Advertisement

Assessment and Management of the Delirious Patient in the Intensive Care Unit

Chapter
  • 1.4k Downloads

Abstract

Delirium is common in critical care patients and is challenging to diagnose. This account describes delirium risk factors, diagnostic criteria, screening tools and the consequences of delirium for patients including long-term cognitive impairment. It outlines currently available non-pharmacological and pharmacological management interventions to reduce and manage delirium symptoms.

Keywords

Delirium Acute confusion Risk factors Delirium monitoring Multidisciplinary management 

Summary of Abbreviations

CAM-ICU

Confusion Assessment Method for the Intensive Care Unit

DSM-5

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

ICDSC

Intensive Care Delirium Screening Checklist

NICE

National Institute for Health and Care Excellence

PAD

Pain, Agitation and Delirium

RASS

Richmond Agitation Sedation Score

References

  1. 1.
    Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y (2007) Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 33:66–73CrossRefPubMedGoogle Scholar
  2. 2.
    Inouye SK, Westendorp RG, Saczynski JS (2014) Delirium in elderly people. Lancet 383:911–922CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    American Psychiatric Association (2013) DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5, 5th edn. American Psychiatric Association, Washington, DCGoogle Scholar
  4. 4.
    Lipowski ZJ (1989) Delirium in the elderly patient. N Engl J Med 320:578–582CrossRefPubMedGoogle Scholar
  5. 5.
    Peterson JF, Pun BT, Dittus RS et al (2006) Delirium and its motoric subtypes: a study of 614 critically ill patients. J Am Geriatr Soc 54:479–484CrossRefPubMedGoogle Scholar
  6. 6.
    Cole MG, Ciampi A, Belzile E, Dubuc-Sarrasin M (2013) Subsyndromal delirium in older people: a systematic review of frequency, risk factors, course and outcomes. Int J Geriatr Psychiatry 28:771–780CrossRefPubMedGoogle Scholar
  7. 7.
    Ely EW, Shintani A, Truman B et al (2004) Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 291:1753–1762CrossRefPubMedGoogle Scholar
  8. 8.
    Pisani MA, Kong SY, Kasl SV, Murphy TE, Araujo KL, Van Ness PH (2009) Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 180:1092–1097CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Pandharipande PP, Girard TD, Jackson JC et al (2013) Long-term cognitive impairment after critical illness. N Engl J Med 369:1306–1316CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    McCusker J, Cole M, Dendukuri N, Belzile E, Primeau F (2001) Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study. CMAJ 165:575–583PubMedPubMedCentralGoogle Scholar
  11. 11.
    Inouye SK (2006) Delirium in older persons. N Engl J Med 354:1157–1165CrossRefPubMedGoogle Scholar
  12. 12.
    Teitelbaum JS, Ayoub O, Skrobik Y (2011) A critical appraisal of sedation, analgesia and delirium in neurocritical care. Can J Neurol Sci 38:815–825CrossRefPubMedGoogle Scholar
  13. 13.
    van den Boogaard M, Pickkers P, Slooter AJ et al (2012) Development and validation of PRE-DELIRIC (PREdiction of DELIRium in ICu patients) delirium prediction model for intensive care patients: observational multicentre study. BMJ 344:e420CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Spronk PE, Riekerk B, Hofhuis J, Rommes JH (2009) Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med 35:1276–1280CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Barr J, Fraser GL, Puntillo K et al (2013) Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 41:263–306CrossRefPubMedGoogle Scholar
  16. 16.
    Delirium: diagnosis, prevention and management (2010) At http://www.nice.org.uk/guidance/cg103. Accessed 1 Oct 2013
  17. 17.
    Ely EW, Margolin R, Francis J et al (2001) Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 29:1370–1379CrossRefPubMedGoogle Scholar
  18. 18.
    Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y (2001) Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med 27:859–864CrossRefPubMedGoogle Scholar
  19. 19.
    Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 113:941–948CrossRefPubMedGoogle Scholar
  20. 20.
    Ely EW, Truman B, Shintani A et al (2003) Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 289:2983–2991CrossRefPubMedGoogle Scholar
  21. 21.
    Patel SB, Poston JT, Pohlman A, Hall JB, Kress JP (2014) Rapidly reversible, sedation-related delirium versus persistent delirium in the intensive care unit. Am J Respir Crit Care Med 189:658–665CrossRefPubMedGoogle Scholar
  22. 22.
    Neufeld KJ, Hayat MJ, Coughlin JM et al (2011) Evaluation of two intensive care delirium screening tools for non-critically ill hospitalized patients. Psychosomatics 52:133–140CrossRefPubMedGoogle Scholar
  23. 23.
