Transcript Delirium - Tennessee Psychological Association

Delirium Assessment in the ICU:
A New Frontier
Sharon M. Gordon PsyD
Chief of Psychology, VA TN Valley Health Care System
Assistant Clinical Professor of Psychiatry
Vanderbilt University School of Medicine
Financial Conflicts
None
I am a government employee
Thank You Federal
Tax Payers!!!!
Objectives
– Participants will learn the 4 features that are present
in delirium
– Participants will learn to discriminate between
delirium and other diagnoses such as dementia
– Participants will learn how to administer a brief,
bedside tool to diagnose delirium in the ICU
– Participants will learn how using this brief tool can
improve practice in the ICU
So what is a Psychologist doing
in the ICU anyway?
What Are The Needs in the ICU?
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What is the patient’s current mental status?
Does patient understand his/her condition?
Is patient capable of making decisions?
Is patient behavior because of confusion
(i.e. delirium) or psychosis?
Common language to describe what we are
seeing: confused, agitated, oriented x1, etc.
How can the staff determine all of the above
if the patient is on a ventilator?
How Can A Psychologist Help
Meet These Needs?
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Help staff use a common language to
describe what they are seeing
Help staff to make decisions based on data
rather than subjective opinion
Help staff recognize that cognitive
functioning is just as important as physical
functioning in the ICU
• What exactly are we seeing?????
So many terms…
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Acute confusional state
ICU Psychosis
Confusion
Acute brain syndrome
Altered mental status
Toxic or metabolic encephalopathy
Sundowning
“He’s agitated” “She’s out of it”
Turns out……..
What we were seeing was….
DELIRIUM
What is Delirium?
4 Key Features:
• Disturbance of consciousness with reduced
ability to focus, sustain or shift attention
• A change in cognition or the development
of a perceptual disturbance that is not better
accounted for by pre-existing, established
or evolving dementia
Diagnostic Statistical Manual- 4th edition (DSM-IV)
Delirium Definition Continued:
• Develops over a short period of time and
tends to fluctuate over the course of the day
• There is evidence form the H&P and/or labs
that the disturbance is caused by a medical
condition, substance intoxication or
medication side effect
Diagnostic Statistical Manual- 4th edition (DSM-IV)
Classic Quote: “Delirium, a Syndrome
of Cerebral Insufficiency”
“The failure of metabolic processes to maintain the
function of the organ or the loss through death of
enough functioning units (cells) renders the
function of the organ insufficient.”
Engel and Romano, J Chron Dis, 9(3):260-277, 1959
Delirium
Acute Brain Failure in Man
1980
Zbigniew J. Lipowski, M.D.
1924–1997
“Delirium constitutes a ubiquitous and
thus clinically important sign of cerebral
functional decompensation caused by
physical illness”
“Ravelstein” by Nobel Laureate
Saul Bellow
About his being on ventilator:
“…but my head (I assume it was
my head) was full of visions,
delusions, and hallucinations.
These were not dreams or
nightmares. Nightmares have
an escape hatch…”
What is Delirium?
Diagnostic Statistical Manual- 4th edition (DSM-IV)
4 Key features:
- Disturbance of consciousness with reduced ability to focus,
sustain or shift attention
- A change in cognition or the development of a perceptual
disturbance that is not better accounted for by pre-existing,
established or evolving dementia
- Develops over a short period of time and tends to fluctuate
over the course of the day
- There is evidence form the H&P and/or labs that the disturbance
is caused by a medical condition, substance intoxication or
medication side effect
Call a Horse a Horse
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Acute Confusional State
Organic Brain Syndrome
Reversible Dementia
Poor Historian
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Change in Mental Status
Metabolic Encephalopathy
Dysergastic Reaction
Subacute Befuddlement
ICU Psychosis
Delirium
Delirium
• Acute change in cognition
– Develops over hours to days
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Fluctuating course throughout the day
Reduced ability to focus, sustain, or shift attention
Disorganized thinking
Disturbance of consciousness
– Hyperactive (25%)
– Mixed (25%)
– Hypoactive (50%)
Subtypes of Delirium
Hypoactive
Patient may be quiet and even peaceful, despite
cognitive impairment. More difficult to assess.
Hyperactive
Patient may be combative with agitation that may
require sedation (is diagnosed more frequently).
