FEMALE SPEAKER: Welcome to Mayo Clinic COVID-19, Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc., and is in accordance with ACCME guidelines.

MATT WARNER: Hi, welcome to the Multidisciplinary Education, Translation, and Research in Intensive Care spring virtual critical care conference, METRIC 2020. My name is Matt Warner. I'm an anesthesiologist and intensive care physician at the Mayo Clinic. Today, we'll be discussing delirium, and its importance to the care of the critically ill patient.

We have a really remarkable group of clinicians and scientists joining us today from very diverse training backgrounds and clinical practices. They are truly experts in their fields and in delirium recognition and management. I'll first start off by having each of the panelists introduce themselves, say a short bit about themselves, where they work, and what their background is in this field. So I'll start with Dr. Dale Needham.

DALE NEEDHAM: Hi, I'm Dale Needham, I'm a professor of pulmonary and critical care medicine and of physical medicine rehabilitation and of nursing at Johns Hopkins University. I work as [INAUDIBLE] of medical intensive care unit, and do clinical practice and research with respect to delirium in the ICU setting.

MATT WARNER: Great, thank you very much for joining us. Next, I'll have Dr. Alejandro Rabinstein say a few words. Seems maybe have some difficulty there. How about Dr. Luda Karnatovskaia?

LIOUDMILA KARNATOVSKAIA: Hi, there. My name is Dr. Karnatovskaia. I work at the Mayo Clinic intensive care unit, and I do a lot of work with psychological and cognitive outcomes of ICU patients.

MATT WARNER: Great, and next, we have Dr. Sarah Leung.

SARAH LEUNG: Hi, my name is Sarah. I am a pharmacist. I've spent the majority of my career practicing in the medical intensive care unit at Mayo Clinic. My research area interest is in delirium in critically ill patients and in other patient populations.

MATT WARNER: Great, thanks for joining. And next, Dr. Jillene Chitulangoma.

JILLENE CHITULANGOMA: Hi there, my name is Jillene Chitulangoma. And I'm the ICU PT lead therapist here in Rochester Mayo. So I work in critical care on a daily basis.

MATT WARNER: Perfect. And now we also have Emily Bodensteiner Schmitt joining us as well from occupational therapy.

EMILY BODENSTEINER SCHMITT: Yes, I am Jilllene's counterpart. I am the ICU occupational therapy lead at Mayo Rochester. Been working in critical care for about 3 and 1/2 years now.

MATT WARNER: Perfect. Is there anyone I missed? Dr. Rabinstein, are you on the phone? All right. Well, if he can join, he'll join. But I'd like to begin simply by discussing a very simple question of what is delirium, and how is it defined, especially in its relevance to critically ill patients. How do we define it in our practice? And I'll open this up to anyone. So anyone can please begin. Maybe, Dr. Needham, do you have a few words about discussing what is delirium at a broad definition level?

DALE NEEDHAM: Sure, I'm happy to answer that. So I think that one important point to start this discussion is to recognize that there's great heterogeneity in the nomenclature that's used here. And recently, there's a publication that helps teach us that. For example, if you're a neurologist, you might use the term acute encephalopathy. But if you're an intensivist or a geriatrician, you might use the term delirium. In fact, we are trying to talk about the same things, despite the differences in nomenclature.

Importantly, the clinical manifestations of the abnormal pathophysiology we refer to as delirium, and the actual pathophysiologic process we refer to as acute encephalopathy-- some of the key clinical features of delirium include inattention. So patients are unable to sustain or move their inattention. In addition, they may have difficulties with cognition or perception, difficulties with memory, or difficulties with hallucinations or delusions, for instance. This is acute onset, happens within a couple of days usually, of an acute medical event, most often.

MATT WARNER: Great, thank you for that. So it sounds like something that comes on relatively suddenly in many of these patients, and there's some discrepancy in how we actually describe the condition. Dr. Luda, can you talk a little bit about how you actually diagnose it? Are there criteria to diagnosis this, or how to reliably ascertain if a patient has delirium?

LIOUDMILA KARNATOVSKAIA: Usually, we use the CAM-ICU worksheet, which is done by nursing, for diagnosis of delirium. So primarily, we look at the risk factors also, which would be any type of sensory impairment, the aging process. People with dementia, Parkinson's disease particularly are vulnerable-- people with stroke. Any type of polypharmacy, toxins, drugs are also a major risk factor of metabolic derangements. Any forms of infections, people undergoing withdrawal from medications or toxins, any type of organ failure. Sleep deprivation is also a major risk factor. Any type of lines and catheters, and of course, immobility. These are all risk factors for delirium.

