ICU Delirium - Physiopedia

As the survival of critically ill patients improves, ICU delirium has become a growing public health issue. Delirium is defined as a rapid change in ... Search Search Search Togglenavigation pPhysiopedia pPhysiopedia About News Contribute Courses Resources Contact Donate Login pPhysiopedia About News Contribute Courses Resources Shop Contact Donate p o + Contents Editors Categories Share Cite Contentsloading... Editorsloading... Categoriesloading... Whenreferingtoevidenceinacademicwriting,youshouldalwaystrytoreferencetheprimary(original)source.Thatisusuallythejournalarticlewheretheinformationwasfirststated.InmostcasesPhysiopediaarticlesareasecondarysourceandsoshouldnotbeusedasreferences.Physiopediaarticlesarebestusedtofindtheoriginalsourcesofinformation(seethereferenceslistatthebottomofthearticle).IfyoubelievethatthisPhysiopediaarticleistheprimarysourcefortheinformationyouarereferingto,youcanusethebuttonbelowtoaccessarelatedcitationstatement.Citearticle ICUDelirium Jumpto:navigation,search OriginalEditor-KarenWilsonTopContributors-KarenWilson,KimJackson,AdamVallelyFarrell,UchechukwuChukwuemekaandAdmin Contents 1Introduction 2DeliriumSubtypes 3CausesandRiskFactors 4Pathophysiology 5Diagnosis 6AssessmentandMonitoring 7PreventionandTreatment 8ImplicationsforPhysicalTherapyPractice 9DifferentialDiagnosis 10FurtherReading 11References Introduction[edit|editsource] Source:WikimediaCommons,Author:Calleamanecer,License:CreativeCommons Attribution-ShareAlike3.0UnportedAsthesurvivalofcriticallyillpatientsimproves,ICUdeliriumhasbecomeagrowingpublichealthissue.Deliriumisdefinedasarapidchangeinconsciousness(hourstodays)characterizedbyreducedenvironmentalawareness,decreasedattentionandalteredcognition.Theseclinicalfeaturescanmanifestthemselvesasmemorydeficits,disorientation,hallucinations,fluctuatinglevelsofalertness,andmotorabnormalities.[1] AccordingtoElyetal[2]asmuchas83%ofICUpatientsonmechanicalventilationdevelopdelirium.ThisfigureissignificantasICUdeliriumisassociatedwithnegativepatientandhealthcareoutcomes.Theseoutcomesinclude: increasedtimeonmechanicalventilation,[3] increasedlikelihoodofbeingdischargedtoalong-termcarefacility[4] longerICUandhospitallengthofstay,[5][6] elevatedhealthcarecosts,[7] increasedcognitivedysfunction,[3] andincreasedriskofdeath.[8] DeliriumSubtypes[edit|editsource] Deliriumcanbedividedinto3subtypes:hyperactive,hypoactive,andmixed.Thetable[9]belowmatcheseachsubtypewithcommonclinicalmanifestations. Subtype ClinicalManifestations Hyperactive Agitation,restlessness,emotionallability,hallucinations Hypoactive Lethargy,decreasedresponsiveness,slowedmotorskills Mixed Fluctuationbetweenhyper-andhypoactivesymptoms Incriticallyillpatients,mixeddeliriumisthemostcommonsubtype(54.9%).Hypoactivedeliriumissecond(43.5%),followedbyasmallpercentageofpatientswhodisplaypurelyhyperactivesymptoms(1.6%).[10]ICUpatientsaged65andolderareparticularlysusceptibletohypoactivedelirium.[10] CausesandRiskFactors[edit|editsource] Deliriumdevelopsasaresultofmultiplecausesandriskfactors.Oldage,dementia,depression,smoking,andalcoholuseareamongthepersonalfactorsthatincreasepatientsusceptibility.[11][12]Inaddition,another20+riskfactorsrelatedtomedicalstatushavebeenidentifiedbytheliterature.[13]Belowisacommonmnemonicusedtohelpcliniciansidentifycausesrelatedtoillnessandtreatment: IllnessandTreatment-RelatedCausesofDelirium D Drugs E Eyes,ears,andothersensorydeficits L LowO2states(e.g.heartattack,stroke,andpulmonaryembolism) I Infection R Retention(ofurineorstool) I Ictalstate U Underhydraton/undernutrition M Metaboliccauses(DM,Post-operativestate,sodiumabnormalities) [Adaptedfrom:SaintLouisUniversityGeriatricsEvaluationMnemonicsScreeningTools(SLUGEMS).Developedorcompiledby:FacultyfromSaintLouisUniversityGeriatricsDivisionandSt.LouisVeteransAffairsGRECC.] Inhospitals,othercommonriskfactorsincludetheabsenceofdaylight,lackofvisitors,sleepdeprivation,immobility,andhospitallines.