Category: health care

Quiz Show on Delirium

Here’s an old post from February 15, 2011 from my previous blog The Practical Psychosomaticist called Quiz Show Versus Grand Rounds for Delirium Education:

“So you want to put on a game show contest to educate clinicians about delirium? Contact David Meagher, a psychiatrist in (where else?) Limerick, Ireland. He reported on this innovative educational workshop in the November 2010 Vol. 3 issue of the Annals of Delirium, the newsletter for the European Delirium Association (EDA). He also published the study which describes the contest in International Psychogeriatrics[1].

The workshop focused on clinician attitudes toward drug therapy for distressed delirious patients. It explored pre-existing attitudes and practice toward the use of medications to manage delirium and exposed participants to a very interactive educational event modeled after a popular TV quiz show. There were two teams (skeptics versus neuroleptics) furnished with a list of statements about delirium pharmacotherapy. The participants later completed a post-workshop questionnaire that explored changes in attitudes as a result of the workshop.

The participants were all experts on the subject and there was a good deal of variability in attitudes and practice. Some of the questions put to the teams involved using antipsychotics prophylactically to prevent delirium, the mechanism of action of antipsychotics, and what role benzodiazepines play in the treatment of non-alcohol withdrawal delirium.

One of the more puzzling findings was that the frequency of antipsychotic use was inversely proportional to the perception of the strength of supporting evidence. In other words, the less they knew about antipsychotics, the more often they used them. Most participants seemed to believe that the principal mechanism of action of antipsychotics is sedation, despite the lack of supporting evidence.

Some clinicians used antipsychotics to relieve the stress of caregivers rather than that of delirious patients, an example of patients getting the right treatment for the wrong reasons as observed by Meagher—and many of us in the field.

The workshop also highlighted the tendency of clinicians to focus on risk management rather than effective therapeutic intervention in the management of delirious patients with disruptive behavior and severe distress. This mainly relates to focus on the potential adverse effects of antipsychotics such as extrapyramidal side effects, metabolic, and cerebrovascular effects.

The quiz show activity was fun and challenging. The device of dividing the participants into two small teams with larger audience participation cut down on the anxiety that could be provoked by giving the “wrong answer”. The questions were true/false and didn’t always have clear right or wrong answers. It was highly interactive, a component of continuing medical educational (CME) activities that is increasingly encouraged because it’s more likely to lead to changes in clinician attitude and practice. The one-time Grand Rounds CME “seat time” is going the way of the dinosaur.

So a couple of findings from the quiz show post-activity questionnaire were that clinicians were more likely to use antipsychotics prophylactically and to use antipsychotics to manage hypoactive delirium.

 Our delirium intervention project group members are not quite as enthusiastic yet about these two interventions. We’re a bit more inclined at least initially to focus on non-pharmacologic multicomponent strategies such as the example below:

  • Minimize the use of immobilizing catheters, intravenous lines, and physical restraints
  • Avoid immobility, early mobilization
  • Monitor nutrition
  • Provide visual and hearing aids
  • Monitor closely for dehydration
  • Control pain
  • Monitor fluid-electrolyte balance
  • Monitor bowel and bladder functioning
  • Review medications
  • Reorient communications with the patient
  • Place an orientation board, clock, or familiar objects (ie, family photographs) in patient rooms
  • Encourage cognitively stimulating activities such as word puzzles
  • Facilitate sleep hygiene measures, including relaxation music or tapes at bedtime, warm drinks, and gentle massage
  • Minimize noise and interventions at bedtime, e.g., by rescheduling medication times

But I’m just as enthusiastic about interactive educational methods to engage learners in order to build a culture more likely to produce champions who will lead the delirium prevention effort—try the delirium multicomponent criss-cross puzzle below. The clues are contained in the list of multicomponent tactics above.”

  1. Meagher, D.J., Impact of an educational workshop upon attitudes towards pharmacotherapy for delirium. Int Psychogeriatr, 2010. 22(6): p. 938-46.

