Dr. Regina Koepp  0:00  
As Mental Health and Senior Care Providers who specialize with older adults, it is critical that we have tools to help us differentiate dementia from delirium from depression from psychosis in medically vulnerable older adults. And today's episode is all about that. Today I'm going to interview my dear friend and colleague Dr. Walid Nassif. Dr. Nassif is Chief psychiatrist, Director of inpatient psychiatry consultation liaison service coordinator of psychiatry residents and medical student education and coordinator and site director consultation liaison fellowship and geriatric psychiatry fellowship programs at the Atlanta VA Health Care System. Dr. Nassif is also an assistant professor at Emory University School of Medicine Department of Psychiatry and Behavioral Sciences. He has won numerous teaching awards including Educator of the Year Award at the Emory Department of Psychiatry and Behavioral Sciences, and the Emory medical student annual Teaching Award. He completed his psychiatric residency at the University of Rochester New York and consultation liaison fellowship at Strong Memorial Hospital University of Rochester, New York as well. He is boarded in psychiatry and geriatric psychiatry, and today he's going to help us differentiate between dementia, delirium, depression and psychosis. This is a special episode because this episode actually comes with a bonus. So Dr. Nassif will be on video in this bonus reviewing the MOCA that is the Montreal cognitive assessment for cognitive function. He'll review the MOCA on video and we'll talk about the mocha in detail. And so if you're a subscriber and you, you know, have a continuing education podcast subscription, you will have access to that very important video. If you're not a subscriber, go to www dot mental health and ageing.com to learn more about how to subscribe to the podcast and earn continuing education credits. All right, let's jump into today's episode with Dr. Walid Nassif. So enjoy it, you know, you and I have worked together for let's see more than 10 years now this I've so enjoyed learning from you and getting to work collaboratively with you. You know, we've had some interesting cases that I've consulted with you about. So I'm glad that you're here today to talk about delirium and dementia and differential diagnosis and helping us really understand the critical nature of delirium and, and understanding it. Before we get into that, will you share a little bit about who you are as a person as a psychiatrist, what inspired you to specialize in psychiatry.

Dr. Walid Nassif  2:59  
So, interestingly, I'm one of those people who are fortunate enough to be able to claim that I landed exactly where I thought I should land. And here we are, 30 years later, practicing psychiatry, and particularly the subspecialty of consultation liaison, which deals with the medically and surgically ill patients in the General Hospital, who require psychiatric input. This is my sub specialty. And I'm very happy to say that I'm one of those people who can honestly say, if I had to do it all over again, at the end of high school, this is exactly where I would be landing. So I think I chose well, I'm very happy with what I do. Continue to be very passionate with what I do, and enjoy teaching at multiple levels, here at Emory and at the so that the specialty of consultation liaison psychiatry, it's an additional year of training at the conclusion of general psychiatry residency training pertains to exactly providing psychiatric support to med surg and intensive care units in a general hospitals. So it's quite specialized. It is heavily laden with medical knowledge, you really cannot leave medical school behind, like unfortunately too many psychiatrists do. And that is probably the reason why I ended up in consultation liaison psychiatry, I remember when I was in psychiatric residency training. I felt a certain degree of grief at the idea that I was going to have to leave medicine behind and what I had learned and ended up becoming a shrink essentially, and that really just didn't sit too well with me. I remember actually moonlighting in medicine. While I was training in psychiatry, I trained at the University of Rochester, and the local VA actually needed people on week tends to cover their hospital. And the hospital was medical, surgical and intensive care. And I actually did that for for three years during my residency training, all the while thinking, I'm going to have a hard time letting this go. I love medicine, I love psychiatry, that's where I want to be. But I am also a, quote, real doctor. And I don't want to stop being a real doctor. And then interestingly, during my last year of training, the fourth year of residency training, I rotated on the constantly is on service. And it was like a eureka moment for me. Because this was one specialty in psychiatry that was simply fully immersed in medicine. We were rounding on medicine and surgery in the intensive care unit, we had to maintain our skill, knowledge sharpness, about medical illness. And it really was sort of a revelation for me. And it was difficult because precisely, the area of cognitive disorders is I think, universally not emphasized in psychiatric residency training throughout the country, and I think worldwide, I knew very little about dementia, delirium, other brain disorders, hard brain disorders, felt very comfortable managing your routine psychiatric disorders, but I knew very little about dementia, delirium, and I had a brutal mentor, who was like, What is this, you gotta learn this, and I could have easily dismissed her and said, I don't need to know this, this is really fringe knowledge, I'm just gonna go back to managing depression and borderline personality and schizophrenia. But she was very encouraging and very rigorous, and I decided that I was going to swim rather than sink. And I put in extraordinary effort. During those four months, I felt like I had learned as much as I had learned in the previous two years. And I did so well, actually, that I felt really I had grown tremendously learning this new field within psychiatry, that she offered me to do a fellowship and consult liaison at that point. And I embraced that concept. So I pursued another year of fellowship training with her, felt I really had grown into this new identity. And within a couple of years, she actually left the University of Rochester and left me hanging in there as the director of the service. I enjoyed it tremendously. And I grew into it. And I remained director on the sealed service at the University of Rochester, for the following several years. And then I've pretty much done constantly is on ever since and I enjoy it tremendously. At the same time, I had developed my interest and passion for teaching, I was teaching students and residents. And I've continued to do that here at Emory. I've been at Emory through the VA, since 2006, essentially, and I took over the CL service in 2007. So I've been doing this work for 14 years now and have consistently trained medical students, residents, psychology interns and Cl fellows constantly exam fellows. And with some success with the teaching people have approached me to take on additional training. So I now train juris psychiatry fellows as well, and our trained forensic psychiatry fellows here and I enjoy it tremendously. I think teaching is very much part of my identity. So this is who I am. I come from Lebanon originally and I, I think I always knew I wanted to be a psychiatrist ever since I went to medical school, which in the French system, I'm French dream begins right after high school. So at age 18, I knew I wanted to be a psychiatrist. And I pretty much never changed my mind about that. So it's been a wonderfully fulfilling and ever and like I said, I would do it all over again. If I had to start over. Here I am. And thank you for inviting me. 

