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Excellence • Innovation • Diversity

Kathleen M. Cox, PhD(c), DNP, APRN, ACNP-BC, CNE

Delirium in Acute Care: Do We

Know It When We See It?

Participants will be able to:

differentiate delirium from common conditions that mimic delirium; classify types of delirium; and discuss techniques to utilize in the clinical environment to identify delirium

recognize and apply types of delirium assessments and describe how they may be incorporated in the clinical environment

compare and contrast sedation and “wake up and breathe” protocols and delirium screening instruments for potential use in the ICU and acute care

choose and apply delirium prevention and treatment strategies for use in acute care

Number of ICU beds as proportion of all hospital beds increased about 30% in 30 years

Reduction in critical illness mortality and increase in survivors

Up to 70% of ICU/critical illness survivors have long-term physiologic and cognitive symptoms

Geriatric population suffer more loss of cognitive and independent functionality

Development of ICU delirium major factor in long-term cognitive impairment (LTCI)

Estimated to complicate 2 million admissions annually

Other complications include higher mortality, increased risk of stroke, more rapidly advancing dementia, and poor post-illness quality of life

Delirium identified as independent risk factor for increased mortality, longer ICU and hospital stays, increased costs

…so what can we do?

Early intervention and management!

Acute brain dysfunction

Clinical recognition of extent, seriousness, and dimension of delirium in acute care settings

Less than half of acute care settings utilize a delirium screening tool

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DSM V definition:

◦ disturbance in attention with reduced ability to focus, direct, sustain, or shift attention combined with reduced awareness and orientation to immediate surrounding environment

◦ acute onset over hours to days that tends to fluctuate in severity over the course of any 24 hour period

◦ additional disturbance in cognitive functioning either in memory, orientation, language use, visuospatial abilities or in sensory perception

Acute change or fluctuation of cognitive status that includes inattention and disorganized thinking or altered level of consciousness

Three recognized types: hyperactive, hypoactive, and mixed

Most obvious is hyperactive

Most common is hypoactive

Hypoactive and mixed delirium more strongly associated with long-term deficits in mobility, executive function, learning, and memory

BRAIN-ICU study: 25% of patients that manifested delirium had cognitive impairment @ 1 yr that mimics Alzheimer’s and other symptoms “typically associated with TBI”

Duration of delirium also independent risk factor for worse executive function @ 1 year

Critical care is complicated & task-heavy, some providers unaware of delirium prevalence so may not be prioritized

Traditional approaches lean on sedation, assumptions about cognitive baseline in elders

Belief that delirium is temporary & “expected”

Idea that delirium is recognizable without use of screening instruments

Sedation-related delirium rapidly reversible (about 12% of patients) but 75% have “persistent delirium”

Delirium screening must be part of comprehensive approach that includes sedation protocols

Assessing serially throughout the day best approach because of fluctuating nature of delirium

Two recommended screening instruments are CAM-ICU and ICDSC

Intensive care delirium screening checklist (ICDSC)

Meta-analysis of CAM-ICU and ICDSC demonstrated moderate sensitivity and good specificity

Gusamo-Flores, D., Salluh, J.I., Chalhub, R.A., & Quarantini, L. (2012). The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis

of delirium: A systematic review and meta-analysis of clinical studies. Critical Care, 16:R115. http://ccforum.com/content/16/4/R115

http://ccforum.com/content/16/4/R115

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Confusion Assessment Method for the ICU (CAM-ICU)

Gusamo-Flores, D., Salluh, J.I., Chalhub, R.A., & Quarantini, L. (2012). The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis

of delirium: A systematic review and meta-analysis of clinical studies. Critical Care, 16:R115. http://ccforum.com/content/16/4/R115

Meta-analysis rated CAM-ICU “excellent” as a diagnostic tool for delirium in critically ill patients

Society of Critical Care Medicine (SCCM) established pain, agitation (sedation), delirium, immobility & sleep disruption guidelines (PADIS)

Pain management requires consistent approach = standardized pain mgmt protocols & careful multimodal titration

Analgesia before sedation using validated pain assessment tools = reduction of sedation, LOS, and pain intensity

Agitation/sedation: light sedation, avoid benzos if possible, consider dexmedetomidate

Delirium: regular assessment with a validated instrument; multicomponent non-pharmacologic interventions recommended

Immobility: focus on functional optimization and disability reduction

Sleep: No routine physiologic sleep monitoring; suggest A/C for ventilated patients; noise & light reduction

ABCDEF bundle to align & coordinate care for elements related to delirium prevention & mgmt

Assess, Prevent, & Manage Pain

Both Spontaneous Awakening & Spontaneous Breathing Trials

Choice of Analgesia & Sedation

Delirium: Assess, Prevent, and Manage

Early Mobility & Exercise

Family Engagement and Empowerment

Use of the ABCDEF bundle demonstrates improved clinical outcomes, better ICU survival, less post-ICU impairment an increases in restraint-free care

http://ccforum.com/content/16/4/R115

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Basis for any sedation protocol must be a validated sedation scale

Richmond Agitation/Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) widely studied in r/t delirium

Similar rates of delirium assessment in conjunction with CAM-ICU

First steps were reinforcement and standardization of SAT/SBTs and RASS

Education initiatives and inservices held for CAM-ICU prior to implementation

Kappa value .61 indicated strong agreement between investigator & staff in ID of delirium

Less agreement when Kappa calculated for RASS scoring

Other findings included:

◦ differences in expectations between surgery and medicine physician teams

◦ Perpetuation of misinformation and bad habits of long-established practice patterns

◦ Differences in patient behavior in timing of investigator and nurse’s assessment