MATT WARNER: Perfect. And so the diagnosis, you said, is with a validated scale such as the CAM-ICU?

LIOUDMILA KARNATOVSKAIA: Correct.

MATT WARNER: And Dr. Needham-- just for your perspective-- is the CAM-ICU a good measure to detect delirium? Are we missing cases, or does it reliably ascertain most of the cases of delirium in the ICU?

DALE NEEDHAM: So in the Society of Critical Care Medicine's pain, agitation, sedation, and delirium guidelines-- known as the PAD guidelines-- back in about 2013, they did an extensive review of the measurement properties of lots of delirium screening instruments. And the recommendation from those prior PAD guidelines are that ICUs routinely use one of two screening instruments, either the CAM-ICU or the Intensive Care Delirium Screening Checklist, sometimes referred to as the checklist, or as the ICDSC. So both of these instruments have relatively good measurement properties in critically ill patients.

But I think all of us know that when they're used outside of the critical care unit-- if they're used on the hospital floor, if they're used in the recovery room or the PACU-- these instruments do not perform so well. And also, in the ICU setting, as patients' severity of illness decreases, we may also see a decrease in the sensitivity of these instruments. They are specifically screening instruments. They're designed to take one to two minutes only, so they're not perfect.

And as patients have less severity, they may become less sensitive, meaning that you may have a false negative test. But these tests remain highly specific, meaning that if you've got a positive CAM-ICU, then the patient has a very high likelihood of actually having delirium. Did that make sense?

MATT WARNER: It makes a lot of sense. So really, these tools are very good at detecting delirium in patients with severe disease when they are obviously, delirious at the time of their assessment. But we might have some underestimation, or missing some cases of less severe delirium, just by the nature of the instrument, and how it's unable to be obtained on a continuous nature.

DALE NEEDHAM: That's correct. And I think that as Luda had alluded to, it's tremendously important to recognize the wealth of information that our front line providers-- often nurses, but also OTs and PTs-- have, especially if it's the same person caring for the patient over a number of days. And also, it's important to recognize the huge amounts of information that family members have to provide as well to tell us whether or not the patient's cognitively normal, or something seems quite different.

So sometimes, there are nurses that have had a lot of training in delirium who will say the patient's CAM-ICU is negative, but I think it's a false negative, and then go on to explain why. The test for inattention, for example, on the CAM-ICU, is a very, very simple test. And there are more robust ways to test for inattention that may be more sensitive in those cases where we think that the cognition really is abnormal, but the screening test is negative.

MATT WARNER: Well, great. That whole idea of using proxies, either family, or nurses, or people caring for these patients very closely, is actually a great way that we talk about how do we advance our understanding of diagnosing a variety of things, probably in resource settings that are relatively limited. Jillene or Emily, could you please talk from your perspective about delirium, how you guys perceive a patient to potentially be delirious, and how it might impact your work as physical therapists or occupational therapists?

JILLENE CHITULANGOMA: I'll let you start.

EMILY BODENSTEINER SCHMITT: I think from an OT-- sorry. I think from an OT perspective, we're frequently assessing as well, utilizing the CAM-ICU or the ICDSC. And I think I echo most of my colleagues when I say we see potentially a lot more false negatives, I think, with the CAM-ICU. A lot of times, we'll progress to the ICDSC if we think we might be getting a false negative on the CAM-ICU.

But we'll mostly see this very easily in our attempts to engage patients in meaningful activity or mobility, that they're not able to attend to the commands that we're giving, that they're unable to even successfully use common objects, or interact in an appropriate manner. So I think that it's often very easy to subjectively identify patients as delirious during our treatment sessions. Jillene, anything to add?

JILLENE CHITULANGOMA: Yeah, I think one of the misconceptions that a lot of the time I see people finding is that if they're oriented to person, place, the date, they think that they're not delirious, but in fact, they're CAM-positive or delirious in regards to the inability to attend to our tasks that we're trying to perform. So there's a disconnect sometimes, I find, from orientation versus delirium. Those two things are very separate. Someone can be delirious, but be oriented to some respect. So those are things kind of we watch for on a daily basis in our practice.