    Han JH, Wilson A, Vasilevskis EE et al (2013) Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med 62:457–465CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Bellelli G, Morandi A, Davis DH et al (2014) Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing 43:496–502CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Markowitz JD, Narasimhan M (2008) Delirium and antipsychotics: a systematic review of epidemiology and somatic treatment options. Psychiatry (Edgmont) 5:29–36Google Scholar
  26. 26.
    Inouye SK, Bogardus ST Jr, Charpentier PA et al (1999) A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 340:669–676CrossRefPubMedGoogle Scholar
  27. 27.
    Wunsch H, Gershengorn H, Mayer SA, Claassen J (2011) The effect of window rooms on critically ill patients with subarachnoid hemorrhage admitted to intensive care. Crit Care 15:R81CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Godfrey M, Smith J, Green J, Cheater F, Inouye SK, Young JB (2013) Developing and implementing an integrated delirium prevention system of care: a theory driven, participatory research study. BMC Health Serv Res 13:341CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Schweickert WD, Pohlman MC, Pohlman AS et al (2009) Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 373:1874–1882CrossRefPubMedGoogle Scholar
  30. 30.
    Schreiber MP, Colantuoni E, Bienvenu OJ et al (2014) Corticosteroids and transition to delirium in patients with acute lung injury. Crit Care Med 42:1480–1486CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Luukkanen MJ, Uusvaara J, Laurila JV et al (2011) Anticholinergic drugs and their effects on delirium and mortality in the elderly. Dement Geriatr Cogn Dis Extra 1:43–50CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Reade MC, Finfer S (2014) Sedation and delirium in intensive care. N Engl J Med 370:1567CrossRefPubMedGoogle Scholar
  33. 33.
    Balas MC, Vasilevskis EE, Olsen KM et al (2014) Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med 42:1024–1036CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Girard TD, Kress JP, Fuchs BD et al (2008) Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 371:126–134CrossRefPubMedGoogle Scholar
  35. 35.
    Mehta S, Burry L, Cook D et al (2012) Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA 308:1985–1992CrossRefPubMedGoogle Scholar
  36. 36.
    Pisani MA, Murphy TE, Araujo KL, Slattum P, Van Ness PH, Inouye SK (2009) Benzodiazepine and opioid use and the duration of intensive care unit delirium in an older population. Crit Care Med 37:177–183CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Jamadarkhana S, Gopal S (2010) Clonidine in adults as a sedative agent in the intensive care unit. J Anaesthesiol Clin Pharmacol 26:439–445PubMedPubMedCentralGoogle Scholar
  38. 38.
    Muellejans B, Lopez A, Cross MH, Bonome C, Morrison L, Kirkham AJ (2004) Remifentanil versus fentanyl for analgesia based sedation to provide patient comfort in the intensive care unit: a randomized, double-blind controlled trial [ISRCTN43755713]. Crit Care 8:R1–R11CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Adams R, Brown GT, Davidson M et al (2013) Efficacy of dexmedetomidine compared with midazolam for sedation in adult intensive care patients: a systematic review. Br J Anaesth 111:703–710CrossRefPubMedGoogle Scholar
  40. 40.
    Page VJ, Ely EW, Gates S et al (2013) Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Respir Med 1:515–523CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Mey-Massetti C, Cheng CM, Sharpe BA et al (2010) The FDA extended warning for intravenous haloperidol and torsades de pointes: how should institutions respond? J Hosp Med 5:E8–16Google Scholar
  42. 42.
    Committee JF (2014) British national formulary, 67th edn. BMJ Group and Pharmaceutical Press, LondonGoogle Scholar
  43. 43.
    Tahir TA, Eeles E, Karapareddy V et al (2010) A randomized controlled trial of quetiapine versus placebo in the treatment of delirium. J Psychosom Res 69:485–490CrossRefPubMedGoogle Scholar
  44. 44.
    Boettger S, Jenewein J, Breitbart W (2015) Haloperidol, risperidone, olanzapine and aripiprazole in the management of delirium: a comparison of efficacy, safety, and side effects. Palliat Support Care 13:1079–1085Google Scholar
  45. 45.
    Amato L, Minozzi S, Vecchi S, Davoli M (2010) Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev. (3):CD005063. John Wiley & Sons, Ltd. doi:  10.1002/14651858.CD005063.pub3
  46. 46.
    Pandharipande P, Banerjee A, McGrane S, Ely EW (2010) Liberation and animation for ventilated ICU patients: the ABCDE bundle for the back-end of critical care. Crit Care 14:157CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Irwin SA, Pirrello RD, Hirst JM, Buckholz GT, Ferris FD (2013) Clarifying delirium management: practical, evidenced-based, expert recommendations for clinical practice. J Palliat Med 16:423–435CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of AnaesthesiaWatford General HospitalWatfordUK

Personalised recommendations