Transcript ICU Psychosis / Delirium

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.
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)
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)
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
 4 Components
– 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
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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
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)
Strange environment
Noise
Physical restraint
Medical terminology
Strip lighting
Environmental factors
Malnutrition
Drugs
Invasive lines
Loss of dignity
Abnormal routines
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,
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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
– Patients normal daily activities
– Time of day
– Weather
Repetition of explanations and information is
necessary
Involve the family
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?