Sharon M. Gordon PsyD Chief of Psychology, VA TN Valley Health Care System

1. Sharon M. Gordon PsyD Chief of Psychology, VA TN Valley Health Care System Assistant Clinical Professor of Psychiatry Vanderbilt University School of Medicine Delirium Assessment in the ICU: A New Frontier

2. Financial Conflicts None I am a government employee Thank You Federal Tax Payers!!!!

3. Objectives • Participants will learn the 4 features that are present in delirium • Participants will learn to discriminate between delirium and other diagnoses such as dementia • Participants will learn how to administer a brief, bedside tool to diagnose delirium in the ICU • Participants will learn how using this brief tool can improve practice in the ICU

4. So what is a Psychologist doing in the ICU anyway?

8. What Are The Needs in the ICU? • What is the patient’s current mental status? • Does patient understand his/her condition? • Is patient capable of making decisions? • Is patient behavior because of confusion (i.e. delirium) or psychosis? • Common language to describe what we are seeing: confused, agitated, oriented x1, etc. • How can the staff determine all of the above if the patient is on a ventilator?

9. How Can A Psychologist Help Meet These Needs? • Help staff use a common language to describe what they are seeing • Help staff to make decisions based on data rather than subjective opinion • Help staff recognize that cognitive functioning is just as important as physical functioning in the ICU • What exactly are we seeing?????

10. So many terms… • Acute confusional state • ICU Psychosis • Confusion • Acute brain syndrome • Altered mental status • Toxic or metabolic encephalopathy • Sundowning • “He’s agitated” “She’s out of it”

11. Turns out……..

12. What we were seeing was…. DELIRIUM

13. What is Delirium?4 Key Features: • Disturbance of consciousness with reduced ability to focus, sustain or shift attention • A change in cognition or the development of a perceptual disturbance that is not better accounted for by pre-existing, established or evolving dementia Diagnostic Statistical Manual- 4th edition (DSM-IV) Diagnostic Statistical Manual- 4th edition (DSM-IV

14. Delirium Definition Continued: • Develops over a short period of time and tends to fluctuate over the course of the day • There is evidence form the H&P and/or labs that the disturbance is caused by a medical condition, substance intoxication or medication side effect Diagnostic Statistical Manual- 4th edition (DSM-IV)

15. Classic Quote: “Delirium, a Syndrome of Cerebral Insufficiency” “The failure of metabolic processes to maintain the function of the organ or the loss through death of enough functioning units (cells) renders the function of the organ insufficient.” Engel and Romano, J Chron Dis, 9(3):260-277, 1959

16. DeliriumAcute Brain Failure in Man 1980 Zbigniew J. Lipowski, M.D. 1924–1997 “Delirium constitutes a ubiquitous and thus clinically important sign of cerebral functional decompensation caused by physical illness”

17. “Ravelstein” by Nobel Laureate Saul Bellow About his being on ventilator: “…but my head (I assume it was my head) was full of visions, delusions, and hallucinations. These were not dreams or nightmares. Nightmares have an escape hatch…”

18. What is Delirium? Diagnostic Statistical Manual- 4th edition (DSM-IV) 4 Key features: - Disturbance of consciousness with reduced ability to focus, sustain or shift attention - A change in cognition or the development of a perceptual disturbance that is not better accounted for by pre-existing, established or evolving dementia - Develops over a short period of time and tends to fluctuate over the course of the day - There is evidence form the H&P and/or labs that the disturbance is caused by a medical condition, substance intoxication or medication side effect

19. Acute Confusional State Organic Brain Syndrome Reversible Dementia Poor Historian Change in Mental Status Metabolic Encephalopathy Dysergastic Reaction Subacute Befuddlement ICU Psychosis Call a Horse a Horse Delirium

20. Delirium • Acute change in cognition • Develops over hours to days • Fluctuating course throughout the day • Reduced ability to focus, sustain, or shift attention • Disorganized thinking • Disturbance of consciousness • Hyperactive (25%) • Mixed (25%) • Hypoactive (50%)

21. Hyperactive Patient may be combative with agitation that may require sedation (is diagnosed more frequently). Subtypes of Delirium Hypoactive • Patient may be quiet and even peaceful, despite cognitive impairment. More difficult to assess. Mixed • Combination of both types

22. Delirium Subtypes Combative Agitated Restless Alert & Calm Lethargic Sedated Stupor

23. Delirium Subtypes Combative Agitated Restless Alert & Calm Lethargic Sedated Stupor

24. Delirium Subtypes Hyperactive Delirium Combative Agitated Restless Alert & Calm Lethargic Sedated Stupor Hypoactive Delirium

25. Delirium Subtypes Hyperactive Delirium Combative Agitated Restless Mixed Delirium Alert & Calm Lethargic Sedated Stupor Hypoactive Delirium

26. What it is not • Dementia • Depression • Sundowning • Alcohol withdrawal Syndrome • Delirium tremens

27. Delirium rapid onset fluctuation clouded consciousness inattention, disorganized thought not chronic Dementia variable to insidious onset not fluctuating no clouding of consciousness many domains impaired persistent/chronic (?) Delirium versus Dementia Gordon SM, Intensive Care Med 30:1997-2008, 2004 Jackson JC, Intensive Care Med 30:2009-2016, 2004

28. Delirium Definition DSM IV criteria: a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops in a short period of time (hours to days) and fluctuates over time. Three Types: Hyperactive Hypoactive Mixed Diagnostic and Statistical Manual of Mental Disorders (DSM IV)

29. Age over 70 Transfer from a nursing home Renal failure Prior Hx of depression Liver disease Prior Hx of dementia History of CHF History of stroke, epilepsy Cardiogenic or septic shock Alcohol abuse within a month HIV Visual or Hearing Tube feeding Drug OD or illicit drug Rectal or bladder catheters Hypo or hypernatremia Psychoactive meds Central venous catheters Hypo or hyperglycemia Malnutrition Hypo or hyperthyroidism Use of physical restraints Hypothermia or Fever Who is at Risk?

