Futures-delirium

Agitation? Delirium? Both? and What to Do About It
Kathryn T. Von Rueden RN, MS, ACNS-BC, FCCM Clinical Nurse Specialist, R Adams Cowley Shock Trauma Center, Assistant Professor University of Maryland, School of Nursing
Delirium: “a part of the scenery ?”
Ely, W: Semin Respir Crit Care Med. 2001;22(2)
Delirium: DSM-IV Diagnostic Criteria
reduced clarity of awareness of the environment reduced ability to focus, sustain, or shift attention Memory deficit, disorientation, language problem Perceptual disturbance Unexplained by a chronic dementia 3. Acute onset (hrs to days) with fluctuating course throughout the day 4. Evidence of an illness, trauma, or drug effect
Agitation: a behavior, not a diagnosis
1. Strong, tumultuous emotions, continual movement, disorientation, inability to listen or follow Fidgeting, pulling at dressings, catheters, sheets, etc. Disorientation Inability to listen, communicate, or follow commands Acute, fluctuating changes in mental status, hallucination and inattention. 1. Hyperactive (20%) 2. Hypoactive (30%) 3. Mixed (50%) Incidence of delirium/ agitation in ICUs
 60-87% of patients requiring mechanical ventilation STC prevalence study:  24% IMC & ICU trauma patients Impact of delirium on patient outcomes

Impact on Resources
 35-40% 1-year mortality, 62% increase from baseline  17.5 million inpatient days  $5-6 billion/yr in Medicare expenses  Increased rates of institutionalization & terminal decline  1 of the 6 leading causes of preventable injury in people over 65 yo
Pathophysiologic Basis of Delirium
Multifactorial !!

 Metabolic & electrolyte imbalances  Medical therapies including drugs  Endorphin hyperfunction  Increased central noradrenergic function  Brain response to infection and injury includes production of inflammatory cytokines, cell infiltration, and tissue damage  Imbalances in synthesis, release, and inactivation of neurotransmitters  Primary neurotransmitter alterations: GABA (γ-aminobutryic acid) & GABA receptors Dopamine Acetylcholine deficiency Serotonin imbalance
Pre-existing / Non-modifiable Risk Factors
 Dementia  Chronic illness (including hypertension)  Advanced age  Depression  Smoking  Alcoholism  Apolipoprotein E4 phenotype  Severity of illness on hospital admission
Hospital Related / Iatrogenic Risk Factors
 Hypoxia  Metabolic disturbances  Electrolyte imbalances  Prolonged restraint use  Sleep deficits  Heart failure  Sepsis  Immobility  Acute infections  Withdrawal syndromes
Assessment of Agitation
1. Consciousness 2. Agitation 3. Anxiety 4. Sleep 5. Pt Vent Synchrony
Delirium Evaluation in ICU
Intensive Care Delirium Screening Checklist (ICDSC) Evidence-Based Strategies to PREVENT & Manage Delirium & Agitation

Pharmacologic / Interdisciplinary Collaborative Interventions
 Correct underlying insult, metabolic or hemodynamic derangements or hypoxemia
 Stop inappropriate medications
 Use sedation protocols & daily interruption of sedation
 Pain control
 Targeted pharmacologic therapy:
• Sedatives: midazolam, lorazepam, propofol • Dopamine receptor blockade: Haloperidol • Alpha-2 agonists: dexmetomidine, clonidine • Antipsychotics: respiridone, olanzapine
Agitation: Drug Management
Short Term < 24 hrs Midazolam Propofol LongTerm > 24 hrs Lorazepam Avoid in elderly ?? Paradoxical early DISinhibition Interfere with sleep architecture Benzodiapines and Delirium, Pandharipande et al Anesthesiology 2006 Lorazepam is an independent risk factor for transitioning to delirium Benzodiapines, Opiods and Delirium, Pisani M et al Crit Care Med 37:177-183, 2009  Increased delirium duration associated with Benzodiazepines &/or opioids (RR 1.64) “may be modifiable risk factors for delirium”
E-B Sedation Management is Based on Objective Assessment!
• Indication: 1st tx pain, physiologic causes • Set Sedation Goal: evaluate daily; use a valid/reliable sedation scale • Sedative selection: consistent with goals • Sedation management strategy: Nurse driven sedation protocol; include pharmacist • Sedation weaning strategy: include SBT Nurse Driven Protocols & Daily Interruption of sedation…… • Decreases days on mechanical vent • Decreases ICU LOS • Decreases Hospital LOS • Decreases VAP Delirium: Drug Management