◦ Misunderstanding of RASS relationship to CAM-ICU

Things to THINK about with +delirium patients

Toxic situations & Tight Titration

Hypoxemia

Infection/Immobilization

Nonpharmacologic interventions

K+ or electrolyte imbalances

DELIRIUM-S

Drugs

Eyes, ears

Low oxygen states

Infection

Retention, restraints

Ictal

Underhydration, undernutrition

Metabolic

Subdural, sleep deprivation

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Infection

Withdrawal

Acute metabolic states

Trauma

CNS pathology

Hypoxia

Deficiencies

Endocrinopathies

Acute vascular events

Toxins or drugs

Heavy metals

I WATCH DEATHCOCOA PHSS Delirium Dementia

Consciousness Decreased or hyper Alert

Orientation Disorganized Disoriented

Course Fluctuating Steady decline

Onset Acute/subacute Chronic

Attention Inattention Usually normal

Psychomotor Agitated or lethargic Usually normal

Hallucinations Perceptual disturbance Usually absent

Sleep/wake cycle Abnormal Usually normal

Speech Slow, incoherent Aphasic, anomic, or difficulty

finding words

Strict use of sedation protocols with minimal sedation emphasized

SBT/SAT trials for ventilated patients strongly associated with less sedation, shorter vent and ICU days

Use drugs with lower delirium profile for sedation (DEXCOM study)

Atypical antipsychotics may be used instead of or with haloperidol

Prevention is best!

Targeting common factors such as immobilization, sleep deprivation, hearing & visual impairment, dehydration reduces risk of delirium

Even passive ROM is effective if patient cannot do active ROM

Early mobility should consist of multidisciplinary intervention with PT/OT, nursing staff, physicians

Brummel, N., Girard, T., Ely, E., Pandharipande, P., Morandi, A., Hughes, C.,…Jackson, J. (2014). Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial. Intensive Care Medicine, 40(3), 370-379.

Repeated re-orientation of patients

Large clocks & calendars in patient rooms

Sleep protocols-minimize unnecessary noise, lights

Removal of restraints, catheters

Keep glasses/hearing aids near

Scheduled pain management

Early mobilization

Cognitive activities

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Delirium identification with validated instrument a must

Delirium prevention & treatment requires multidisciplinary approach

Delirium protocols must be part of comprehensive strategy that involves pain & sedation management

Delirium prevention & treatment largely nursing-driven but requires interdisciplinary buy-in

ABCDEF bundle an evidence-based, validated approach to implementation

Balas, M., Vasilevskis, E., Olsen, K., Schmid, K., Shostrom, V., Cohen, V., …Burke, W. (2014). Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Critical Care Medicine, 42(5), 1024-1036.

Barnes-Daly, M.A., Phillips, G., Ely, E., (2017). Improving hospital survival and reducing brain dysfunction at seven California community hospitals: Implementing PAD guidelines via the ABCDEF bundle in 6,064 patients. Critical Care Medicine, 45(2), 171-178.

Brummel, N., Girard, T., Ely, E., Pandharipande, P., Morandi, A., Hughes, C.,…Jackson, J. (2014). Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial. Intensive Care Medicine, 40(3), 370-379.

Devlin, J., Roberts, R., Fong, J., Skrobik, Y., Riker, R., Hill, N., Robbins, T., & Garpestad, E. (2010). Efficacy & safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, double-blind, placebo-controlled pilot study. Critical Care Medicine, 38(2), 419-427

Girard, T., Kress, J., Fuchs, B., Thomason, J., Schweickert, W., Pun, B., …Ely, E. (2008). Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care [Awakening and Breathing Controlled Trial]: a randomized controlled trial. Lancet, 12(371), 126-134

Jackson, J., Pandharipande, P., Girard., T., Brummel, N.,Thompson, J., Hughes, C., …Ely, E. (2014). Depression, post-traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: a longitudinal cohort study. Lancet, 2(5), 369-379.

Pandharipande, P., Girard, T., Jackson, J., Morandi, A., Thompson, J., Pun, B., …Ely, E. (2013). Long-term cognitive impairment after critical illness. New England Journal of Medicine, 369, 1306-1316.

Patel, M., Jackson, J., Morandi, A., Girard, T., Hughes, C., Thompson, J., Kiehl, A., Elsatd, M., Wasserstein, M., Goodman, R., Beckham, J., Chandrasekhar, R., Dittus, R., Ely, E., & Pandharipande, P. (2016). Incidence & risk factors for Intensive-Care Unit-related Post-traumatic stress disorder in veterans and civilians. Am J of Respiratory & Critical Care Medicine, 193(12), 1373-1381.

Pun, B., Balas, M., Barnes-Daly, M.A., Thompson, J., Aldrich, J.M., Barr, J., …Ely, E. (2014). Caring for critically ill patients with the ABCDEF bundle: Results of the ICU liberation collaborative in over 15,000 adults. Critical Care Medicine, 47(1), 3-14.

Wallace, D., Angus, D., Seymour, C., Barnato, A., & Kahn, J. (2015). Critical care bed growth in the United States. Am J of Respiratory & Critical Care Medicine, 191(4), 410-416.

Wilcox, M. E., Brummel, N.E., Archer, K., Ely, E.W., Jackson, J.C., Hopkins, R.O. (2013). Cognitive dysfunction in ICU patients: risk factors, predictors, and rehabilitation interventions. Critical Care Medicine, 41, S81-S98.

ABCDEF Bundle

ICUdelirium.org

https://www.icudelirium.org/medical-professionals/overview

Questions?

https://www.icudelirium.org/medical-professionals/overview