Podcast – Delirium and Dementia: Clearing the Fog of Misunderstanding

Voice Over:

The Dementia Researcher Podcast, talking careers, research conference highlights, and so much more.

Dr Kamar Ameen-Ali:

Hello and welcome to the Dementia Researcher Podcast. In this show this week, we're going to be discussing the relationship between delirium and dementia and how we can raise awareness of this historically neglected area of research. We'll hear about how these two conditions are different yet have similar symptoms and why that can often lead to misdiagnosis. We'll also find out about current research in this area from our brilliant guests, as well as what more we can do to raise awareness of delirium, specifically amongst health and care staff and family members and caregivers of people living with dementia.

I'm Dr. Kamar Ameen-Ali, and it's a pleasure to be hosting this show. I'm a senior lecturer at Teesside University and my research is focused on understanding the brain diseases that cause dementia and why certain risk factors like traumatic brain injury can increase the chances of dementia in later life. Joining me today to talk about their work and help raise awareness and understanding of delirium and dementia are three brilliant experts in their respective fields. I'm delighted to welcome Dr. Ahmad Khundakar, one of my colleagues from Teesside University, Anna Wilson from South Tees Hospitals NHS Foundation Trust, and Dr. Mani Krishnan from Tees Esk and Wear Valleys NHS Foundation Trust. Hi everyone.

Professor Mani Santhana Krishnan:

Hi, Kam.

Anna Wilson:

Hi.

Dr Kamar Ameen-Ali:

Okay, let's do some proper introductions. So, Ahmad, you start off, tell us about yourself.

Dr Ahmad Khundakar:

Hello, I'm Dr. Ahmad Khundakar. I'm associate professor and head of integrated science at Teesside University. My background is in dementia research, so I initially worked up at Newcastle doing postpartum brain tissue analysis, focusing really mainly on Lewy body dementia. But since I've been at Teesside, I've been looking more at the molecular basis of alpha-synuclein aggregation and looking at this within the context of diagnosis. I've also started a little bit on some more societal work, so looking at the role of delirium, how delirium is managed within care homes.

Dr Kamar Ameen-Ali:

Thanks, Ahmad. Anna, would you like to introduce yourself next?

Anna Wilson:

Hi, I'm Anna Wilson. I'm dementia lead nurse at South Tees. I've been a nurse for 25 years. I started my career in critical care, spent 18 years in critical care before moving into general practise and then into dementia care. The last three years, my background, delirium has weaved through my background and my career from critical care and now with a more focus on older people and frailty in my role as dementia aid nurse. So not as much of a research background as everybody else, but very much more of a clinician. However, I have just signed off the last module for my MSc, which has been quite stressful, so I'm pleased I've just passed that and obviously there's been research elements into that. So, I did as my independent project look at improving delirium care planning for patients with dementia in the acute setting.

Dr Kamar Ameen-Ali:

That sounds really interesting, Anna, and I think the good thing about this podcast is we're going to get unique perspectives. It's not just about the research perspective, but also from the clinician's perspective as well with you and Dr. Krishnan. So, I think that's really going to help us understand this topic more. So, thank you. Hi, Krish, can you go next, please?

Professor Mani Santhana Krishnan:

Hi, I'm Mani Krishnan. I'm an old age psychiatrist by profession. I've been a consultant for more than 20 years, and I worked in liaison psychiatry in general hospitals and that's when my passion on delirium came along. And this year happened to be a decade of delirium for me. I've spent about 10 years of work on delirium, and I think as you mentioned about the topic, this is something very close to my heart, because as an old age psychiatrist, I see the both sides of it, both dementia and delirium, and it's quite appreciative that you are doing this podcast and hope to raise the awareness as well as get some research going on.

Dr Kamar Ameen-Ali:

Thank you, Krish, and thank you all. It's great to have you join me this morning. So, the idea for today's podcast came after I attended the Teesside Dementia Conference for World Delirium Awareness Day back in March where all of you gave wonderful talks about delirium from your unique perspectives. As a dementia researcher myself, I had a vague idea about what delirium was, but attending that event really made me realise that delirium and dementia are connected in many ways and we can actually learn a lot about the causes of dementia if we better understand delirium as it often has a known cause and it's treatable, which is unlike what dementia is currently.

