ICU Delirium: Difference between revisions

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== Causes and Risk Factors ==
== Causes and Risk Factors ==
Delirium develops as a result of multiple causes and risk factors. Old age, dementia [McNicoll 2003], depression, smoking and alcohol use [all others-->[Brummel 2013] are among the personal factors that increase patient risk.<ref name=":2">Brummel N, Girard T. Preventing delirium in the intensive care unit. Crit Care Clin 2013; 29(1): 51–65</ref><ref>McNicoll L, Pisani MA, Zhang Y, Ely EW, Siegel MD, Inouye SK. Delirium in the intensive care unit: occurrence and clinical course in older patients. J Am Geriatr Soc 2003; 51:591-598</ref> Another 20+ risk factors related to the patient's medical condition have been identified by the literature.<ref>Cavallazzi R, Saad M, Marik PE. Delirium in the ICU: an overview. Ann Intensive Care 2012; 2: 49</ref> Below is a common mnemonic used to help clinicians identify potential causes related to illness and treatment:
Delirium develops as a result of multiple causes and risk factors. Old age, dementia, depression, smoking and alcohol use are among the personal factors that increase patient risk.<ref name=":2">Brummel N, Girard T. Preventing delirium in the intensive care unit. Crit Care Clin 2013; 29(1): 51–65</ref><ref>McNicoll L, Pisani MA, Zhang Y, Ely EW, Siegel MD, Inouye SK. Delirium in the intensive care unit: occurrence and clinical course in older patients. J Am Geriatr Soc 2003; 51:591-598</ref> Another 20+ factors related to the patient's medical condition have been identified by the literature.<ref>Cavallazzi R, Saad M, Marik PE. Delirium in the ICU: an overview. Ann Intensive Care 2012; 2: 49</ref> Below is a common mnemonic used to help clinicians identify potential causes related to illness and treatment:
*D-Drugs
{| class="wikitable"
*E- Eyes, ears, and other sensory deficits
|'''D'''
*L- Low O2 states
|Drugs
*I- Infection
|-
*R- Retention (of urine or stool)
|'''E'''
*I- Ictal state
|Eyes, ears, and other sensory deficits
*U- Underhydraton/undernutrition
|-
*M- Metabolic causes
|'''L'''
|Low O<sub>2</sub> states
|-
|'''I'''
|Infection
|-
|'''R'''
|Retention (of urine or stool)
|-
|'''I'''
|Ictal state
|-
|'''U'''
|Underhydraton/undernutrition
|-
|'''M'''
|Metabolic causes
|}
Adapted from: Saint Louis University Geriatrics Evaluation Mnemonics Screening Tools (SLU GEMS). Developed or compiled by: Faculty from Saint Louis University Geriatrics Division and St. Louis Veterans Affairs GRECC.
Adapted from: Saint Louis University Geriatrics Evaluation Mnemonics Screening Tools (SLU GEMS). Developed or compiled by: Faculty from Saint Louis University Geriatrics Division and St. Louis Veterans Affairs GRECC.


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== Pathophysiology ==
== Pathophysiology ==
The pathophysiology of delirium is not well understood. Theories related to its development and progression cite anatomical changes in the brain and neurotransmitter imbalances (ex. abnormal levels of serotonin, decreased acetylcholine, excess dopamine) as possible physiologic mechanisms.<ref>ICU Delirium and Cognitive Impairment Study Group. For Medical Professionals-- ABCDEF's of prevention and safety. [http://www.icudelirium.org/medicalprofessionals.html-- http://www.icudelirium.org/medicalprofessionals.html]. Accessed March 8, 2018.</ref>
The pathophysiology of delirium is not well understood. Theories related to its development and progression cite anatomical changes in the brain and neurotransmitter imbalances (ex. abnormal levels of serotonin, decreased acetylcholine, excess dopamine) as possible physiologic mechanisms.<ref name=":3">ICU Delirium and Cognitive Impairment Study Group. For Medical Professionals-- ABCDEF's of prevention and safety. [http://www.icudelirium.org/medicalprofessionals.html-- http://www.icudelirium.org/medicalprofessionals.html]. Accessed March 8, 2018.</ref>


