ICU DELIRIUM

Thomas Tobinson, MDAssociate Professor, Surgery

August 5th, 2009AGS

WHO CARES ABOUT THE BRAIN?

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WHY IS DELIRIUM IMPORTANT?

DELIRIUM

Most common postoperative complication in the elderly

Closely related to adverse outcomes

Potentially preventable, and there is room to improve treatment

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WHAT IS DELIRIUM?

Curr Opin Crit Care (2005) 11:360.

Delirium is an acute, fluctuating change in mental status, with inattention and altered levels of consciousness

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DIAGNOSTIC CRITERIA FOR DELIRIUM

• Coexisting physiologic disturbance

• Acute onset

• Disturbance of consciousness

• Change in cognition

Diagnostic and Statistical Manual of MentalDisorders DSM IV - Fourth Edition (1994). Slide 5

MULTIFACTORIAL MODEL OF DELIRIUM

JAMA (1996) 275:852.

Predisposing Factors/Vulnerability

Precipitating Factors/Insults

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MULTIFACTORIAL MODEL OF DELIRIUM

JAMA (1996) 275:852.

High Risk

Low Risk

DELIRIUM

Predisposing Factors/Vulnerability

Precipitating Factors/Insults

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MULTIFACTORIAL MODEL OF DELIRIUM

JAMA (1996) 275:852.

High Vulnerability

Low Vulnerability

Noxious Insult

Less Noxious Insult

High Risk

Low Risk

DELIRIUM

Predisposing Factors/Vulnerability

Precipitating Factors/Insults

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MULTIFACTORIAL MODEL OF DELIRIUM

JAMA (1996) 275:852.

High Vulnerability

Low Vulnerability

Noxious Insult

Less Noxious Insult

Predisposing Factors/Vulnerability

Precipitating Factors/Insults

High Risk

Low Risk

DELIRIUM

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Cataract surgery1 < 5%

Medical ward2 15%Vascular operation3 36%Hip fracture4 40%VA SICU5 44%Trauma ICU6 59%Medical ICU7 72%

INCIDENCE OF DELIRIUM

1. Int Psych (2002) 14:301.

2. NEJM (1999) 340:669.

3. Gen Hosp Psych (2002) 24:28.

4. JAGS (2002) 50:850.

5. Ann Surg (2009) 249:173.

6. Am J Surg (2008) 196:864.

7. JAGS (2006) 54:479.

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MULTIFACTORIAL MODEL OF DELIRIUM

JAMA (1996) 275:852.

High Vulnerability

Low Vulnerability

Noxious Insult

Less Noxious Insult

Predisposing Factors/Vulnerability

Precipitating Factors/Insults

High Risk

Low Risk

DELIRIUM

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RISK FACTORSFOR DELIRIUM AFTER TRAUMA

Pre-existing Patient Factors

Injury- specific Factors

Emergency Room

Findings

Operative Variables

ICU Variables

TRAUMA TIMELINE

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Am J Surg (2008) 196:864.

PREEXISTING RISK FACTORS

DELIRIUM

Present(n = 41)

Absent(n = 28)

Age, years 48 ± 22 38 ± 16 P < .03

AUDIT Score (alcohol abuse) 9 ± 9 10 ± 11 P < .71

Charlson Index (comorbidities) 0.7 ± 1.3 0.4 ± 1.3 P < .35

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↑Age

RISK FACTORSFOR DELIRIUM AFTER TRAUMA

Pre-existing Patient Factors

Injury- specific Factors

Emergency Room

Findings

Operative Variables

ICU Variables

TRAUMA TIMELINE

Slide 14

Am J Surg (2008) 196:864.

INJURY-SPECIFIC RISK FACTORS

DELIRIUM

Present(n = 41)

Absent(n = 28)

Injury Severity Score 26 ± 12 20 ± 9 P < .02

Head AIS 2.3 ± 2.0 1.7 ± 1.7 P < .20

Abdomen AIS 0.7 ± 1.4 0.9 ± 1.5 P < .48

Extremity AIS 1.5 ± 1.7 1.0 ± 1.6 P < .28

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↑Age ↑ISS

RISK FACTORSFOR DELIRIUM AFTER TRAUMA

Pre-existing Patient Factors

Injury- specific Factors

Emergency Room

Findings

Operative Variables

ICU Variables

TRAUMA TIMELINE

Slide 16

Am J Surg (2008) 196:864.