So, I was very keen to have you on the podcast to share your knowledge and to raise awareness of this topic with our listeners. So, with the introductions done, we can then get down to it and make a start. Okay. So, I think a good to start would be to introduce our listeners to what delirium is because I suspect many people will have heard of it but might not quite be sure what it is. So Krish, can you start by telling us what delirium is and how exactly it is different to dementia? Because obviously in your work you see both sides of things, as you said.

Professor Mani Santhana Krishnan:

So, delirium is a combination of symptoms, it's a syndrome. There are a few things that is going wrong. There is a problem with attention, awareness, and cognition. Those are the three things that goes wrong. If you think of dementia, there is also problem with attention and cognition, but not necessarily the awareness bit. Again, we can talk too complex about it or make it simple. So, the main things are there is a problem that happens fairly suddenly that is due to certain changes in the brain function due to altered systemic problem that could be physical health causes. So, there is usually an underlying cause for delirium that causes, if I want to put it in another way, like a heart failure. It's almost like a bit of a brain failure when brain is put under a stress, like heart is put under a stress, whereas dementia is a chronic cognitive impairment whereby due to a neurodegeneration, there is a loss of neurons.

There is a gradual reduction in the higher functions of the brain, which may also include sometimes attention and awareness, but that wouldn't have happened all of a sudden. So that is a difference. So sometimes what happens is when people have acute delirium, it almost mimics dementia if you have not seen them. So, somebody who has seen somebody with a chronic dementia and somebody with an acute delirium might be the same. They may present as the same. The key here is getting the history, getting the temporal correlationship. So that's going to be the difference. So again, delirium is fairly an acute process. It happens in matter of hours and days compared to matter of weeks and months. So that's the difference.

Dr Kamar Ameen-Ali:

Okay. It sounds like there might be many symptoms that are similar between dementia and delirium, but the key thing is the time of onset, so one is acute, and one tends to be more chronic. And so really knowing the person is important there.

Professor Mani Santhana Krishnan:

At the outset, I want to say it, just because somebody has got dementia doesn't mean that they can't have delirium. So that's going to be the biggest thing which we will discuss later on. So, delirium superimposed dementia, so they are not mutually exclusive.

Dr Kamar Ameen-Ali:

Okay, and that's an interesting point. So, we'll come back to that. Anna, the fact that there are symptoms that are similar between delirium and dementia, as we've just heard, it must make it really quite difficult for clinicians and for care staff to identify when someone has developed delirium, particularly as we've heard if they're already living with dementia. So how is delirium assessed and how exactly is it diagnosed by clinicians?

Anna Wilson:

Absolutely. It's a challenge for clinicians, especially in acute care. For example, they might be meeting that patient for the first time and the diagnosis of impairment in the background, the risk is staff assume that's the patient's baseline, and that unfortunately does happen. So as Krish says, the importance is getting that history from somebody who knows the patient well, loved ones nearest and dearest, and also using the validated screening tools that are available. So, the most validated tool is the 4AT delirium screening tool. And that is what's advocated by in all our national guidance within the NHS at least, but Krish will correct me if I'm wrong, but I do think it is internationally used as well. But certainly, within the NICE guidance within the National Audit of Dementia, within the National Audit of Inpatient Falls, that is all advising and recommending that we use the 4AT screening tool. So best practise is to use that tool and screen a patient on admission within the first 24 hours.

Dr Kamar Ameen-Ali:

For our listeners who are researchers, what is the 4AT tool? What's it testing for?