== Diagnosis ==
== Diagnosis ==
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== Assessment and Monitoring ==
== Assessment and Monitoring ==
Guidelines for treating Pain, Agitation and Delirium (PAD)<ref>Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013; 41(1):263-306</ref> recommend two tests for the assessment of delirium in adult ICU patients:
Guidelines for treating Pain, Agitation and Delirium (PAD)<ref>Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013; 41(1):263-306</ref> recommend two tests for the assessment of delirium in adult ICU patients:
 
# [http://www.icudelirium.org/docs/2013-Tufts-ICU-Delirium-Screening-Checklist.pdf The Intensive Care Delirium Screening Checklist] (ICDSC)
(1) [http://www.icudelirium.org/docs/2013-Tufts-ICU-Delirium-Screening-Checklist.pdf The Intensive Care Delirium Screening Checklist] (ICDSC)
# [http://www.icudelirium.org/docs/CAM_ICU_worksheet.pdf The Confusion Assessment Method for the ICU] (CAM-ICU)
 
(2) [http://www.icudelirium.org/docs/CAM_ICU_worksheet.pdf The Confusion Assessment Method for the ICU] (CAM-ICU)
 
The following video provides a step by step demonstration of the CAM-ICU.  
The following video provides a step by step demonstration of the CAM-ICU.  
https://www.youtube.com/watch?v=yEwBzKTbJEk


== Prevention and Treatment ==
== Prevention and Treatment ==
In 2010, Vasilevskis et al [cite] proposed the ABCDE model to screen and prevent delirium among ICU patients. The mnemonic consists of the following concepts:
In 2010, Vasilevskis et al.<ref>Vasilevskis EE1, Pandharipande PP, Girard TD, Ely EW. A screening, prevention, and restoration model for saving the injured brain in intensive care unit survivors. Crit Care Med 2010;38(10 Suppl):S683-91.</ref> proposed the ABCDE model to screen and prevent delirium among ICU patients. The mnemonic consists of the following concepts:
*A-Assess, prevent and manage pain: behavioral pain scale [http://www.icudelirium.org/docs/behavioral-pain-scale.pdf], critical-care pain observation tool (CPOT*) [valid in delirious ICU patients; facial expressions, body movements, muscle tension, compliance with the ventilator for mechanically ventilated patients or vocalization for nonintubated patients- http://www.icudelirium.org/docs/cpot-description-and-directives-020616.pdf]
{| class="wikitable"
*B-Both Spontaneous Awakening Trials (SAT) [daily sedative and narcotic interruptions as long as pain is controlled] and Spontaneous Breathing Trials (SBT): The ABC or Wake Up and Breath study [Girard, 2008; ABC study] found that daily SAT and SBT paired together improved patient outcomes  (i.e. decreased time on the ventilator, reduced time spent in the ICU and hospital, and improved one-year survival)
|'''A'''
*C-Choice of analgesia and sedation: avoid benzodiazepines [barnes 2016]; association between commonly prescribed sedative medications (ex. benzodiazepines---lorazepam is an independent factor for transition to delirium; less of a risk for other sedatives such as morphine, fentanyl, propofol [anes 2006; SICU/TICU benzos 2008]) and delirium; comfort first>>>then goal directed delivery of sedatives
|Assess, prevent and manage pain
*D-Delirium: assess, prevent and manage (see the assessment and monitoring section for details)
|-
>"Repeated reorientation of patients >Provisions of cognitively stimulating activities for the patients multiple times a day >A nonpharmacological sleep protocol--minimize sleep deprivation [brummel] >Early mobilization activities >Timely removal of catheters and physical restraints >Use of eye glasses and magnifying lenses, hearing aids and earwax disimpaction >Early correction of dehydration >Use of a scheduled pain management protocol >Minimization of unnecessary noise/stimuli"
|'''B'''
*E-Early mobility and exercise:
|Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)  
>" safe and feasible in critically ill patients" >"Early mobility decreases days of delirium [lancet 2009, Aust 2009], days on mechanical ventilation [lancet 2009, Aust, 2009], and ICU and hospital length of stay [morris 2008]. Functional outcomes are also improved with early mobility." [lancet, aust 2009] >"only intervention resulting in a decrease in days of delirium."
|-
 
|'''C'''
In addition to ABCDE model, Brummel et al [cite] advocate identifying and correcting individualized causal factors of delirium (ex. minimizing noise and unnecessary interruptions of sleep for a sleep deprived patient with ICU delirium).
|Choice of analgesia and sedation
 
