This course is designed to educate the student to the important role critical care nurses play in assessing, diagnosing, treating, and evaluating delirium in the critically ill patient. Focus will be placed on identification of delirium in order to provide interventions that decrease the complications associated with delirium. The role of the nurse in standardized assessment of delirium will be presented. Special focus will be on the geriatric patient as this population has a greater risk for developing delirium.
Course Objectives
Define delirium
State 3 types of delirium
Discuss the severity of the problem for critically ill patients
List the signs and symptoms of delirium
Describe the standardized assessment tools for delirium in the mechanically ventilated patient
List 2 non-pharmacological interventions for prevention and treatment of delirium
List 2 pharmacological interventions for treatment of delirium in the ICU patient
Describe geriatric considerations when assessing and treating ICU delirium
About Delirium:
Post-operative confusion, acute confusion, ICU syndrome, or ICU psychosis are terms that have traditionally been used to describe states where a patient is confused, has hallucinations, or shows increased activity or levels of agitation. More accurately, delirium, is the term that should be used to describe these behaviors. Delirium is defined as a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time (hours to days) and fluctuates over time. Hypoactive, hyperactive, and mixed are three types of delirium. Hyperactive delirium is associated with agitation and characterized by restlessness, fidgeting, pulling out tubes and lines, and sometimes combativeness. Hypoactive delirium is a lethargic level of consciousness, inactivity, and apathy. Mixed delirium is characterized by fluctuation between hypoactive and hyperactive. In the ICU setting, delirium is noted to be a fluctuating mental status, inattention, disorganized thinking, and an altered level of consciousness that may or may not be accompanied by agitation. Patients are at high risk of developing ICU delirium due to the stressful nature and constant stimuli of the environment.
The serious threat of delirium in ICU patient and the association with increased length of ICU stay, increased hospital stay, increased time on the ventilator, higher ICU costs, a 3-fold increase risk of death, and potential long term cognitive impairment should spark the urgency of prevention, identification, and treatment of delirium in the ICU for the critical care nurse. The inclusion of ICU delirium in the 2002 Society of Critical Care Medicines’ (SCCM) clinical practice guideline for the sustained use of sedation and analgesia provides a standardized approach to identification and treatment of delirium in the ICU.
Pathophysiology of Delirium:
The exact pathophysiology of delirium is unknown. Mechanisms for the development of delirium that have been proposed include: insufficiency of cerebral metabolism, a central abnormality caused by an imbalance of central cholinergic and adrenergic metabolism, an impairment in cerebral oxidative metabolism, and a stress reaction as evidence by abnormally high circulating corticosteroids. Imbalance of dopamine, GABA, and acetylcholine is also implicated in the pathophysiology of delirium.
The etiology of delirium in the ICU has been attributed to both general medical conditions and substance-induced delirium and may be a sign of organ dysfunction.
General medical conditions that may cause delirium include:
Other precipitating and contributory factors may include:
Physical restraints
Urinary catheterization
Malnutrition
Dehydration
Abnormal sodium, potassium, and blood glucose
Social isolation
New and different environment
Why is Delirium a Concern for ICU Nurses?
The inability of the critically ill intubated patient to communicate verbally makes it difficult to assess for delirium. Due to the difficulty in assessing and identifying delirium in ICU patients, delirium goes largely unrecognized. Delirium has traditionally been thought of as a normal, temporary condition with few long-term consequences, so focus on delirium as a high priority for the safe care of patients has not been emphasized. Delirium in now believed to affect approximately 50% of critically ill patients and 50% to 80% of ventilated patients. Assessment of delirium has been difficult because, until 2001, there where no published assessment tools for the nonverbal, intubated patients. Many of the medications that are provided to patients in order to treat their underlying disease process may also contribute to the development of delirium. The leading cause of delirium in the critically ill patient includes many of the medications given to the ICU patients to treat their underlying condition and provide comfort. For example, drugs with anticholinergic properties, benzodiazepines, narcotics, and other psychoactive drugs pose the greatest risk for developing delirium. Increased length of stay, increased risk of death in the ICU, and increased risk of death 6 months after discharge highlights the importance of prevention and early recognition of delirium.
Recognizing Delirium:
Signs and symptoms of delirium include cognitive, behavioral, and physiologic components and typically occur around day 2 or 3 of ICU admission.
Cognitive signs of delirium:
Diminished attention span
Reduced ability to focus
Disorientation to person, place, and time
Confusion over daily events
Hallucinations (visual are more common)
Abnormal results on a mental status examination
Behavioral signs of delirium:
Excessive restlessness
Sluggishness and lethargy
Inappropriate behavior
Irritability
Picking or groping at bed linens, gown
Attempting to get out of bed
Crying out, screaming, moaning, muttering
Personality changes
Changes in affect
Physiologic signs of delirium:
Tremors (alcohol withdrawal)
Seizures (alcohol withdrawal)
Typical signs of hyperactive type delirium include:
Over alertness
Increased in psychomotor activity
Heightened response to stimuli
Typical signs of hypoactive delirium include:
Apathetic
Lethargic
Due to the subtle signs of symptoms associated with hypoactive delirium it is often undiagnosed or misdiagnosed.
Delirium Diagnostic Tools:
Two tools that are used to assess delirium in the ICU are, “The Intensive Care Delirium Screening Checklist” and the “Confusion Assessment Method or the ICU (CAM-ICU)”. The CAM-ICU was adapted from the Confusion Assessment Method (CAM). The CAM-ICU provides an assessment method for patients who are mechanically ventilated and unable to communicate verbally. The benefit of using the CAM-ICU is that it does not require the assessment to be done by a specifically trained individual. The assessment tool can be completed in less than 2 minutes by nurses and doctors with no formal psychiatric training.