Anna Wilson:

So, the 4AT is a validated delirium assessment tool, and for delirium and cognitive impairment, it tests for alertness. So, it asks questions, is the patient markedly drowsy for example? Are they easily rousable? If they're asleep, can you wake them up? And then there's scoring for normal mild sleepiness and wake up within 10 seconds. That's normal. But if it's clearly abnormal, there's score a four for that. And then it's an aggregate score. It then asks questions on age, date of birth, where they are and it counts mistakes, and then it looks at attention and acute change and fluctuating course. So, it's an easy sort of scoring tool so that if the patient is between one and three, then it guides staff to query a cognitive impairment. And if it's four or more, it suggests that patient may well have delirium.

Dr Kamar Ameen-Ali:

And it sounds like it's something that's quite quick and easy to administer then because that would be important in that acute setting as you mentioned.

Anna Wilson:

Yeah, absolutely. It's for use by anybody. It doesn't need specialist training. It should take less than two minutes to undertake, and it's for use our staff in acute environments, they're not mental health specialists. So, it's for use by staff who are not specialists in mental health.

Dr Kamar Ameen-Ali:

So, in your opinion, would you say that it's possible delirium could be underdiagnosed, or would you say that we're capturing people that are experiencing delirium and they're getting diagnosed and therefore treated, or is it something that you think might be underdiagnosed?

Anna Wilson:

I think it is often underdiagnosed. I think we are getting better. I think there is better awareness certainly within my organisation, and we recently all attended a regional delirium conference, which was, it covered a wider area and definitely things are improving, but without a doubt it's a work in progress and it is often I would say underdiagnosed. Yes.

Dr Kamar Ameen-Ali:

Ahmad, I'll come to you next. I know that you've got a personal experience of delirium in your family. Do you want to tell us a little bit about that?

Dr Ahmad Khundakar:

I came around delirium maybe in a bit of a circuitous route. I mean, I have been a dementia researcher, as I was saying for a long time. Obviously as I said, predominantly looking at post-mortem tissue samples and sort of trying to unpick what happens to the person during life by the pathological changes that occurred within the brain. So, it all came full circle for me. My mom started developing the symptoms of Parkinson's disease around 2014, and as the Parkinson's progressed, she experienced quite a few episodes of delirium. She fell quite a lot, and obviously the falling side of things can often lead to delirium. So generally, it was quite well managed, but we had quite a bad experience with my mom in hospital. The first time that she fell, she actually broke a hip, and because of that, she ended up on the rehab pathway and I think the delirium was acknowledged.

Actually, I recently got her medical notes, and I reviewed them just to pick up whether delirium was mentioned, and it was mentioned on this occasion when she was on the rehab route, and I think she was treated very well as a result of that. But the second time that she fell, unfortunately, this was the night after she got back home after she'd been on this rehab pathway for three months and she didn't break a hip. And that maybe sounded like a positive thing, but in terms of the awareness around delirium, it wasn't. So, she ended up on the general ward, and as a result of that, the delirium wasn't really picked up. She was given an antipsychotic drug, she has Parkinson's disease, and that had quite serious consequences for her. This was in the middle of summer as well. So, we were first informed by a nurse who contacted us and said that my mom was being difficult, was the word that she was using.

So, we went into see my mom, and the first time really, we saw her after we'd left her, she'd been given the antipsychotic, we barely recognised her. That led to what I think was a high poor delirium episode where she was really withdrawn, because she'd been quite aggressive and quite vocal on the ward, she was moved to a side room. I mentioned this was in the middle of summer. So, she became very dehydrated. She became very malnourished. So, what seemed to be happening was the nurses and the team were leaving food for her, leaving drinks for her. She wasn't touching them because she was in this high poor delirium state, and that really exacerbated things. So, we ended up in this real vicious circle with my mom, and really because of the episode, we never really got her back to her previous cognitive state.

It really impacted on her general kind of quality of life. And because of that, she couldn't live independently beyond that point. So, she ended up in a care home, which was great, and she lived out the rest of her days. She died in 2020 during COVID, unfortunately. But she lived out the rest of her days in a very nice environment, I think within the care home, and she was very well looked after there. But that really was the thing that sent me down this path really. It made me view delirium in a very different way. I lectured on delirium. I had knowledge of delirium about, well, the neurochemical kind of aspect of delirium, I guess you could say from my academic side of things. But until you actually experience it firsthand and you see the kind of impact that it has, you don't realise really what it is and how dangerous it could be.