|-
|'''D'''
|Delirium: assess, prevent and manage
|-
|'''E'''
|Early mobility and exercise
|}
In addition to ABCDE model, Brummel et al.<ref name=":2" /> advocate identifying and correcting for individualized causal factors of delirium (ex. minimizing noise and unnecessary interruptions of rest for sleep deprived patients with ICU delirium).
== Implications for Physical Therapy Practice ==
== Implications for Physical Therapy Practice ==
Physical therapists have an integral role in preventing and managing ICU delirium. Perhaps the most important measure is engaging patients in early mobilization, in conjunction with nurses, occupational therapists and physicians. Early mobilization in the ICU decreases the number of days on mechanical ventilation, decreased ICU and hospital length of stay and is the only intervention to date that has been shown to decrease the number of days of delirium. Frequent patient orientation, use of vision and hearing aids and family training/education are additional interventions that can be integrated into evaluation and treatment sessions. The CAM-ICU is a quick and easy tool for assessing and monitoring course of delirium across therapy sessions.
Physical therapists have an integral role in preventing and managing ICU delirium. Perhaps the most important measure is engaging patients in early mobilization, in conjunction with nurses, occupational therapists and physicians. Early mobilization in the ICU decreases the number of days on mechanical ventilation,<ref>Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R, McCallister KE, Hall JB, Kress JP. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373(9678):1874-82</ref><ref name=":4">Needham DM, Chandolu S, Zanni J. Interruption of sedation for early rehabilitation improves outcomes in ventilated, critically ill adults. Aust J Physiother 2009; 55(3):210</ref> decreased ICU and hospital length of stay<ref>Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A, Anderson L, Baker S, Sanchez M, Penley L, Howard A, Dixon L, Leach S, Small R, Hite RD, Haponik E. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008;36(8):2238-43</ref> and is the only intervention to date that has been shown to decrease the number of days of delirium<ref name=":4" />. Frequent patient orientation, use of vision and hearing aids and family training/education are additional interventions that can be integrated into evaluation and treatment sessions.<ref name=":3" /> The CAM-ICU is a quick and easy tool for assessing and monitoring course of delirium across therapy sessions.


== Differential Diagnosis ==
== Differential Diagnosis ==
The multifactorial nature of delirium can make it easy to mistake for other brain conditions. The following conditions should also be considered as sources of altered consciousness and cognitive impairment for patients with suspected ICU delirium:  
The multifactorial nature of delirium can make it easy to mistake for other brain dysfunctions. The following conditions should also be considered in the differential diagnosis of ICU delirium:  
* Infectious (encephalitis, meningitis, UTI, pneumonia)  
* Infectious (encephalitis, meningitis, UTI, pneumonia)  
* Withdrawal (alcohol, barbiturates, benzodiazepines)  
* Withdrawal (alcohol, barbiturates, benzodiazepines)  
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* Toxins, substance use, medication (alcohol, anesthetics, anticholinergics, narcotics)  
* Toxins, substance use, medication (alcohol, anesthetics, anticholinergics, narcotics)  
* Heavy metals (arsenic, lead, mercury)
* Heavy metals (arsenic, lead, mercury)
Source: IABPG. Nursing best practice guidelines: causes of delirium. http://pda.rnao.ca/content/causes-delirium


== Further Reading ==
== Further Reading ==
* ICU Delirium and Cognitive Impairment Study Group. For Medical Professionals-- ABCDEF's of prevention and safety. [http://www.icudelirium.org/medicalprofessionals.html-- http://www.icudelirium.org/medicalprofessionals.html]
* [http://www.icudelirium.org/medicalprofessionals.html ICU Delirium and Cognitive Impairment Study Group]

Revision as of 05:58, 10 March 2018

Introduction[edit | edit source]

As the survival of critically ill patients improves, the development of delirium in the ICU has become a growing public health issue. Delirium is defined as a rapid change in consciousness (hours to days) characterized by reduced environmental awareness, decreased attention and altered cognition. These clinical features can manifest themselves as memory deficits, disorientation, hallucinations, fluctuating levels of alertness and motor abnormalities.[1]

According to Ely et al.,[2] as much as 83% of ICU patients on mechanical ventilation develop delirium. This figure is significant as ICU delirium is associated with negative patient and healthcare outcomes. These outcomes include increased time on mechanical ventilation,[3] longer ICU and hospital length of stay,[4][5] higher health care costs,[6] increased cognitive dysfunction[3] and increased risk of death.[7]

Delirium Subtypes[edit | edit source]

Delirium can be divided into 3 subtypes: hyperactive, hypoactive and mixed. The table below matches each subtype with common clinical manifestations.

