142| Delirium – A Conversation With Dr. Kirk Stucky

In this episode, we discuss various aspects of delirium with Dr. Kirk Stucky. Topics covered include definitions and terminology, prevalence, risk factors, functional reserve, hypoactive and hyperactive presentations, pathophysiology, differential diagnosis with dementia, mental health symptoms, cognitive assessment, and prevention/intervention.

If you’d like to receive APA-approved CE credit for listening to this episode, click here.

About Kirk

Dr. Stucky obtained his Psy.D. in clinical psychology from Florida Tech in 1995. He completed his internship at Union Memorial Hospital in Baltimore, Maryland, and his residency in medical psychology at Hurley Medical Center in Flint, Michigan. At Hurley he has been a long term member of the Level 1 Trauma team and inpatient rehabilitation team.  He is currently chair of the Department of Behavioral Health and an assistant professor for the Michigan State University College of Human Medicine. He is also the acting Chair of the hospital Ethics Committee.  Being board certified in rehabilitation psychology and clinical neuropsychology, he has been dedicated to advancing the interests of both specialties including the development of integrated training standards and exploring new opportunities for advanced hospital practice.  He has published five books, numerous chapters, and peer reviewed articles on a range of topics including neurorehabilitation, hospital based practice, critical care psychology, ethics, and advanced specialty training.  As the program director of an APPCN, CRPPT, and APA accredited fellowship, he has had the privilege of teaching and supervising trainees for 29 years and mentoring a talented cadre of psychologists who have successfully obtained board certification in clinical neuropsychology, rehabilitation psychology, and health psychology.


Aung Thein, M. Z., Pereira, J. V., Nitchingham, A., & Caplan, G. A. (2020, September 7). A call to action for delirium research: Meta-analysis and regression of delirium associated mortality. BMC Geriatrics, 20(1).https://doi.org/10.1186/s12877-020-01723-4

Baller, E. B., Hogan, C. S., Fusunyan, M. A., Ivkovic, A., Luccarelli, J. W., Madva, E., Nisavic, M., Praschan, N., Quijije, N. V., Beach, S. R., & Smith, F. A. (2020, November). Neurocovid: Pharmacological Recommendations for Delirium Associated With COVID-19. Psychosomatics, 61(6), 585–596. https://doi.org/10.1016/j.psym.2020.05.013

Blair, G. J., Mehmood, T., Rudnick, M., Kuschner, W. G., & Barr, J. (2018, April 26). Nonpharmacologic and Medication Minimization Strategies for the Prevention and Treatment of ICU Delirium: A Narrative Review. Journal of Intensive Care Medicine, 34(3), 183–190. https://doi.org/10.1177/0885066618771528

Bramness, J. G., Pandey, S., Moe, J. S., Toft, H., Lien, L., & Bolstad, I. (2022, September). History of Delirium Tremens in AUD Patients in Treatment: Relationship to AUD Severity and Other Factors. Substance Abuse and Rehabilitation, Volume 13, 65–72. https://doi.org/10.2147/sar.s361810

Bramness, J. G., Heiberg, I. H., Høye, A., & Rossow, I. (2023, July 19). Mortality and alcohol‐related morbidity in patients with delirium tremens, alcohol withdrawal state or alcohol dependence in Norway: A register‐based prospective cohort study. Addiction, 118(12), 2352–2359. https://doi.org/10.1111/add.16297

Breitbart, W., Gibson, C., & Tremblay, A. (2002, May). The Delirium Experience: Delirium Recall and Delirium-Related Distress in Hospitalized Patients With Cancer, Their Spouses/Caregivers, and Their Nurses. Psychosomatics, 43(3), 183–194. https://doi.org/10.1176/appi.psy.43.3.183

Bugiani, O. (2021, May 24). Why is delirium more frequent in the elderly? Neurological Sciences, 42(8), 3491–3503. https://doi.org/10.1007/s10072-021-05339-3

Chandrakumar, A., Bhardwaj, A., & ‘t Jong, G. W. (2018, October 2). Review of thiamine deficiency disorders: Wernicke encephalopathy and Korsakoff psychosis. Journal of Basic and Clinical Physiology and Pharmacology, 30(2), 153–162. https://doi.org/10.1515/jbcpp-2018-0075