And what shocked me more than anything was the fact that how little was known about it, and you think that when someone goes into hospital that this would be the first place that it would be recognised but really wasn't acknowledged at all. And us as family members weren't really part of the process, which was a very frustrating thing for us. So since then, I've been very keen working with Anna, working with Krish to really highlight awareness and just simple kind of things, just the simple recognition and not just thinking about reaching for drugs, trying to find out what the cause of it is and acting accordingly. That's really the key sort of message that we want to get across.

Dr Kamar Ameen-Ali:

I think that's an important point, isn't it? Because if the cause of the delirium can be identified then it is treatable. I noticed that you talked about hypoactive delirium. Krish, can you tell us, does that mean there are subtypes then of delirium that people can experience and what does that look like?

Professor Mani Santhana Krishnan:

Delirium could be of three types. It could be hyperactive delirium, hypoactive delirium, and there is a mixed delirium, which is a hyper and hypoactive delirium. So hypoactive delirium is commonly missed. As the name says, people are not very active. So hyperactive is the most identified one because they make agitations, they make noises, all those things. But having said that, hypoactive delirium is more common. So, unless there is a shouting patient, they may not be picked up because of the hypoactive delirium. I'm sure Anna will know from her experience. When you are in a big cubicle of ward patients, the loud one gets the attention, the kind of a little old, whatever name you want to call it, Molly or Jenny or Steven might not get, they even make a comment, like a flippant comment of saying that, oh, they are not a bit of bother.

When somebody says they are not a bit of bother, that's where I start bothering because they're the one who probably are quietly fading away. So, another telltale sign of some other hypoactive, or if you go into a bedside, like a side table or something like that, you'll have lots of drinks left unconsumed, partially consumed. So, these are the things you just need to be a detective and be curious when it comes to hypoactive rather than hyperactive, they will know that person is making lot of noise. They are shaking the bed, they're agitated, and the mortality is also quite high with hypoactive. So, it is important that we pick that up.

Dr Kamar Ameen-Ali:

Could that be linked to the fact that they will consume less water and less food with hypoactive delirium? So, then that could potentially...

Professor Mani Santhana Krishnan:

Absolutely, they only make the delirium worse. Yeah.

Dr Kamar Ameen-Ali:

Yeah, make it worse. So far, we've talked about it very much in the context of older people experiencing delirium, but Krish, I understand that people of any age can actually experience delirium. Is that true?

Professor Mani Santhana Krishnan:

Absolutely. So, delirium is a condition. In fact, I was speaking yesterday at the conference, I was saying shouldn't say it as a golden thread, but it's almost like a thread that weaves from cradle to grave. So young infants can get delirium, neonates get quite severe delirium, and I'm sure as mothers’ people will know that young children, when they have fever, they can have what you call a delirious state where they can go into a bit confused state like how the children will run around. And then younger adult, when they have a severe kind of a systemic problem, they can get delirium, ICU delirium, which is again any age group ICU can and post-surgical in any age can also have delirium. Yeah.

Dr Kamar Ameen-Ali:

I think that's an important message to get across because I think it is often talked about in the context of older people having delirium. And so, then there is potentially the risk of it getting missed in younger people. But Anna, it does seem that particularly older people will be at an increased risk because of all of the potential risk factors that we might come onto in a bit, especially if they enter hospital or a care home. So, I read that that potentially could increase their risk once they enter a hospital or a care home. Why might that be the case? And if that's true, is there anything that can be done about that?