MATT WARNER: Great. Thank you for sharing that, I appreciate it. Can we talk about delirium? What are the implications for the acute management of patients? For example, how will delirium impact a patient's stay in the ICU and in the hospital? And also, are there longer term implications of delirium? Does it affect how they recover over time? Does it affect cognitive dysfunction over time? Anyone can answer.

ALEJANDRO RABINSTEIN: Let me try to see. Can you hear me?

MATT WARNER: Oh, yeah. Hey, Dr. Rabinstein, thank you for joining us.

ALEJANDRO RABINSTEIN: Hi. So Alejandro Rabinstein, neurology, training internal medicine and neurology and neurocritical care here at Mayo. So I agree with everything that has been said. Obviously, delirium has a very important deleterious role in the day to day experience of the ICU. And it makes care for the patient more difficult, the length of hospitalization more prolonged, both in the ICU, and the hospital in general. It also is thus far, the strongest identified risk factor for persistent cognitive impairment after the patient is released from the ICU. And this cognitive impairment can potentially be permanent, at least as far as the type of follow ups that we have had in the studies available thus far.

The question that sometimes comes up-- and I think it's a valid question-- is how often delirium uncovers underlying cognitive impairment that was present and compensated prior to the critical illness, and how often it actually represents a truly new development for the patient. And I think that we need better research to discriminate between those two alternatives. But certainly, patients who are delirious in the hospital have the risk of having worse cognitive function following the acute hospitalization for critical illness.

MATT WARNER: So that's very interesting. Obviously, something that's happening the hospital could affect long term cognitive trajectories in patients. For example, with hypotension, we know that prolonged exposure to low blood pressure can cause greater risk for organ injuries. Is that the same with delirium, where if you have a prolonged course of delirium, that the higher dose of delirium portends a worse prognosis over time, as far as cognition? Or is it any delirium can lead to potentially higher risk for worse cognitive outcomes?

ALEJANDRO RABINSTEIN: Both. The association has been identified with the presence of delirium, but certainly the duration of delirium that can be defined as number of days with delirium or fewer delirium-free days in the ICU. But the burden of delirium certainly is associated with greater risk in most studies associated with a greater risk of persistent cognitive impairment. So there may be those related effects.

But again, it's not that the delirium or the acute encephalopathy in itself is like hypotension. Encephalopathy is a syndromic diagnosis. It is an expression of something that is going on in the brain. I think that prolonged delirium or acute encephalopathy in the ICU tells us that it's a brain that is less able to compensate for the critical illness, whatever it is affecting physiologically, the brain is liking it less, and cannot deal with it. And so what happens later on is just another manifestation of that. The brain just cannot recover well following the critical illness.

MATT WARNER: Great, I think he said something really important there, that the delirium itself isn't a unique disease entity. It's more of a symptom of everything else that's happening to the patient. Is that correct?

ALEJANDRO RABINSTEIN: Yeah, yeah, yeah. I would consider it a syndrome. Certainly, it is an expression. It is not a noxious element in itself. It is an expression of whatever number of insults the brain is feeling. That is how it is manifesting the response to those insults during acute illness. So it could be equated to acute kidney injury. It should not be equated to, let's say, hypotension.

MATT WARNER: Great, thanks for the insight. So we know that it's obviously, undesirable for patients, and it's associated with poor outcomes. Can we talk about preventative therapies? Are there ways to reliably prevent delirium in a patient who is critically ill? And we can start looking at non-pharmacologic and pharmacologic approaches. I'll open it up. I'd like to hear from our pharmacist, Dr. Sarah Leung, if I could, about are the pharmacologic options to prevent delirium?

SARAH LEUNG: Good question, Dr. Warner. There's no literature that would suggest that any one agent has been identified that can help prevent a patient from developing delirium. Usually, we can find alternative agents to medicines that we know increase a patient's risk for developing delirium. An example of this would be choosing a non-benzodiazepine agent for sedation for someone who requires sedation to allow for mechanical ventilation or the like.

There have been some studies that evaluate different pharmacological therapies. Haloperidol is a typical antipsychotic that has been studied the most-- or reported most in the literature. But in a critically ill patient population, we really haven't found any one piece of literature that would suggest that it's helpful. So in terms of using a medicine to prevent the development of delirium specifically, I can't say that we have a tool in our box.

