Delirium in the Hospital Setting

1. Delirium in the Hospital Setting Mary Fletcher, RN,BS,BSN

4. “1 in 3 survivors of critical illness suffer long-term cognitive impairment consistent with mild to moderate dementia.” • Jackson, JC, Gordon, SM, Hart, RP, Hopkins, RO, Ely EW (2004).The association between delirium and cognitive decline: a review of the empirical literature.Neuropsychological Review Jun;14(2):87-98

5. Objectives • Define delirium and describe how it is different than dementia. • Identify risk factors that may lead to delirium. • Define the three types of delirium. • Discuss interventions for the prevention and treatment of delirium.

6. Delirium Acute onset of disturbance of consciousness in which cognition and perception is altered : • Decline in attention • Decline in cognition • Disturbances of consciousness • Reduced environmental awareness • Disturbed sleep-wake cycle • A waxing and waning course

7. Deliriumvs Dementia Delirium Sudden onset, change from baseline Memory and thinking problems not previously present Usually clears in a few days, but may persist after discharge depending on severity Dementia Develops slowly over months or years Memory and cognition problems on admission Permanent condition Patients with dementia may develop delirium

8. Subtypes of Delirium • Hypoactive- • Reduced psychomotor activity • Reduced alertness • More common in elderly patients • Under recognized • 50% of cases of delirium- poorestprognosis

9. Subtypes of Delirium Hyperactive- • Agitation • Increased responsiveness to stimuli • Overly alert • Trying to remove tubes, lines etc • 25 % of cases of delirium Mixed- • Alternating features of both hypo and hyper active delirium

10. Causes of Delirium • Research suggests that delirium is associated with an imbalance of neurotransmitters • Most prevalent hypothesis is low levels of acetylcholine, high levels of dopamine

11. Causes of Delirium • The mechanisms of delirium are not fully understood • These imbalances can basically be attributed to physiological, or drug induced factors

12. Causes Physiological • Metabolic disturbances • Fluid and electrolyte imbalance, • Infectious process • Sleep deprivation

13. Causes Physiological- • Disturbance in oxygenation • Cardiogenic, • Respiratory, • Impaired 02 utilization

14. Causes Drug-induced- • Drug Intoxification • Alcohol • benzodiazepines • Opioids • Anticholenergics • Street drugs- cocaine, methamphetamine, LSD, heroin, other Opioids, designer drugs or club drugs

15. Causes Drug-induced • Drug Withdrawal • Hyperactive seen with benzodiazepines, anticholenergics, alcohol, nicotine • Drug Side-effects especially in older adults

16. Risk Factors- Baseline • Statistically significant in 2 or more multivariate analyses Admission severity of illness Pre-existing dementia Hx of hypertension Alcoholism Coma • Identified as significant risk in non-ICU literature, conflicting evidence in ICU research Age Immobility

17. Risk Factors-Iatrogenic • Precipitating, may be modifiable • Benzodiazepines- independent risk factor for the transition to delirium • Opioids- dose dependent relationship • Immobility for >3 days in ICU setting

18. Risk Factors- May Contribute Sensory impairment Polydrug treatment Sleep deprivation Undiagnosed medical conditions such as sepsis Cardiovascular disorder Frailty Malnutrition Dehydration

19. Risk Factors-may contribute • Admitted emergently • Fracture on admission • Uncontrolled pain • Male gender • Hx of depression • Psychiatric co-morbidity • Incontinence, fecal impaction

20. Recognition Acute onset- change from baseline behavior usually first noted by nurses or family members Inattention- easily distractible, difficulty focusing Disorganized thinking- irrelevant conversation, unclear, illogical, switching from subject to subject Altered level of consciousness- alert, vigilant, lethargic, stupor, unresponsive

21. Recognition Disorientation- to person, place, time, or situation Memory impairment-unable to follow instructions, impaired short-term memory Psychomotor agitation or retardation- active and restless or sluggish

22. Recognition Altered sleep/wake cycle-insomnia or daytime sleepiness Fluctuating behavior- may have periods of lucidity Perceptual disturbances-hallucination, illusions, misinterpretations

23. “I saw my wife die in a plane crash. The nurses kept saying everything was OK, but I didn’t believe them.” 40 yr old male with chicken pox “I was put in a different room. They told me it was for infection control, but I knew it was for my execution. I'd heard the nurses talk about “CTO”, Compulsory Termination Order. One had been issued for me.” 70 yr old male with sepsis

24. “I was at a cocktail party and I kept saying I had to go back to the hospital. I was still sick. I screamed and screamed. Then you came through the wall in your blue pajamas and I knew I’d be alright.” 38 yr old male with new onset CRF “I could hear babies crying and being killed. I was so scared of everyone, even my Dad.” 24 yr old asthma pt after only 2 days on the vent

25. “The nurses were drinking beer and smoking cigarettes instead of taking are of me. One tried to burn me with a cigarette.” 20 yr old male in TB isolation “The nurses had a microwave oven at the desk and they were making pizza. I thought they didn’t offer me some because they didn’t like me.” 34 yr old female toxic shock syndrome “Dogs were jumping in and out of the window and chipmunks were eating off my lunch tray.” 75 yr old female with pneumonia

26. Confusion Assessment Method- Four Features- must have #1 and #2 • Acute onset and fluctuating course • Inattention and either #3 or #4 or both 3. Altered level of consciousness 4. Disorganized thinking

27. Prevention • Medical history for previous organic brain syndromes or psychiatric conditions, chemdep problems • Evaluation q shift for signs of delirium- CAM, CAM-ICU, ICDSC (Intensive Care Delirium Screening Checklist) • Frequent orientation • Maintain sleep/wake cycle- bright during the day, dark at night