My Opinion So Far of the 2nd Covid-19 Booster

My title for this post indicates my opinion of the Covid-19 vaccine 2nd booster. I missed nearly all of the FDA Advisory Committee meeting last Wednesday but got the last hour of the discussion of the questions:

“Following the scheduled presentations and open public hearing, the VRBPAC will be asked to discuss and provide input on the following topics (no voting questions):


• What considerations should inform strain composition decisions to ensure that available COVID-19 vaccines continue to meet public health needs, e.g.:
-Role of VRBPAC and FDA in coordinating strain composition decisions
-Timelines needed to implement strain composition updates
-Harmonization of strain composition across available vaccines


• How often should the adequacy of strain composition for available vaccines be assessed?


• What conditions would indicate a need for updated COVID-19 vaccine strain composition, and what data would be needed to support a decision on a strain composition update?


• What considerations should guide the timing and populations for use of additional COVID-19 vaccine booster doses?”

I think the Stat News summary is helpful. There is a link to the recorded meeting. Sorry, it was over 8 hours long and I don’t think I can sit through that much technical difficulty—which was reportedly more of a problem than usual.

I’m a little disappointed that the duration of the protection from the 2nd booster might be only about 8 weeks, according to the Israeli presentation. Then what? FDA Director Peter Marks frankly calls the 2nd booster a “stopgap” measure. We need a new vaccine, not a series of boosters of the same old, same old.

Can the drug companies coordinate their efforts to come up with a new vaccine that will target the most prevalent variants of concern? Frankly, I doubt it, especially if they have to get going on the production in June and there doesn’t seem to be consensus on what variants would be important by the time the new vaccine would be needed, which is this fall. The virus mutates quickly and not in predictable ways.

I think we’re well past the idea of getting a vaccine that will lead to a sterilizing immunity, especially since it sounds like a product that stimulates nasal mucosa IgA antibodies would be necessary—if you can keep from sneezing the product back out on your sleeve. If the vaccines keep me out of the hospital, I guess I’d be happy with that. It looks like immunity will wane no matter what you do and there doesn’t seem to be a correlate of protection nor any guarantees on durability.

Counting hospitalizations for Covid as a way of tracking infections might be misleading since many hospitals are now not counting them if they’re not the primary reason for admission.

While I think getting the 2nd booster is fine as a stopgap measure for now, and I’ll likely get it, I’m hoping for a new vaccine in the coming months.

University of Iowa Ophthalmology Always a Top Contender

Well, I suppose I should tell you why you’re seeing these oldie blog posts from a different era in my career. It’s because I didn’t know whether I’d even be able to see well enough to write after my retinal detachment surgery, which was this past Friday. So, I scheduled a few posts from the past just in case.

The University of Iowa Ophthalmology Department is always highly ranked in the country according to U.S. News & World Report. It was seventh in 2021-2022.

I found out 3 weeks ago that I’ve been walking around with a detached right retina for years probably. One of the biggest risks for developing the condition is being over 50 years old. Hey, do you want to look like me by the time your fifty—ish?

I never could have been a contender

You know, what Sena and I think of whenever we hear about retinal detachment is Sugar Ray Leonard and his retinal tear in 1982 when he was at the top of his career. He almost didn’t have the surgery right away until a doctor told him might go blind if he chose to put it off. I think we pretty much stopped watching boxing because of how dangerous it is.

Don’t slap me on the head, I just had retinal detachment surgery!

Leonard’s description of his retinal detachment is classic: “The only thing I felt, I’d get hit in the eye and it swells, then all of a sudden it felt like a shade. It felt like a little shade opens in your eye — you don’t completely see the full picture. It looked like my eye was swollen, well… it felt like my eye was swollen because my vision at that time was getting worse because that curtain was coming down….

“I didn’t even know what (the doctor) was talking about. He said, ‘You have a detached retina.’ I said, ‘OK’. We thought we could come after the fight. Seriously,” said Leonard, who was told by the world renown surgeon Ronald G. Michels that holding off this surgery for another week could lead to blindness.”

He had the surgery right away.