EMERGENCY ROOM RISK FACTORS

DELIRIUMPresent(n = 41)

Absent(n = 28)

Systolic blood pressure (arrival) 129 ± 35 132 ± 22 p = .60

Heart rate (arrival) 98 ± 20 90 ± 21 p = .10

Glascow Coma Score (arrival) 12 ± 4 15 ± 1 p < .01

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↑Age ↑ISS ↓GCS

RISK FACTORSFOR DELIRIUM AFTER TRAUMA

Pre-existing Patient Factors

Injury- specific Factors

Emergency Room

Findings

Operative Variables

ICU Variables

TRAUMA TIMELINE

Slide 18

Am J Surg (2008) 196:864.

OPERATIVE RISK FACTORS

DELIRIUMPresent(n = 41)

Absent(n = 28)

Number of operations 1.3 ± 1.3 0.4 ± 0.6 P < .01

Anesthesia time, minutes 267 ± 289 99 ± 178 P < .01

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↑Age ↑ISS ↓GCS ↑Operations↑Anesthesia

RISK FACTORS FOR DELIRIUM AFTER TRAUMA

Pre-existing Patient Factors

Injury- specific Factors

Emergency Room

Findings

Operative Variables

ICU Variables

TRAUMA TIMELINE

Slide 20

Am J Surg (2008) 196:864.

ICU RISK FACTORS

DELIRIUMPresent(n = 41)

Absent(n = 28)

Max. base excess (1st 24 hours) 7.7 ± 4.7 4.8 ± 3.2 P = .11

Lowest hematocrit, % 31 ± 9 36 ± 8 P = .01

Blood transfusion total, units 2.8 ± 4.4 0.5 ± 1.5 P < .01

Multiple Organ Failure Score 1.2 ± 1.4 0.04 ± 0.2 P < .01

Required mechanical ventilation 92% 41% P < .01

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↑Age ↑ISS ↓GCS ↑Operations↑Anesthesia

↓Hct↑Transfusion↑ MOF ScoreNeeded Vent

RISK FACTORSFOR DELIRIUM AFTER TRAUMA

Pre-existing Patient Factors

Injury- specific Factors

Emergency Room

Findings

Operative Variables

ICU Variables

TRAUMA TIMELINE

MULTIFACTORIAL MODEL OF DELIRIUM

JAMA (1996) 275:852.

High Vulnerability

Low Vulnerability

Noxious Insult

Less Noxious Insult

Predisposing Factors/Vulnerability

Precipitating Factors/Insults

High Risk

Low Risk

DELIRIUM

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AGE AND POSTOPERATIVE DELIRIUM

0

20

40

60

80

100

5059 6069 7079 8089

Age, years

Incidence of

Delirium,%

Ann Surg (2009) 249:173.Slide 24

PREOPERATIVE RISK FACTORS

DELIRIUM

Present(n = 64)

Absent(n = 80)

Age, years 69 ± 9 61 ± 6 P < .001

Albumin, g/dL 3.3 ± 0.8 3.9 ± 0.4 P < .001

Hematocrit, % 38 ± 7 44 ± 4 P < .001

Functional status 91 ± 11 99 ± 3 P < .001

Cognitive dysfunction 2.8 ± 1.6 4.6 ± 0.7 P < .001

Comorbidities 4.6 ± 2.4 1.8 ± 1.4 P < .001

Ann Surg (2009) 249:173.Slide 25

INTRAOPERATIVE RISK FACTORS

DELIRIUM

Present (n = 64)

Absent (n = 80)

Blood loss, mL 752 ± 1033 655 ± 1515 P = .73

OR time, minutes 298 ± 137 282 ± 105 P = .44

Intraop hypotension (SBP < 90) 88% 27% P < .001

Ann Surg (2009) 249:173.Slide 26

MULTIFACTORIAL MODEL OF DELIRIUM

JAMA (1996) 275:852.