MATT WARNER: Very interesting. Anyone else have anything to add regarding preventative therapies, pharmacologic or non-pharmacologic?

ALEJANDRO RABINSTEIN: I would add in terms of the medications what not to do. I mean, there are many medications that can induce delirium. And I think that those are very, very common in ICUs in general. We all know about benzodiazepines. But certainly, you have many other medications that can have deleterious cognitive effect, starting from serotonin agents, and [INAUDIBLE] interaction, and opiates that also have serotonin function, and a number of others. So I think that while we do have a silver bullet of a medication to prevent delirium, we certainly can diminish their use of poisons that can induce delirium.

SARAH LEUNG: Absolutely. And in addition to the benzodiazepines and opioid agents, like Dr. Rabinstein had mentioned, the other ones that I'm often reviewing my patients' profile for would be an acute withdrawal of antidepressants, or even perhaps an acute withdrawal of dexmedetomidine has been higher on the list. The use of antihistamines, high dose corticosteroids, or dopamine agonists like levodopa or bromocriptine for our patients that have Parkinson's disease.

JILLENE CHITULANGOMA: I think there's a lot of physical things that we can do also to help reduce the risks, not only avoiding the sedative medications, but also just the environment around us. I mean, that's what we deal with on a daily basis as therapists, OT and PT, trying to promote daily routines, lights on during the day, shades open, beds facing windows, use of glasses, hearing aids. Talking to the patient, making sure you're communicating with them, even if they are intubated and sedated, reorienting, and if needed, going through those daily checks of checking orientation, checking and monitoring the CAM-ICU.

Limiting the amount of time we're allowing patients to sleep during the day, so that their days and nights aren't flipped. Lots of environmental factors-- making sure we're trying to disturb them less during the nighttime so they can actually sleep. So sleep hygiene is really important. I don't know, Emily, would you have more to add to the list? There's a lot of things that we look at on a daily basis from a therapy perspective.

EMILY BODENSTEINER SCHMITT: I think you're covering it very well. But I think just never underestimating the impact of grounding them as humans, even when they're going through a critical illness. Our human nature is to move, to communicate, to be social. And all those things can't be completely removed, or that's almost like an acute withdrawal from human nature. That can impact delirium as well.

JILLENE CHITULANGOMA: Yeah, having a good means of communication, you know? Whether they're able to nod yes or no might be the very form, or even blink. Sometimes, we're trying to find a means of communication with folks so that we can communicate with them, changing it as time goes on with what they're able to communicate with a writing board, but having some form of communication. And in learning about those patients too, using that Get To Know Me board to understand who that patient is as a person, so we understand how to better treat them. So that's important in preventing delirium as well.

MATT WARNER: That's great. So there's a lot of things, it sounds like, that fall into that kind of broad category of humanizing the way we interact with patients, and kind of making the hospitals seem less like a foreign place, and make it more familiar to them, surround them with the things they're comfortable with, and the things that would be more consistent with routine life outside the hospital.

LIOUDMILA KARNATOVSKAIA: Also, sleep enhancement cannot be overemphasized. Because in studies looking at sleep disruptions in critically ill patients, average number of interactions per night, regardless of what the ICU, was greater than 10. And another study that looked at sleep patterns in the ICU patients using polysomnography, there was basically, a dissociation of EEG findings and the sleep-wake state.

So they were able to see theta waves, which usually are seen in states of deep relaxation and meditation in patients who were awake and interactive. They could see the beta activity, which is basically, activity seen in normal conscious individuals, in patients in coma states. So there was a completely dissociated state between the sleep and the presentation.

And essentially, any interactions that enhance sleep, being earplugs, reducing this light exposure, has been actually shown to decrease delirium, including the use of melatonin and melatonin-agonist supplementation. There've been some studies and meta-analyses that actually showed reduction in delirium prevalence and duration of ICU stay as well. So I thought to mention that in a little bit more detail.

MATT WARNER: Great, so the importance of sleep, certainly. And it sounds like you had pointed to melatonin as something that's potentially preventive, if we can use melatonin to promote normal sleep cycles?

LIOUDMILA KARNATOVSKAIA: Potentially.