The CAM-ICU has four features, which are determined by the patient, nurse, and family interview:
Feature 1: an acute onset of mental status changes or a fluctuating course
Feature 2: inattention
Feature 3: disorganized thinking
Feature 4: an altered level of consciousness
The patient is diagnosed as delirious if both features 1 and 2 and either 3 or 4 are positive.
The worksheet that can be used for the assessment of delirium:
Feature 1: Acute Onset or Fluctuating Course
Positive if you answer ‘yes’ to either 1A or 1B.
Positive
Negative
1A: Is the pt different than his/her baseline mental status?
Or
1B: Has the patient had any fluctuation in mental status in the past 24 hours
as evidenced by fluctuation on a sedation scale (e.g. RASS), GCS, or
previous delirium assessment?
Yes
No
Feature 2: Inattention
Positive if either score for 2A or 2B is less than 8.
Attempt the ASE letters first. If pt is able to perform this test and the score is clear,
record this score and move to Feature 3. If pt is unable to perform this test or the
score is unclear, then perform the ASE Pictures. If you perform both tests, use the
ASE Pictures’ results to score the Feature.
Positive
Negative
2A: ASE Letters: record score (enter NT for not tested)
Directions: Say to the patient, “I am going to read you a series of 10 letters. Whenever you hear the letter
‘A,’ indicate by squeezing my hand.” Read letters from the following letter list in a normal tone.
S A V E A H A A R T
Scoring: Errors are counted when patient fails to squeeze on the letter “A” and when the patient squeezes
on any letter other than “A.”
Score (out of 10): ______
2B: ASE Pictures: record score (enter NT for not tested)
Directions are included on the picture packets.
Score (out of 10): ______
Feature 3:Disorganized Thinking
Positive if the combined score is less than 4
Positive
Negative
3A: Yes/No Questions
(Use either Set A or Set B, alternate on consecutive days if necessary):
Set A Set B
1. Will a stone float on water? 1. Will a leaf float on water?
2. Are there fish in the sea? 2. Are there elephants in the sea?
3. Does one pound weigh more than 3. Do two pounds weigh
two pounds? more than one pound?
4. Can you use a hammer to pound a nail? 4. Can you use a hammer to cut wood?
Score ___(Patient earns 1 point for each correct answer out of 4)
3B:Command
Say to patient: “Hold up this many fingers” (Examiner holds two fingers in
front of patient) “Now do the same thing with the other hand” (Not repeating
the number of fingers). *If pt is unable to move both arms, for the second part of the command
ask patient “Add one more finger)
Score___(Patient earns 1 point if able to successfully complete the entire command)
Combined Score (3A+3B):
_____ (out of 5)
Feature 4: Altered Level of Consciousness
Positive if the Actual RASS score is anything other than “0” (zero)
Overall CAM-ICU (Features 1 and 2 and either Feature 3 or 4):
Early recognition of delirium is a key to decreasing the complications associated with delirium. Goals of care for the patient with delirium include:
Patient is oriented to person, time and place
Patient does not demonstrate signs or symptoms of anxiety, fear, and confusion
Patient responds to simple, concrete questions
Treatment of delirium, according to the 2002 SCCM clinical practice guidelines, falls within the category of patient comfort and should include assessment and treatment of pain and sedation level. Treatment should also focus on the underlying condition and removing the cause so that the patient condition improves and long-term consequences are minimized. Interventions for delirium include both non-pharmacological and pharmacological interventions. No interventions have been specifically tested for efficacy in the ICU, but interventions that have been used to decrease delirium outside the ICU are:
Repeatedly reorienting patient
Providing cognitively stimulating activities
Non-pharmacological sleep protocols
Early mobilization activities
Range-of-motion exercises
Removal of catheters and restraints
Use of patients eye glasses and magnifying lenses
Use of hearing aids and removing earwax
Correcting dehydration
Scheduled pain protocols
Minimizing unnecessary noise and stimuli
Decreasing interruptions in the sleep wake cycle to increase patient comfort.
Medication Review:
Reviewing the patients’ current medications is essential in providing treatment. The patient may be receiving pharmacologic agents that are causing or contributing to the state of delirium. Focus should be on sedative, analgesics, and anti-cholinergic drugs that may be prescribed for the patient. There are no drugs that the US Food and Drug Administration have approved for the treatment of delirium. The SCCM guidelines do include the use of haloperidol (Haldol) as a treatment recommendation, but this medication has not been studied specifically in the ICU patient. The recommended dose of haloperidol (Haldol) mg IVP every 6 hours, but the side effects must be monitored closely. Prolonged QT interval, torsades de pointes, and extrapyramidal side effects can occur and should be monitored for closely. Haldol is classified as an antipsychotic, Butyrophenone, & dopamine agonist. The FDA indications for Haldol include Gilles de la Tourette’s syndrome, hyperactive behavior, psychotic disorders, and schizophrenia. The mechanism of action of Haldol is complex and not completely established. It is known to produce a selective effect on the central nervous system (CNS) by competitive blockade of postsynaptic dopamine (D2) receptors in the mesolimbic dopaminergic system and an increased turnover of brain dopamine to produce tranquilizing effects. . Haldol is metabolized via the hepatic system. Contraindications to administering Haldol include: comatose states, hypersensitivity to Haldol, Parkinson’s disease, and toxic central nervous system depression. Common adverse effects of Haldol are hypotension, constipation, Xerostomia, Akathisia, Dystonia, Extrapyramidal disease, Parkinsonia, somnolence, and blurred vision.
Nursing CE Course
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