High Vulnerability

Low Vulnerability

Noxious Insult

Less Noxious Insult

Predisposing Factors/Vulnerability

Precipitating Factors/Insults

High Risk

Low Risk

DELIRIUM

Slide 27

WHY IS DELIRIUM IMPORTANT?

DELIRIUM

Most common postoperative complication in the elderly

Closely related to adverse outcomes

Potentially preventable, and there is room to improve treatment

Slide 28

DELIRIUM AND POOR OUTCOMES

• Increased length of hospital stay

• Increased hospital cost

• Increased need for institutionalization

• Increased mortality

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OUTCOMES AND DELIRIUM: TRAUMA ICU

DELIRIUM

Present(n = 41)

Absent(n = 28)

ICU stay, days 8 ± 1 2 ± 1 P < .01

Hospital stay, days 15 ± 2 6 ± 1 P < .01

Discharge institutionalization 85% 44% P < .01

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OUTCOMES AND DELIRIUM: VA

DELIRIUM

Present(n = 64)

Absent(n = 80)

ICU stay, days 9.7 ± 8.0 4.6 ± 2.1 P < .001

Hospital stay, days 16.3 ± 10.9 7.9 ± 3.9 P < .001

Hospital cost, $1,000s 50.1 ± 33.6 31.6 ± 14.1 P < .001

Institutionalization 33% 1% P < .001

Ann Surg (2009) 249:173.Slide 31

MORTALITY AND DELIRIUM

DELIRIUM

Present(n = 64)

Absent(n = 80)

In-hospital mortality 5% 0% P = .086

30-day mortality 9% 1% P = .045

6-month mortality 20% 3%a P = .001

a n=78 (2 patients lost to 6-month follow-up)

Ann Surg (2009) 249:173.Slide 32

MOTOR SUBTYPES OF DELIRIUM

• A spectrum of psychomotor behavior is found in delirium

• Delirium motor subtypes: Hypoactive Hyperactive Mixed type

J Neuropsychiatry Clin Neurosci (2000) 12:51. Slide 33

RICHMOND AGITATION-SEDATION SCORE+4 Combative+3 Very agitated+2 Agitated+1 Restless 0 Alert/calm-1 Drowsy-2 Light sedation-3 Moderate sedation-4 Deep sedation-5 Unarousable

JAMA (2003) 289:2983. Am J Resp Crit Car Med (2002) 166:1228. Slide 34

MOTOR SUBTYPES OF DELIRIUM

+4 Combative+3 +2 +1 Restless 0 Alert/calm-1 Drowsy-2 -3 -4 -5 Unarousable

JAMA (2003) 289:2983. Am J Resp Crit Car Med (2002) 166:1228.

HYPERACTIVE

HYPOACTIVE

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MOTOR SUBTYPES OF DELIRIUM

+4 Combative+3 +2 +1 Restless 0 Alert / Calm-1 Drowsy-2 -3 -4 -5 Unarousable

JAMA (2003) 289:2983. Am J Resp Crit Car Med (2002) 166:1228.

MIXED

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MOTOR SUBTYPES OF DELIRIUM: INCIDENCE

Post-Op SICU Medical ICU Trauma ICUHypoactive 66% 44% 46%

Hyperactive 1% 2% 15%

Mixed type 33% 55% 39%

JAGS (2006) 54:479.Ann Surg (2009) 249:173.Am J Surg (2008) 196:864. Slide 37

MOTOR SUBTYPES OF DELIRIUM: OUTCOMES

DVAMC

MOTOR SUBTYPE

No deliriumn = 98

Mixedn = 23

Hypoactiven = 50

Age, years 60 ± 6 65 ± 9 71 ± 9 P = .001

6-month mortality 3% 9% 32% P = .041

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MOTOR SUBTYPES OF DELIRIUM:ADVERSE EVENTS

DVAMC

MOTOR SUBTYPE

Hypoactive(n = 8)

Mixed(n = 11)

Pulled line/tube 25% 82% P = .024

Sacral decubitus ulcer 75% 0 P = .001

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WHY IS DELIRIUM IMPORTANT?