I had a crack team of surgeons and the nursing and other staff were the best. I’m not going to bore you with a blow-by-blow account of the procedure. It did involve sharp objects. I got by with minimal sedation and pain control was good. They did a procedure called a scleral buckle (which is made of silicone) in which they tie this belt around the eye, cinch it tight until it pops like a grape, and then charge you $10 million. I think it’s covered by insurance, but check with your carrier just to make sure.

One thing that does tend to happen when I get sedation is an uptick in my baseline absent-mindedness. Shortly after we got home after the procedure, I couldn’t find my house keys or my car keys (don’t worry, I wasn’t driving). I even called the hospital to check if I’d left them there. Later, I happened to open the cupboard where I usually place them—and there they were. I had put them away and immediately forgot that I did it.

I’m now counting on Sena to give me the mandatory eye drops, 17 drops per hour from 6 nine-quart bottles until death. Don’t bother to eat, sleep, or go to the bathroom in any regular way—you’ll be too busy administering eye drops. Are we clear on that?

The swelling is already going down. I can carry around my eye in a bushel basket now instead of a wagon. Sena can barely look at it without cringing. But if I were to try to give myself the drops, they’d be dribbling down my shirt.

If you don’t get your eyes examined after you see what looks like a curtain coming down over your eye or see flashes of light—you should get your head examined. Psychiatrists will likely charge you only $10 million.

Picture credit Wikimedia: Not copyrighted material.

Going Down Blogging Memory Lane

I’ve been going down the blogging memory lane lately and thought I’d repost what was probably the very first post I published on my first blog, The Practical Psychosomaticist. The title was “Letter from a Pragmatic Idealist.”

While a lot of water has gone under the bridge since mid-December of 2010, some principles remain the same. Some problems still remain, such as the under-recognition of delirium.

Just a few thoughts about words, just because I’m a writer and words are interesting. The word “Psychosomaticist” is clunky and I’ve joked about it. I tried to think of another name for the blog.  I thought “Pragmatic Idealist” was original until I googled it—someone already had coined it. Then I considered “The Practical Idealist”, with the same result. The same thing happened with “The Practical Psychiatrist.” All of the terms had been used and the associations didn’t fit me. I couldn’t find anyone or any group using the term “The Practical Psychosomaticist.” 

Finally, after the Academy of Psychosomatic Medicine (APM) changed its name to the Academy of Consultation-Liaison Psychiatry (ACLP) in 2016, I changed the name of the blog to The Practical C-L Psychiatrist, finally dropping the name “psychosomatic” along with its problematic associations.

I guess the chronicle would be incomplete without an explanation of what happened to that blog. Around 2016, the General Data Protection Regulation (GDPR) was adopted by the European Parliament. WordPress, a popular blogging platform which I use, eventually decided that even hobby bloggers had to come up with a quasi-legal policy document to post on their websites to ensure they were complying with the GDPR regulation and not misusing anyone’s personal data.

I didn’t think that applied to hobby bloggers like me yet it was required. I wasn’t collecting anyone’s personal data and not trying to sell anything. I deleted my blog in July of 2018.  Because I loved to write, I eventually started a new blog around the last year of my phased retirement contract with my hospital in 2019.

Anyway, here’s the December 15, 2010 post, “Letter from a Pragmatic Idealist.”

“I read with interest an article from The Hospitalist, August 2008 discussing the Center for Medicare and Medicaid Services (CMS) requirement for hospitals to submit information on Medicare claims regarding whether a list of specific diagnoses were present on admission (POA)[1]. The topic of the article was whether or not delirium would eventually make the list of diagnoses that CMS will pay hospitals as though that complication did not occur, i.e., not pay for the additional costs associated with managing these complications. At the time this article was published, CMS was seeking public comments on the degree to which the conditions would be reasonably preventable through application of evidence-based guidelines.

I have no idea whether delirium due to any general medical condition made the list or not. But I have a suggestion for a delirium subtype that probably should make the list, and that would be intoxication delirium associated with using beverage alcohol in an effort to treat presumed alcohol withdrawal. There is a disturbing tendency for physicians (primarily surgeons) at academic medical centers to try to manage alcohol withdrawal with beverage alcohol, despite the lack of medical literature evidence to support the practice [2, 3]. At times, in my opinion, the practice has led to intoxication delirium in certain patients who receive both benzodiazepines (a medication that has evidence-based support for treating alcohol withdrawal) combined with beer—which generally does not.