Anna Wilson:

The researchers will be able to go into more detail about the brain changes associated with ageing, but essentially older people do have a more vulnerable brain with a decreased capacity to cope with stresses of things like acute illness or constipation or dehydration and all these risk factors that contribute to a delirium. It's a marker of frailty really, that makes these patients more vulnerable, adding a cognitive impairment or a dementia to that, then the brain's even more vulnerable. So as Krish pointed out, obviously the younger and fitter you are, the bigger the insult it needs to trigger a delirium. So older, frailer patients are more at risk because they're older and frailer and have all these other things going on in the background. From the point of view of mitigating that risk, the first thing is to assess for it properly. Obviously, education's a huge component for staff to understand these risks and act upon them, but essentially to mitigate the risk is really good, multidisciplinary working, it's really good nursing care, and it's not necessarily rocket science.

It's getting the basics right. But that's not to say that that's always easy because there's lots of conflicting demands on the time of nurses, of doctors, of allied health professionals, and when there's more things to muddy the waters in the background, it takes a bit, like Krish said, to be a detective and take that time to unpick all of these things as to what might be the underlying cause. But what there is a little bit of research around is things like delirium bundles and that guides staff to do the right thing at the right time. And that's something that we've brought in within our electronic health records to schedule the screening for delirium, which then links to a prompt to complete a bundle of care that is based on best practise and guidelines around managing delirium, essentially looking for underlying causes and treating them and just giving staff a bit of a tool to do the right things at the right time.

So that's one way of mitigating, but I think education is huge and it's something that it needs to not only continue but be expanded and not only staff, but also the general public, which is what we're all here today to talk about. Because staff really need to listen to families when they're telling this isn't their norm and involve families. We all talk about patient-centred care, but that's so important in that patient-centred care, the family, we might be the experts in our field of care, whatever that is, but obviously the family, the loved one, the carer is the expert in that individual person.

Dr Kamar Ameen-Ali:

I think that's a really nice way of putting it because really having that communication between family members, caregivers, or friends of the person is really, really important because actually we can overcomplicate things with tests and with guidelines, but actually just speaking to people that know the person can be really quick indication of whether there's been any acute change there. So, I'm glad that you mentioned that that's really important. But maybe Ahmad, I can come to you if we are going to talk a little bit about what's happening in the brain of someone when they experienced delirium, because as a neuroscientist, what do we know about those changes and how is that different particularly to dementia? Because obviously we're talking about delirium and dementia and how they're similar, how they're different because they seem to give rise similar symptoms. But I assume that there are different changes that are happening in the brains of people when they experience these two conditions.

Dr Ahmad Khundakar:

Fundamental differences, I guess, are around the fact that you have pathology present within the case of neurodegenerative diseases that cause dementia. So, Alzheimer's disease obviously defined by the plaques and the tangles. Lewy body dementia is defined by the presence of alpha synuclein. So, these are obviously proteins that accumulate within the brain, come together, spread throughout the brain, cause neurodegeneration within the brain. So, there's a structural component that you have there within the context of dementia. Obviously, that differs from delirium in that you don't have that, although obviously it's very common within the context of dementia. And the reasons why it's not that that might occur is obviously that has been alluded to earlier on, the brain may be prone to the developing delirium because of the things around the kilter I guess you could say. So, if you think about it from a neurochemical point of view, obviously within the context of Alzheimer's disease, we have significant reductions in acetylcholine that define Alzheimer's disease and dementia with Lewy bodies as well. Within the context of Parkinson's disease, obviously a huge reduction in dopamine that defines that particular disease.

So, these two neurochemicals in particular seem to be important in the appearance of delirium. So there seems to be an imbalance going on here. We have to think about treatment as well. If we're giving, for example, L-dopa or dopamine agonists, which will raise levels of dopamine in the brain, often it's quite difficult to get the dosing right. So that again, might be a reason why the brain may be prone to experience delirium. But obviously delirium, as Krish has alluded to, is an acute syndrome that occurs as a result of something. So this is something that's occurring, could be as on top of the dementia pathology as well, something like an infection, something like just a simple thing like change of environment or as I've alluded to, dehydration, malnutrition, these kinds of things can be the thing that sort of knock the brain out of kilter further into the delirious state. So, there's an underlying propensity, I guess, you could say, to develop delirium that dementia contributes to. But yes, delirium can still occur independently of that process.

