Delirium in Critical Care. Recognition, Management, Research tasters Dr Valerie Page Watford General Hospital
What does it look like?
Diagnosing delirium
CAM-ICU
CAM-ICU Feature 1: Acute onset of mental status changes, or Fluctuating course. AND Feature 2: Inattention Squeezing hand correctly on 4 As in a 10 letter sequence AND Feature 3: Disorganised thinking; 4 simple questions, one command OR Feature 4: Altered level of consciousness
Delirium Screening Checklist 1) Altered level of consciousness 2) Inattention 3) Disorientation 4) Hallucinations or delusions 5) Psychomotor agitation or retardation 6) Inappropriate speech or mood 7) Sleep/wake cycle disturbance 8) Symptom fluctuation
Months backward test Used to assess focus and sustained attention & Central processing speed Sensitivity for delirium 83% - 93% Explain clearly to subject Different positive test results quoted Meagher et al World Journal of Psychiatry 2015
Delirium or Depression? The symptoms of delirium, when they are present, are prominent and take diagnostic precedence as delirium frequently indicates serious and urgent physical pathology or morbidity. Because of their clinical overlap, in a hospital setting, clinicians should not rule out delirium in any patient withsuspected depression Take home messages: O Sullivan et al Lancet Psychiatry 2014
Delirium or Depression? Overlapping features Affective changes Sleep disturbance Underactivity or lethargy Apathy Agitation Impaired speed of information processing Delusions or hallucinations Impaired memory
Delirium Prominent features Fluctuation in intensity of symptoms Acute onset Altered consciousness Marked inattention Underlying physical cause Disorientation Disorganised thinking Poor comprehension
Management of Delirium I Treat cause(s)
Management of Delirium II Non-pharmacological Orientation Visual and Hearing aids Mobilisation Promote sleep Attention to bowels Reduce medical restraints Reduce anticholinergic drug load Sedation protocol
HELP?
Promoting sleep
Early Mobilisation Protocol in Mechanically Ventilated Patients Schweickert et al, Lancet 2009;373:1874-82
What s the time? Feb 2015 401 bed spaces 62% surgical bed spaces no clock visible 100 clocks installed July 2015 for 93 of 283 patients clock too far, small, obstructed 88 used watch or phone 90 80 70 60 50 40 30 20 10 Number of patients able to see a clock Before intervention After intervention 0 Surgical Medical Overall
Reduce the drug burden
1.5 year prospective QI (before/after) study of 296 ICU patients. Balas M, CCM 2014 epub
Watford first 2 days Average number of RASS per shift 3.56 Number of RASS -1 to +1 = 18.7% In 28.3% of patients No correlation with APACHE
Sedation survey Survey Monkey Critical care network leads Nurses February 2016 127 responses
Q1: How long have you worked as an intensive care nurse? Answered: 127 Skipped: 0
Q2: What sort of ICU do you work in? Answered: 127 Skipped: 0
Q3: In your opinion, (choose a point on this scale), how important is it to maintain light sedation (awake or easily aroused) in ventilated patients?
Q4: If a patient becomes agitated, do you feel you would usually be able to tell the most likely cause, pain, related to delirium or anxiety/fear?
Q5: If you believe agitation is due to pain, how confident would you be in giving a prn (as required) bolus of analgesia (fentanyl or morphine) without referring to a doctor?
Q6: If you believe a patient's agitation is related to delirium, how confident would you feel in giving a dose of haloperidol (already prescribed), without referring to a doctor first? (Assume no contraindications)
Q7: If you believe an agitated patient is anxious and frightened, how confident would you feel in giving a 1mg dose of midazolam (already prescribed), without asking a doctor first?
Q8: If it were entirely up to you, would you take part in a trial of nurse-led sedation?
Management of delirium III Pharmacological
Haloperidol
Haloperidol subsyndromal delirium ICDSC 1-3 RCT haloperidol 1mg 6 hrly vs. placebo Primary outcome incidence of delirium 68 of 481 eligible randomised APACHE 19-20 Al-Qadheebet al. CCM 2015 epub2015
Results Delirium haloperidol 12/34 (35.3%) vs. placebo 8/34 (23.5%) Haloperidol subjects spent less time agitated 0 [0-2] vs. 2 [1-6] No impact on days in coma, on ventilator, destination Medication discontinued for protocolised haloperidol concern 20.6% vs. 5.9; p=0.15
Haloperidol Phase III randomised double-blind controlled trial of oral risperidone, haloperidol or placebo for delirium management in palliative care Dose titration twice daily to maximum 4mgs (2mgs if >65) Rescue midazolam N=239 80 risperidone, 79 haloperidol, 80 placebo Australasian Journal on Ageing 2015
Results Risperidone delirium symptoms 0.57 (95% CI 0.17, 0.98) than placebo Haloperidol delirium symptoms 0.29 (0.11, 0.48) Pooled analysis antipsychotics survival vs placebo (p=0.026) Midazolam use lower in placebo gp.
Hope-ICU Delirium in the ICU: a prospective doubleblind RCT of haloperidol vs. placebo
Results Delirium-free/coma-free in 14 days median (IQR) Days in coma 14 days median (IQR) Days in delirium 14 days median (IQR) Haloperidol Placebo Statistics 5 (0-10) 6 (0-11) p=0.55 1.2 (2.14) 1.2 (1.9) p=0.99 5 (2-8) 5 (1-8) p=0.99
Resolution of delirium over time 0.8 Proportion alive delirium/coma free 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Day number Haloperidol Placebo
Agitation 0.35 Proportion of patients who are agitated (RASS +2 to +4) in first 14 days Proportion alive in ICU 0.30 0.25 0.20 0.15 0.10 0.05 Haloperidol Placebo 0.00 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Statins and delirium Prospective cohort study August 2011 to February 2012 Consecutive ICU admissions 319 patients no statins vs. 151 patients statins Daily CAM-ICU assessment
Daily statin and less risk of delirium OR (95% CI) P Statin 1.93 (1.12 to 3.36) 0.02 Age 1.01 (0.99 to 1.04) 0.31 APACHE 0.78 (0.73 to 0.84) <0.01 Daily risk of delirium following statin administration, N = 375, Person days = 2267
Friends and Family www.icusteps.org
Only use antipsychotics if needed for agitation Talk to patients and relatives about delirium Use months of the year backwards to screen for delirium in extubated patients Are the patients in your hospital able to tell what time it is?
Acknowledgements Professor Danny McAuley, Queens University, Belfast Drs Tim Alce & Annalisa Casarin Research Fellows Xiao Bei Zhao RN Dr Neil Soni, Imperial College, London Watford ICU staff Intensive Care Foundation Karen Cotton, EoE innovation and nursing lead.
Delirium Does sleep deprivation contribute to delirium? Does delirium contribute to sleep deprivation? Review of 17 surgical studies not a risk factor Plausible but not proven