I’ve co-authored a couple of articles for our institution’s pharmacy newsletter and several of my colleagues and pharmacists petitioned the pharmacy subcommittee to remove beverage alcohol from the formulary at our institution, where beer and whiskey have been used by some of our surgeons to manage withdrawal. Although our understanding was that beverage alcohol had been removed last year, it is evidently still available through some sort of palliative care exception. This exception has been misused, as evidenced by cans of Old Style Beer with straws in them on bedside tables of patients who are already stuporous from opioid and benzodiazepine. A surgical co-management team was developed, in my opinion, in part to address the issue by providing expert consultation from surgeons to surgeons about how to apply evidence-based practices to alcohol withdrawal treatment. This has also been a failure.

I think it’s ironic that some professionals feared being sanctioned by CMS for using Haloperidol to manage suffering and dangerous behavior by delirious people as reported by Stoddard in the winter 2009 article in the American Academy of Hospice and Palliative Medicine (AAHPM) Bulletin[4]. Apparently, CMS in fact did have a problem with using PRN Haloperidol (not FDA approved of course, but commonly used for decades and recommended in American Psychiatric Association practice guidelines for management of delirium), calling it a chemical restraint while having no objection to PRN Lorazepam, which has been identified as an independent predictor of delirium in ICU patients[5]. Would the CMS approve of using beer to treat alcohol withdrawal, which can cause delirium?

As a clinician-educator and Psychosomatic Medicine “supraspecialist” (term coined by Dr. Theodore Stern, MD from Massachusetts General Hospital), I’ve long cherished the notion that we, as physicians, advance our profession and serve our patients best by trying to do the right thing as well as do the thing right. But I wonder if what some of my colleagues and trainees say may be true—that when educational efforts to improve the way we provide humanistic and preventive medical care for certain conditions don’t succeed, not paying physicians and hospitals for them will. I still hold out for a less cynical view of human nature. But if it will improve patient care, then add this letter to the CMS suggestion box, if there is one.”

1.        Hospitalist, D. (2008) Delirium Dilemma. The Hospitalist.

2.        Sarff, M. and J.A. Gold, Alcohol withdrawal syndromes in the intensive care unit. Crit Care Med, 2010. 38(9 Suppl): p. S494-501.

3.        Rosenbaum, M. and T. McCarty, Alcohol prescription by surgeons in the prevention and treatment of delirium tremens: historic and current practice. General Hospital Psychiatry. 24(4): p. 257-259.

4.        Stoddard, J., D.O. (2009) Treating Delirium with Haloperidol: Our Experience with the Center for Medicare and Medicaid Services. Academy of Hospice and Palliative Medicine Bulletin.

5.        Pandharipande, P., et al., Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology, 2006. 104(1): p. 21-6.

My Old Elevator Pitches on Delirium

I thought it would be fun to take a look back at my chronicle as expressed in my old blog posts. As the featured image shows, I used to have a blog I called The Practical Psychosomaticist, which I started back in 2010. It was mostly about how to diagnose, manage, and prevent delirium. One of them was about developing elevator pitches promoting delirium awareness. My blog post Elevator Pitch for a Delirium Prevention Project is below:

“Sir Winston Churchill: Be clear, be brief, be seated.

I have been told that I could improve my chances of selling my product of delirium prevention to various stakeholders by developing a good elevator pitch. An elevator pitch is a short summary used to quickly and simply define a product or service and sell it. The idea is that you should be able to deliver the pitch in the time it takes to ride an elevator or about thirty seconds to two minutes.

I’m a doctor, not a salesman. But I’ll give it a shot.

