Delirium Guideline

 

VBMC TRAUMA CARE SERVICES GUIDELINE

Delirium Guideline

Adult ICU Delirium Guideline

ICU delirium, often referred to as “ICU psychosis,” is an acute onset of confusion, inattention, and other disturbances in cognition.  It is an often under-assessed and under-reported complication to hospitalization.  It has been found that up to 80% of adult patients develop delirium while hospitalized post-operatively, especially in the ICU.  Not only is the development of ICU delirium troublesome to the patients, patients’ family and the providers, patients who develop delirium have an increased rate of mortality^3,6, a prolonged length of stay^3,6, prolonged ventilator time⁶, decreased cognition⁶, and increased costs²⁷. It is the expectation that delirium prevention, assessment, and treatment be multidisciplinary.     

ICU delirium can be divided into subtypes; hyperactive, hypoactive, or mixed¹.  Hyperactive is characterized by agitation or emotional liability.  Hypoactive is the most common and may have the highest level of mortality⁶.   It is difficult to assess, characterized by lethargy, decreased responsiveness or flat affect.  

Several independent risk factors for the development of delirium have been suggested including increased age, severity of illness, and the use of benzodiazepines¹⁶ although, there is no consensus.  Delirium development is most likely multi-factorial and may include among others: hearing and vision impairment, pain, blood transfusions⁴, sleep disturbance, cognitive impairment prior to hospitalization (dementia)³, and alcohol abuse³.  

 

The following mnemonics can assist in remembering common risk factors for the development of delirium^7,15.

 

Toxic (shock, organ failure,

            deliriogenic meds)

Hypoxemia

Infection

Non-pharmacologic causes

K⁺ or other electrolyte problem

 

Drugs

Eyes & Ears (cannot see or hear – glasses/ hearing aids)

Low O₂ state (MI, stroke, PE)

Infection

Retention of urine or stool

Ictal

Underhydration/Undernutrition

Metabolic

(S)ubdural

Every patient in an adult ICU^3,14 should be screened at least every shift, and with any abrupt change in level of consciousness, for the presence of delirium.  VBMC has adopted the Confusion Assessment Method for the ICU (CAM-ICU)⁵ as our assessment tool in the ICU.  

Frequently it is the patient’s loved ones who identify delirium prior to the assessment by the healthcare provider.  In the absence of a known baseline cognitive status, loved ones are often the best tool for assessing changes and possible delirium development. 

   

 ICU Delirium Appendix A

Prevention Guideline

Because there is no clear treatment of delirium, prevention is the best practice.  

Techniques for prevention of delirium in all care levels include:

§  Consistent purposeful hourly rounding

o   Assess for 4 P’s – Pain, Potty, Positioning, and Possessions 

o   Establish relationship based on patient feeling safe

o   Use language such as “I will not be far away,” or “I will be back in one hour.”

§  Remove all deliriogenic drugs if possible (e.g. benzodiazepines, anticholinergics, steroids) ^3,14,16

§  Use restraint alternative if possible.  The use of restraints is linked to higher rates and longer duration of delirium²⁰. 

§  Orient patient to person, place, time & situation¹⁴

§  Provide patient with hearing and/or vision correction¹⁴

§  Provide sunlight¹⁹ or room lights on for first morning assessment and maintain until lights out around 9pm  to reinforce the diurnal cycle³   (exception: head patients)

§  Cluster care to allow for improved rest/sleep

§  Provide early progressive mobility^3,14 

§  Maintain RASS of -1 to +1            (If RASS is +2 to +4, may consider mild sedation)

§  Reconcile home medications

§  Review Appendix C – Pharmacologic Treatment Guideline

 

ABCDE bundle (ICU Only)

The ABCDE bundle is a best practice bundle which helps remind us of the most important and helpful topics when preventing and treating delirium².

 

Awakening and Breathing Trial Coordination (Spontaneous Breathing Trial guideline)

 

Delirium Non-pharmacologic Interventions (Pain control, orientation, Eye/Ears, & Sleep)

 

Early Mobility

 

Appendix B

Assessment Guideline

 

Please see CAM-ICU Worksheet (Appendix D) to aid in assessment.

There are four features of delirium that are assessed when utilizing the CAM-ICU. To be considered CAM-ICU positive or delirium positive, the patient must have positive assessments of Features 1 AND 2 AND either 3 or 4.

Feature 1:  Level of Consciousness (LOC) – Is there a change (last 24 hours) from baseline LOC?

