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Sharon M. Gordon PsyD

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Title: Sharon M. Gordon PsyD


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

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?
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What Are The Needs in the ICU?
  • What is the patients 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
  • Hes agitated Shes 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 HP 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
Delirium Acute Brain Failure in
Man 1980
Zbigniew J. Lipowski, M.D. 19241997
  • 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 HP and/or labs that the
disturbance is caused by a medical condition,
substance intoxication or medication side effect
19
Call a Horse a Horse
  • Acute Confusional State
  • Organic Brain Syndrome
  • Reversible Dementia
  • Poor Historian
  • Change in Mental Status
  • Metabolic Encephalopathy
  • Dysergastic Reaction
  • Subacute Befuddlement
  • ICU Psychosis

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

Gordon SM, Intensive Care Med 301997-2008,
2004 Jackson JC, Intensive Care Med 302009-2016,
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
Who is at Risk?
  • 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
  • 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

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 DeliriumCommon Things are Common
  1. Age and Pre-existing dementia
  2. Sepsis / infections
  3. CHF and other perfusion deficits
  4. Metabolic and hypoxemic circumstances
  5. Immobilization, sleep disruption, sensory
    deprivation (eyes, ears)
  6. Taking away withdrawal syndromes (EtOH,
    nicotine)
  7. 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 2001271297-1304, n216 Ely EW,
ICM 2001271892-1900 Boogaard M, BMJ. 2012 Feb
9344e420 (10 items in final model)
35
Risk Factors
  • Baseline Vulnerability (predisposing)
  • -Risk factors r/t persons 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 2001271892-900 Ely EW JAMA
2001286,2703-2710 Ely EW CCM 200129,1370-79 McNi
coll L, JAGS 200351591-98
Bergeron N, ICM 200127859-64 Thomason J, AJRCCM
2003167A968 Ely EW CCM 200432106-112 Peterson
et al, AJRCCM 2003167A968
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 2001286,2703-2710
  • Ely EW CCM 200129,1370-79

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 200432106-112 2 Bergeron, ICM
200127859-64 3 Ely EW JAMA 2001286,2703-2710 4
Ely EW CCM 200129,1370-79 5 Inouye, Am J Med
1999106565-573 6 Lawlor, Arch Intern Med
2000160786-794 7 McCusker, Arch Intern Med
2002162457-463
44
In-Hospital Mortality
Delirium On Admission
Develop Delirium
Postop Delirium
  • Acute MI

9
4-13
22-76
10-26
Arch Intern Med 2002162(4)457-63 Am J
Psychiatry 1999156(5 Suppl)1-20 JAMA
1994271(2)134-9 NEJM 19953351857-63 www.ahrq.g
ov
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
51
Monitoring and Support of Organ Dysfunction
Cardiovascular
Pulmonary
Renal
52
  • How do you monitor for brain failure (i.e.
    delirium)?

53
Triad of Neurologic Monitoring
Arousal SAS, RASS, MAAS
Delirium CAM-ICU
Consciousness Wakefulness Content
Physiological Brain Activity BIS-EEG, ERP, P300
Plum and Posner Diagnosis of Stupor and Coma
54
Two Step Approach to Assessing Consciousness
  • Step 1 Level
  • Sedation Assessment (Ramsay, SAS, RASS)
  • Step 2 Content
  • Delirium Assessment (CAM-ICU)
  • Intensive Care Delirium Screening Checklist
  • (ICDSC)

55
Richmond Agitation-Sedation Scale(RASS)
  • 4 Combative
  • 3 Very agitated
  • 2 Agitated
  • 1 Restless
  • 0 Alert /calm
  • -1 Drowsy eye contact gt10 sec
  • -2 Light sedation eye contact lt10 sec
  • -3 Moderate no eye contact
  • -4 Deep physical stimulation required
  • -5 Unarousable no response even with physical

Verbal Stimulus
Physical Stimulus
Sessler CN, et al. AJRCCM 2002 1661338-1344.
Ely et al, AJRCCM 2001163A954
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How was it validated?
  • Monitoring Sedation Status Over Time in ICU
    Patients Reliability and Validity of the Richmond
    Agitation-Sedation Scale (RASS)
  • 290-paired observations by nurses
  • RASS demonstrated excellent inter-rater
    reliability
  • Able to detect changes in sedation status over
    time
  • Against level of consciousness and delirium
  • Correlated with doses of sedatives and analgesics
  • Ely EW et al JAMA. 20032892983-2991

58
Ely EW, JAMA 20032892983-91
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Two Step Approach to Assessing Consciousness
  • Step 1 Level
  • Sedation Assessment (Ramsay, SAS, RASS)
  • Step 2 Content
  • Delirium Assessment (CAM-ICU)
  • Intensive Care Delirium Screening Checklist
  • (ICDSC)

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