L14: ICU Delirium

Define Delirium

A sign of acute brain dysfunction; "disturbance of consciousness"

ICU Delirium is characterized by a(n) ________ change in cognition or perception

Acute onset

How does ICU Delirium differ from Dementia?

ICU = acute onset  | Dementia = NOT acute onset

What is the time-frame in which delirium can develop?

Develops over a short period of time; hours to days 

Typically is approximately 2-3 days

How does cognition change with ICU Delirium?

• Fluctuating inattention over time

• Impaired ability to receive, process, store, and recall information

T/F: ICU Delirium is usually reversible

True

What does ICU Delirium usually result from (in other words, what is ICU Delirium of consequence of)?

• Medical Condition

• Medication (polypharmacy)

• Toxin Exposure

• Substance Overused or Withdrawal

What patient population is ICU delirium most common / prevalent in?

Ventilated Patients! (60-80% of ventilated patients experience delirium)

What is ICU Delirium associated with?

• Prolonged Hospital Stays

• Medical Complications

• Greater Dependency of Care on Discharge

• Higher Nursing Home Discharges

• Increased Mortality

How long do ICU Delirium symptoms persist? In other words, after patient recovery from delirium, how long do they tend to experience symptoms?

• Symptoms may persists for 1 year after onset 

• For most patients -- symptoms persists for at least 6 months

• Only 4 - 14% of patients completely recovery from ICU delirium before discharge

T/F: The etiology of ICU Delirium is multifactorial and well-known

False! (etiology unknown -- thought to be multifactorial)

What are the different multifactorial etiology theories regarding the cause of ICU delirium?

• Neutrotransmiter Imbalances -- ↓ Acetylcholine and ↑ Dopamine 

  • Anti-cholinergic medications can cause delirium

  • Cholinesterase inhibitors have improved delirium

• Inflammation & Cytokines

• Alteration in Blood Brain Barrier

• Hypo-perfusion

What are the risk factors for ICU Delirium?

• Male

• Advanced Age

• History of Dementia

• Malnutrition

What are the common diagnoses of patients that experience ICU Delirium?

• Sepsis

• Metabolic Disorders

• Dehydration

• Hypoxia

• Trauma

• CNS Pathology

• Hip Fracture

What are precipitating factors (events/triggers) for ICU Delirium?

• Mechanical Ventilation

• Opioids or Benzodiazepine Use

• Retraints & Lines

• Sleep Deprivation

• Polypharmacy

• Pain

• ICU Environment (e.g., no windows)

What is ICU Delirium characterized by?

ICU Delirium is characterized by acute cognitive changes, inattention, and alterations in LOC throughout the day

What are the different types of delirium?

• Hyperative Delirium

• Hypoactive Delirium 

• Most Common → mixed presentation; fluctuation between hyper- and hypo-active states

What is Hyperactive Delirium?

• Agitation / Emotional Labiality

  • Rapid and exaggerated changes in mood or affect

• Common Signs / Symptoms

  • Psychomotor Agitation

  • Restlessness

  • Finger Tapping

  • Combativeness

  • Frequent Position Changes

  • Irritability

What is Hypoactive Delirium?

• Decreased Responsiveness / Apathy 

  • Lack of interest, enthusiasm, or concern

• Signs/Symptoms:

  • Psychomotor Retardation

  • Slowed or Absent Response to Stimuli

  • Staring into Space

  • Lethargy

  • Flat Affect

What is the least common type of delirium?

Hyperactive Delirium

T/F: Delirium is not recognized in over 50% of patients

True!

Delirium goes unrecognized in 66% - 84% of all patients

What are potential psychological impacts of ICU Delirium?

• Anxiety & Depression 

  • Typically is confounded with pre-existing anxiety/depression 
    

• PTSD 

  • Nightmares, delusions, & hallucinations

  • Difficult to rationalize emotional component

  • Impact of sedation (e.g., patient on ventilator)

Neurocognitive Deficits can last for ________ to ________

6 months, 1 year
After 1 year, there is minimal improvement

What long-term Neurocognitive Deficits maybe noted after ICU Delirium?

• Deficits noted in...

  • Memory

  • Attention

  • Concentration

  • Executive Functioning (reasoning, problem solving, planning, and execution)

What is the most affected neurocognitive deficit in patients after delirium?

Short Term Memory

What are the potential mechanisms responsible for neurocognitive deficits seen in patients after delirium?

• Hypoxemia

• Hyperglycemia

• Delirium

• Hypotension

What is the Confusion Assessment Method (CAM-ICU)?

• Incorporates the RASS (Richmond Agitation Sedation Scale)

  • In order to use the CAM-ICU, a score of ≥ -3 is required on the RASS

  • If a patient has a score of -4 or -5 → re-assess at a later time 

  • RASS Scoring

    • Higher Number = more combative and agitated

    • Lower Number = less responsive

• 4-part asessment method

• Time: 1 minute

• Valid and Reliable in the ICU -- widely used

• Positive CAM-ICU requires all of the following

  • + Feature 1

  • + Feature 2

  • Either + Feature 3 or Feature 4

What is Feature 1 of the CAM-ICU?

Acute Onset or Fluctuating Course

What is Feature 2 of the CAM-ICU?

Inattention

What is Feature 3 of the CAM-ICU?

Disorganized Thinking

What is Feature 4 of the CAM-ICU?

Altered Level of Consciousness

What is the Delirium Rating Scale - Revised 98 (DRS-98)?

• 13 Item for Severity Score 

  • 3 optional diagnostic items for total score 

  • Higher Score = Worse Delirium

  • Can use information from anyone (except the patient); typically over 24 hours

• Performed at Initial Assessment and is repeated within a single episode
  

What is the Intensive Care Delirium Screening Checklist (ICU-DSC)?

• 8-Item Quick Screen 
  

• Scoring on 0 - 8 Scale:

  • 0 = Normal

  • 1 -3 = Sub-Syndromal Delirium

  • 4 - 8 = Delirium
    

What are the different methods to prevent ICU Delirium from occurring?

• Re-Orientation

• Cogntiively Stimulating Activities

• Early Mobilization / ROM Exercise

• Removal of Catheters & Physical Restraints

• Use of Eye Glasses & Hearing Aids

• Re-Hydration

• Minimizing / Reduction of Pain, Noise, & Unnecessary Stimuli

• Daily Interruption of Sedation

• Maintaining Day / Night Orientation

What is  "Sedation Vacation"?

Short-term break from sedations for patients in the ICU; PT should really try and take advantage of this!

What are Treatment Options for Delirium?

• No Medication

• Some sedatives may exacerbate delirium (minimize these)

• Trial Haloperidol (Haldol) -- inhibits neurotransmission

• EARLY MOBILITY