Dr. Regina Koepp  9:04  
and you have one additional element to this to your to your story. You were just in Lebanon visiting your dad who's 91 you shared with me?

Dr. Walid Nassif  9:14  
Absolutely. I have not shied away from international travel despite the COVID epidemic. And my dad lives alone. He's 91 years old, and I watch him with loving son eyes, but also with the scrutinizing eyes of the psychiatrist who is watching, you know, around the corner for cognitive impairment to sit in and there's a little bit of that not much actually remains really quite sharp. So I think he's still qualified for what we would call normal aging, not so much dementia, essentially because he remains independent. He remains independent. He makes a few mistakes here and there. We have someone assist him sorting out his medications and keeping track of some items like that. Home. But by and large, he remains fully independent originally one, which essentially says, according to DSM five, that he does not have dementia. He has mild cognitive disorder. Today it's called, you know, mild neurocognitive disorder.

Dr. Regina Koepp  10:20  
Tell me a little bit about your dad just as a man, I'm curious.

Dr. Walid Nassif  10:24  
Oh, my dad is a historical figure in our small country of Lebanon. He's a retired general from the Lebanese army. But he served as a military adviser for three different presidents. So he had very high important positions in the presidential palace. And over the years, really, sadly, new Lebanon when it was in its glory days in the 60s and early 70s. And sadly, has seen it kind of fall apart in the last couple of decades, which is very sad for him. It's very hard for him to accept what has happened to his country. But he also has extraordinarily vivid and beautiful memories of all the things that were accomplished. In Lebanon, heyday, Lebanon used to be a beacon of hope, coexistence, and democracy, and tolerance and diversity among the various religious groups, which contributed to incredible prosperity for the country up until just a couple of years ago. And he was intimately involved with all of this, you know, we have beautiful pictures, there's actually a couple of books published on my father's life. And in them are extraordinary pictures, you know, with various heads of state throughout the decades, you know, from 1960, on to 2000, pretty much. So he is very lively and sociable, enjoys talking enjoys telling his stories, which I think really keeps him very vibrant and very alive. And I do not mention my mother, because she passed away in 1973. And my father never remarried. So he's been a widower ever since. But managing really very well, quite well, despite the sad situation. So here's kind of in a nutshell, our little family history. I have two siblings, one of them is a physician. And my sister is a doctor of philosophy from Sorbonne University in France. But they're both French citizens and live in France, actually. We take turns visiting my Dad,

Dr. Regina Koepp  12:35  
where are you in the birth order?

Dr. Walid Nassif  12:37  
Second, middle child

Dr. Regina Koepp  12:38  
in the middle, I had no idea that this was your family history. That's incredible. Thank you for sharing that with me. I've known you for 10 years, and I'm just an I get to learn new things about you all the time. That's great. Okay, let's dive in a little bit. So So you have this rich history in concert liaison, which we will call CL. Tell us about delirium. So why is this in the context of aging in the context of cognitive disorders? Why is this such an important topic for mental health providers to be aware of?

Dr. Walid Nassif  13:17  
This is probably one of the most common mental status changes that occurs in the elderly. It is actually the number one cause for consult on the consulting is on service, then I direct here at the VA. So we may see anywhere, you know, from 700 to 900 patients per year individual patients. And I want to say it is our number one reason for consultation, not always identified as such, we often get consultations for dementia, or for capacity to make informed medical decisions, or occasionally realized psychosis or real like depression. And our conclusion after evaluating the patient is actually delirium. And none of those previously mentioned conditions actually is mutually exclusive with delirium. So you could easily have depression and delirium, you very often have dementia and delirium. It's actually one of the most common associations in the elderly, who is medically ill. And, of course, many patients with delirium present with psychotic symptoms, which are the symptoms that are most spectacular, if you will, or impressive to the medical teams. So they call us because the patient is hallucinating or because the patient is very paranoid, or because the patient is making wild accusations about being experimented on or this not being a real hospital or people in, you know, fakes might really be in doctors, and we go in there and indeed, psychosis is one of the more prominent facets of delivery. And, but the true diagnosis is delirium with psychotic symptoms, which are very common part and parcel of delirium. So, it is very common, but not just in, in our field in psychiatry, you know, I always tell trainees that coffee is on psychiatry will not just deal with standard psychiatric patients, of course, we see every patient with schizophrenia or bipolar disorder, who is on the medical side and is posing some, you know, challenge for the management. But we'll see, we'll also see a lot of people who never had mental illness who are uncles and aunts and grandparents, who, when they come into the hospital, and are subjected to significant medical stress, develop confusional symptoms, and they develop delirium, and the older we are, the more likely we are to develop delirium. So this is a syndrome that happens to anyone, all of us, we do not have to have mental illness in our family to expect that our fathers, our uncles, and eventually ourselves will develop confusional symptoms in the context of severe medical illness. So that's why I think it's really important to recognize it, be able to differentiate it from dementia and not misinterpret it as severe depression or severe psychosis, when it is actually a syndrome of simply acute brain failure. Delirium is a syndrome of acute brain failure. When our brain fails because it is subjected to trauma stress, it is deprived from its essential nutrients from oxygen from glucose. When it is heated, when it is cooled, our brain suffers and when our brain suffers acutely, it develops confusional symptoms. We do not develop blindness or mutism, or paraplegia, or hemiplegia, when our brain is suffering initially, we developed primarily delirium, acute confusional symptoms, and I'll make that point several times during our talk today. So that's why I think it's really sort of a universal syndrome that can happen to anyone more so when we age. And it is essential to recognize it and understand how to best differentiate it from dementia because I think dementia is the greatest differential diagnosis that lends itself to the most confusion out there among healthcare professionals, and family members to absolutely and family members.