Pitch to a staff nurse: I’m Dr. JA and I teach nurses how to assess, treat, and prevent delirium in hospitalized patients. Delirium is an acute confusional episode that mimics mental illness but is actually a medical emergency. Delirium worsens concentration, can lead to hallucinations, withdrawal, changes in appetite, reduced mobility, and sleep disturbance. When nurses have the skills and tools to prevent delirium, they ultimately do less work yet provide safer and more effective care for their patients, thereby promoting healing. Delirium leads to increased death rates, longer lengths of hospital stay, and persisting cognitive impairment. Nurses work harder to take care of them because confusion makes patients less cooperative, emotionally volatile, harder to communicate with, and sometimes even violent. Nurses want and need to know how to prevent delirium and I can help them do that.

Pitch to a potential funding source: I’m Dr. JA and I teach doctors and nurses how to assess, treat, and prevent delirium, an acute confusional disorder caused by multiple medical problems that mimics mental illness but is actually a medical emergency. They may be slow to respond, withdrawn, have attitude changes, and have mood symptoms. Because the risk for delirium is higher in the elderly, physicians and nurses in hospitals actually have to work harder to treat delirious patients with serious medical disorders. That’s because the patients are too cognitively impaired to cooperate with treatment, too disorganized to consent for them, and too agitated and restless to sit still for necessary tests. Doctors and nurses want and need to learn how to use assessment skills and tools to prevent delirium. This vital educational resource allows them to provide the best health care for older patients.

Pitch to Patient and Carers: I’m Dr. JA and I help doctors and nurses care for patients who may be at high risk for or who are in fact suffering from delirium. Delirium is an abrupt change in your mental state that represents a distinct change from your usual self and is often alarming to you and your loved ones. You can be disoriented, restless, hallucinate, have delusions and personality changes, or be very sleepy and seem depressed. Delirium is often temporary but can cause longer hospital stays, or the need for long-term care and raises the risk for falls and bed sores. Those at risk are over age 65, already have memory problems or dementia, have a broken hip, or several serious medical illnesses. We’ll assess regularly for changes in your emotions, behavior, or thinking and if they occur, we’ll use a special test to spot delirium early. We’ll work to prevent delirium by providing high-quality medical care. Occasionally, distress and behavioral changes could make patients a risk to themselves and if non-medication methods don’t reduce these, then a short course of medication called Haldol may be used.”

Well, all of the elevator pitches are way too long. But the message is still important.

Reminder: FDA Advisory Committee Meeting Today on Covid-19 Vaccine Boosters

Just a reminder; today the FDA Advisory Committee will meet from 8:30 AM to 5:00 PM, ET today to discuss Covid-19 vaccine boosters. I’ll be unable to post a “play by play” as I have in the past because I have something else on my schedule.

Especially noteworthy is the Briefing Document in the meeting materials, entitled:

“Considerations for COVID-19 Vaccine Booster Doses and Process for COVID-19 Vaccine Strain Selection to Address Current and Emerging Variants.”

Section 7 starts on page 17, “Topics for VRBPAC Discussion.” The important issue is determining strain composition of Covid-19 vaccines and what goes into consideration for the optimal use of additional booster doses.

April 6, 2022 Update:

“Topics for VRBPAC Discussion


Following the scheduled presentations and open public hearing, the VRBPAC will be asked to discuss and provide input on the following topics (no voting questions):


• What considerations should inform strain composition decisions to ensure that available COVID-19 vaccines continue to meet public health needs, e.g.:
-Role of VRBPAC and FDA in coordinating strain composition decisions
-Timelines needed to implement strain composition updates
-Harmonization of strain composition across available vaccines


• How often should the adequacy of strain composition for available vaccines be assessed?


• What conditions would indicate a need for updated COVID-19 vaccine strain composition, and what data would be needed to support a decision on a strain composition update?


• What considerations should guide the timing and populations for use of additional COVID-19 vaccine booster doses?”

Quick Announcement on Covid-19 2nd Vaccine Booster

According to a University of Iowa Hospitals & Clinics announcement on The Loop, 2nd booster doses were available to employees, volunteers, and patients starting April 4, 2022.

Permissive Recommendation for Covid Vaccine 2nd Booster?