Cole, M. G., Ciampi, A., Belzile, E., & Zhong, L. (2008, November 13). Persistent delirium in older hospital patients: a systematic review of frequency and prognosis. Age And Ageing, 38(1), 19–26. https://doi.org/10.1093/ageing/afn253

De, J., & Wand, A. P. F. (2015, November 5). Delirium Screening: A Systematic Review of Delirium Screening Tools in Hospitalized Patients. The Gerontologist, 55(6), 1079–1099. https://doi.org/10.1093/geront/gnv100

Fong, T. G., Davis, D., Growdon, M. E., Albuquerque, A., & Inouye, S. K. (2015, August). The interface between delirium and dementia in elderly adults. The Lancet Neurology, 14(8), 823–832. https://doi.org/10.1016/s1474-4422(15)00101-5

Francis, J., & Kapoor, W. N. (1990, January). Delirium in hospitalized elderly. Journal of General Internal Medicine, 5(1), 65–79. https://doi.org/10.1007/bf02602312

Friedman, J. I., Soleimani, L., McGonigle, D. P., Egol, C., & Silverstein, J. H. (2014, February). Pharmacological Treatments of Non-Substance-Withdrawal Delirium: A Systematic Review of Prospective Trials. American Journal of Psychiatry, 171(2), 151–159. https://doi.org/10.1176/appi.ajp.2013.13040458

Gélinas, C., Bérubé, M., Chevrier, A., Pun, B. T., Ely, E. W., Skrobik, Y., & Barr, J. (2018, February 1). Delirium Assessment Tools for Use in Critically Ill Adults: A Psychometric Analysis and Systematic Review. Critical Care Nurse, 38(1), 38–49. https://doi.org/10.4037/ccn2018633

Gibb, K., Seeley, A., Quinn, T., Siddiqi, N., Shenkin, S., Rockwood, K., & Davis, D. (2020, April 2). The consistent burden in published estimates of delirium occurrence in medical inpatients over four decades: a systematic review and meta-analysis study. Age And Ageing, 49(3), 352–360. https://doi.org/10.1093/ageing/afaa040

Goldberg, T. E., Chen, C., Wang, Y., Jung, E., Swanson, A., Ing, C., Garcia, P. S., Whittington, R. A., & Moitra, V. (2020, November 1). Association of Delirium With Long-term Cognitive Decline. JAMA Neurology, 77(11), 1373. https://doi.org/10.1001/jamaneurol.2020.2273

Grassi, L., Caraceni, A., Mitchell, A. J., Nanni, M. G., Berardi, M. A., Caruso, R., & Riba, M. (2015, February 7). Management of Delirium in Palliative Care: a Review. Current Psychiatry Reports, 17(3). https://doi.org/10.1007/s11920-015-0550-8

Greaves, D., Psaltis, P. J., Ross, T. J., Davis, D., Smith, A. E., Boord, M. S., & Keage, H. A. (2019, August). Cognitive outcomes following coronary artery bypass grafting: A systematic review and meta-analysis of 91,829 patients. International Journal of Cardiology, 289, 43–49. https://doi.org/10.1016/j.ijcard.2019.04.065

Grover, S., & Ghosh, A. (2018, December). Delirium Tremens: Assessment and Management. Journal of Clinical and Experimental Hepatology, 8(4), 460–470. https://doi.org/10.1016/j.jceh.2018.04.012

Grover, S., Ghosh, A., & Ghormode, D. (2015, April). Experience in Delirium: Is It Distressing? The Journal of Neuropsychiatry and Clinical Neurosciences, 27(2), 139–146. https://doi.org/10.1176/appi.neuropsych.13110329

Guenther, U., Weykam, J., Andorfer, U., Theuerkauf, N., Popp, J., Ely, E. W., & Putensen, C. (2011, December 31). Implications of Objective vs Subjective Delirium Assessment in Surgical Intensive Care Patients. American Journal of Critical Care, 21(1), e12–e20. https://doi.org/10.4037/ajcc2012735

Heinrich, M., Nottbrock, A., Borchers, F., Mörgeli, R., Kruppa, J., Winterer, G., Slooter, A. J. C., & Spies, C. (2021, May 2). Preoperative medication use and development of postoperative delirium and cognitive dysfunction. Clinical and Translational Science, 14(5), 1830–1840. https://doi.org/10.1111/cts.13031