Dr Kamar Ameen-Ali:

So, I wonder then if it's important, not necessarily to think straight away what medication can be used to treat this, especially when somebody might be on multiple medications already. If we're talking about an older person that might be being treated for dementia, might be being treated for hypertension, high cholesterol, lots of other things, but it might be really important to try and identify what's causing the delirium. And that might be something as simple as rehydration or reducing someone's pain or anything like that. And actually, that's much better than straightaway reaching for what medication can we give this person.

Dr Ahmad Khundakar:

100%. I mean, it is that taking a step back and really understanding what the patient is experiencing at the time. And as Krish and Anna have really importantly alluded to is that it's this investigation work. That's the really important thing. And I can understand, I can understand why these things may occur. What happened with my mom was in an acute setting and often thinking they're there to obviously treat the problem that my mom was in there for. And maybe there's not this kind of more holistic view about what my mom was experiencing at that particular time. Key to all of it is obviously getting to know the patient and understanding what they're going through at the time. And if the patient can't communicate that themselves, if they're obviously undergoing the experience of delirium, the importance of understanding from family members, from loved ones, or if a person doesn't have a family member, for instance, a representative from the care home or someone that's with them at the time that can explain how they've ended up in that state.

And yes, taking that step back rather than just reaching for the drug that they think, obviously they're there, they're doing this for the right reasons, but understanding is this really the right thing to be doing at this particular time? I think obviously if the person's going through an acute episode, hyper delirium and they can't be calmed down, what is the cause of it? Is the drug going to be the right thing that's going to really help them with alleviating that, but also long-term as well, what is going to be the long-term implication of giving something like an antipsychotic drug or giving a sedative? Could it be solved by a lot simpler kind of thing, just simply finding out what the actual cause of it is itself. So, the good thing about delirium, what I've gleaned from entering this kind of world really is just the simple things can be the most effective.

Just a simple knowledge around what is it that's causing this. And it might be just something light for instance, as Krish has really put across really nicely, I think in some of the presentations he's given, things like just the glass are dirty, has the hearing aids been checked? What's the lighting like? Sometimes there's a lot of confusion that goes on from you're taking a person from their home environment or from a care home where they're nice and warm, they're familiar with the staff to this really unfamiliar environment with lots of bleeping going on, lots of bright lights from the hospital, maybe a bit of other aggravations going on in the ward. How is all this coming together for this person and could this be improved for them? So just simple things like this I think can really help.

Dr Kamar Ameen-Ali:

That's great. Thanks, Ahmad. So Krish, we talked a little bit earlier about delirium and dementia, and I'm really keen to unpack this a little bit. We know that they're different, but are people who live with dementia at a higher risk of experiencing delirium? And if that's the case, then why? Why they at that higher risk?

Professor Mani Santhana Krishnan:

Just following on from the previous discussion Anna and Ahmad had, I just want to make some statements before moving on to the delirium and dementia. So as Ahmad and Anna indicated, you don't need a robotic operation, you don't need new multi-million-pound gadget, you don't need a brand-new nuclear medicine or something like that. You need good quality nursing care to improve delirium risks. And any meeting, any lecture I give people, sometimes I get a negative feedback of, "Dr. Krishnan did not give any cutting-edge research update on anything like that." So, I'm going to make three statements before I move on. Number one, as of today, 23rd of May 2025, there is no evidence-based treatment for delirium currently available anywhere in the world. So, there is no pharmacological treatment that is directly given for delirium. So that's a fact.

Any tablet people will be probably shouting at me on the podcast or symptoms for delirium like agitation, like aggression. It's like saying when you have a chest infection, give paracetamol for chest infection, that's for fever for the infection, the infection treatment is an antibiotic, like that, delirium does not have a chemical treatment. That's a first statement. Second statement, non-pharmacological treatment, which is hearing aid, cleaning the glasses or even having them a glass because most of the patients who attend hospitals will come to hospital without their own glasses. So, they will become visually impaired already. So, getting their spare pair of glass, spare pair of hearing aid, putting the battery, it becomes a rocket science to put a battery into your hearing aid.

