Title: Sharon M. Gordon PsyD
1Delirium 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
2Financial Conflicts
- None
- I am a government employee
- Thank You Federal Tax Payers!!!!
3Objectives
- 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
4So what is a Psychologist doing in the ICU
anyway?
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8What 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?
9How 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?????
10So 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
11Turns out..
12What we were seeing was.
13What 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
14Delirium 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)
15Classic 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
17Ravelstein 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
18What 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
19Call 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
20Delirium
- 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)
21Subtypes 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
22Delirium Subtypes
Combative Agitated Restless
Alert Calm
Lethargic Sedated Stupor
23Delirium Subtypes
Combative Agitated Restless
Alert Calm
Lethargic Sedated Stupor
24Delirium Subtypes
Hyperactive Delirium
Combative Agitated Restless
Alert Calm
Lethargic Sedated Stupor
Hypoactive Delirium
25Delirium Subtypes
Hyperactive Delirium
Combative Agitated Restless
Mixed Delirium
Alert Calm
Lethargic Sedated Stupor
Hypoactive Delirium
26What it is not
- Dementia
- Depression
- Sundowning
- Alcohol withdrawal Syndrome
- Delirium tremens
27Delirium 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
28Delirium 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)
29Who 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
30Delirium
- 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
31Risk Factors
- Baseline Vulnerability
- Underlying Brain Disease (Dementia, stroke,
Parkinson) - Increased Age
- Institutionalization
- Chronic disease (HIV, ETOH dependency, diabetes,
etc) - Visual/Hearing deficits
32Risk Factors
- Precipitating
- Medications
- Infection
- Dehydration
- Immobility/restraints
- Malnutrition
- Tubes/catheters
- Electrolyte imbalance
- Sleep Deprivation
33Causes of DeliriumCommon 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
34Studies 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)
35Risk 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
36Framework for Risk
Precipitating Stimulus
Baseline Vulnerability
High
Noxious
Low
Mild/None
37Framework for Risk
Precipitating Stimulus
Baseline Vulnerability
High
Noxious
Low
Mild/None
38Framework for Risk
Precipitating Stimulus
Baseline Vulnerability
High
Noxious
Low
Mild/None
39Framework for Risk
Precipitating Stimulus
Baseline Vulnerability
High
Noxious
Low
Mild/None
40Framework for Risk
Precipitating Stimulus
Baseline Vulnerability
High
Noxious
Low
Mild/None
41Key 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
42Why 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
44In-Hospital Mortality
Delirium On Admission
Develop Delirium
Postop Delirium
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
45Delirium Monitoring in ICUs - 1999
46Delirium Monitoring in ICUs - 2007
47Morandi et al, Intensive Care Med 2008
Morandi et al, Intensive Care Med 2008
48The biggest problem is that doctors are focused
only on the organs that got patients into the
hospital, ignoring newly acquired brain problems
49Delirium Pathophysiology
Flacker, et al. Gerontol. Bio Scie 1999 54A
B239-B246
50Delirium Pathophysiology
Flacker, et al. Gerontol. Bio Scie 1999 54A
B239-B246
51Monitoring 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
54Two 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)
55Richmond 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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57How 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
58Ely EW, JAMA 20032892983-91
59Two 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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