Herling, S. F., Greve, I. E., Vasilevskis, E. E., Egerod, I., Bekker Mortensen, C., Møller, A. M., Svenningsen, H., & Thomsen, T. (2018, November 23). Interventions for preventing intensive care unit delirium in adults. Cochrane Database of Systematic Reviews, 2019(1). https://doi.org/10.1002/14651858.cd009783.pub2

Hosie, A., Davidson, P. M., Agar, M., Sanderson, C. R., & Phillips, J. (2012, September 17). Delirium prevalence, incidence, and implications for screening in specialist palliative care inpatient settings: A systematic review. Palliative Medicine, 27(6), 486–498. https://doi.org/10.1177/0269216312457214

Hshieh, T. T., Yue, J., Oh, E., Puelle, M., Dowal, S., Travison, T., & Inouye, S. K. (2015, April 1). Effectiveness of Multicomponent Nonpharmacological Delirium Interventions. JAMA Internal Medicine, 175(4), 512. https://doi.org/10.1001/jamainternmed.2014.7779

Hshieh, T. T., Yang, T., Gartaganis, S. L., Yue, J., & Inouye, S. K. (2018, October). Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness. The American Journal of Geriatric Psychiatry, 26(10), 1015–1033. https://doi.org/10.1016/j.jagp.2018.06.007

Inouye, S. K., Foreman, M., Mion, L., Katz, K., & Cooney, L. (2001, November 12). Nurses’ Recognition of Delirium and Its Symptoms. Archives of Internal Medicine, 161(20), 2467. https://doi.org/10.1001/archinte.161.20.2467

Kiely, D. K., Jones, R. N., Bergmann, M. A., & Marcantonio, E. R. (2007, February 1). Association Between Psychomotor Activity Delirium Subtypes and Mortality Among Newly Admitted Postacute Facility Patients. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 62(2), 174–179. https://doi.org/10.1093/gerona/62.2.174

Kotfis, K., van Diem-Zaal, I., Williams Roberson, S., Sietnicki, M., van den Boogaard, M., Shehabi, Y., & Ely, E. W. (2022, July 5). The future of intensive care: delirium should no longer be an issue. Critical Care, 26(1). https://doi.org/10.1186/s13054-022-04077-y

Laurila, J. V., Laakkonen, M. L., Laurila, J. V., Timo, S. E., & Reijo, T. S. (2008, September). Predisposing and precipitating factors for delirium in a frail geriatric population. Journal of Psychosomatic Research, 65(3), 249–254. https://doi.org/10.1016/j.jpsychores.2008.05.026

Lee, S., Chen, H., Hibino, S., Miller, D., Healy, H., Lee, J. S., Arendts, G., Han, J. H., Kennedy, M., & Carpenter, C. R. (2022, March 11). Can we improve delirium prevention and treatment in the emergency department? A systematic review. Journal of the American Geriatrics Society, 70(6), 1838–1849. https://doi.org/10.1111/jgs.17740

Liston, E. H. (1982, April). Delirium in the Aged. Psychiatric Clinics of North America, 5(1), 49–63. https://doi.org/10.1016/s0193-953x(18)30887-6

Ludolph, P., Stoffers‐Winterling, J., Kunzler, A. M., Rösch, R., Geschke, K., Vahl, C. F., & Lieb, K. (2020, June 12). Non‐Pharmacologic Multicomponent Interventions Preventing Delirium in Hospitalized People. Journal of the American Geriatrics Society, 68(8), 1864–1871. https://doi.org/10.1111/jgs.16565

Magny, E., Le Petitcorps, H., Pociumban, M., Bouksani-Kacher, Z., Pautas, R., Belmin, J., Bastuji-Garin, S., & Lafuente-Lafuente, C. (2018, February 23). Predisposing and precipitating factors for delirium in community-dwelling older adults admitted to hospital with this condition: A prospective case series. PLOS ONE, 13(2), e0193034. https://doi.org/10.1371/journal.pone.0193034

Marcantonio, E. R. (2011, June 7). Delirium. Annals of Internal Medicine, 154(11), ITC6. https://doi.org/10.7326/0003-4819-154-11-201106070-01006

