some thought and, but it’s not, it’s, it’s again, still in development that those people may be at higher risk for, you know, developing dementia or Alzheimer’s disease in particular down the road.  and then there’s some thought, again, we still need a study this further is that some of those people may be at higher risk for developing delirium because there’s already some underlying brain damage. So, say if they undergo a knee operation, they may be at higher risk for getting confused after the procedure and then does that put them on the road to Alzheimer’s. And so, I think, you know, one of the key questions is that we need to think, both directions. So, for example, if we know someone’s coming in for a planned procedure, you know, one day could it be that we actually, the same way that we do say a preoperative cardiac assessment to make sure they’re good to go cardiac wise.

You know, could we one day do a similar assessment at least for elective procedures doing a preoperative, you know, cognitive risk assessment, combination of, you know, both a brief clinical assessment but also, you know, bio biomarkers as well. And then, you know, though I think we would love to have everybody undergoing a delirium prevention protocol. You know, it’s, it’s such a labor intensive process, especially we think about smaller community hospitals that have, you know, have very limited resources in terms of human power. And so, you know, can we at least try to make sure that we’re taking care of those at high risk.

Phil:
Scientists are working hard to develop strategies for avoiding delirium if possible, but also reducing its impact once a patient leaves the hospital.

Dr. Khan is working on studying what effect music might have on delirium, and Dr. Babar Khan, another Regenstrief Scientist, and current president of the American Delirium Society, is studying how exercise and brain stimulation might reduce the impact.

I asked Dr. Lindroth and Dr. Khan how patients and families in the ICU could protect themselves.

Phil:
So can a family member or a loved one do anything to prevent or minimize or prepare for the possibility of their loved one going to the ICU? And can they do anything to sort of prep ahead of time for what delirium will look like and the effects of delirium?

Heidi Lindroth:
Yeah, absolutely. I think, I mean, the first step is just being aware that what delirium is, what it looks like, and how that person can, like, knowing that it might occur, I think is a big piece of that battle.  So it’s not a surprise when it happens and you know that the healthcare professionals need to know about it.  hat your loved one is not the same. Their behavior is different and changing and you’re really concerned about it.

I think to prepare for it, I think being aware is, is part of that preparation. But the other piece of that is if your loved one becomes hospitalized, they’re in the ICU, being present as much as you can or making sure someone is there with them, actively engaging in, in conversation or, reminiscing or anything that’s gonna help their brain stay engaged and grounded in the reality that you’re sharing right now.

I mean, sometimes, you know, in the ICU people have breathing tubes, they’re sedated, they can’t respond. But that does not mean they cannot hear. They can likely still hear you.  It’s supposedly the last sense to go. So even though they might not be able to converse with you, telling them that you’re there, what’s going on, they’re safe, what the plan is, what it’s like outside. Even like when I work as a bedside nurse, I like have a conversation regardless if someone can respond and I just talk about what’s going on outside, what’s going on right now, you know, just to have that. It would be like as if they were responding to me, I still talk to them like they would be.

My hope with that is that it’s helping their brain if they can hear me on some level, stay engaged. The other pieces of that is you can make sure your loved one has their hearing aids, their eyeglasses on. Even if they have a breathing tube in that’s gonna help them be able to interact with their environment. Making sure they can be or helping them or maybe, helping and supporting them, encouraging them to be active while they’re in the hospital.  I’ve heard from patients that it’s, it is utterly difficult to move, once you’ve been that ill.  But it is so important to do. And even if it’s as little as doing bed exercises, just really helping that person keep moving is going to help reduce delirium and help them maintain some other, their physical function.

Sikandar Khan:
So in the   previous study that was published by Dr. Pandharipande and the Vanderbilt group looking at survivors of respiratory failure and critical illness, 6% of them had some kind of cognitive impairment at baseline coming into the hospital stay. 74% of them developed delirium in the ICU. And at 12 months, 34% of all of these patients had cognitive scores similar to someone who had traumatic brain injury. 24% of them had cognitive score similar to someone with mild Alzheimer’s disease. So, in terms of what we can do, it is going to be based on, it’s going to be a, a challenging road. But it is going to be addressing, risk factors such as heart disease, blood pressure, maintaining, functional status through aggressive rehab,  but then also being patient, allowing time for recovery, having a good support system with family members so that the patient isn’t overburdened and the care caregivers are also not burned out by taking care of the patient. In addition, watching the medications that you’re prescribed to reduce medications that could be high on the anticholinergic burden scale and removing any medications that could be making thinking difficult.

But,  at this time, the best recommendation in addition to these is, you know, time and continued efforts for recovery.

Phil:
Gotcha. Take the time…get back on your feet, protect your brain.

Sikandar Khan:
Yeah. It’s going to take time.

Phil:
Protect your physical health.

Sikandar Khan:
Right.

Phil:
And protect your family’s mental health.

Sikandar Khan:
Yup. Exactly.

Phil:
That sounds a lot like what we do over at the HABC for, for helping loved ones of people with cognitive impairment.

Sikandar Khan:
Right, right. And asking to get a referral to a critical care recovery center where a multidisciplinary approach can actually evaluate your medications, evaluate your rehab, evaluate your symptoms of PTSD, anxiety, depression which are which are often quite high in this patient subgroup. Making sure you’re getting the specialized care that you need for these.

Phil:
How widespread are critical care recovery units? Are those pretty ubiquitous in the United States now or are they still kind of niche, or…?

Sikandar Khan:
They are very niche. They are growing, but there are probably 11 to 15 centers across the US so it’s very specialized.

Phil:
Yeah. And we have one here in Indianapolis. Is that at Eskenazi or…?

Sikandar Khan:
That’s correct.  the very first critical care recovery center in the United States was set up at,  Eskenazi Health the Critical Care Recovery Center that is led by Dr. Babar Khan, from Regenstrief.

Phil:
That’s really cool.

Sikandar Khan:
It’s a huge bonus for,  patients, caregivers, and clinicians to be able to have,  a center like that to visit.

If you’d like to learn more about delirium head to this episode’s page on regenstrief.org/theproblem, where you can find articles, videos, and other resources.

Listen to our other episodes on prevention, out now, and join us next time in the season finale.

We’ll see you then, on The Problem.

Music this episode was by Blue Dot Sessions, Broke for Free, and Ketsa. Our theme, and additional musical cues were written and performed, as always, by Just Stay Inside.

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