Dr. Regina Koepp  17:35  
I often will hear family members say, Oh, my loved one is just at a new stage of dementia. And I think Oh, no house, how recently did these changes occur? Tell me what was happening around when these changes occurred. And then I'll say you need to go get them checked out medically. Tell us tell us a little bit about what some of the features are when a person is experiencing delirium. So a person does not have to be medically hospitalized post surgery to experience delirium. They can delivery experienced delirium in different settings based on what's happening physiologically.

Dr. Walid Nassif  18:11  
Absolutely. And you know, what is very important to recognize that the same insults the same medical conditions that will create delirium in your grandfather, who is 90 years old, may not at all create delirium in your mother who's 60 years old, or definitely not a new if you are 30 years old. So it's really a spectrum that one has to situate the problem is the same insult will not cause the same symptoms in different people based on the health of their pre existing brain, essentially. So your brain is known to have what we call significant cognitive reserve, when you are young and healthy, that cognitive reserve declines over time, so that by age 60, or 70, you may not appear to have any clear cognitive impairment, but you have less flexibility to manage or withstand external insults. So that you may be completely normal. But if you develop a severe UTI, or pneumonia, and it's 70 or 65, you may start developing confusion or symptoms, whereas you wouldn't if you were 30 years old. So depending on who the person is, and what their age is, and the health of their brain prior to the insult, that really is largely what's going to determine whether you develop acute confusional symptoms, also called delirium.

Let me backtrack a little bit on the terminology that we use, I think that lends itself to a lot of confusion out. The term delirium traditionally has been described in textbooks as this acute syndrome, that is very abrupt, and that is characterized primarily by I impaired attention, often disorientation, impaired level of consciousness with fluctuations of consciousness. And I think that's where most trainees get hung up on this description. And if they don't see that at the bedside, then they're quick to dismiss delirium as the actual diagnosis in front of them. I have seen countless medical residents and even attendings tell me, Well, that can't be delirium. I've not seen fluctuations of consciousness, or when we talk to the patient, you know, he was able to sustain attention for a few minutes, and he looked sharp to me. Yet last night, he was ripping his lines. And the nurses said, you know, he looked paranoid, and he was saying, we were talking about him in the hallway. What is that that sounds more like psychosis. To me, it doesn't sound like delirium. Well, that's where we go wrong is because any one of the deficits and the traditional symptoms of delirium that we all learned in school, such as an attention, fluctuations of consciousness, you know, disorientation may or may not be present. At any one point in time when you interview the patient. The same patient may look radically different at 9am, compared to 3am, when the nurse rounded and documented that they look paranoid, and they were trying to get out of bed, and they said they wanted to leave AMA and so on. Over the years, in my experience, I have noticed primarily that delirium can be not only very varied in its presentation, but that it will also change over the course of a day or two days or three days. And it's important to take the whole picture into account to reach the correct diagnosis rather than a snapshot during rounds in the morning where the patient may appear superficially, well, may be able to crack a few jokes, answer some questions coherently. And the medical team moves on to the next patient and concludes the patient is sharp. There is no delirium here. That's not what I recognized as delirium based on what I've learned in school. And we have something strange that's happening at night, or whatever happened yesterday may be an exaggeration on the part of the nurses, or what have you. And that is simply incorrect. You must take into account all the events, all the descriptions, no matter how subtle they are, that have occurred over a several day period, and feed them into your differential diagnosis to reach the correct diagnosis, essentially, and absolutely do not rely on any one snapshot, particularly if the snapshot is one of reasonably coherent, interactive, logical patient. Obviously, if you see them, and they're very confused, and they don't know where they are, or they don't remember why they came to the hospital in the first place, or they don't recognize you, they forgot the conversation you had with them two hours prior. That is very, very telling, you know, very consistent with with delirium, but that's often not what you see. So it's very important to recognize that delirium is a spectrum of pathology, it can be extremely mild, extremely subtle, certainly not something you're going to elicit on a superficial two minute conversation. And it can be extraordinarily severe, much like we all learn in school where the patients are disoriented, inattentive, agitated, sweating, trying to get out of bed pulling lines, you know, hearing voices, seeing things in the corner of the eye, claiming there are animals scurrying, you know, under their bed, or crawling up on the wall, etc. That is the very classic, severe picture of delirium that you will read in the textbook. Remember, most textbooks are supposed to illustrate the most severe form of any condition, you're not gonna see pictures of somebody who looks good in a textbook. So, and that's where people often get it wrong is that if they don't see what they've learned in the textbook, they miss the diagnosis entirely. Or they focus on one aspect of the delirium that impressed them the most, for example, the hallucinations or delusions, or the patient who looks like they're staring and not responding to their environment, and a mistaken diagnosis of depression is made. And we're going to talk a little bit more about that about this unusual presentation of delirium, which is called the quiet delirium or the hypo active delirium, which very often mimics depression.

Dr. Regina Koepp  24:39  
Would you like to go into that now?

Dr. Walid Nassif  24:42  
No, and let me continue by telling you that there are multiple terms used in medicine today to essentially describe the same thing. I think everybody's heard delirium, and I think that's a term that DSM uses. The other most frequent term that actually describes delirium is acute confusional state. Nowadays in the emergency rooms, particularly the medical residents and the medical doctors love to use the term AMS altered mental state AMS 99% of the time when they say the patient presented with AMS, they mean, the patient presented with delirium. They had an acute mental status change. And I will go as far as to say that in someone who has no prior psychiatric history, any acute mental status change in the general hospital or in the context of a severe medical illness is delirium until proven otherwise. What is the likelihood that at age 80, you're developing new onset schizophrenia, when you're having UTI or an ammonia awareness? That's absurd, essentially, that is delirium until proven otherwise. So you will see a lot of acute confusional state you will see a lot of AMS our colleagues, the neurologists have one favorite term, and that's called encephalopathy. It sounds so fancy, so scientific, so, so elaborate, but all it means is pathology of the brain. That's what encephalopathy means. So it's one of the most vague terms you could possibly use to describe any mental status change. So encephalopathy. Sadly, it can be used interchangeably to describe an acute delirium. For example, they will say the patient is presenting with metabolic encephalopathy, or infectious encephalopathy or hepatic encephalopathy or a anoxic encephalopathy. That is a bit vague for the simple reason that sometimes some of these conditions are very long standing, and they may not be reversible at all. For example, a patient who suffers a toxic encephalopathy, essentially, their brain has been deprived of oxygen for any length of time, many of them will not recover back to their previous baseline, there has been permanent damage that that brains sustains. And sadly, you often see the neurologist still describing the same patient two years later, as a patient who has a anoxic encephalopathy. Whereas in the first few days of an incident like that, there is significant hope that that brain might recover from the hypoxic injury, and that you may see substantial improvement in their cognitive capability over the next few days. So what are we talking about? Are we talking about a brief time limited delirium, like suffering of the brain? Because it was deprived of oxygen? Or are we talking about permanent brain damage that resulted from a prolonged hypoxic episode? So for that reason, I don't like the term encephalopathy very much, because it is too vague. And it doesn't really tell you whether this is reversible or not, or how long it's been going on. I think the only benefit of that term is that it often is preceded or followed by the presumed etiology by the presumed cause of the mental status change. So when you say toxic or anoxic, or hepatic or pancreatic, or Verni case, for example, in the context of alcohol use, then, you know, presumably what the cause of the mental status changes, and I think that can be helpful. But I think really differentiating between delirium and dementia is is important. And using the term encephalopathy is sometimes too vague and doesn't really help you understand what are we talking about?