So, getting their right hearing aid batteries in, all those will improve. So why I'm saying it not because Krish is feeling that, like that, Cochrane review clearly indicates that 43% of delirium complications could be reduced by multi-component non-pharmacological interventions. 50% of delirium risk could be reduced by that. So that's number one. So that's the second point. And then the third point I just want to make a mention is that it is educating patients and carers for detecting some of those things so that they may be able to get that non-pharmacological intervention going. So those are the three things I want to say.

Dr Kamar Ameen-Ali:

We talked earlier about delirium and dementia, how they're different, but I guess what we'd like to know is people that are living with dementia at a higher risk of experiencing delirium?

Professor Mani Santhana Krishnan:

The main thing is delirium and dementia, fortunately or unfortunately have this two-way process relationship. So, I will talk both sides, which is very, very important. So, anybody who has delirium, who develops delirium, especially older adults, they have a higher risk of developing dementia. So, if you think of somebody having a delirium in older adult, about 20% of them do not return back to their baseline normal cognitive level. So that is a very high risk. So that is one important factor we need to keep in mind. Second thing is people with dementia will also have a higher risk of developing delirium. And you asked the question why it is. So, Ahmad talked about vulnerable brain, so I would use that same analogy. So, we already have a frail elderly person who not only have physical vulnerability, prone to develop infections, falls and various things including sensory impairment.

They also have a cognitive vulnerability because of the neurodegeneration. So, the brain is at risk. So, what I would normally give a bridge analogy. So, if you have an old 100-year-old bridge in a countryside, they will sometimes put a warning not for heavy vehicles or something like that. So, you can send some smaller micro cars without naming the names of the cars. You can't send a big tractor, an articulated vehicle, or a lorry. So, delirium. So, if you think of a bridge as a patient with dementia, delirium would be like a big lorry or a tanker. So, they can still take a day-to-day stress, but a big tanker like delirium comes, it creaks and cracks the bridge. So, delirium is one of the significant comorbidities that can happen when people with dementia. And the difference is people will be already confused and disoriented in various things. They will be more confused, more disoriented, they'll have a new symptom. That's how you find is there a delirium superimposed dementia.

Dr Kamar Ameen-Ali:

So, it does sound like there is this kind bidirectional relationship then between delirium and dementia where having delirium can maybe increase someone's chances of then getting dementia or it can worsen thinking and memory problems that somebody might already be experiencing that isn't quite meeting the threshold of dementia. But equally, people with dementia are at high risk of experiencing delirium as well.

Professor Mani Santhana Krishnan:

And one last point I want to say is again, why we are doing the whole podcast. I want to get the message across to the public and professionals is that delirium could be one of the factors that could help to prevent future dementia. So, if you think of a modifiable risk factor, there is a study by Sarah Richardson from Northeast Newcastle called a DECIDE study where she did a delirium and dementia correlation. The severe the delirium is, more frequent the episodes of delirium, and longer the delirium last, there is a higher chance within a 12-month period they will develop dementia. So, reducing the delirium severity, reducing the delirium frequency, reducing the length of delirium episode all might be a protective factor for future dementia. This is something really important because downstream for all of us, when we are getting older, it is important that we don't get into delirium.

Dr Kamar Ameen-Ali:

So, I think it might be that we'll see delirium being included in that framework of modifiable risk factors for dementia.

Professor Mani Santhana Krishnan:

That's exactly what I spoke yesterday about, Kam.

Dr Kamar Ameen-Ali:

Right.

Professor Mani Santhana Krishnan:

Unfortunately, we need the likes of yourself and Ahmad for that because why it's not happening in a Gill Livingston paper, the Lancet paper you are referring, there's 45% right now. If you add delirium, it'll be almost like 60% of delirium could be preventable because you don't have high quality epidemiological research on that. And that's really, really important. I think you hit the nail on the head.