30. Delirium Risk factors for developing? • Underlying dementia • Recent surgery • Dehydration/renal insufficiency • Multiple medications • Older age Inouye SK, et al. Ann Int Med, 1993 Inouye SK, et al. J Ger Psych Neur, 1998

31. Risk Factors • Baseline Vulnerability • Underlying Brain Disease (Dementia, stroke, Parkinson) • Increased Age • Institutionalization • Chronic disease (HIV, ETOH dependency, diabetes, etc) • Visual/Hearing deficits

32. Risk Factors • Precipitating • Medications** • Infection • Dehydration • Immobility/restraints • Malnutrition • Tubes/catheters • Electrolyte imbalance • Sleep Deprivation

33. Causes of Delirium:Common Things are Common • Age and Pre-existing dementia • Sepsis / infections • CHF and other perfusion deficits • Metabolic and hypoxemic circumstances • Immobilization, sleep disruption, sensory deprivation (eyes, ears) • Taking away – withdrawal syndromes (EtOH, nicotine) • Giving - Drugs, drugs, and more drugs

34. Studies of Risk Factors in ICU • In multivariate analysis, hypertension, smoking history, abnormal bilirubin level, epidural use and morphine were statistically significantly associated with delirium • Mean number of risk factors per patient found in one cohort was 11 +/- 4 ! Dubois MJ, ICM 2001;27:1297-1304, n=216 Ely EW, ICM 2001;27:1892-1900 Boogaard M, BMJ. 2012 Feb 9;344:e420 (10 items in final model)

35. Risk Factors • Baseline Vulnerability (predisposing) -Risk factors r/t person’s baseline - Often we cannot modify these • Precipitating • These are things that happen to the patient • Insults • Often Iatrogenic • Baseline + Precipitating = Delirium

36. Framework for Risk Precipitating Stimulus Baseline Vulnerability High Noxious Low Mild/None

37. Framework for Risk Precipitating Stimulus Baseline Vulnerability High Noxious Low Mild/None

38. Framework for Risk Precipitating Stimulus Baseline Vulnerability High Noxious Low Mild/None

39. Framework for Risk Precipitating Stimulus Baseline Vulnerability High Noxious Low Mild/None

40. Framework for Risk Precipitating Stimulus Baseline Vulnerability High Noxious Low Mild/None

41. Key Points: ICU Delirium • 60% to 80% of ventilated patients develop delirium • 20% to 50% of lower severity ICU patients develop delirium • TRANSLATION: right now ~ 30,000 to 40,000 ICU patients are delirious in U.S. alone • Delirium leads to increased mortality, longer hospital stay, poorer recovery, and higher costs of healthcare Ely EW ICM 2001;27:1892-900 Ely EW JAMA 2001;286,2703-2710 Ely EW CCM 2001;29,1370-79 McNicoll L, JAGS 2003;51:591-98 Bergeron N, ICM 2001;27:859-64 Thomason J, AJRCCM 2003;167:A968 Ely EW CCM 2004;32:106-112 Peterson et al, AJRCCM 2003;167:A968

42. Why monitor for Delirium? • 60-80% of ventilated patients develop delirium • 20-50% of lower severity ICU patients develop delirium • Over 40,000 ventilated patients are delirious every day • Delirium leads to increased mortality, longer hospital stay, poorer recovery, and higher costs of healthcare. Ely EW JAMA 2001;286,2703-2710 Ely EW CCM 2001;29,1370-79

43. “Invisible” Organ Dysfunction • 60% to 70% unrecognized • Delirium is not routinely monitored in the ICU 1 • Validated tools - DSC 2 or CAM-ICU 3-4 • Hyperactive vs. Hypoactive delirium • “ICU Psychosis” traditionally an expected outcome • In non-ICU settings, delirium has been associated with prolonged stay, institutionalization, and death 5-7 1 Ely EW CCM 2004;32:106-112 2 Bergeron, ICM 2001;27:859-64 3 Ely EW JAMA 2001;286,2703-2710 4 Ely EW CCM 2001;29,1370-79 5 Inouye, Am J Med 1999;106:565-573 6 Lawlor, Arch Intern Med 2000;160:786-794 7 McCusker, Arch Intern Med 2002;162:457-463

44. Acute MI In-Hospital Mortality Delirium On Admission Develop Delirium Postop Delirium 9% 10-26% 22-76% 4-13% Arch Intern Med 2002;162(4):457-63 Am J Psychiatry 1999;156(5 Suppl):1-20 JAMA 1994;271(2):134-9 NEJM 1995;335:1857-63 www.ahrq.gov

45. Delirium Monitoring in ICUs - 1999

46. Delirium Monitoring in ICUs - 2007

47. Morandi et al, Intensive Care Med 2008 Morandi et al, Intensive Care Med 2008

48. …The biggest problem is that “doctors are focused only on the organs that got patients into the hospital, ignoring newly acquired brain problems…”

49. Delirium Pathophysiology • Flacker, et al. Gerontol. Bio Scie 1999; 54A: B239-B246

50. Delirium Pathophysiology • Flacker, et al. Gerontol. Bio Scie 1999; 54A: B239-B246