To assess LOC for the purpose of the CAM, the Richmond Agitation and Sedation Scale (RASS) is used for patients in the ICU.  This is a simple linear scale to assess how agitated vs sedated the patient is.  The CAM-ICU cannot be assessed if the patient has a RASS score of -4 or -5 (deep sedation).  If the patient has a score of -3 (moderate sedation) to +4 (combative), continue with the assessment.  Keep in mind that medications and procedures can affect this score.  This feature is positive if the answer to the question is “yes”.

Feature 2:  Inattention – Can the patient maintain concentration?

This is done by holding the patient’s hand and reading the following letters (3 seconds apart).  

 

S A V E A H A A R T

 

Please keep in mind of the patient has a hearing deficit you may need to speak very loudly.

Ask the patient to squeeze your hand every time they hear the letter “A.”  

This feature is positive if the patient makes more than 2 errors.

Feature 3:  Altered Level of Consciousness – Is the patient anything but alert and calm?

This feature is positive if the patient’s RASS score is anything but 0.  This will likely be positive for many patients.

Feature 4:  Disorganized Thinking – Is the patient not thinking clearly?

This feature has two parts:  Yes/No Questions or Commands.  

Yes/No Questions:  Ask the following four questions (if not intubated).

1)     Will a stone float on water?

2)     Are there fish in the sea?

3)     Does one pound weigh more than two pounds?

4)     Can you use a hammer to pound a nail?

Command:  

 “Hold up this many fingers.”  Hold up two fingers in front of patient (if patient has visual difficulty, be aware).  Then ask them to repeat on the other side.  If they are unable to move one side, ask the patient to “Add one more finger.” 

This feature is positive if there is more than one error made.

 

Appendix C

Pharmacologic Treatment Guideline

 

Utilize the prevention guidelines for delirium first

Resume home medications as appropriate

Consider limiting the use of benzodiazepines¹⁶

Decrease sedation and pain medications to keep RASS -1 to +1 as appropriate.

 

If CAM-ICU positive despite above interventions, consider the use of antipsychotics:

 

·       haloperidol (Haldol) 2.5mg IV every 15 to 30 min, increasing dose as needed to effect

o   Consider scheduling 5mg IV every 8 hours or 2.5mg PO every 8 hours. Increase by 2.5mg every 8 hours to effect. Max of 30mg/day^10,21

o   Notable side effect: reduction of the seizure threshold

·       quetiapine (Seroquel) 50mg PO/PT twice daily

o   Increase by 50mg every 12 hours to effect. Max 400mg/day divided⁸

·       olanzapine (Zyprexa) 5mg PO/PT at Bedtime

o   Increase by 2.5mg daily to effect. Max of 15mg/day¹³

·       ziprasidone (Geodon) 40mg PO/PT twice daily²²

o   Increase by 20mg twice daily. Max 80mg twice daily.

o   Notable side effects: leukopenia, neutropenia, agranulocytosis

·       risperidone (Risperdal) 0.5mg PO/PT twice daily²⁶

o   Increase by 0.25mg twice daily. Max 3mg twice daily.

 

*All of the above increase the QTc interval and cause sedation. Caution with QTc > 460 to 500 on EKG. 

- Risk of QTc prolongation: haloperidol > ziprasidone > quetiapine > olanzapine

- Risk of sedation: quetiapine > X > olanzapine

 

Caution in patients with dementia, neurologic impairment, neurotrauma, alcohol withdrawal, Parkinson’s disease, as these patient populations have traditionally been excluded from primary literature.

Black boxed warning for use of antipsychotics in elderly patients with dementia-related psychosis due to increased risk of death compared to placebo.^{23, 24, 25}

 

References:

1.     American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5^th ed.).  Arlington, VA: American Psychiatric Publishing.

2.     Balas, M., Vasilevskis, E., Burke, W., Boehm, L., Pun, B., Olsen, K., Peitz, G., & Ely, E.W.  (2012).  Critical care nurses’ role in implementing the “ABCDE Bundle” into practice.  Critical Care Nurse, 32(2), p 35-47.

3.     Barr, J., Fraser, G., Puntillo, K., Ely, E.W., Gélinas, C., Dasta, J., Davidson, J., Devlin, J., et al.  (2013).  Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit.  Critical Care Medicine.  41, 263-306.