[11] Pathophysiology[edit|editsource] Thepathophysiologyofdeliriumisnotwellunderstood.Theoriesrelatedtoitsdevelopmentandprogressionciteanatomicalchangesinthebrainandneurotransmitterimbalances(ex.abnormallevelsofserotonin,decreasedacetylcholine,excessdopamine)aspossiblephysiologicmechanisms.[14] Diagnosis[edit|editsource] Therearenoimagingorlaboratoryteststodiagnosedelirium.Deliriumisadiagnosisofexclusionthatrequirescarefulclinicaltestingandobservation. AssessmentandMonitoring[edit|editsource] ICUPain,Agitation,andDelirium(PAD)[15]guidelinesrecommendtwotestsfortheassessmentofdeliriuminadultICUpatients: TheIntensiveCareDeliriumScreeningChecklist(ICDSC) TheConfusionAssessmentMethodfortheICU(CAM-ICU) ThefollowingvideodemonstrateshowtoperformtheCAM-ICU. PreventionandTreatment[edit|editsource] Deliriumpreventionshouldbemulticomponentinterventiontailoredtopatientneeds.[16]TheABCDEFbundleprovidesaframeworktoscreenandpreventdeliriuminICUpatients.[17]Theconceptscorrespondingtoeachletterofthemnemonicareasfollows: Evidenced-BasedPreventionandTreatmentStrategiesforICUDelirium A Assess,preventandmanagepain B BothSpontaneousAwakeningTrials(SAT)andSpontaneousBreathingTrials(SBT) C Choiceofanalgesiaandsedation D Delirium:assess,preventandmanage E Earlymobilityandexercise F Familyengagementandempowerment Inadditiontotheaforementionedstrategies,patientmanagementshouldincludemeasurestopreventinfection,dehydration,constipation,andhypoxia.[16]Ifpossible,movementofpatientswithinandbetweenroomsorwardsshouldbeavoided.Othersimple,yetvitalpreventativemeasuresincludefrequentpatientreorientation,[14][16]useofpatients'customaryvisionandhearingaids,[14][16]andpromotionofgoodsleephygiene.[11][16] Ifpreventionisunsuccessful,treatmentofdeliriumshouldfocusonidentifyingandmanagingtheunderlyingcauses.Thecareteamshouldalsoensureeffectivecommunicationandreorientation,andprovidereassuranceforpeoplediagnosedwithdelirium.[16]Ifapersonwithdeliriumisdistressedorconsideredarisktothemselvesorothers,andverbalandnon-verbalde-escalationtechniquesareineffectiveornotappropriate,short-termhaloperidol,amedicationoftenprescribedforacutepsychosis,shouldbeconsidered,startingatthelowestclinicallyappropriatedose.[15] ImplicationsforPhysicalTherapyPractice[edit|editsource] PhysicaltherapistsplayanimportantroleinpreventingandmanagingICUdelirium.Perhapsthemostimportantmeasureisengagingpatientsinearlymobilizationinconjunctionwithnurses,occupationaltherapists,andphysicians. EarlymobilizationintheICUhasbeenshowntoreducethenumberofdaysonmechanicalventilation,[18][19]decreaseICUandhospitallengthofstay[20]andistheonlyinterventiontodateproventodecreasethenumberofdaysofdelirium[19].Familytraining,patientreorientation,deliriumassessment,useofappropriatevisionandhearingaids,andpainmanagementcanreadilybeintegratedintotherapysessions.TheCAM-ICUisaquickandeasytoolthatallowsphysicaltherapiststoassessandmonitorthecourseofapatient'sdeliriumovertime. DifferentialDiagnosis[edit|editsource] Themultifactorialnatureofdeliriumcanmakeiteasytomistakeforotherbraindysfunctions.Belowisanon-exhaustivelistofconditionsthatshouldbeconsideredinthedifferentialdiagnosisofICUdelirium: Dementia PsychiatricDisorders(ex.schizophrenia) Depression TraumaticHeadInjury Pain Stroke MyocardialInfarction [Sources:AmericanFamilyPhysician-Delirium,BMJBestPractice-AssessmentofDelirium] FurtherReading[edit|editsource] Foruptodateresearchanddevelopmentsontheassessment,prevention,andmanagementofICUdeliriumvisittheICUDeliriumandCognitiveImpairmentStudyGroup. References[edit|editsource] ↑AmericanPsychiatricA.Diagnosticandstatisticalmanualofmentaldisorders.5thedition.Washington,DC:AmericanPsychiatricAssociation;2013 ↑ElyEW,InouyeSK,BernardGR,GordonS,FrancisJ,MayL,etal.Deliriuminmechanicallyventilatedpatients:validityandreliabilityoftheconfusionassessmentmethodfortheintensivecareunit(CAM-ICU).JAMA.2001;286(21):2703-10 ↑3.03.1SalluhJ,WangH,SchneiderEB,NagarajaN,YenokyanG,DamlujiA,etal.Outcomeofdeliriumincriticallyillpatients:systematicreviewandmeta-analysis.BMJ2015;350:h2538 ↑YoungJ,MurthyL,WestbyM,AkunneA,O’MahonyR.Diagnosis,prevention,andmanagementofdelirium:summaryofNICEguidance.Bmj.2010;341:c3704. ↑ElyEW,GautamS,MargolinR,FrancisJ,MayL,SperoffT,etal.TheimpactofdeliriumintheIntensivecareunitonhospitallengthofstay.IntensiveCareMed.2001;27:1892-1900 ↑ThomasonJW,ShintaniA,PetersonJF,PunBT,JacksonJC,ElyEW.Intensivecareunitdeliriumisanindependentpredictoroflongerhospitalstay:aprospectiveanalysisof261non-ventilatedpatients.CritCare2005;9(4):R375–R381 ↑MilbrandtEB,DeppenS,HarrisonPL,ShintaniAK,SperoffT,StilesRA,etal.CostsAssociatedwithDeliriuminMechanicallyVentilatedPatients.Crit.CareMed.2004;32(4):955-962 ↑ElyEW,ShintaniA.,TrumanB,SperoffT,GordonSM,HarrellFE,etal.Deliriumasapredictorofmortalityinmechanicallyventilatedpatientsintheintensivecareunit.JAMA2004;291(14):1753-62 ↑MeagherD.Motorsubtypesofdelirium:past,present,andfuture.IntRevPsychiatry.2009;21(1):59-73 ↑10.010.1PetersonJ,PunBT,DittusRS,ThomasonJW,JacksonJC,ShintaniAK,etal.Deliriumanditsmotoricsubtypes:astudyof614criticallyillpatients.JAmGeriatrSoc.2006;54(3):479-84 ↑11.011.111.2BrummelN,GirardT.Preventingdeliriumintheintensivecareunit.CritCareClin.2013;29(1):51–65 ↑McNicollL,PisaniMA,ZhangY,ElyEW,SiegelMD,InouyeSK.Deliriumintheintensivecareunit:occurrenceandclinicalcourseinolderpatients.JAmGeriatrSoc.2003;51:591-598 ↑CavallazziR,SaadM,MarikPE.DeliriumintheICU:anoverview.AnnIntensiveCare.2012;2:49 ↑14.014.114.2ICUDeliriumandCognitiveImpairmentStudyGroup.ForMedicalProfessionals--ABCDEF'sofpreventionandsafety.Availablefrom:http://www.icudelirium.org/medicalprofessionals.html.(Accessed8March2018). ↑15.015.1BarrJ,FraserGL,PuntilloK,ElyEW,GélinasC,DastaJF,etal.;AmericanCollegeofCriticalCareMedicine.Clinicalpracticeguidelinesforthemanagementofpain,agitation,anddeliriuminadultpatientsintheintensivecareunit.CritCareMed.2013;41(1):263-306 ↑16.016.116.216.316.416.5NationalInstituteforHealthandCareExcellence. Delirium:prevention,diagnosisandmanagement(2019).Availablefrom: https://www.nice.org.uk/guidance/cg103(Accessed8March2020) ↑ICUliberation.ABCDEFBundle.Availablefrom:https://www.sccm.org/ICULiberation/ABCDEF-Bundles.(Accessed28January2019). ↑SchweickertWD,PohlmanMC,PohlmanAS,NigosC,PawlikAJ,EsbrookCL,etal.Earlyphysicalandoccupationaltherapyinmechanicallyventilated,criticallyillpatients:arandomisedcontrolledtrial.Lancet.2009;373(9678):1874-82 ↑19.019.1NeedhamDM,ChandoluS,ZanniJ.Interruptionofsedationforearlyrehabilitationimprovesoutcomesinventilated,criticallyilladults.AustJPhysiother.2009;55(3):210 ↑MorrisPE,GoadA,ThompsonC,TaylorK,HarryB,PassmoreL,etal.Earlyintensivecareunitmobilitytherapyinthetreatmentofacuterespiratoryfailure.CritCareMed.2008;36(8):2238-43 Retrievedfrom"https://www.physio-pedia.com/index.php?title=ICU_Delirium&oldid=235011" Categories:AcuteCareCriticalCareCardiopulmonaryAcuteRespiratoryDisorders-ConditionsCardiovascularDisease-ConditionsStrokeStroke-ConditionsHeadHead-ConditionsConditions SignuptoreceivethelatestPhysiopedianews EmailAddress IgivemyconsenttoPhysiopediatobeintouchwithmeviaemailusingtheinformationIhaveprovidedinthisformforthepurposeofnews,updatesandmarketing. 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