Dr. Regina Koepp  28:38  
Right? Yeah, I think that those are helpful distinctions. So acute confusional state altered mental state and set philosophy, which neurology uses but it's not your favorite. Those can all be terms to use in place ever, in lieu of delirium.

Dr. Walid Nassif  28:57  
And I have a few more that are actually very important for those of you who work in a hospital setting. The term anticholinergic psychosis is a misnomer really, and tackle the blocking of acetylcholine creates confusional state. Everybody knows that if you take too much anticholinergic agents, and those are frequently used in medicine, for example, Benadryl, visceral anoraks, which are both hydroxyzine oxybutynin. Many tri cyclic antidepressants carry a psychogenic 10 For example, us in psychiatry carry a substantial anticholinergic property which is actually toxic to the brain and can cause acute confusional symptoms. Those confusional symptoms as I mentioned earlier in this interview, can often present with psychotic symptoms. Many patients who aren't in areas will experience hallucinations, visual, auditory or otherwise, and often also develop delusions, particularly paranoid delusions are very common in delirium. So if the ICU staff, for example, is impressed by the drama associated with a delusion or hallucination, or a wild accusation of experimentation, that is typically what they focus on. They call it psychosis when it actually is in delirium. If you interview that patient in detail, you will notice the patient doesn't know where they are or cannot recall the date, or doesn't know how long they've been there, or for what reason they're in the hospital that patient is delirious. But the most prominent symptom is the delusion or the hallucination, which lends our medical colleagues often to call these syndromes psychosis, whereas the two terms should be delirium. So anticholinergic delirium is much more accurate than anticholinergic psychosis. The other big one, actually, the bigger one is the infamous ICU psychosis, you may have heard that term, very commonly used in the ICU, and it is a very problematic term. Because number one, much like with anticholinergic psychosis, I see psychosis is not a psychosis. It's a delirium accompanied by psychotic symptoms often, so paranoia and hallucinations are very common in delirium. But the more problematic aspect of this term ICU psychosis is that it's really dismissive or reductionistic. It's almost like our surgical colleagues say, Oh, they all develop this, you know, when they go to the ICU, post op, everybody has ICU psychosis, we don't have to worry about it. It's something that gets better on its own. Problem solved, you know, the wound is healing properly, the patient is afebrile there is no bleeding, our job is done, the patient is well, but the patient is very delirious. And that delirium may go on for a long time. And that delirium can carry ominous consequences in a vulnerable individual. And that is a point that I wish to make probably repeatedly today is that we all learned that delirium is a transient mental status change that the majority of people recover with no sequentially. And that's probably true. But that is absolutely not true of patients with pre existing cognitive impairment. Let's say you already have a diagnosis of early dementia or moderate dementia, if you go into an ICU and you are delirious for three weeks, because of infection because of steroids because of opioids because of a number of conditions, you will likely not recover back to your previous baseline at the conclusion of that ICU stay.

And there's very good evidence to suggest that making that delirious shorter intervening early, trying to keep the patient as healthy as possible quickly to prevent the long term consequences of delirium is essential. I have seen way too many patients who have gone into the ICU following some benign surgery, and not come out the same people and the families get extraordinarily upset. What happened, they're not the same person. They can't really think clearly, they're not remembering what happened. We can't leave them alone anymore. They used to be independent. Before the surgery, you are hiding something from us, what did you give them, there must have been a big problem during the surgery on in the OR, that the hospital is concealing? Well, that may not be true at all, simply a prolonged severe delirium is enough to do enough brain damage, to leave that person significantly more impaired at the conclusion of their hospital stay. So here is a very important message. Delirium is generally reversible, and overall benign, in a young and healthy brain. If you have an older brain with no cognitive reserve, particularly if you have pre existing cognitive impairment, you've already been diagnosed with cognitive disorder. Delirium can have substantial adverse consequences on your cognitive function if it's left unattended for a prolonged period of time. And that's a very important message, why we cannot just simply dismiss it by saying, Oh, we figured it out. It's delirium. And we can move on, we don't move on, we need to figure out why and what are the contributing factors? And can we do something about them to try to lessen the burden on that brain so that the patient can recover better than if they were left untreated for a prolonged period of time? That's a very important message.

Dr. Regina Koepp  34:45  
I have also seen I'm curious if you can help lend some insight into this older brains with mild cognitive impairment at most. I was working with an 89 year old person who had mild calm impairment at most. And he had multiple, a couple of neuro psychological evaluations to rule out, ruled out a major neurocognitive disorder. He had a lung infection, had delirium, the delirium lasted or the psych, the delusions falling, he got stable he got out of the hospital, he was hospitalized God stable discharged, had to move to a memory care was able to step down from memory care to assisted living. But the delusions persisted and persisted for months and months. And so I'm curious if you could lend insight into that even though he was physiologically stable. The the delusions associated with the delirium persisted for months.

