ICU Psychosis / Delirium Dawn Oddie

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

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

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!

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.

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)

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

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)

(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?)

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

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

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)

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)

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

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

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??

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

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)

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

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)

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

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

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

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

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

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)

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

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

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

Questions?