Subtype Clinical Manifestations
Hyperactive Agitation, restlessness, emotional lability, hallucinations
Hypoactive Lethargy, decreased responsiveness, slowed motor skills
Mixed Fluctuation between hyper- and hypo- active symptoms

Source: Meagher D. Motor subtypes of delirium: past, present and future. Int Rev Psychiatry. 2009 Feb;21(1):59-73

In critically ill patients, mixed delirium is the most common subtype (54.9%). Hypoactive delirium is second (43.5%), followed by a small percentage (1.6%) of patients who display purely hyperactive symptoms.[8] ICU patients aged 65 and older are particularly susceptible to hypoactive delirium.[8]

Causes and Risk Factors[edit | edit source]

Delirium develops as a result of multiple causes and risk factors. Old age, dementia, depression, smoking and alcohol use are among the personal factors that increase patient risk.[9][10] Another 20+ factors related to the patient's medical condition have been identified by the literature.[11] Below is a common mnemonic used to help clinicians identify potential causes related to illness and treatment:

D Drugs
E Eyes, ears, and other sensory deficits
L Low O2 states
I Infection
R Retention (of urine or stool)
I Ictal state
U Underhydraton/undernutrition
M Metabolic causes

Adapted from: Saint Louis University Geriatrics Evaluation Mnemonics Screening Tools (SLU GEMS). Developed or compiled by: Faculty from Saint Louis University Geriatrics Division and St. Louis Veterans Affairs GRECC.

Additional risk factors common to the hospital setting include absence of daylight, lack of visitors, sleep deprivation, immobility, sedatives and hospital lines/catheters.[9]

Pathophysiology[edit | edit source]

The pathophysiology of delirium is not well understood. Theories related to its development and progression cite anatomical changes in the brain and neurotransmitter imbalances (ex. abnormal levels of serotonin, decreased acetylcholine, excess dopamine) as possible physiologic mechanisms.[12]

Diagnosis[edit | edit source]

Given the unknown pathophysiology, there is no imaging or laboratory tests that can diagnose delirium. As such, delirium is a diagnosis of exclusion that requires careful clinical testing and observation.

Assessment and Monitoring[edit | edit source]

Guidelines for treating Pain, Agitation and Delirium (PAD)[13] recommend two tests for the assessment of delirium in adult ICU patients:

  1. The Intensive Care Delirium Screening Checklist (ICDSC)
  2. The Confusion Assessment Method for the ICU (CAM-ICU)

The following video provides a step by step demonstration of the CAM-ICU.

Prevention and Treatment[edit | edit source]

In 2010, Vasilevskis et al.[14] proposed the ABCDE model to screen and prevent delirium among ICU patients. The mnemonic consists of the following concepts:

A Assess, prevent and manage pain
B Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)
C Choice of analgesia and sedation
D Delirium: assess, prevent and manage
E Early mobility and exercise

In addition to ABCDE model, Brummel et al.[9] advocate identifying and correcting for individualized causal factors of delirium (ex. minimizing noise and unnecessary interruptions of rest for sleep deprived patients with ICU delirium).

Implications for Physical Therapy Practice[edit | edit source]

Physical therapists have an integral role in preventing and managing ICU delirium. Perhaps the most important measure is engaging patients in early mobilization, in conjunction with nurses, occupational therapists and physicians. Early mobilization in the ICU decreases the number of days on mechanical ventilation,[15][16] decreased ICU and hospital length of stay[17] and is the only intervention to date that has been shown to decrease the number of days of delirium[16]. Frequent patient orientation, use of vision and hearing aids and family training/education are additional interventions that can be integrated into evaluation and treatment sessions.[12] The CAM-ICU is a quick and easy tool for assessing and monitoring course of delirium across therapy sessions.