Mixed
Combination of both types
Delirium Subtypes
Combative
Agitated
Restless
Alert & Calm
Lethargic
Sedated
Stupor
Delirium Subtypes
Combative
Agitated
Restless
Alert & Calm
Lethargic
Sedated
Stupor
Delirium Subtypes
Combative
Agitated
Restless
Hyperactive Delirium
Alert & Calm
Lethargic
Sedated
Stupor
Hypoactive Delirium
Delirium Subtypes
Combative
Agitated
Restless
Hyperactive Delirium
Mixed
Delirium
Alert & Calm
Lethargic
Sedated
Stupor
Hypoactive Delirium
What it is not
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Dementia
Depression
Sundowning
Alcohol withdrawal Syndrome
–Delirium tremens
Delirium versus Dementia
• Delirium
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• Dementia
rapid onset
fluctuation
clouded consciousness
inattention, disorganized thought
not chronic
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variable to insidious onset
not fluctuating
no clouding of consciousness
many domains impaired
persistent/chronic (?)
Gordon SM, Intensive Care Med 30:1997-2008, 2004
Jackson JC, Intensive Care Med 30:2009-2016, 2004
Delirium Definition
DSM IV criteria: a disturbance of consciousness with
inattention accompanied by a change in cognition or
perceptual disturbance that develops in a short period of
time (hours to days) and fluctuates over time.
Three Types:
Hyperactive
Hypoactive
Mixed
Diagnostic and Statistical Manual of Mental Disorders (DSM IV)
Who is at Risk?
• Age over 70
• Transfer from a nursing
home
• Renal failure
• Prior Hx of depression
• Liver disease
• Prior Hx of dementia
• History of CHF
• History of stroke,
epilepsy
• Cardiogenic or septic
shock
• Alcohol abuse within a
month
• HIV
• Visual or Hearing
• Tube feeding
• Drug OD or illicit drug
• Rectal or bladder
catheters
• Hypo or hypernatremia
• Psychoactive meds
• Central venous catheters
• Hypo or hyperglycemia
• Malnutrition
• Hypo or
hyperthyroidism
• Use of physical restraints
• Hypothermia or Fever
Delirium
Risk factors for developing?
–Underlying dementia
–Recent surgery
–Dehydration/renal insufficiency
–Multiple medications
–Older age
Inouye SK, et al. Ann Int Med, 1993
30 Psych Neur, 1998
Inouye SK, et al. J Ger
Risk Factors
• Baseline Vulnerability
– Underlying Brain Disease (Dementia, stroke,
Parkinson)
– Increased Age
– Institutionalization
– Chronic disease (HIV, ETOH dependency, diabetes,
etc)
– Visual/Hearing deficits
Risk Factors
• Precipitating
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Medications**
Infection
Dehydration
Immobility/restraints
Malnutrition
Tubes/catheters
Electrolyte imbalance
Sleep Deprivation
Causes of Delirium:
Common Things are Common
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2.
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Age and Pre-existing dementia
Sepsis / infections
CHF and other perfusion deficits
Metabolic and hypoxemic circumstances
Immobilization, sleep disruption, sensory deprivation
(eyes, ears)
6. Taking away – withdrawal syndromes (EtOH, nicotine)
7. Giving - Drugs, drugs, and more drugs
Studies of Risk Factors in ICU
• In multivariate analysis, hypertension,
smoking history, abnormal bilirubin level,
epidural use and morphine were statistically
significantly associated with delirium
• Mean number of risk factors per patient
found in one cohort was 11 +/- 4 !
Dubois MJ, ICM 2001;27:1297-1304, n=216
Ely EW, ICM 2001;27:1892-1900
Boogaard M, BMJ. 2012 Feb 9;344:e420 (10 items in final model)
Risk Factors
• Baseline Vulnerability (predisposing)
-Risk factors r/t person’s baseline
- Often we cannot modify these
• Precipitating
– These are things that happen to the patient
– Insults
– Often Iatrogenic
• Baseline + Precipitating = Delirium
Framework for Risk
Baseline Vulnerability
Precipitating Stimulus
High
Noxious
Low
Mild/None
Framework for Risk
Baseline Vulnerability
Precipitating Stimulus
High
Noxious
Low
Mild/None
Framework for Risk
Baseline Vulnerability
Precipitating Stimulus
High
Noxious
Low
Mild/None
Framework for Risk
Baseline Vulnerability
Precipitating Stimulus
High
Noxious
Low
Mild/None
Framework for Risk
Baseline Vulnerability
Precipitating Stimulus
High
Noxious
Low
Mild/None
Key Points: ICU Delirium
• 60% to 80% of ventilated patients develop delirium
• 20% to 50% of lower severity ICU patients develop
delirium
• TRANSLATION: right now ~ 30,000 to 40,000
ICU patients are delirious in U.S. alone
• Delirium leads to increased mortality, longer
hospital stay, poorer recovery, and higher costs of
healthcare
Ely EW ICM 2001;27:1892-900
Ely EW JAMA 2001;286,2703-2710
Ely EW CCM 2001;29,1370-79
McNicoll L, JAGS 2003;51:591-98
Bergeron N, ICM 2001;27:859-64
Thomason J, AJRCCM 2003;167:A968
Ely EW CCM 2004;32:106-112
Peterson et al, AJRCCM 2003;167:A968
Why monitor for Delirium?