Marcantonio, E. R. (2017, October 12). Delirium in Hospitalized Older Adults. New England Journal of Medicine, 377(15), 1456–1466. https://doi.org/10.1056/nejmcp1605501

Mattison, M. L. (2020, October 6). Delirium. Annals of Internal Medicine, 173(7), ITC49–ITC64. https://doi.org/10.7326/aitc202010060

McCoy, T. H., Castro, V. M., Hart, K. L., & Perlis, R. H. (2021, July). Stratified delirium risk using prescription medication data in a state-wide cohort. General Hospital Psychiatry, 71, 114–120. https://doi.org/10.1016/j.genhosppsych.2021.05.001

Meagher, D., Agar, M. R., & Teodorczuk, A. (2017, July 30). Debate article: Antipsychotic medications are clinically useful for the treatment of delirium. International Journal of Geriatric Psychiatry, 33(11), 1420–1427. https://doi.org/10.1002/gps.4759

Mehta, S., Cook, D., Devlin, J. W., Skrobik, Y., Meade, M., Fergusson, D., Herridge, M., Steinberg, M., Granton, J., Ferguson, N., Tanios, M., Dodek, P., Fowler, R., Burns, K., Jacka, M., Olafson, K., Mallick, R., Reynolds, S., Keenan, S., & Burry, L. (2015, March). Prevalence, Risk Factors, and Outcomes of Delirium in Mechanically Ventilated Adults*. Critical Care Medicine, 43(3), 557–566. https://doi.org/10.1097/ccm.0000000000000727

Meyburg, J., Dill, M. L., Traube, C., Silver, G., & von Haken, R. (2017, February). Patterns of Postoperative Delirium in Children*. Pediatric Critical Care Medicine, 18(2), 128–133. https://doi.org/10.1097/pcc.0000000000000993

Morandi, A., Davis, D., Bellelli, G., Arora, R. C., Caplan, G. A., Kamholz, B., Kolanowski, A., Fick, D. M., Kreisel, S., MacLullich, A., Meagher, D., Neufeld, K., Pandharipande, P. P., Richardson, S., Slooter, A. J., Taylor, J. P., Thomas, C., Tieges, Z., Teodorczuk, A., . . . Rudolph, J. L. (2017, January). The Diagnosis of Delirium Superimposed on Dementia: An Emerging Challenge. Journal of the American Medical Directors Association, 18(1), 12–18. https://doi.org/10.1016/j.jamda.2016.07.014

Mueller, A., Spies, C. D., Eckardt, R., Weiss, B., Pohrt, A., Wernecke, K. D., & Schmidt, M. (2020, May). Anticholinergic burden of long-term medication is an independent risk factor for the development of postoperative delirium: A clinical trial. Journal of Clinical Anesthesia, 61, 109632. https://doi.org/10.1016/j.jclinane.2019.109632

Obad, A., Peeran, A., Little, J. I., Haddad, G. E., & Tarzami, S. T. (2018, February 13). Alcohol-Mediated Organ Damages: Heart and Brain. Frontiers in Pharmacology, 9. https://doi.org/10.3389/fphar.2018.00081

Oh, E. S., Fong, T. G., Hshieh, T. T., & Inouye, S. K. (2017, September 26). Delirium in Older Persons. JAMA, 318(12), 1161. https://doi.org/10.1001/jama.2017.12067

Ota, Y., Capizzano, A. A., Moritani, T., Naganawa, S., Kurokawa, R., & Srinivasan, A. (2020, May 10). Comprehensive review of Wernicke encephalopathy: pathophysiology, clinical symptoms and imaging findings. Japanese Journal of Radiology, 38(9), 809–820. https://doi.org/10.1007/s11604-020-00989-3

Oudman, E., Wijnia, J. W., Oey, M. J., van Dam, M. J., & Postma, A. (2020, September 21). Wernicke Encephalopathy in schizophrenia: a systematic review. International Journal of Psychiatry in Clinical Practice, 25(3), 233–237. https://doi.org/10.1080/13651501.2020.1819333

Perälä, J., Kuoppasalmi, K., Pirkola, S., Härkänen, T., Saarni, S., Tuulio-Henriksson, A., Viertiö, S., Latvala, A., Koskinen, S., Lönnqvist, J., & Suvisaari, J. (2010, September). Alcohol-induced psychotic disorder and delirium in the general population. British Journal of Psychiatry, 197(3), 200–206. https://doi.org/10.1192/bjp.bp.109.070797