Dr. Walid Nassif  35:48  
This is an interesting case, and I cannot claim that I know the ultimate answer to this. There are two possibilities I think here. Number one, they were persistent causes for a persistent confusional state and that patient that may have been missed, and they can be very subtle, you know, and when I'm lecturing on delirium, I have like a three page or three different slide inventory of everything that one needs to check to be absolutely certain. You're not leaving any stone unturned that could be contributing to that patient's confusional state. And when the confusional state can persist chronically, and we have well known examples of that in medicine, for example, hepatic encephalopathy, which is, you know, the altered mental state that occurs in the final stages of brain liver failure. For example, in patients with advanced cirrhosis, those patients are chronically confused, because the liver is so ill, it's not processing a lot of the toxins. So they develop hepatic encephalopathy. They're chronically disoriented, they may be hallucinating, they may be paranoid. And there's no turning back from that unless you essentially put in a new liver. So is that a delirium is that a chronic confusional state? Is that a dementia? It's hard to really argue about the terminology, we know there's going to be a very prolonged confusional state with accompanying prolonged delusions or prolonged hallucinations, which can happen. So it's very important to realize any subtle factors that could be perpetuating the vivarium. Equally important, though, on the differential diagnosis is the idea that within dementia, irrespective of the presence of delirium, delusions, and hallucinations, are extraordinarily common. They are far more common than anyone can appreciate. Actually, the rates of delusions in dementia are in excess of 50%, at some point during the course of the dementia. So what I'm saying here is that, in the course of your garden variety, dementia, your patients are likely to develop delusions and occasionally hallucinations. And those do not have to happen late in the course of the disease, they can actually often be the presenting symptom of dementia. I tell my students often if Grandpa for the first time at age 78, or AD is accusing grandma of infidelity, and it's very angry at the next door neighbor, who is the presumed perpetrator of this, you know, adultery. What do you do first, you do a mocha, you do emoticon, grandpa, because that is the most likely explanation for the development of a paranoid delusion, particularly a jealousy delusion. Very common in the in the delusions of dementia, that is most likely the etiology. It's not new onset schizophrenia, it's not, you know, delusional disorder. It is early dementia. And you will notice now, if you test them, that even though this may not have been diagnosed prior, that grandpa does have cognitive impairment, and that is the presenting symptom of a delusion. Typically paranoid delusions or jealousy, delusions are what we see. So could it be that this case that you just presented Regina was someone with mild cognitive disorder, potentially made worse by an acute episode of delirium in a general hospital that left them a little bit more impaired, and then they went on to developing one of the classic delusions of dementia, which is, like I said, very, very common and has to be treated if it's leading to behavioral disturbance. By the way, we do not treat the delusions of dementia unless they are creating significant behavioral disturbance or interfering with the patient's treatment when necessary. Treatment has to be delivered for the well being of the patient, or if they're causing a lot of personal distress. You know, some patients may be extraordinary really unhappy or distraught by the idea that the wife is cheating on them or that people are breaking into their, you know, attic or their basement? Or they're moving things? Or they're stealing things or messing with them and what have you, those are very common delusions of dementia. And if they're very upset about it, even if they're not attacking anybody, it may be caused for initiating treatment with antipsychotics. So that's my best answer, you know, to the dilemma that is posed by the situation. But I really would like to dispel the notion that dementia and delirium are simply cognitive disorders. They are very frequently accompanied by psychotic symptoms as well.

Dr. Regina Koepp  40:44  
Can we back up to in the case of the ICU, psychosis in quotes? You were giving some differential between delirium with psychotic features. And can you just differentiate for us what delirium was psychotic features versus psychosis with new onset psychotic disorder, schizophrenia? How are you differentiating those just to lend some insight?

Dr. Walid Nassif  41:11  
I mean, the short answer to this is cognitive impairment. As you well know, you may have subtle cognitive deficits in schizophrenia or other major psychotic disorders. But by and large, a patient with schizophrenia knows where they are, knows what they did is knows what's going on around them. They simply harbor a distorted or fixed false belief about reality, and maybe experiencing false abnormal perceptions in the form of illusions or hallucinations. But they're not inattentive. Generally, they know where they are, they know what's going on around them, there is no disorientation or inattention, unless, of course, they're extraordinarily psychotic, but you can't even engage them in an interview. The delirious patient who is experiencing psychotic symptoms is very much cognitively impaired. That's why I insist absolutely upon cognitive testing on all the patients that we see on my service, particularly if it's a new onset, mental status change. And even if the patient looks superficially good, or they're answering questions coherently on superficial conversation, you will be surprised at how many of them struggle to complete a Montreal cognitive assessment. So they look good to the medical team on a two minute rounds in the morning, but you put them to the test, you put that brain to actual task of cognitively working itself. And you're going to find mochas of 18, or 15, or 13, which often surprise you as the evaluator and surprises the patient. And they get frustrated that they can't do what appears to be a simple task of, you know, linking letters to numbers or copying a cube or, you know, generating 10 words beginning with a certain letter, in one minute, and so on. It is remarkable how when you actually perform cognitive testing, in someone in whom you suspect delirium, you're going to be able to put a finger on it, when you put that brain to the test. The other thing that I've noticed often is that while we focus a lot on impaired attention, and delirium, and you may not see it on superficial contact, the longer you put that brain to the test, the quicker they start failing, so many patients will start the test doing very well, the first 234 minutes, and then they tire out, it's almost like they've reached the end of their reserve. And now they're making a lot of mistakes, they're jumping back and forth with the test, they're getting frustrated, because their brain is simply not cooperating anymore. And you can see that you can have a little bit of good attention for a few minutes, but you tire out very quickly in the context of partial delirium. But again, all of those can be demonstrated generally with a good cognitive exam. So if in doubt, perform a cognitive exam at the bedside. And I know it's a difficult thing, and very few people actually do it on a regular basis, but it is essential for the identification of a cognitive disorder that is presenting with psychotic symptoms, like you said, so the short answer is, what they're bringing to the test, test them cognitively. And you will have your answer in 95% of cases. Now, that's not to say that a patient with psychosis, well known pre established psychosis can develop delirium. So you have a patient with schizophrenia who gets admitted to the ICU because of some medical complication. Could they have both and that's often a differential diagnosis. The ICU calls us to come and help manage the psychosis that's out of control. It's their schizophrenia. And we go in there and we say, well, yeah, he does have schizophrenia, but that was very well controlled, up until they came into the ICU. And we think right now they have delirium superimposed on their pre existing schizophrenia. And the hallmark of that delirium is that that patient is disoriented, inattentive, unable to copy 3d figures, unable to do simple calculations, that simple abstractions. So they have both, essentially. And that's really how you can use the correct diagnosis.

