Delirium IN ICU BY KIRSTY RYAN AND ALISTAIR

Delirium IN ICU BY KIRSTY RYAN AND ALISTAIR WHITE

Contents: What is Delirium? Why is it important? How do we recognise it? What causes it? How do we prevent it? How do we treat it?

Definition: An acute state of confusion (NICE, 2010) Acute onset, fluctuating confusion Inattention Impaired consciousness Disordered thinking

Types of Delirium Hyperactive restlessness, agitation, aggression. Hypoactive delirium: (Most Common) sleepy, withdrawn and quiet, difficult to recognise. Mixed! Hypo-Hyperactive Delirium

Why is it important? Prevalence! 33 - 85% of people in ICU develop delirium. It increases mortality three fold! Delirium is associated with poor short and long term outcomes. It increases risk of long hospital stays. It causes distress to patients, families and staff! It can be difficult to manage. Approximately half of all episodes of delirium are preventable !

How would it feel? Frustrating. Anxiety provoking. Confusing. Upsetting. Despair. Exhausting. People can also develop PTSD from their experience of delirium!

PTSD and Delirium in ICU A patient who has experienced Delirium in ICU can go onto develop PTSD well after their delirium has resolved. PTSD: when a person has flash backs, anxieties and fears surrounding their past experiences in ICU with Delirium, to the point where it is affecting their day-to-day activities. They may be so affected they refuse appointments, or even stop going out. Early recognition and referral to psychology!

How do we recognise Delirium? Symptom recognition Regular CAM ICU assessments!

Symptoms: Less aware of surroundings. Auditory hallucinations. Reduced ability to orientate to surroundings. Visual hallucinations. Concerned that other people are trying to harm them. Sleeping during the day and waking up during the night. Have moods that quickly change. Confusion at particular times: evenings and nights. Unable to follow conversation/ speak clearly. Paranoia. Vivid dreams that may continue when someone wakes up.

CAM ICU It takes 2 minutes to do Fast access: on the back of your ICU chart! It is evidence based.

What Causes Delirium? Patient Illness Iatrogenic Pre-morbid Cognitive Status Infection / Sepsis Surgical / Bypass Time Co-morbidities Organ Dysfunction Drugs / Sedatives Age ARDS Blood Transfusion + Anaemia Hearing/Visual Impairment Metabolic Disturbance Environment Alcohol/ Smoking/ Drug use Hypotension Sleep

How do we prevent it? Treat Illnesses as much as possible. Adjust Iatrogenic causes (What we do) as much as possible! Use a Targeted RASS system: so we reduce sedation! Delirium is not always preventable!

Targeted RASS RED (RASS -3/-5) Clinical condition requires deeper level of sedation (RASS -3/-5) to facilitate resuscitation, interventions and stabilisation. AMBER (RASS -2/-1) Clinical condition requires moderate level of sedation (RASS -2/-1) to enable continued stabilisation and optimisation of clinical condition. GREEN (RASS> -1) Clinical condition ready for sedation to be stopped and trail of extubation.

Targeted RASS Communication is clear between Consultant and Nursing staff. Less sedation lowing the risk of delirium. Amber sedation can allow for CAM-ICU assessment – early recognition. Amber and green are the best, allowing for spontaneous breathing (good for lungs and delirium prevention).

How do we treat it? Early recognition through CAM-ICU Assessment! Non-Pharmacological Treatment

Non-Pharmacological Management Sleep Hygiene Orientation Family Early Mobilisation Early De-catheterisation “Peek-a-Boo” Mitts Nutrition Support the family too – offer diaries.

Sleep Hygiene Lack of sleep can cause delirium! Promote a healthy sleep pattern. Reduce noises and lights at night. Reduce as much as possible the number of interventions. Make sure people are not too warm/cold as this disturbs sleep. Don’t let sleep deprivation go on for days!

Pharmacological Treatment Sedation cause delirium! Aim for a Low RASS with minimal sedation Daily sedation holds and spontaneous breathing trials Look for and treat pain Consider Alpha Agonists: Clonidine/ Dexmedetomidine Avoid Benzodiazepines Treat withdrawal Treat underlying illnesses – Temp, sepsis, metabolic, Anaemia, Pain Haloperidol/ quetiapine as per ACC delirium guidelines.