28. Prevention • Sedation vacation for ICU patients • Early mobilization • Multidisciplinary team- RNs, HCAs, MDs, PT, OT, dietitian, family • Medication review

29. Interventions-Medical-Search for and correct medical causes Dehydration Malnutrition Electrolyte imbalance Adequate pain control Hypoxia Sepsis or other inflammatory process Drug or alcohol intoxification or withdrawal

30. Intervention-Medical- Stop contributing to the problem Medications- Review and DC any that may cause delirium : benzodiazepines Opioids anticolenergics

31. Intervention-Medical Medications- consider changing propofol – more research needed, but one study showed no increase in onset of delirium with propofol dexameditomide – 2 large studies showed significant reduction in delirium duration compared to benzos (expensive- cost prohibitive) Consider antipsychotics – little evidence exists to support their use haloperidol, risperidol, quetiapine, olanzapine Currently, no drugs have FDA-approval for the treatment of delirium

32. Nursing Interventions- Supported by Research

33. Interventions-Nursing Mental engagement- exercise the brain Reorientation-clocks, calendars Familiar objects from home- pictures, pillow, blanket Improve sensory input- eye glasses, hearing aides, adequate lighting during the day

34. Interventions-Nursing Calm, clear communication- avoid arguments Avoid restraints, if possible- 1:1 sitter or family member Increased activity as tolerated- early mobilization “Wake up and breathe”- ICU pts

35. Interventions-Nursing Minimize unnecessary noise/stimuli. Promote normal sleep/wake cycle – ear plugs, white noise Quiet Time

36. Sleep • Normal Sleep- periodic reversible state of cognitive and sensory disengagement from the external environment essential for rest, repair, and survival Sedation is not normal sleep • Sleep architecture • Nonrapid eye movement • N1 – light sleep, transition from wakefulness • N2 – less arouseable • N3 - deep sleep, high threshold for arousal, restorative, Role in memory consolidation • Rapid eye movement – • brain highly active, associated with dreaming and perceptual learning, restorative properties

37. Sleep Stages Normal adult hypnogram demonstrating usual sleep stage transitions. REM indicates rapid eye movement sleep

39. EEGs of 5 ICU Patients Sleep fragmentation in 5 critically ill patients. Black areas represent sleep and white areas represent wakefulness

40. Complications • Aspiration pneumonia • Physical injury • Poor fluid and food intake • Prolonged hospitalization • Increased costs • Psychological stress • Functional impairment • Long-term cognitive impairment • Institutionalization • Death

41. Expected Practice- AACN • Implement delirium assessment for all ICU patients using validated tools such as the CAM-ICU • Create strategies to decrease delirium risk factors • Use benzodiazepines with caution

42. Clinical Practice Guidelines Journal of Critical Care Medicine- January, 2013 • Routinely monitor ICU patients for delirium . Most reliable tools are CAM-ICU and ICDSC • Early mobilization • Promote sleep by optimizing patients environments using strategies to control light and noise, to cluster patient care activities and to decrease stimuli at night

43. Clinical Practice Guidelines (cont) • Withhold antipsychotics in patients with baseline prolonged QT, Torsades de Pointes or those receiving other medications known to prolong QT • Do not use rivastigmine to reduce the duration of delirium • Use dexameditomide rather then benzodiazepines unless delirium is related to alcohol or benzo withdrawal

44. Statistics • Estimated 85% of critically ill patients suffer delirium • Delirium unrecognized in 65% of the time • Pts with delirium verses similar unaffected pts: More likely to die within 6 months - 34% vs. 15% Average 5 to 10 day longer hospital stays More likely to end up in a nursing home 16% vs. 3% • Delirium the strongest independent determiner of length of hospital stay

45. Statistics • Psychiatric disturbances- • PTSD 45% at ICU discharge, 24% at 8yrs after discharge • Depression 28% of ICU pts within the first year of ICU discharge • Anxiety disorder- 23-48% of pts 28 months after ICU discharge

46. Statistics • Cognitive dysfunction following delirium Attention/concentration Planning/organizing Memory, short-term, verbal, visual 1 in 3 survivors of critical illness suffer long-term cognitive impairment consistent with mild to moderate Dementia Limited data on long-term cognitive outcomes following delirium. Significant questions remain regarding the nature of long-term effects of delirium

47. Statistics • Costs- • Delirium associated with 35% higher ICU costs • 31% higher costs in med/surg setting • Higher rates of readmission and long-term care needs • Delirium adds an estimated $4-16 billion dollars per year in health care costs

48. ICUdelirium.org

50. References Ali, A., Patel, M., Jabeen, S., Bailey, R., Patel, T., Shahid, M., Riley, W., & Arain, A. (2011), Insight into delirium. Innovations in Clinical Neuroscience, 8(10). Catic, A., (2011). Identification and management of in-hospital drug-induced delirium in older patients. Drugs and Aging 28(9). Conley, D., (2011). The gerontological clinical nurse specialists role in prevention, early recognition, and management of delirium in older adults. Urologic Nursing, 31(6). * Delirium Overview, (2012) Retrieved from http://www.mc.vanderbilt.edu/icudelirium/overview.html. * Kamdar, B., Needham, D., & Collop, N., (2011). Sleep deprivation in critical illness: It’s role in physical and psychological recovery. Journal of Intensive care Medicine. 27(2). * Kuehn, B., (2010), Delirium often not recognized or treated despite serious long-term consequences. Journal of American Medical Association, 304(4)