MATT WARNER: Are there other therapies? In my training and beyond, I've seen people say dexmedetomidine might be something that mimics natural sleep. I'm not condoning the practice, but for patients who are ventilated, I've seen people say, let's turn the propofol up and let them sleep tonight. Obviously, that's not an actual sleep. Does anyone have any insight on those sort of continuous infusions, whether it be dexmedetomidine or whatever it might be, to help with restfulness or sleep, whether it's harmful or helpful?

ALEJANDRO RABINSTEIN: I think that over sedation is always harmful.

MATT WARNER: I'm sorry, say that again?

ALEJANDRO RABINSTEIN: I think that over sedation is always harmful.

MATT WARNER: Perfect. So regardless of what the agent is, turning up the propofol at night is not a good technique to decrease delirium, and it's likely going to do the opposite. I take it that's what you're saying?

ALEJANDRO RABINSTEIN: Yeah. If not, ask Michael Jackson.

MATT WARNER: OK. Can we talk about acute management of delirium, or then preventative strategies? Are there things that can treat delirium when delirium is happening in real time, whether it's medication or behavioral interventions?

EMILY BODENSTEINER SCHMITT: I think a lot of times in delirious patients, the tendency for a therapist is to back off therapy, because they're more challenging to work with. They don't follow our commands, and safety hazards can be presented when we have patients that aren't necessarily following our commands. But at the same time, I personally believe that those are higher priority patients to be engaging in activity multiple times per day. And so I advocate strongly for extra therapy for any patients that are already showing acute delirium, to kind of, as I said, re-ground them in their humanness and human nature, routines, and patterns, and things like that.

JILLENE CHITULANGOMA: I would agree with that. I think engaging in daily routines, whether it's brushing your teeth in the morning and washing your face, getting up and into the chair for breakfast or out for a walk, those are things that we do on a daily basis, and they're really important. And I agree with Emily that the ones who do have the delirium are, in my mind, really important patients that we need to see and be working with to try to help them through that time, and reduce their risk for ongoing delirium. So lots of important aspects.

I mean, we're at times, sitting people up who are having a hard time waking up from being sedated for multiple days and intubated, sitting at a RASS of -5, -4. Days and days after being completely off sedation, we're sitting those people up at your bed in more of a total [INAUDIBLE] position to try to rouse them up and wake them up, to help get them to wake up and rouse, so that they have less days sedated, and less days at a really low RASS, which puts them at greater risk for delirium.

MATT WARNER: Great, so it sounds like patients that have delirium that's more hypoactive in nature just need more engagement, or that's something that could be very helpful for them. Can we take a moment just to discuss-- and I'll open it up to anyone-- maybe Dr. Needham can discuss the kind of different types of delirium, or subtypes of delirium. When the lay public thinks of delirium, they probably think of the very agitated, hyperactive, combative-type patient. Can you just briefly describe the kind of different spectrum of delirium?

DALE NEEDHAM: Sure. So you have alluded to hyperactive delirium, where patients tend to be very agitated. And in the ICU setting, we're very concerned about them causing harm to themselves or to their health care providers, given that they have multiple medical devices on which they often rely for life support. At the other end of the spectrum, there's hypoactive delirium, a type of delirium that's probably much more likely to be overlooked, where the patient may appear to be sort of in a calm state. They're not interacting, they're not moving around very much. But that also is delirium, and that also is concerning for the long term negative outcomes that we've talked about.

And then of course, there's mixed delirium. So that's where patients may have aspects of both hyper and hypoactive. Even within the same day, they may fluctuate between these two. So we need to be concerned about all of these. And we need to recognize that many of us may overlook the patients with hypoactive delirium, but they should not be overlooked, and that these patients may have many concerning problems. And the first thing we need to be doing if they are on sedative agents is reducing those doses as the first modifiable thing that we could do to address hypoactive delirium.

MATT WARNER: Great, thank you. And are there medications? We talked about antipsychotics probably aren't the best line for preventing delirium. They're certainly not great evidence that the routine use of these prevents delirium. In certain types of delirium, for example, the hyperactive, are antipsychotics indicated in some patients if they're at risk for harming themselves or others?

SARAH LEUNG: I'll take that one. I think that every person on this panel might have a different opinion on this. I will say that Dr. Needham had mentioned the concept of addressing modifiable risk factors, which I think should be the first step in any case, whether it be hypo or hyperactive delirium. Now we might not have the luxury of time in someone with hyperactive delirium, if they're at risk to harm themselves or others, where we might need to use an antipsychotic to help in those situations.