4.     Behrends, M., DePalma, G., Sands, L., Leung, J.  (2013). Association between intraoperative blood transfusions and early postoperative delirium in older adults.  Journal of American Geriatric Society.  61, 365-370.

5.     Ely, E.W., Inouye, S.K., Bernard, G.R., et al.  (2001).  Delirium in mechanically ventilated patients:  Validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU).  JAMA, 286, 2703-2710.

6.     Ely, W.E., Shintani, A., Truman, B., Speroff, T., Gordon, S., Harrell, F., Inouye, S., Bernard, G., & Dittus, R.  (2004).  Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit.  JAMA, 291(14); 1753-1762.

7.     DELIRIUM – Adapted by Vanderbilt University from Saint Louis University Geriatrics Evaluation Mnemonics Screening Tools (SLU GEMS).

8.     Devlin JW, Roberts RJ, Fong JJ, et al. Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, double-blind, placebo-controlled pilot study.  Crit Care Med 2010;38(2):1-9.

9.     Lexi-Comp Online. Olanzapine. Accessed 25 November 2013. <http://www.uptodate.com/contents/olanzapine-drug-information?source=search_result&search=olanzapine&selectedTitle=1%7E103#F203196>  

10.  Lexi-Comp Online. Haloperidol. Accessed 25 November 2013. <http://www.uptodate.com/contents/haloperidol-drug-information?source=search_result&search=haldol&selectedTitle=1%7E116#F178617>

11.  Lexi-Comp Online. Quetiapine. Accessed 25 November 2013. < http://www.uptodate.com/contents/quetiapine-drug-information?source=search_result&search=quetiapine&selectedTitle=1%7E79#F212162

12.  Milbrandt EB, Kersten A, Kong L, et al. Haloperidol use is associated with lower hospital mortality in mechanically ventilated patients. Crit Care Med 2005;33:226-29.

13.  Rea RS, Battistone S, Fong JJ, et al. Atypical Antipsychotics versus Haloperidol for Treatment of Delirium in Acutely Ill Patients. Pharmacotherapy 2007;27(4):588-94.

14.  Riker, R. & Fraser, G.  (2013).  The new practice guideline for pain, agitation and delirium.  Am J Crit Care; 22, 153-157.

15.  THINK – Adapted with permission by Vanderbilt University from Marta Render, MD – Veteran Affairs In-patient Evaluation Center (IPEC).

16.  Pandharipande, P., Shintani, A., Peterson, J., Pun, B.T., Wilkinson, G., Dittus, R., Bernard, G. & Ely, E.W.  (2006).  Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients.  Anesthesiology; 104(1), 21-26.

17.  Vasilevskis, E., Ely, E.W., Speroff, T., Pun, B., Boehm, L., & Dittus, R.  (2010).  Reducing iatrogenic risks:  ICU-acquired delirium and weakness—crossing the quality chasm.  Chest, 138(5), 1224-1233.

18.  Whitlock EL, Vannucci, A., Avidan, MS.  (2001).  Postoperative delirium.  Minerva Anetesiol.  77,  448-456.

19.  Wilson, L.  (1972).  Intensive care delirium:  The effect of outside deprivation in a windowless unit.  Arch Intern Med, 130(2), 225-226.

20.  Micek, S., Anand, N., Laible, B., Shannon, W., & Kollef, M.  (2005).  Delirium as detected by the CAM-ICU predicts restraint use among mechanically ventilated medical patients.  Crit Care Med33(6), 1260-1265.

21.  Skorbik YK, Bergeron N, Dumont M, et al. Olanzapine vs haloperidol: treating delirium in a critical care setting. Intens Care Med 2004; 30: 444-449.

22.  Girard TD, Pratik PP, Carson SS, et al. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: The MIND randomized, placebo-controlled trial. Crit Care Med 2010; 38:428-437.

23.  Gill SS, Bronskill SE, Normand SL, et al. Antipsychotic drug use and mortality in older adults with dementia. Ann Intern Med 2007; 146(11):775-786.

24.  Schneeweiss S, Setoguchi S, Brookhart A, et al. Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients. CMAJ 2007; 176(11):1613.

25.  http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm124830.htm

26.  Han CS, Kim YK. A Double-Blind Trial of Risperidone and Haloperidol for the Treatment of Delirium. Psychosomatics 2004;45:297-301.

27.  Milbrandt EB, Deppen S, Harrison PL, et al. Costs associated with delirium in mechanically ventilated patients. Crit Care Med 2004; 32:955-962.