ACC Delirium Guidelines Hyperactive Hypoactive TBI Associated Delirium Haloperidol Risperidone Olanzapine/ Quetiapine Haloperidol (low dose only) Clonidine/ Dexmedetomidine Consider and Treat Sleep Deprivation Dexmedetomidine/ Clonidine

Rescue for Severe Agitation Midazolam 5 mg IV Repeat 10 mins if required OR Lorazepam 0. 5 – 1 mg Propofol infusion

Sleep Deprivation Trazadone 50 - 100 mg Zopiclone 7. 5 – 15 mg

Do pharmacological interventions actually make a difference to incidence of delirium? Pharmacological treatments remain controversial. Risk of treatment has to be weighed up against benefits. There are lots of small and not so robust trials for the treatment of delirium. Evidence is controversial and sometimes contradictory. There is not enough evidence to change current practice but this is a developing area of research. Several trials investigating the efficacy of antipsychotics show they achieve treatment objectives in most patients but not all. Antipsychotics can have negative side-effects on cognitive function, over-sedation and can lead to a prolonged QT interval and Torsades de Points. A SMALL recent trial with a one off dose of intra-operative dexamethasone has shown to lower incidence of delirium in Cardiac Surgery. Again this is not enough evidence to change practice as yet – further more robust evidence needs to be presented. Trazadone is a non-tricyclic anti-depressant that helps with insomnia. Effective in the elderly.

How patients and family said they wanted to be looked after … Ensure patient and staff safety - monitoring - increase staff to patient ratio. Communicate with MDT. Consistency and sharing of knowledge between staff. Stay calm - including family members! Ensure staff and family are well supported. Education. Humour. Flexible visiting. Reassurance delirium is not permanent. Use patient dairies!!!

Is it applicable to Neuro? Targetted RASS and CAM-ICU are still applicable to Neuro ICU. It can be difficult to distinguish neurological deficit and delirium. Innovative ways of communication can still allow effective assessment. Early referral to AHP can aid early mobilisation and thorough assessments in differentiating delirium and neurological deficits. A positive CAM-ICU in Neuro can identify deterioration of neurological function. Neuro – ICU and HDU are currently trialling a new restraining mitt!

Any other reasons to implement? … Plan, Implement, Assess, Evaluate How can we as an MDT justify management plans, treatment plans, administration of medications if a validated assessment has not been used to diagnose the condition? They have delirium …said who, how do you know? … The validated assessment tool CAM-ICU confirms diagnosis and justifies subsequent treatments. Most of the non-pharmacological prevention and management points are beneficial to the patient for more than just delirium centred. Optimisation can increase patient recovery, patient flow. Cost effective!

Quiz! How common is Delirium in ICU? Name two types of delirium. What is the most common type of delirium? Name 2 things that we may do in ICU that increase risk of delirium. Where is the CAM-ICU assessment tool? Name 2 different non-pharmacological treatment approaches. Name 2 Pharmacological treatment approaches.

References / Useful Resources Bannon, L, et al. 2016. Impact of non- pharmacological interventions on prevention and treatment of delirium in critically ill patients: protocol for a systematic review of quantitative and qualitative research. Systematic Reviews. 5(75). Pp 1 -9. 10. 1186/s 13643 -016 - 0254 -0 Burns, K. et al. 2009. Delirium after Cardiac Surgery: A retrospective case-control study of incidence and risk factors in a Canadian Sample. BC Medical Journal. 51(5). Pp 206 -210. Healthcare Improvement Scotland. 2013. Staff, patients and families experiences of giving and receiving care during an episode of delirium in an acute hospital care setting. [Online]. [Accessed: 14/04/2016]. Available from: http: //www. healthcareimprovementscotland. org/our_work/person-centred_care/opac_improvement_programme/delirium_report. aspx Kostera, S. et al. 2011. Risk Factors of Delirium after Cardiac Surgery: A Systematic Review. European Journal of Cardiovascular Nursing. 10(4). Pp 197 -204. National Institute for Health and Care Excellence. 2010. Delirium: prevention, diagnosis and management. [Online]. [Accessed: 12/04/2016]. Available from: https: //www. nice. org. uk/guidance/cg 103/chapter/introduction Page, V et al. 2009. Routine delirium monitoring in a UK critical care unit. Critical Care. 13(1), R 16. Peterson, J. et al. 2006. Delirium and its motoric subtypes: a study of 614 critically ill patients. Journal of the American Geriatrics Society. 54(3). Pp 479 -484 Royal College of Psychiatrists. 2012. Delirium. [Online]. [Accessed: 12/04/2016]. Available from: http: //www. rcpsych. ac. uk/healthadvice/problemsdisorders/delirium. aspx Zaal, J. et al. 2015 A systematic Review of risk factors for delirium in the ICU. Critical Care. 43(1). Pp 40 -47. http: //www. icudelirium. org/docs/CAM_ICU_training. pdf