• 60-80% of ventilated patients develop delirium
• 20-50% of lower severity ICU patients develop
delirium
• Over 40,000 ventilated patients are delirious
every day
• Delirium leads to increased mortality, longer
hospital stay, poorer recovery, and higher costs
of healthcare.
Ely EW JAMA 2001;286,2703-2710
Ely EW CCM 2001;29,1370-79
“Invisible” Organ Dysfunction
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60% to 70% unrecognized
Delirium is not routinely monitored in the ICU 1
Validated tools - DSC 2 or CAM-ICU 3-4
Hyperactive vs. Hypoactive delirium
“ICU Psychosis” traditionally an expected outcome
In non-ICU settings, delirium has been associated with
prolonged stay, institutionalization, and death 5-7
1 Ely
EW CCM 2004;32:106-112
2 Bergeron, ICM 2001;27:859-64
3 Ely EW JAMA 2001;286,2703-2710
4 Ely EW CCM 2001;29,1370-79
5 Inouye, Am J Med 1999;106:565-573
6 Lawlor, Arch Intern Med 2000;160:786-794
7 McCusker, Arch Intern Med 2002;162:457-463
In-Hospital Mortality
Acute MI
9%
Delirium
On Admission
10-26%
Develop
Delirium
Postop
Delirium
22-76%
4-13%
Arch Intern Med 2002;162(4):457-63
Am J Psychiatry 1999;156(5 Suppl):1-20
JAMA 1994;271(2):134-9
NEJM 1995;335:1857-63
www.ahrq.gov
Delirium Monitoring in ICUs - 1999
Delirium Monitoring in ICUs - 2007
Articles on Delirium in ICU
(MeSh or Text headings in English)
Number of Articles
70
60
50
40
30
20
10
Morandi etetal,al,
Intensive
Care Care
Med 2008
Morandi
Intensive
Med
2008
Year
2007
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…The biggest problem is that “doctors are
focused only on the organs that got patients into
the hospital, ignoring newly acquired brain
problems…”
Delirium Pathophysiology
Flacker, et al. Gerontol. Bio Scie 1999; 54A: B239-B246
Delirium Pathophysiology
Flacker, et al. Gerontol. Bio Scie 1999; 54A: B239-B246
Monitoring and Support
of Organ Dysfunction
Cardiovascular
Pulmonary
Renal
How do you monitor for brain
failure (i.e. delirium)?
Triad of Neurologic Monitoring
Arousal
SAS, RASS, MAAS
Delirium
CAM-ICU
Consciousness
Wakefulness
&
Content
Physiological Brain Activity
BIS-EEG, ERP, P300
Plum and Posner
Diagnosis of
Stupor and Coma
Two Step Approach to
Assessing Consciousness
Step 1 Level:
Sedation Assessment (Ramsay, SAS, RASS)
Step 2 Content:
Delirium Assessment (CAM-ICU)
Intensive Care Delirium Screening Checklist
(ICDSC)
Richmond Agitation-Sedation Scale
(RASS)
+4
+3
+2
+1
Combative
Very agitated
Agitated
Restless
0
Alert /calm
-1
Drowsy
-2
Light sedation eye contact <10 sec
-3
Moderate
no eye contact
-4
Deep
physical stimulation required
-5
Unarousable
eye contact >10 sec
Verbal Stimulus
Physical
no response even with physical Stimulus
Sessler CN, et al. AJRCCM 2002; 166:1338-1344.
Ely et al, AJRCCM 2001;163:A954
How was it validated?
Monitoring Sedation Status Over Time in ICU
Patients Reliability and Validity of the
Richmond Agitation-Sedation Scale (RASS)
• 290-paired observations by nurses
• RASS demonstrated excellent inter-rater reliability
• Able to detect changes in sedation status over time
• Against level of consciousness and delirium
• Correlated with doses of sedatives and analgesics
Ely EW et al JAMA. 2003;289:2983-2991
Ely EW, JAMA 2003;289:2983-91
Two Step Approach to
Assessing Consciousness
Step 1 Level:
Sedation Assessment (Ramsay, SAS, RASS)
Step 2 Content:
Delirium Assessment (CAM-ICU)
Intensive Care Delirium Screening Checklist
(ICDSC)