Rengel, K. F., Pandharipande, P. P., & Hughes, C. G. (2018, April). Postoperative delirium. La Presse Médicale, 47(4), e53–e64. https://doi.org/10.1016/j.lpm.2018.03.012

Salluh, J. I. F., Wang, H., Schneider, E. B., Nagaraja, N., Yenokyan, G., Damluji, A., Serafim, R. B., & Stevens, R. D. (2015, June 3). Outcome of delirium in critically ill patients: systematic review and meta-analysis. BMJ, 350(may19 3), h2538–h2538. https://doi.org/10.1136/bmj.h2538

Schwebach, C., & Vempati, A. (2023). Alcohol Withdrawal with Delirium Tremens. Journal of education & teaching in emergency medicine8(3), S1–S33. https://doi.org/10.21980/J8S35N

Sepulveda, E., Franco, J. G., Trzepacz, P. T., Gaviria, A. M., Meagher, D. J., Palma, J., Viñuelas, E., Grau, I., Vilella, E., & de Pablo, J. (2016, May 26). Delirium diagnosis defined by cluster analysis of symptoms versus diagnosis by DSM and ICD criteria: diagnostic accuracy study. BMC Psychiatry, 16(1). https://doi.org/10.1186/s12888-016-0878-6

Serafim, R. B., Soares, M., Bozza, F. A., Lapa e Silva, J. R., Dal-Pizzol, F., Paulino, M. C., Povoa, P., & Salluh, J. I. F. (2017, July 12). Outcomes of subsyndromal delirium in ICU: a systematic review and meta-analysis. Critical Care, 21(1). https://doi.org/10.1186/s13054-017-1765-3

Shaw, R. C., Walker, G., Elliott, E., & Quinn, T. J. (2019, November). Occurrence Rate of Delirium in Acute Stroke Settings. Stroke, 50(11), 3028–3036. https://doi.org/10.1161/strokeaha.119.025015

Sinha, S., Kataria, A., Kolla, B. P., Thusius, N., & Loukianova, L. L. (2019, June). Wernicke Encephalopathy—Clinical Pearls. Mayo Clinic Proceedings, 94(6), 1065–1072. https://doi.org/10.1016/j.mayocp.2019.02.018

Slooter, A. J. C., Otte, W. M., Devlin, J. W., Arora, R. C., Bleck, T. P., Claassen, J., Duprey, M. S., Ely, E. W., Kaplan, P. W., Latronico, N., Morandi, A., Neufeld, K. J., Sharshar, T., MacLullich, A. M. J., & Stevens, R. D. (2020, February 13). Updated nomenclature of delirium and acute encephalopathy: statement of ten Societies. Intensive Care Medicine, 46(5), 1020–1022. https://doi.org/10.1007/s00134-019-05907-4

Smith, T. O., Cooper, A., Peryer, G., Griffiths, R., Fox, C., & Cross, J. (2017). Factors predicting incidence of post-operative delirium in older people following hip fracture surgery: a systematic review and meta-analysis. International journal of geriatric psychiatry32(4), 386–396. https://doi.org/10.1002/gps.4655

So, Y. (n.d.). Wernicke encephalopathy (M. Aminoff, & J. Wilterdink, Eds.). MediLib. Retrieved April 16, 2024, from https://medilib.ir/uptodate/show/4818

Solano, J. J., Clayton, L. M., Parks, D. J., Polley, S. E., Hughes, P. G., Hennekens, C. H., Shih, R. D., & Alter, S. M. (2021, September 23). Prehospital Ketamine Administration for Excited Delirium with Illicit Substance Co-Ingestion and Subsequent Intubation in the Emergency Department. Prehospital and Disaster Medicine, 36(6), 697–701. https://doi.org/10.1017/s1049023x21000935

Sørensen, H. J., Holst, C., Knop, J., Mortensen, E. L., Tolstrup, J. S., & Becker, U. (2019, February 17). Alcohol and delirium tremens: effects of average number of drinks per day and beverage type. Acta Psychiatrica Scandinavica, 139(6), 518–525. https://doi.org/10.1111/acps.13006