Dr. Regina Koepp  45:24  
You mentioned the MOCA, I just want to back up for a minute because this is pretty important point. I get asked so often well, how do you even present a cognate cognitive screener? Like a mocha at bedside when the person is disoriented? And how do you even present it at bedside when somebody is delirious?

Dr. Walid Nassif  45:49  
If I sense that the patient is going to be defensive about it, or uncooperative or has some pre pre existing awareness that they're not going to perform very well. And those are the patients who are generally most reluctant to engage in a detailed cognitive exam, which essentially demonstrates to them how poorly their brain is functioning. Nobody likes to be faced with that reality. You know, as people well know, that the hardest thing to lose is your own mind. It is a sensitive problem. Now if we have clear evidence of disorientation and attention, the expressing of delusional thoughts or incoherent thinking or strange ideation, you already have your diagnosis if that patient does not have pre existing mental illness, and this is occurring in the context of severe medical illness in someone who's very old, that is delirium until proven otherwise. Generally speaking, you have a sense that the patient is going to be a bit defended about showing you the deficits, I will start by pulling a chair and sitting by the bedside, and striking up a nice supportive, gentle conversation with them to establish rapport. It's very important to establish rapport with these patients before you go with full guns blazing, you know, I want you to remember five words and what's wrong with you, you can't generate, you know, 10 words that start with the letter S or what have you. It's very important, then I slowly inch towards the idea that, you know, you seem to be having a bit of difficulty here or your family's described that. You seemed a bit confused about what had happened. What did you think of how well you're thinking right now? And then I eventually tell them, would you mind if we did a little bit of testing to ascertain whether you are having difficulty with your memory and your concentration, and those are usually the only terms I announced to the patient that I'm going to be testing, concentration and memory, which are important. And I often try to normalize it for them, I tell them, many patients who are admitted to the medical hospital, particularly when they have multiple medical problems, and have advanced age, experienced difficulty with memory and concentration. This is not a pass or failed test. This just simply helps us understand where you're at, and maybe track your improvement over the next few days, would you mind if we did a little bit of testing. And if I have a suspicion that they're not going to be able to complete the whole test, I try to go where the money is. So I, I will start with orientation and attention, and maybe try to get them to copy a finger or two. And then often, that's all I need to really have my diagnosis because the impairment is very clear. And it's right there. And you can demonstrate it on a piece of paper. So you kind of have to play it wisely and gauge how much time you're going to have with any one patient patients with you. And that's usually how I go about it. But of course, if they're willing and able to complete the whole test, that is money in the bank, of course, just help us track whether they're improving or getting worse over time. And it's very fortunate, and many of you don't know this, but we have multiple versions of MOCA, not just one. And if we are administering a mocha to the same patient. Care serially, I'd like to mix it up. Because you do not want their long term memory affecting the score of the next test. They may well remember what you gave them the day before, etcetera. So I mix it up when I'm testing the same patient over the course of their hospital stay. right do you have I think at least six versions of smoker five or six. By the way, Mocha is only one of a number of other tests available. You know, I used to have a different test, the Nassif test, which was actually a little more detailed, a little more elaborate.

And I honestly had great difficulty persuading my medical colleagues that a patient had actually delirium because they were not able to, you know, identify the small parts of a watch They were not able to do elaborate language tests and so on. So I would write the whole half page describing where the deficits were. And my medical counterparts were not impressed. And they were not impressed primarily because there was no score. It was a description. And I found that if you tell them oh, but he scored 15 out of 30, on Mocha, Oh, okay. It was the immediate, okay, because the score spoke volumes when the detailed description did not. So the score is a very powerful tool, folks. And that's why I recommend Mocha, but you can really use any number of other tests. Here at the VA, we have the St. Louis University mental status examination, which is also scored over 30. And it's actually a template for it in our computerized record system, it's an excellent test, it's a little different from okay. And surprisingly, patients tend to score about the same if you use one or the other, even though the two tests are quite different. So that really tells you when the brain is suffering, you're going to be able to to identify the suffering if you test the patient. There's also a test called the sage test, it's a little more detail a little more elaborate. And I doubt that you will miss delirium if you do a sage on your patient. So that's just an illustration of what can be done.

Dr. Regina Koepp  51:24  
Now, you had mentioned earlier, quiet delirium. Tell us a little bit about that.

