Behavioral/Psychosocial - Delirium, Dementia, Violence, Depression

Delirium - what is it? types?

• an acute organic mental syndrome with potentially reversible impairment of consciousness and cognitive function that fluctuates in severity

• 3 TYPES

  • Mixed (hyperactive AND hypoactive type in same patient), the most common and seen in 55% of patients with delirium

  • Hypoactive (second most common (OFTEN UNDIAGNOSED), seen in 43% of patients with delirium

  • Hyperactive (least common type, seen in approximately 2% of patients with delirium)

    • NOTE: a patient with dementia may develop delirium superimposed on dementia

Delirium - RISK factors

• non-modifiable (history of dementia, recent history of substance abuse, greater age, increasing APACHE score, prior coma, pre-ICU emergency surgery or trauma)

• modifiable (benzodiazepines, blood transfusions, immobility, restraints, pain, sensory deprivation OR overload, sleep disruption/deprivation)

Delirium - 2 assessment tools

• Confusion Assessment Method for the ICU (CAM-ICU)

• Intensive Care Delirium Screening Checklist (ICDSC)

Delirium - CAM-ICU assessment

1. patient must have an ACUTE ONSET OF MENTAL STATUS CHANGES OR A FLUCTUATING COURSE (if negative, STOP ASSESSMENT)

2. AND the patient must also exhibit INATTENTION (SAVEAHAART or CASABLANCA) (if negative, STOP ASSESSMENT)

3. in addition to first 2 criteria, patient needs to exhibit EITHER DISORGANIZED THINKING (following commands? answering questions?)

4. OR ALTERED LEVEL OF CONSCIOUSNESS (RASS)

Delirium - PREVENTION TECHNIQUES

• interventions may not prevent delirium when non-modifiable risk factors are present, but when discussing MODIFIABLE RISK FACTORS, interventions may result in less severe delirium and/or a shorter duration of delirium

• utilize strategies to promote patient orientation (provide visual/hearing aids, encourage communication/reorient patient repetitively, place familiar objects from patient’s home in the room, attempt consistency in nursing staff, allow television during day with daily news or per patient preference, play music)

• Assess/manage environment (promote sleep hygiene (LIGHTS OFF AT NIGHT/ON DURING DAY), control excess noise at night, avoid restraints, remove/camouflage tubes)

• Control clinical parameters (SBP >90mmHg, O2 sat >90%, treat underlying metabolic derangements/infections)

• Prevent delirium secondary to substance abuse (alcohol, opiates, benzodiazepines, nicotine) (ASSESS for chronic substance abuse/adjust meds accordingly (keep in mind tolerance), provide benzos to prevent/minimize alcohol or benzo withdrawal; provide opiates to patient with known chronic opiate use; consider nicotine patch)

• Ensure processes are in place to implement the evidence-based strategies of the ABCDEF bundle (A = Assess, prevent, manage pain; B = Both spontaneous awakening/breathing trials; C = Choice of analgesia and sedation; D = Delirium (assess, prevent, manage); E = early mobility/exercise; F = Family engagement/empowerment)

• do NOT use pharmacological agents to PREVENT delirium (EXCEPT for patients with substance abuse history)

Delirium - PHARMACOLOGICAL MANAGEMENT

• the use of drugs to treat delirium is generally reserved for hyperactive delirium that is NOT responsive to non-pharmacological measures

  • address pain with analgesics

  • for delirium that is related to alcohol or benzo withdrawal, USE BENZOS

  • for delirium that is unrelated to alcohol or benzo withdrawal, when treating a patient who is receiving mechanical ventilation, USE DEXMEDETOMIDINE (Precedex)

  • use of haloperidol (Haldol) or a statin is NOT recommended for delirium treatment (HOWEVER, short-term use of Haldol may be used for patients with significant distress secondary to the symptoms of delirium (such as hallucinations/delusion-associated fearfulness) or for those who are delirious and have agitation that could be physically harmful to themselves/others

    • HALOPERIDOL MAY PROLONG THE QT INTERVAL and cause torsades de points V-tach (OBTAIN BASELIEN QTc interval measurement, and monitor the QTc regularly throughout therapy; monitor for the addition of other drugs that may prolong QT interval)

Dementia - what is it?