Stollings, J. L., Kotfis, K., Chanques, G., Pun, B. T., Pandharipande, P. P., & Ely, E. W. (2021, August 16). Delirium in critical illness: clinical manifestations, outcomes, and management. Intensive Care Medicine, 47(10), 1089–1103. https://doi.org/10.1007/s00134-021-06503-1

Thom, R. P., Levy-Carrick, N. C., Bui, M., & Silbersweig, D. (2019, October 1). Delirium. American Journal of Psychiatry, 176(10), 785–793. https://doi.org/10.1176/appi.ajp.2018.18070893

Tieges, Z., Evans, J. J., Neufeld, K. J., & MacLullich, A. M. (2017, April 9). The neuropsychology of delirium: advancing the science of delirium assessment. International Journal of Geriatric Psychiatry, 33(11), 1501–1511. https://doi.org/10.1002/gps.4711

Traube, C., Silver, G., Gerber, L. M., Kaur, S., Mauer, E. A., Kerson, A., Joyce, C., & Greenwald, B. M. (2017, May). Delirium and Mortality in Critically Ill Children: Epidemiology and Outcomes of Pediatric Delirium*. Critical Care Medicine, 45(5), 891–898. https://doi.org/10.1097/ccm.0000000000002324

Valentine, A., & Bickham, J. (2005, August 18). Delirium and Substance Withdrawal. Acute Care of the Cancer Patient. (pp. 545-554). CRC Press. http://books.google.ie/books?id=3hXnwAEACAAJ&dq=Acute+Care+of+the+Cancer+Patient&hl=&cd=1&source=gbs_api

van Montfort, S., van Dellen, E., Stam, C., Ahmad, A., Mentink, L., Kraan, C., Zalesky, A., & Slooter, A. (2019). Brain network disintegration as a final common pathway for delirium: a systematic review and qualitative meta-analysis.NeuroImage: Clinical, 23, 101809. https://doi.org/10.1016/j.nicl.2019.101809

van Velthuijsen, E. L., Zwakhalen, S. M. G., Pijpers, E., van de Ven, L. I., Ambergen, T., Mulder, W. J., Verhey, F. R. J., & Kempen, G. I. J. M. (2018, February). Effects of a Medication Review on Delirium in Older Hospitalised Patients: A Comparative Retrospective Cohort Study. Drugs & Aging, 35(2), 153–161. https://doi.org/10.1007/s40266-018-0523-9

Weinrebe, W., Johannsdottir, E., Karaman, M., & Füsgen, I. (2015, March 24). What does delirium cost? Zeitschrift Für Gerontologie Und Geriatrie, 49(1), 52–58. https://doi.org/10.1007/s00391-015-0871-6

Wilson, J. E., Mart, M. F., Cunningham, C., Shehabi, Y., Girard, T. D., MacLullich, A. M. J., Slooter, A. J. C., & Ely, E. W. (2020, November 12). Delirium. Nature Reviews Disease Primers, 6(1). https://doi.org/10.1038/s41572-020-00223-4

Witlox, J., Eurelings, L. S., de Jonghe, J. F., Kalisvaart, K. J., Eikelenboom, P., & van Gool, W. A. (2010). Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA304(4), 443–451. https://doi.org/10.1001/jama.2010.1013

Yang, F. M., Marcantonio, E. R., Inouye, S. K., Kiely, D. K., Rudolph, J. L., Fearing, M. A., & Jones, R. N. (2009, May). Phenomenological Subtypes of Delirium in Older Persons: Patterns, Prevalence, and Prognosis. Psychosomatics, 50(3), 248–254. https://doi.org/10.1176/appi.psy.50.3.248

Zaal, I. J., Devlin, J. W., Peelen, L. M., & Slooter, A. J. C. (2015, January). A Systematic Review of Risk Factors for Delirium in the ICU*. Critical Care Medicine, 43(1), 40–47. https://doi.org/10.1097/ccm.0000000000000625

Zamoscik, K., Godbold, R., & Freeman, P. (2017, June). Intensive care nurses’ experiences and perceptions of delirium and delirium care. Intensive and Critical Care Nursing, 40, 94–100. https://doi.org/10.1016/j.iccn.2017.01.003