Dr. Walid Nassif  51:30  
This is a very important item on the differential diagnosis, quiet delirium, also the correct medical term as hypoactive delirium is actually very often overlooked. This is a situation where patients are delirious. But delirium is not presenting with the classic presentation of agitation, insomnia, restlessness, paranoid, pulling lines, trying to get out of bed, trying to leave the hospital ama refusing medical care, because they don't trust you or because they're frustrated, and they don't know why they're in the hospital and so on. Those are patients who tend to be prostrated, essentially, with significant Psychomotor retardation, they may lie in bed staring at the ceiling, or they're staring at the TV, but they're clearly not following what's going on on the TV. They're not showing much emotion. So their effect is very blunted. They don't seem to respond to good news, like, you know, we have good news for you, your MRI is negative, or, you know, your EKG looks much better today, or the family comes and visits them. And they don't really show much emotional effect or pleasure at meeting loved ones, and so on. And it is so easy to jump to the conclusion that they must be horribly depressed, this illness has gotten the best of them. They're not even responding to good news, they kind of look like they've given up. rule out depression is the most frequent cause for consultation in patients with hypoactive delirium. And here again, same old story, you go in the room, and you ask a few questions, and you do a mocha and you realize the patient doesn't even know where they are. They don't know why they came to the hospital, how long they've been there, they don't remember that they had a major surgery five days prior, et cetera. The correct diagnosis is hypoactive delirium. prior to the surgery, or to the hospital stay, that patient was not depressed, and may not even have any antecedents of depression. If this syndrome coincides with the development of the medical illness, and is accompanied by clear, cognitive deficits, demonstrable at the bedside, your correct diagnosis is hypoactive delirium. It is the biggest masquerader as major depression. And it's very important not to superficially rush to the conclusion that we are dealing with major depression without examining that patient a little bit more up close, because it would be very tempting now to add an antidepressant to their already overloaded regimen. And you're only adding insult to injury by adding more agents for that person to metabolize more agents that could, you know, present toxicity to the brain. So before you do all of this, you know, one simple principle in delirium management is to do away with everything that could be contributing to the delirium, and reviewing the medication list in great detail is very important. And doing away with any of the offending agents and those in the general medical hospital typically tend to be high those benzodiazepines, very bad for your brain and for your cognition. Any opioids can be very damaging to cognitive function. Now sometimes there's no way around them because the patient is in severe pain, but minimizing the dose and maybe doing away with it and replacing it with as non steroidal anti inflammatories as soon as possible may be key. Number three steroids can we do away with them or reduce those. And number four, the anticholinergic agents, which we mentioned earlier, please, please, please do not prescribe hydroxyzine or Benadryl for sleep or for anxiety and 85 year old who's medically compromised, you're only going to make their cognition worse, those anticholinergic agents should be avoided in the elderly, particularly if they have cognitive impairment. So those are the four biggest offenders if you will. And it's important to try to trim the medication list. eliminate those that you can eliminate, before you start thinking about how can I treat the delirium? How can we help this patient be a little bit calmer, maybe be less paranoid, less terrified of what's going on around them less preoccupied with the conspiracy or with the animals crawling up on the walls or on their skin, etc, which can often be very distressing to patients who are who are delirious.

Dr. Regina Koepp  56:05  
Now, before we go into treatment, I do want to ask just for a quick differential between delirium and dementia. I know we've talked a lot about cognitive impairment and delirium, and the vulnerability and the limited cognitive reserve sort of making the brain more vulnerable. But how do you differentiate at bedside?

Dr. Walid Nassif  56:27  
This is a central question, and one that is most prone to confusion, so to speak. First, let me preface by saying much too often the medical folks will write delirium versus dementia in their differential diagnosis, which is a fair question to ask, Are we dealing with delirium or dementia here? The problem is, it is not one versus the other. It is one and or the other. One is not mutually exclusive of the other. And most patients actually, if you look at the literature describing delirium, they tell you number one, that up to half of all demented patients who are admitted to the general medical hospital are delirious upon admission, they have a pre existing diagnosis of dementia. And when they present to the emergency room, they are also delirious on top of the dementia. What does that mean? That means that they have an intercurrent medical problem that has made their cognition acutely worse than their baseline. Here is the key, I've just said the key to that differential diagnosis, a patient with delirium is acutely cognitively worse than what their baseline is. So if you have good collateral sources of information, and can have family members or medical notes, or a doctor who knows the patient very well give you an accurate description of that what that patient looked like a few days ago, or last week. And this is not at all what you're seeing in front of you. In the emergency room, this patient is far more impaired, they're inattentive, they're disoriented, they barely seem to recognize their family members, they're calling their daughter or their wife or whatever, you know, you have delirium on your hands. And acute cognitive loss compared to your baseline is the signature for delirium. Whether that happens in a patient who had no history of dementia, or a patient who had a pre existing history of dementia, except now they are far worse than their baseline, I think if you go to the definitions can be extremely difficult to differentiate between the two is the Leon's gonna tell you, they have to have impaired attention and third level of consciousness. And you know, they have to be, you may not be able to test all of this at all in the emergency room, they won't cooperate with you at all. What you need is clear differentiation of their cognitive baseline compared to what you have in front of you. And if what you have in front of you is far worse than your baseline, then, you know, they have theory, if you have good documentation to support that they actually had pre existing cognitive impairment, they're already known with cognitive disorder, or they have a plain old diagnosis of Alzheimer's disease in our chart, then you know that it's delirium and dementia, also called delirium superimposed on dementia, or delirium on dementia. So here again, it doesn't have to be one or the other. It could be one and the other. And the more cognitive impairment you have at baseline, the more likely you are to develop delirium for any intercurrent medical problem, the smallest of UTIs, the smallest of dehydration, and grandpa who hasn't been eating well for two days and have an episode of vomiting or two because of the GI bonk is enough to put To protect delirium and grandpa, and that now Grandpa has delirium superimposed on pre existing cognitive impairment. So that is really my summary as to help people how to differentiate between the two. Now, if you don't know what the patient's baseline is, because there's no family, and this is the first time you see the patient, and you have no medical records on them, you really don't know, you don't know you can make.

You can create hypotheses, you know, let's say the patient is 80 years old. And they have diabetes and hypertension and hyperlipidemia chances are very strong that they already had pre existing cognitive impairment, because of that deadly triad on your brain vasculature, you know, the cerebral vascular disease. triad is there and they've had it for 20 years, and they don't take good care of themselves. They don't watch what they eat, they don't treat their hypertension, well, you can already hypothesize that they probably had significant cognitive impairment, even if it's not documented. And now they have a superimposed pneumonia, or they were exposed to opioids, and they're very, very confused. So probably have delirium on top of pre existing cognitive disorder. And you won't know exactly what their baseline until the delirium has cleared. Once it has cleared, you can test them again, and establish a baseline for their cognition. That's really the rule of thumb is if you don't know what it was, you just focus on the delirium treat the delirium. Once that's cleared, and we're not talking a day or two, we're talking several days of stability, no more insults to the brain. Now you can retest that brain and find out what is the new baseline for that patient. Remember, the new baseline may be lower than what it was before. As I've explained earlier in the ICU, many of these patients who suffer prolonged severe delirium do not recover back to their previous baseline.