I think that we still tend to use haloperidol more frequently, because of its administration. It is the only antipsychotic that is available IV as well as IM, so it can be given rapidly if necessary. So that would still be the antipsychotic that I see used most frequently. But interested to hear what the rest of the panel thinks.

ALEJANDRO RABINSTEIN: Yeah, I think that is exactly the case. I think that we tend to over-utilize atypical antipsychotics that unfortunately, later on, continue to be used, even after the discharge from the ICU. So the patient gets agitated, gets put on, let's say, quetiapine, and then quetiapine gets continued, even as the patient starts getting better. I think that that is a slippery slope that one has to consciously avoid.

SARAH LEUNG: Quite often, at the bedside after a patient requires a dose of haloperidol as a rescue medicine, the reflex discussion to be had afterwards is what medicine should we start as a maintenance therapy for the treatment of delirium? And I think that is always a good time to discuss the role of antipsychotics in the ongoing management of delirium. In some patients, that might be worthwhile to use an antipsychotic. However, there is not a lot of evidence to guide that that would be an effective and appropriate therapy.

But without having a lot of tools in our box, our hands are often tied. So I do still see us using antipsychotics orally as maintenance medicines for the management of delirium. But Dr. Rabinstein is very correct that these medicines quite often can get initiated, and then they're continued as the patient transfers to a floor service. And there is some literature that would suggest that these patients are even dismissed from the hospital on these meds.

[INTERPOSING VOICES]

SARAH LEUNG: And then when the patients get to their outpatient providers, they're unclear the indication for the medicine. And there might be a propensity to keep the medicine onboard, because they're unclear of the indication. And these medicines have complications and adverse effects that really are lifelong. It can increase metabolic syndrome, increase hyperlipidemia, weight gain, other things that really do increase the morbidity of these patients.

MATT WARNER: Great, thank you. I was wondering if-- Dr. Luda, I know you study a lot of kind of these psychosocial aspects of care. Could you discuss the role of the family in delirium, either prevention or management? And also, what do you tell families whose loved one might be delirious in the ICU? How do you approach that subject?

LIOUDMILA KARNATOVSKAIA: So, the role of the family-- or one of the big roles-- is that they orient the patient towards the life that was before the hospital. They remind them of the normal states that they used to be in. They sometimes bring the eyeglasses and hearing aids, and other assistive devices that we're not aware that the patient needs. And that alone can be a non-pharmacological intervention to prevent delirium. So they know what the patient needs that we may not be aware of. We ask the family to fill out the Get To Know Me board so that we know what the patient likes, what they are as a human being, so that we can interact with them as such. Sometimes, that also helps to bring the human part of the interaction into the picture.

We talk to the family about what delirium is, in that it's kind of the patient is there, but they're not quite themselves, and it's a normal consequence of critical illness, and not to be scared of that, and just to provide reassurance to re-orient the patients, and to just be there for them. If the family is very emotional, I personally try to encourage them to calm down outside the room so they do not transfer that heightened emotional state onto the patient, who is very vulnerable at this moment in time. And we just try to talk to them as human beings-- the family members-- and explain to them a little bit more about what's normal in the ICU, and what's not, and how to manage that, really. There's no specific scenario, per se, that I can tell you.

MATT WARNER: No, that's really great. So there's obviously, a big role in the family in just normalizing the life for the patient the best they can, and to serve as that person of reorientation, and just a calming presence for the person in the ICU.

LIOUDMILA KARNATOVSKAIA: Yeah, anything they can bring from home, photographs, mementos that patients can remember [INAUDIBLE] it may also help to improve their mental state, and perhaps delirium as well.

MATT WARNER: Perfect. Now in the last five or 10 minutes here, I really just wanted to talk about the current times we're living in with the novel coronavirus, SARS-CoV-2, and the COVID-19 pandemic that's kind of sweeping everywhere. Obviously, many places are changing their ICU practice significantly, in that number one, resources are limited. Number two, we're trying to prevent spread of disease to health care workers and to others.

So there's limitations in, for example, the number of family members that can enter units that some places, trying to limit who can go into rooms. We're trying to conserve personal protective equipment, which means, for example, occupation and physical therapy-- that might impact how many times you can go in and interact with the patient. And so there are certainly things going on that suggest that we could see an uptick in ICU delirium over the next few months if we are unable to do the normal things that really humanize care for that patient, especially if they're left alone in a very foreign environment.