I have a question about the permissive recommendation by the CDC for the 2nd Covid vaccine booster. Does that mean I should get the booster or that I can get it if I just want one?

There’s an important distinction between “should” and “can.” According to the AMA, the CDC gave permissive recommendation, which means that it’s not saying you should get it, but that you can if you so choose:

“The CDC’s action is commonly known as a “permissive recommendation,” meaning that certain people may get the second booster if they wish to get it, though the agency itself is not yet officially urging them to do so.”

There are a couple of recently updated tables on the CDC website in which the language is clearly permissive about the 2nd booster dose.  One is dated April 2, 2022, Stay Up to Date with Your Covid-19 Vaccines. The other is dated April 1, 2022, Covid-19 Vaccine Boosters.

Some of us may be finding it challenging to get the booster scheduled right now. I wonder if that means even those providing the booster might be wondering who should or should not get one.

Does vaccine supply have a bearing on the issue? Or is there significant uncertainty about the necessity for the 2nd booster?

I wonder if experts are waiting for further guidance from the scheduled FDA Advisory Committee meeting on April 6, 2022.

That’s this coming Wednesday. I’d like to listen to the meeting as I have in the past, but I have a schedule conflict that day. That’s not the only conflict I have.

No officials are clearly saying that I should not get the 2nd booster. On the other hand, neither are they clearly saying I should.

Maybe I’ll wait for an FDA update after the April 6 meeting. And I wonder if that will lead to a CDC Advisory Committee meeting.

Update April 5, 2022: Here’s a link to a new article on CDC Director Rochelle Walensky’s remarks intended to clarify the confusion about this issue of whether the 2nd booster is needed or not. It turns out it all depends (as it usually does). If I’ve been infected with Omicron in the last 2-4 months, then I might not need one, at least for now.

The catch is that my immunity is waning. I might still need the 2nd booster. I’m old enough that it might be a good idea to get it. On the other hand, I’m probably still going to need another jab come autumn. Dr. Walensky says this is “a personal judgment call.”

I’m still waiting for the FDA Advisory Committee’s conclusions on April 6, 2022.

AMA Update on Covid-19 2nd Vaccine Booster

The AMA published an update on the Covid-19 Vaccine 2nd booster and the YouTube presentation is only a couple of days old and pretty thorough. While the CDC indeed gave a permissive recommendation, it sounds like another jab would be recommended in the fall anyway, likely targeting variants. The FDA Advisory Committee still has a meeting scheduled for April 6, 2022. It sounds like Medicare and private insurance will cover the cost. The Federal funding outlook doesn’t sound as positive for the uninsured.

Second Covid Vaccine Booster Got Any Mojo?

Tomorrow’s April Fool’s Day and I thought I’d get this post up today so it wouldn’t get confused with a joke.

I’m genuinely a little confused about the FDA and CDC approval of the 2nd Covid vaccine booster. It’s almost like this vaccine is getting a mojo of some kind, at least with some experts.

Although I’m not keen on getting another jab, I’ll do it if there is reasonable evidence to support it. Not everyone on the FDA Advisory committee is for it. Dr. Paul Offit was quoted in a news story as saying, “We’re going to have to learn to live with mild disease at some point.” 

Dr. Offit is the director of the Vaccine Education Center at Children’s Hospital of Philadelphia. I’ve heard him speak at FDA Advisory Committee meetings during public Zoom meetings on the subject and I respect his opinion. He doesn’t think frequent boosting is a reasonable thing to do. I’m inclined to agree with his opinion that most people won’t do it anyway. I’m sure he’ll have more to say at the April 6 FDA Covid Vaccine Advisory Committee meeting.

I was not surprised to learn that of the 90 million Americans who got their initial Covid vaccine series, only about half got the first booster. What kind of mojo is that?

Even the Pfizer drug company CEO, Albert Bourla, says frequent boosting is impractical.

There is some serious doubt in my mind about the booster mojo. Sena says that it would be helpful if more local infectious disease experts would express their own opinions about the direction this vaccination strategy is going. She has a point.

Does the Covid vaccine booster have any mojo? What do you think?

Featured image picture credit: pixydotorg.