1. ICU Psychosis / Delirium
Dawn Oddie

2. Session Contents Psychosis or delirium? Different types
Contributing factors – pre-existing and in ICU
Symptoms
Causes
Management strategies – medical / nursing
Summary

3. What is it? Recognised in the literature since the 1960’s
Poorly recognised in practice
Recognised that a significant proportion of critically ill patients will suffer from it (15 – 80%)
Associated with poor patient outcomes – increased length of stay and impacts on morbidity and mortality

4. Typical patient scenario
Patient wakes to an abnormal situation,
environment. Deprived of all normality.
Experience multiple physical, mental insults and
alien stimuli.
Exposed to numerous medications, procedures,
monitoring devices.
Surprise, surprise
some patients do not cope well!

5. ICU Psychosis?
Psychosis ‘a severe mental derangement esp. when resulting in delusions and lack of contact with external reality.
The term ICU psychosis implies that the signs and symptoms are associated with a psychiatric disorder, which is the origin of a true psychosis.
Assumed that behavioural signs and symptoms are associated with psychiatric disorder. Rarely are the indications of delirium related to a psychiatric disorder.

6. Greek word de-lira means ‘off the track’
ICU Delirium?
Delirium ‘is an acute reversible organic mental syndrome with disorder of cognitive function, increased or decreased psychomotor activity and a disorder of sleep wake cycle.’
Greek word de-lira means ‘off the track’
Rarely are the indications of delirium related to actual psychiatric disorders
(Justic, 2000)

7. Term is old fashioned, inaccurate
ICU psychosis
Term is old fashioned, inaccurate
and not appropriate
(Borthwick et al 2006)

8. Sub types of delirium 1 – Hypoactive delirium
Global and non specific cerebral dysfunction
Characteristics – withdrawal, lethargy, lack of responsiveness, disorientation
Often related to processes such as infection, hypoxia, hypothermia, hypothyroidism, hyperglycaemia, hepatic & renal insufficiencies
(Type often mistaken for depression – note disorientation is common with delirium, but is not a feature of depression)

9. (Which type is the most harmful for the patient?)
Sub types of delirium
2 – Hyperactive delirium
More specific causes, affecting only certain neurotransmitters in the brain – associated with adverse effects of drug intoxication, chemical withdrawal, and anticholinergic agents
Characteristics – extreme agitation, emotional lability, continual movement, disorientation, unable to follow commands, unintelligible / inappropriate verbal responses, pain is exaggerated
(Which type is the most harmful for the patient?)

10. Mixed Delirium – 2 types
Patients can fluctuate between both types. A number of cerebral mechanisms are being affected because two or more causal factors are occurring almost simultaneously

11. Pathophysiology Exact mechanisms unknown
Thought to be related to neurotransmitter imbalances – dopamine, y-aminobutyric acid & acetylcholine
May involve – Seritonin imbalance, endorphin hyperactivity, increased central noradrenergic activity, damaged interneuronal enzyme system

12. Components of Delirium
Disordered attention or arousal
Cognitive dysfunction (perception, thinking & memory)
Development of acute signs and symptoms
A medical not psychiatric cause
(Hartwick, 2003)

13. Existing predisposing risk factors
Multi-system illnesses – haemodynamic instability
Patient-ventilator desynchrony
Alcohol / drug abuse
Disrupted sleep – wake cycle
Advancing age
Medications – drug side effects / withdrawal
Acidosis
Hypoxaemia
Pain
Severe infection
Frustration
Immobilisation
Cerebral illnesses – dementia, stroke
(Borthwick etal, 2006)

14. Presenting symptoms Lack of awareness of surroundings Disorientation
Distractibility
Memory impairment
Inability to follow commands
Disturbance of sleep-wake cycle

15. Presenting symptoms Speech may be limited, rambling or incoherent
Perceptual disturbances – illusions, hallucinations, delusions
Mood instability – anxiety, fear, anger, depression through to euphoria

16. Should we think differently??
ICU Staff
Staff are accustomed to the sights, sounds and technology – easy to not appreciate the negative impact on the patient
Accept the fact that patients are restless, sleep fitfully and intermittently and are deprived of the everyday comforts of home
Should we think differently??

17. What can we do to help? Recognise the signs
Minimise the contributing factors
Consider psychiatric consultation
Patient safety – mittons, lap belts / cot sides
Management care plan

18. Detection of delirium Validated scoring systems to monitor
sedation and agitation
Sedation Agitation Scale (SAS)
Richmond Agitation Sedation Scale (RASS)
Motor Activity Assessment Scale (MAAS)
Delirium screening tools
Intensive Care Delirium Screening Checklist (ICDSC)
Delirium Detection Score (DDS)
Confusion Assessment Method for the ICU (CAM-ICU)

19. Environmental factors
Strange environment
Noise
Physical restraint
Medical terminology
Strip lighting
Environmental factors
Malnutrition
Drugs
Invasive lines
Abnormal routines
Loss of dignity
Beds

20. Drugs Drugs that exhibit antimuscarinic or dopaminergic
activity are particularly associated with the development
of delirium. Drugs commonly used that have been
shown to be deliriogenic,
Analgesics – codiene, fentanyl, morphine, pethidine
Antidepressants – amitriptyline, paroxetine
Anticonvulsants – phenytoin, phenobarbital
Antihistamines – chlorphenamine, promethazine
Antiemetics – prochlorperazine
Antipsychotics – Chlorpromazine
Antimuscarinics – atropine, hyoscine
Cardiovascular agents – Atenalol, digoxin, dopamine, lidocaine
Corticosteroids – Hydrocortisone, dexamethasone, prednisolone
Hypnotic agents – diazepam, thiopental
Misc – Furosemide, ranitidine
(Litton, 2003)

21. Contributing factors
Often develops in those individuals who are not well managed in terms of pain, sedation and analgesia
Sleep and sensory deprivation, insomnia, pain, continuous stimulation, isolation, and fear set in motion the process of delirium
Dipex

22. Management strategies - care
1. Reorientation
2. Distraction
3. Reduction in stimuli
4. Maintenance of a normal sleep – wake cycle
5. Therapeutic stimulation

23. 1. Reorientation Informal conversational approach Involve the family
Patients normal daily activities
Time of day
Weather
Repetition of explanations and information is necessary
Involve the family

24. Limited attention span
2. Distraction
Fixated by a topic leading to agitation and hyperactive behaviour
Limited attention span
Introduce an alternative topic of conversation / visual stimuli / music
Involve the family

25. 3. Reduction in stimuli Decrease lighting that creates a shadow
Decrease conversations held in earshot of patient
Decrease unnecessary noise (alarm limits)
Cluster care
Avoid putting suffers next to each other

26. 4. Sleep – wake cycle
Reduce sleep disturbances and sleep interruptions
REM sleep (occurs 70 – 90mins into sleep cycle)
Circadian rhythms
Limit interventions at night
Rest periods during day
(Honkus, 2003)

27. 5. Therapeutic stimulation
Reality based stimulation
Use of vision, hearing & mobility aids
Orientating cues – clocks, calendar, personal items, use of windows
Involve the family

28. Medical management
Behavioural changes dismissed as ICU psychosis – treated with sedatives and antipsychotic medications
Neuroleptic agents eg haloperidol, droperidol
Sedation holds
Sedation / pain scores
Rationalising drug regimes
Rationalising monitoring
Rationalising invasive lines

29. Summary ICU Delirium - causes multifactorial
Causes - some not preventable, some are preventable
Early recognition of signs and symptoms
Active early management strategies using multiple tactics

30. Questions?