Dr Kamar Ameen-Ali:

Yeah, we need the evidence based, don't we? So hopefully we'll see that in the next iteration. Before we go, just very, very briefly, I've got one last question for you all. So, what do you think are the current challenges that remain in terms of helping advance our understanding of the link between delirium and dementia, but also in helping to raise awareness of this topic more generally? So, Anna, I'll come to you. So just very briefly, what do you think are those current challenges that we still have to tackle?

Anna Wilson:

I think education of staff and the public but also having a standardised approach to care and resources dedicated to this across the NHS. And it is currently quite variable, even regionally, let alone nationally.

Dr Kamar Ameen-Ali:

Thanks, Anna. And Ahmad, what do you think from your perspective?

Dr Ahmad Khundakar:

Yeah, I mean, just to echo that, I mean, yeah, it's awareness and really people realising the seriousness of it as well. I've currently been doing the study in care homes, just as I alluded to, just around the knowledge and awareness of it. And its frequently mentioned delirium, but it's almost brushed into the carpet that it's just a delirium or she's old, she's got delirium without realising how dangerous that that could be. So that would be my [inaudible 00:42:49].

Dr Kamar Ameen-Ali:

So almost used as a passive way to describe how somebody is without thinking that's actually something that needs to be proactively acted upon.

Dr Ahmad Khundakar:

That's right. I mean, there does seem to be more knowledge of the term delirium, but not necessarily what delirium is and how serious it is.

Anna Wilson:

Yeah, and you get that term in medical notes sometimes that pleasantly confused, which is not a good description at all.

Dr Kamar Ameen-Ali:

And Krish?

Professor Mani Santhana Krishnan:

I'll again give a couple of points. I echo Anna's point and Ahmad's point, so I'll start with again another punchline. There is nothing pleasant about being confused. So, it is really important. It is a very distressing condition and people can recall delirium, so it's not nice to anyone at all. I have experienced delirium, I know very well it's a very uncomfortable feeling. So, the main things are if it is delirium, even if somebody suspects delirium, don't give any synonym, call it delirium. That's the biggest education thing I want to get across. So, coming back to education, I'm going to split it into three different things. Education is the key here, but it's not just about educating patients, carers, families, staff. We need to educate researchers. We need to educate policymakers. We need to educate politicians, because if, again, I'm going to be controversial, forgive me, if it's a heart condition, if it's a cancer, if it's something children problem, women problem or a problem with any other conditions that has high profile charitable organisation fighting for it, would we be in this state?

Because for decades, there is no increase. There is still, the prevalence is 20%, which is very bad, if it's a cancer, if it's a stroke, if it's a heart disease, they will have a national outcry. So, we need to educate policy makers that it's a big win by investing in delirium, you're going to imagine you're going to prevent dementia, you're going to prevent hospital. They say in American population, they say $152 billion more expense that happens for delirium care compared to normal care. So clearly, you're going to save money, you're going to prevent delirium, dementia, you're going to save carer stress. So clearly, we need the policy makers to know, so education, but also education with other way. And surprise, surprise, there is no charitable organisation on delirium, which is really important. Yeah, thank you.

Dr Kamar Ameen-Ali:

And even then, you don't see that much coming from the dementia charities either, which might have that kind of close link with people who might be at high risk of experiencing delirium. That was a really great summary. Thanks, Krish. So, I think that's really all we have time for today. We could keep talking about this topic, really, it's so important. And if you can't get enough of this topic, please visit the Dementia Researcher website. You'll find a full transcript, biographies of our guests, blogs, and much more on this topic as we try to raise awareness and achieve that education as we've talked about today. I would like to thank our incredible guests, Anna, Krish and Ahmad. I'm Kamar Ameen-Ali, and you've been listening to the Dementia Researcher Podcast. Bye everyone.

Professor Mani Santhana Krishnan:

Thank you so much. Bye-bye.

Dr Ahmad Khundakar:

Thank you, Kam.

Anna Wilson:

Bye. Thank you.

Voice Over:

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