• a neurocognitive disorder that affects the brain’s ability to think, reason, and remember clearly

• most commonly affected areas include memory, visual-spatial, language, attention, and problem solving

• unlike delirium, which is acute/temporary, most types of dementia are slow and progressive in onset and are permanent

Delirium vs. Dementia (COMPARISON)

• Delirium

  • acute/fluctuating, rapid progression, reversible, strategies are available for prevention, organic brain changes, may include agitation, but not in all cases

• Dementia

  • CHRONIC, SLOW progression, IRREVERSIBLE, NO KNOWN PREVENTION, organic brain changes, may include agitation. but not always

Dementia - common causes? what is important to know?

• MOST COMMON CAUSE is ALZHEIMER’S DISEASE (75% of all cases); others include vascular brain disease/stroke

• symptoms vary depending upon whether dementia is in early/mid/late stages

• if a patient with dementia requires the ICU, there is a higher likelihood of delirium

• patient safety is a priority, and inclusion of the family/significant others in the plan of care is required

Aggressive/Violent Behavior - nursing considerations

• be aware/alert

• maintain a calm, quiet manner

• maintain a quiet environment

• stand at a slight angle to the patient

• do NOT provide care alone

• activate an emergency response, as needed

Depression - stats

• affects ALL age groups and ALL social classes

• TWICE as frequent in women

• 17.3 million adults in the US (7.1% of all adults in the US) have had at least 1 major depressive episode

Depression - cause?

• there is NO single cause, although researchers have noted some hereditary, environmental, physiological, and psychological factors that may contribute to depression

  • MRIs of brain of depressed individuals HAVE shown changes

  • depression has been associated with an imbalance of brain neurotransmitters

Diagnosis of Depression

• DEPRESSED MOOD (feeling sad or low)

• OR loss of interest or pleasure in nearly all activities

  • PLUS 4 additional signs/symptoms

    • significant loss of appetite or weight loss/gain

    • insomnia or hypersomnia

    • psychomotor agitation or retardation

    • fatigue or loss of energy

    • feelings of worthlessness or guilt

    • impaired thinking or concentration; indecisiveness

    • suicidal thoughts/thoughts of death

Depression - Therapeutic Interventions for Depression

• do NOT isolate patient; provide safety

• avoid excessive environmental stimulation

• do NOT force decision-making

• encourage expression of feelings

• explore sources of emotional support

• involve family members/a personal support system

• ensure the continuation of home medications, as the condition permits

• assess suicide risk; obtain psychiatric referral

Depression - PHARMACOLOGICAL MANAGEMENT (Tricyclic Antidepressants)

• use has declined with the availability of SSRIs

• EXAMPLES of TCAs

  • Amitriptyline

  • Nortriptyline

  • Imipramine

  • Clomipramine

  • Desipramine

• ADVERSE EFFECTS

  • highly lethal in an overdose (tachycardia, hypotension, fatal arrhythmias)

  • vertigo

  • dry mouth, dental caries

  • urinary retention

  • constipation

  • orthostatic hypotension

  • prolonged QT

Depression - PHARMACOLOGICAL MANAGEMENT (SSRIs (overview))

• first-line pharmacological therapy for depression

• abnormalities in brain serotonin activity have been implicated in many emotional and behavioral disorders, including mood disorders, obsessive-compulsive disorder, and aggressive behaviors

• they BLOCK the action of presynaptic serotonin reuptake pump, thereby increasing amount of serotonin available in the synapse and increasing postsynaptic serotonin receptor occupancy

• usually well tolerated and can be administered once a day; usually have fewer adverse effects that TCAs

Depression - PHARMACOLOGICAL MANAGEMENT (SSRIs (examples, adverse effects))

• Examples

  • Fluoxetine (Prozac); Citalopram (Celexa); Escitalopram (Lexapro)

  • Sertraline (Zoloft); Paroxetine (Paxil); Fluvoxamine (Luvox)

  • Bupropion (Wellbutrin); Mirtazapine (Remeron); Venlafaxine (Effexor)

  • Duloxetine (Cymbalta); Desvenlafaxine (Pristiq)

• ADVERSE EFFECTS

  • any adverse effects are dose-dependent; most subside after 1-2 weeks OR after a dose reduction

  • more common adverse effects: headache, abdominal pain, nausea, diarrhea, sleep changes, jitteriness, agitation

  • less common adverse effects: diaphoresis, akithisia (restlessness and an inability to sit still), bruising, changes in sexual functioning

  • can induce a manic or hypomanic episode

  • have the potential for increased suicidality

  • can inhibit the metabolism of some medications, such as antiarrhythmics, benzos, warfarin, tricyclics, and neuroleptics