DELIRIUM

Most common postoperative complication in the elderly

Closely related to adverse outcomes

Potentially preventable, and there is room to improve treatment

Slide 40

PREVENTING DELIRIUM IN THE HOSPITALIZED ELDERLY

• Hypothesis: Reducing the number of risk factors for delirium will prevent delirium in hospitalized elderly patients

• Methods• 852 hospitalized medical patients• Older than 70 years• Compare effectiveness of reducing the risk

factors for delirium to standard of care

NEJM (1999) 340:669. Slide 41

NEJM (1999) 340:669.

MULTICOMPONENT INTERVENTIONSTO PREVENT DELIRIUM

Risk factors Intervention

• Cognitive impairment

• Orientation protocol

• Sleep deprivation • Sleep enhancement

• Immobility • Early mobilization

• Visual impairment • Early vision correction

• Hearing impairment • Hearing protocol

• Dehydration • Change BUN/Cr ratio

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PREVENTING DELIRIUM IN THE HOSPITALIZED ELDERLY

NEJM (1999) 340:669.

STUDY GROUP

Intervention Usual care

Incidence of delirium 9.9% 15.0% P = .02

Total days of delirium 105 161 P = .02

Episodes of delirium 62 90 P = .03

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PREVENTING DELIRIUM IN THE HOSPITALIZED ELDERLY

NEJM (1999) 340:669.

Conclusion

Implementing supportive protocols to patients at high risk of developing delirium can prevent the occurrences and reduce the duration of delirium

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IDENTIFIABLE CAUSES OF DELIRIUM

DELIRIUMS (mnemonic) DEL I R I U MSS

rugs (anticholinergics, polypharmacy)motional (depression)ow PO2 states (MI, PE, anemia, CVA) nfection (sepsis)etention of urine or stoolctal states (seizure, post-ictal)ndernutrition/underhydration etabolic (electrolytes, glucose)ubdural (acute CNS processes) ensory (impaired vision or hearing)

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MEDICAL EVALUATION OF DELIRIUM

H&P evaluation• Mental status• Neuro exam• History of substance

abuse• Vital signs• Review of medications

Laboratory tests• CBC• Glucose• Electrolytes• BUN/Cr• UA• O2 Saturation

Clin Med (2006) 6:303.Slide 46

IDENTIFIABLE CAUSES OF DELIRIUM

0

20

40

60

80

100

No identifiablecause

Identifiablecause

Delirium,%

Ann Surg (2009) 249:173.Slide 47

THE BIPHASIC DISTRIBUTION OF POSTOPERATIVE DELIRIUM

0

5

10

15

20

25

30

1 3 5 7 9 112 4 6 8 10 12

Postoperative day

No identifiable cause of delirium

Delirium due to an identifiable causeNumber of subjects

Ann Surg (2009) 249:173.Slide 48

Haloperidol 2 mg q20 min (while agitation persists)

OR

Degree of agitation Initial dose of haloperidolPO, IM or IV

Mild 0.252 mg

Moderate 24 mg

Severe 48 mg

PHARMACOLOGIC TREATMENT: ICU

Crit Care Med (2002) 30:119. Slide 49

PHARMACOLOGIC TREATMENT: ICU

• Maintenance dose 50% of total loading dose is the maintenance

dose, divided every 68 hours daily Continue maintenance dose for 2448 hours

before tapering

• Taper maintenance dose by 20%30% daily until off

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PHARMACOLOGIC TREATMENT: ICU

Haloperidol AdministrationControl Moderate agitation

2:00 AM – 2 mg IV2:30 AM – 2 mg IV3:00 AM – 2 mg IV3:30 AM – Agitation controlled

Maintain 1 mg TID IV or PO 24 hoursKeep daily dose for 24–48 hours

Taper 0.5 mg PO BID for 24 hr, then DC

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• General recommendation Haloperidol 12 mg q24 hr PRN May be administered PO, IM, or IV

• For elderly patients Haloperidol 0.250.5 mg q4 hr PRN

PHARMACOLOGIC TREATMENT: WARD

American Psychiatric Association. Practice Guideline for Treatment of Patients with Delirium (1999). Slide 52

WHY IS DELIRIUM IMPORTANT?

DELIRIUM

Most common postoperative complication in the elderly

Closely related to adverse outcomes

Potentially preventable, and there is room to improve treatment

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