Sharon M. Gordon PsyDChief of Psychology, VA TN Valley Health Care System

Assistant Clinical Professor of PsychiatryVanderbilt University School of Medicine

Delirium Assessment in the ICU:A New Frontier

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?

• 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 How Can A Psychologist Help Meet These Needs?Meet These Needs?

• 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…

• 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)

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

“Delirium constitutes a ubiquitous and thus clinically

important sign of cerebral functional decompensation caused by physical illness”

Zbigniew J. Lipowski, M.D.

1924–1997

“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

• Acute Confusional State• Organic Brain Syndrome• Reversible Dementia• Poor Historian

• Change in Mental Status• Metabolic Encephalopathy• Dysergastic Reaction• Subacute Befuddlement• ICU Psychosis

Delirium

Delirium

• Acute change in cognition– Develops over hours to days

• Fluctuating course throughout the day• Reduced ability to focus, sustain, or shift attention• Disorganized thinking• Disturbance of consciousness

– Hyperactive (25%)– Mixed (25%) – Hypoactive (50%)

HyperactivePatient may be combative with agitation that may

require sedation (is diagnosed more frequently).

Subtypes of Delirium

HypoactivePatient may be quiet and even peaceful, despite

cognitive impairment. More difficult to assess.

MixedCombination of both types

Delirium Subtypes

Alert & Calm

CombativeAgitatedRestless

LethargicSedated

Stupor

Delirium Subtypes

Alert & Calm

CombativeAgitatedRestless

LethargicSedated

Stupor

Delirium Subtypes

Alert & Calm

CombativeAgitatedRestless

LethargicSedated

Stupor

Hyperactive Delirium

Hypoactive Delirium

Delirium Subtypes

Alert & Calm

CombativeAgitatedRestless

LethargicSedated

Stupor

Hyperactive Delirium

Hypoactive Delirium

Mixed Delirium

What it is not

• Dementia• Depression• Sundowning• Alcohol withdrawal Syndrome

–Delirium tremens

Delirium versus Dementia

• Delirium – rapid onset

– fluctuation

– clouded consciousness

– inattention, disorganized thought

– not chronic

• Dementia– variable to insidious onset

– not fluctuating

– no clouding of consciousness

– many domains impaired

– persistent/chronic (?)

Gordon SM, Intensive Care Med 30:1997-2008, 2004Jackson 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

30

DeliriumDeliriumRisk factors for developing? Risk factors for developing?

–Underlying dementiaUnderlying dementia

–Recent surgeryRecent surgery

–Dehydration/renal insufficiencyDehydration/renal insufficiency

–Multiple medicationsMultiple medications

–Older ageOlder age

Inouye SK, et al. Ann Int Med, 1993Inouye SK, et al. J Ger Psych Neur, 1998

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– Medications**– Infection– Dehydration– Immobility/restraints– Malnutrition– Tubes/catheters– Electrolyte imbalance– Sleep Deprivation

Causes of Delirium:Common Things are Common

1. Age and Pre-existing dementia

2. Sepsis / infections

3. CHF and other perfusion deficits

4. Metabolic and hypoxemic circumstances

5. 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=216Ely 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

Low

High

Mild/None

Noxious

Precipitating Stimulus

Framework for Risk

Baseline Vulnerability

Low

High

Mild/None

Noxious

Precipitating Stimulus

Framework for Risk

Baseline Vulnerability

Low

High

Mild/None

Noxious

Precipitating Stimulus

Framework for Risk

Baseline Vulnerability

Low

High

Mild/None

Noxious

Precipitating Stimulus

Framework for Risk

Baseline Vulnerability

Low

High

Mild/None

Noxious

Precipitating Stimulus

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;27:1892-900Ely EW JAMA 2001;286,2703-2710Ely EW CCM 2001;29,1370-79McNicoll L, JAGS 2003;51:591-98

Bergeron N, ICM 2001;27:859-64Thomason J, AJRCCM 2003;167:A968Ely EW CCM 2004;32:106-112Peterson 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;286,2703-2710Ely EW CCM 2001;29,1370-79

“Invisible” Organ Dysfunction

• 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;32:106-1122 Bergeron, ICM 2001;27:859-643 Ely EW JAMA 2001;286,2703-27104 Ely EW CCM 2001;29,1370-795 Inouye, Am J Med 1999;106:565-5736 Lawlor, Arch Intern Med 2000;160:786-7947 McCusker, Arch Intern Med 2002;162:457-463

In-Hospital Mortality

Acute MI

Arch Intern Med 2002;162(4):457-63 Am J Psychiatry 1999;156(5 Suppl):1-20

JAMA 1994;271(2):134-9NEJM 1995;335:1857-63

www.ahrq.gov

9%9% 4-13%4-13%

DeliriumOn Admission

Develop Delirium

22-76%22-76%10-26%10-26%

PostopDelirium

Delirium Monitoring in ICUs - 1999

Delirium Monitoring in ICUs - 2007

Articles on Delirium in ICU (MeSh or Text headings in English)

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Morandi et al, Intensive Care Med 2008Morandi et al, Intensive Care Med 2008

…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 Monitoring and Support of Organ Dysfunctionof Organ Dysfunction

CardiovascularCardiovascular

PulmonaryPulmonary

RenalRenal

How do you monitor for brain failure (i.e. delirium)?

Triad of Neurologic Monitoring

ArousalSAS, RASS, MAAS

DeliriumCAM-ICU

Physiological Brain ActivityBIS-EEG, ERP, P300

ConsciousnessConsciousness

WakefulnessWakefulness&&

Content Content

Plum and PosnerPlum and PosnerDiagnosis of Diagnosis of Stupor and ComaStupor 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 Combative+3 Very agitated+2 Agitated+1 Restless

0 Alert /calm

-1 Drowsy eye contact >10 sec

-2 Light sedation eye contact <10 sec

-3 Moderate no eye contact

-4 Deep physical stimulation required

-5 Unarousable no response even with physical

Verbal StimulusVerbal Stimulus

PhysicalPhysicalStimulusStimulus

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)