So I'd like to open it up to everybody, but what are the things we can do to kind of combat this challenge? Are there novel kind of telemedicine-based approaches to interact with patients? How do we make sure that we're doing the right things for patients, even though our resources are limited?

LIOUDMILA KARNATOVSKAIA: Well, we still do not have to cease the most basic forms of human contact. We can say to the patients good morning when we enter the room. Even if we wear the protective equipment, we can wish them to have a good day, to ask them to sleep well, to say please and thank you. We are still interacting with human beings, the masks notwithstanding. So you can say sorry if you have talked inappropriately because you're tense.

So you can talk to them, regardless of protective equipment. You can use iPads, which we have started to use in the intensive care unit as well, to bring the human interaction. Dr. [INAUDIBLE], for example, on [INAUDIBLE] have interacted with patients through the computer screens successfully, and oriented them. And the patients were very appreciative of that. And I think it does help with delirium a lot if we can continue the interactions with the patients.

JILLENE CHITULANGOMA: I know I've been using an iPad or phones from the patients to communicate with their family members who haven't been able to come into the hospital. For instance, we have a patient who's a long term patient. Been in the hospital for 50-plus days. And his wife for the first day ever wasn't allowed to come into the hospital on Sunday.

So she asked, and we got her phone all set up the day before. So his phone was unlocked, so we could access and call her real time first thing in the morning. Because that's when she would be there. And she was able to say hi, and interact, and see him standing at the edge of the bed, to really keep up with that day to day contact. And I think that's important during these times.

EMILY BODENSTEINER SCHMITT: I am also a member of the PICS clinic, the post-ICU clinic that is underway at Mayo Clinic. And I think our team is anticipating a greater incidence of post-ICU syndrome following the COVID outbreak, just because of some of the factors that you've talked about, like less access to family support, less access to therapy, potentially, and then just high volumes of patients that are experiencing critical illness at this time. So we're certainly trying to prepare and plan for ways to support them after they get out of the ICU as well.

MATT WARNER: Dr. Needham, what's been your experience where you work with this issue of potential increase in delirium rates, if we're unable to maintain kind of the standard interactions that we do with patients, or trying to get more unique approaches to interact with our patients?

DALE NEEDHAM: I clearly think this is still a work in progress. We're very fortunate to have Dr. [? Megan ?] [? Hose ?] a rehabilitation psychologist, that sees patients while they're critically ill in our ICU. But we're grappling with all of the same issues that we talked about. There are shortages of personal protective equipment across many hospitals, including our own. We're all trying to figure out the best means of video conferencing, or other things, and trying to understand the role of HIPAA, in terms of those kind of communications as well.

So I don't think that there are too many existing best practices for the ICU that have clearly been evaluated. And I think many of us are looking at those things right now. And I think that through social media, such as Twitter-- I think that's the fastest way that people are sharing what is and isn't working in their own ICUs. And I think things will kind of continue to evolve. But we're certainly looking at these issues in the exact same ways that were already talked about.

MATT WARNER: Great, thank you very much. I really appreciate everyone's time today. Certainly, I think we've discussed that delirium is an acute encephalopathy, usually related to an underlying issue that's requiring hospitalization and critical illness. It certainly has long term implications, both during the hospital stay, and also beyond, potentially, with cognitive dysfunction.

As far as preventative therapies, probably the best thing we can do is try to normalize life for the patient the best that we can, avoid adding new pharmacologic agents, remove those that we know can potentially be contributory. And in this day and age, we're really trying to work on ways to continue interacting with our patients, even though we might have limited resources and limited contact by family members. If there's other things people would like to say before we close, I'd welcome them to say a few closing words if they have anything.

LIOUDMILA KARNATOVSKAIA: Also, perhaps another intervention is to limit the use of televisions in the room, and the scary news broadcasts. Because the state of fear and panic and anxiety is not likely to portend well to post-ICU psychological outcomes as well.

MATT WARNER: Great, that's very important, agreed. Great, anyone else? Any last words? OK, well, I'd like to thank everybody, all of our panelists for participating in the discussion. It was very, very helpful, very insightful. I thank you all for your expertise, and taking the time this morning. I'd like to thank all the listeners for watching today. Really appreciate it. So everyone have a good day, stay safe, and continue providing the best care you can for your patients, and yourselves, and your families. Take care.