Predictable side effects, “general safety” Prolongs QTc (greater with IV) Torsades de Pointes Up to 15% in critically ill pts Use with caution if QTc > 450 msec D/C Haldol if QTc increases by >25% Optimize Mg and Ca Atypical (2nd generation) Antipsychotics (6 available in USA): Antagonize multiple receptors eg Alpha 1 & 2, histamine, dopamine D1 Limited data in acute care Unwanted side effects, eg cardiac dysrhythmias, orthostatic hypotension FDA Public Health Advisory: April 2005 Deaths with Antipsychotics in Elderly Patients with Behavioral Disturbances. Atypical Antipsychotics in the Critical Care Population Antihistaminic mechanism of action Short 1/2-life facilitates dose titration Modifying the Incidence of Delirium MIND Study
FDA Approved 1999 Short acting alpha-2 agonist Anxiolytic, anesthetic, hypnotic, analgesic effects Approved for continuous IV < 24 hrs
MIND and MIND-USA Trial
Ziprasidone vs Haloperidol

MENDS Trial:
Lorazapam vs Dexmedetomidine
SEDCOM
Dexmedetomidine vs midazolam
Evidence-based Non-Pharmacologic / Nursing Driven Interventions
www.guideline.gov E-B Practice Guideline: acute confusion/delirium (Sendelbach S)

1. Identify & Modify Risk Factors
 Hypoxia  Metabolic disturbances  Electrolyte imbalances  Sleep deficits  Heart failure  Sepsis  Prolonged restraint use  Immobility  Acute infections  Withdrawal syndromes  Seizures  Dehydration  Hyperthermia  Head trauma  Vascular disorders  Intracranial lesions  Medications 2. Re-orientation to person, place & time (B2)
3. Promote un-interrupted sleep (B2)
4. Promote a healing environment
5. Minimize urinary catheters & restraints (A2)
6. Assure appropriate nutrition (A2)
7. Early mobilization (A2)
8. Geriatric specialist consult/ involvement
9. At least daily assessment using an objective & validated tool
10. Educate nurses and physicians re: Delirium risk factors, prevention, treatment and care (B2)
SCCM Updated Guideline (in press)

AACN Practice Alert (aacn.org 11-11)
Best Practice: What we should be doing!:
Daily Interdisciplinary Rounds
Discuss results of delirium assessment on all patients. ID patients with high number of risk factors for development or persistence of delirium. Review sedation & analgesia therapy Minimum doses to achieve comfort Implement strategies for tight titration; Nurse-driven, pt-targeted sedation delivery with daily sedation vacations Consider the benefit & risk of adding medications that might spare the use of sedatives & avoid respiratory suppression, Eg. haloperidol or atypical antipsychotics
Summary
References

AACN Practice Alert: Delirium assessment and management. Nov.2011 AACN.org
Alexander E: Delirium in the ICU: Medications as risk factors. Crit Care Nurs 2009;29:85-87
Allen, J., Alexander, E. Prevention, Recognition, and Management of Delirium in the Intensive Care Unit.
AACN Advanced
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www.icudelirium.org (Excellent website with multiple resources)
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Corchrane Database of Systematic Reviews, 2009
Interventions for preventing delirium in hospitalized patients
Benzodiazepines for delirium
Antipsychotics for delirium
Multidisciplinary team interventions fir the management of delirium in hospitalized patients

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