Dr. Regina Koepp  1:01:56  
And what does treatment look like you let us in on identifying, identifying what the etiology is what's causing the delirium, also medications that could be contributing? So what are the recommendations for treatment?

Dr. Walid Nassif  1:02:10  
And you've already said most of them here, Regina, the cornerstone of treatment starts with identifying the cause. It's not enough to just make the diagnosis. Often the diagnosis speaks for itself or the medical teams have already made the diagnosis. Your job is to go through with a fine tooth comb through that chart through that history and figure out exactly what are the contributing factors. Most often in the general medical hospital, delirium is multifactorial. It may look like one factor precipitated that delirium. And that's often the case like the day before yesterday, they started him on opioids because he suffered from acute back pain. And that very night, he was tearing up the place pulling out his lines seem very disoriented. So the easy conclusion here is, the opioids cause the delirium. While that's partly true, it's probably not the entire truth. Because when you look at that chart up close, you realize that that patient is also receiving hydroxyzine for anxiety is also hyponatremia. Also have a very high calcium is dipping into the low 90s Every night, because he's not keeping his oxygen mask on or his Oh to cannula on. All of these factors are actually affecting that brain. And the one straw that broke the camel's back was the addition of that opioid medication two nights ago. So the true management involves all the offending factors, not just eliminating the opioids. So when we say multifactorial, you have to look at each and every factor, and try to attend to each and every factor where possible. Sometimes it's not possible because of the underlying medical condition. But where possible, adjust the medications, eliminate any metabolic disturbances, if you can, take away those big offending tickets, like benzos are opioids or steroids, restore adequate oxygenation, make sure that that oxygen mask stays on, hopefully without having to restrain the patient. And that is how you're going to achieve the quickest recovery possible for that patient. So again, the cornerstone of treatment is identifying all the possible causes and attending to them. And then next comes the possibility of behavioral treatment for delirium, which can be very damaging for the overall course of delirium. Actually, delirium has a cost. It's not just the cost that I mentioned earlier that the cognition could take a hit following a severe delirium, but the overall morbidity and mortality are significantly elevated for patients who are delirious versus patients who are not believers for this same medical conditions being treated. And why does that happen? Simply because of the obvious. The obvious is those are patients who are likely to refuse treatment, to refuse vital signs to refuse blood draws to sign out ama prematurely do not remember what the discharge instructions were to not take their medications properly after they leave the hospital. And they suffer significant adverse consequences from that delirium. So it's very important not to ignore it, and protect those patients from themselves, essentially, reduce the risks of delirium, treat the delirium, or you can, if the patient is very paranoid or very distraught, or very agitated, and their distress or their agitation is interfering with their medical care, they're pulling lines, they won't allow the oxygen stay on, they won't allow you to draw the blood, and you're very concerned about their kidney function, which could be tanking, and so on, you've got to do what it takes to save that patient. Most of these patients actually lack the capacity to make informed decisions while they are delirious. So then you turn to the next of kin, or to an existing guardian, if so, and try to get permission to treat them occasionally over their objection. But you're really doing what it takes to save them from themselves. And then that's really what it involves, you know, our work can be become very difficult, with patients insisting they want to leave, they don't trust us. And we're saying, essentially, you are not in your right mind, and we're going to keep you here against your will, we're actually going to restrain you and medicate you and save your life. You know, that can be very, very difficult situation for both the medical teams and for us as consultants, but sometimes that's where you have to do

Dr. Regina Koepp  1:06:48  
in the treatment of delirium. I so often see patients being discharged with antipsychotics started on antipsychotics. Can you speak to that a little bit? And,

Dr. Walid Nassif  1:06:59  
yes, this is a interesting question. And it's a mixed bag. You know, just a couple of years ago, there was a meta analysis that came out, looking at all the studies that looked at the use of antipsychotics for the management of delirium, versus those that did not receive antipsychotics. And the meta analysis said, essentially, there's no difference between the two groups. This came as a nuclear bomb in our field and consultation liaison psychiatry, because I think the very vast majority of Cl psychiatrists do use anti psychotics in the general medical hospital for those patients who mature as I described earlier, are either behaviorally disturbed severely enough to endanger themselves or others, or significantly interfere with their medical management, or show a lot of personal distress as a result of their delusions, or hallucinations. In those patients, I think there are very few CL doctors who will not use antipsychotics, understanding that there may be a blackbox warning for antipsychotics and the elderly, and all of that, we use them with caution. under very strict supervision, we often get EKGs repeatedly to make sure that the QT interval is not being unduly prolonged, as a result of the use of antipsychotics. And our personal observation I've been doing this for 30 years is that often you can gain some control over the agitation, reduce the intensity of the hallucinations, or delusions and bring some peace to the patient and allow further medical treatment to continue which is essential in our business. So yes, we do use them. Clearly, there is no indication for long term use. If the delirium is a self containing pathology, delirium eventually clears it may take a long time and the elderly or the seriously medically ill. But you should never leave someone on anti psychotics ad, you know, at vita aeternum, as they say, just because we use them while they're in the hospital. Preferably we try to taper and discontinue while they're still under our watch and make sure that they're doing well. If not, we give just a few days worth and it's supposed to be tapered and discontinued. Or they have a rapid follow up appointment already scheduled and we communicate clearly with the evaluating physician at that point, that these medications need to be discontinued if the patient looks good. A few days probably won't make a whole lot of difference in terms of long term adverse effects. But absolutely, we need to avoid the temptation of forgetting somebody on Risperidone or household or something like that, just because they had psychotic symptoms in the context of delirium, while hospitalized. 

Dr. Regina Koepp  1:09:47  
Well, thank you so much. I so appreciate your time.

Dr. Walid Nassif  1:09:50  
Thank you for inviting me this was very, very endearing. Thank you, Regina.