Differential Diagnosis[edit | edit source]

The multifactorial nature of delirium can make it easy to mistake for other brain dysfunctions. The following conditions should also be considered in the differential diagnosis of ICU delirium:

  • Infectious (encephalitis, meningitis, UTI, pneumonia)
  • Withdrawal (alcohol, barbiturates, benzodiazepines)
  • Acute metabolic disorder (electrolyte imbalance, hepatic or renal failure)
  • Trauma (head injury, postoperative)
  • CNS pathology (stroke, hemorrhage, tumour, seizure disorder, Parkinson’s)
  • Hypoxia (anemia, cardiac failure, pulmonary embolus)
  • Deficiencies (vitamin B 12 , folic acid, thiamine)
  • Endocrinopathies (thyroid, glucose, parathyroid, adrenal)
  • Acute vascular (shock, vasculitis, hypertensive encephalopathy)
  • Toxins, substance use, medication (alcohol, anesthetics, anticholinergics, narcotics)
  • Heavy metals (arsenic, lead, mercury)

Source: IABPG. Nursing best practice guidelines: causes of delirium. http://pda.rnao.ca/content/causes-delirium

Further Reading[edit | edit source]

  1. ↑ American Psychiatric A. Diagnostic and statistical manual of mental disorders. 5th edition. Washington, DC: American Psychiatric Association; 2013
  2. ↑ Ely EW1, Inouye SK, Bernard GR, Gordon S, Francis J, May L, Truman B, Speroff T, Gautam S, Margolin R, Hart RP, Dittus R. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001; 286(21): 2703-10
  3. ↑ 3.0 3.1 Salluh J, Wang H, Schneider EB, Nagaraja N, Yenokyan G, Damluji A, Serafim RB, Stevens RD. Outcome of delirium in critically ill patients: systematic review and meta-analysis. BMJ 2015; 350: h2538
  4. ↑ Ely EW, Gautam S, Margolin R, Francis J, May L, Speroff T, Truman B, Dittus R, Bernard R, Inouye SK. The impact of delirium in the Intensive care unit on hospital length of stay. Intensive Care Med 2001; 27:1892-1900
  5. ↑ Thomason JW, Shintani A, Peterson JF, Pun BT, Jackson JC, Ely EW. Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients. Crit Care 2005; 9(4): R375–R381
  6. ↑ Milbrandt, E.B., Deppen, S., Harrison, P.L., Shintani, A.K., Speroff, T., Stiles, R.A., Truman, B., Bernard, G.R., Dittus, R.S., Ely, E.W. Costs Associated with Delirium in Mechanically Ventilated Patients. Crit. Care Med. 32 (4):955-962, 2004
  7. ↑ Ely EW, Shintani A., Truman B, Speroff T, Gordon SM, Harrell FE, Inouye SK, Bernard GR, Dittus RS. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291(14): 1753-62
  8. ↑ 8.0 8.1 Peterson J, Pun BT, Dittus RS, Thomason JW, Jackson JC, Shintani AK, Ely EW. Delirium and its motoric subtypes: a study of 614 critically ill patients. J Am Geriatr Soc. 2006; 54(3):479-84
  9. ↑ 9.0 9.1 9.2 Brummel N, Girard T. Preventing delirium in the intensive care unit. Crit Care Clin 2013; 29(1): 51–65
  10. ↑ McNicoll L, Pisani MA, Zhang Y, Ely EW, Siegel MD, Inouye SK. Delirium in the intensive care unit: occurrence and clinical course in older patients. J Am Geriatr Soc 2003; 51:591-598
  11. ↑ Cavallazzi R, Saad M, Marik PE. Delirium in the ICU: an overview. Ann Intensive Care 2012; 2: 49
  12. ↑ 12.0 12.1 ICU Delirium and Cognitive Impairment Study Group. For Medical Professionals-- ABCDEF's of prevention and safety. http://www.icudelirium.org/medicalprofessionals.html. Accessed March 8, 2018.
  13. ↑ Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013; 41(1):263-306
  14. ↑ Vasilevskis EE1, Pandharipande PP, Girard TD, Ely EW. A screening, prevention, and restoration model for saving the injured brain in intensive care unit survivors. Crit Care Med 2010;38(10 Suppl):S683-91.
  15. ↑ Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R, McCallister KE, Hall JB, Kress JP. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373(9678):1874-82
  16. ↑ 16.0 16.1 Needham DM, Chandolu S, Zanni J. Interruption of sedation for early rehabilitation improves outcomes in ventilated, critically ill adults. Aust J Physiother 2009; 55(3):210
  17. ↑ Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A, Anderson L, Baker S, Sanchez M, Penley L, Howard A, Dixon L, Leach S, Small R, Hite RD, Haponik E. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008;36(8):2238-43
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