Sharon M. Gordon PsyD

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Delirium Assessment in the ICU A New Frontier

• Sharon M. Gordon PsyD
• Chief of Psychology, VA TN Valley Health Care
  System
• Assistant Clinical Professor of Psychiatry
• Vanderbilt University School of Medicine

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Financial Conflicts

• None
• I am a government employee
• Thank You Federal Tax Payers!!!!

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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

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So what is a Psychologist doing in the ICU
anyway?
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What Are The Needs in the ICU?

• What is the patients 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?

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How Can A Psychologist Help 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?????

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So many terms

• Acute confusional state
• ICU Psychosis
• Confusion
• Acute brain syndrome
• Altered mental status
• Toxic or metabolic encephalopathy
• Sundowning
• Hes agitated Shes out of it

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Turns out..
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What we were seeing was.

• DELIRIUM

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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

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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 HP 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)

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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
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Delirium Acute Brain Failure in
Man 1980
Zbigniew J. Lipowski, M.D. 19241997

• Delirium constitutes a ubiquitous and thus
  clinically important sign of cerebral functional
  decompensation caused by physical illness

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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

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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 HP and/or labs that the
disturbance is caused by a medical condition,
substance intoxication or medication side effect
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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
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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)

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Subtypes of Delirium

• Hypoactive
• Patient may be quiet and even peaceful, despite
  cognitive impairment. More difficult to assess.

• Hyperactive
• Patient may be combative with agitation that may
  require sedation (is diagnosed more frequently).

• Mixed
• Combination of both types

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Delirium Subtypes
Combative Agitated Restless
Alert Calm
Lethargic Sedated Stupor
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Delirium Subtypes
Combative Agitated Restless
Alert Calm
Lethargic Sedated Stupor
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Delirium Subtypes
Hyperactive Delirium
Combative Agitated Restless
Alert Calm
Lethargic Sedated Stupor
Hypoactive Delirium
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Delirium Subtypes
Hyperactive Delirium
Combative Agitated Restless
Mixed Delirium
Alert Calm
Lethargic Sedated Stupor
Hypoactive Delirium
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What it is not

• Dementia
• Depression
• Sundowning
• Alcohol withdrawal Syndrome
• Delirium tremens

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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 301997-2008,
2004 Jackson JC, Intensive Care Med 302009-2016,
2004
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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)

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Who is at Risk?

• 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

• 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

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Delirium

• Risk factors for developing?
• Underlying dementia
• Recent surgery
• Dehydration/renal insufficiency
• Multiple medications
• Older age

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

• Baseline Vulnerability
• Underlying Brain Disease (Dementia, stroke,
  Parkinson)
• Increased Age
• Institutionalization
• Chronic disease (HIV, ETOH dependency, diabetes,
  etc)
• Visual/Hearing deficits

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Risk Factors

• Precipitating
• Medications
• Infection
• Dehydration
• Immobility/restraints
• Malnutrition
• Tubes/catheters
• Electrolyte imbalance
• Sleep Deprivation

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Causes of DeliriumCommon 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

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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 2001271297-1304, n216 Ely EW,
ICM 2001271892-1900 Boogaard M, BMJ. 2012 Feb
9344e420 (10 items in final model)
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Risk Factors

• Baseline Vulnerability (predisposing)
• -Risk factors r/t persons baseline
• - Often we cannot modify these
• Precipitating
• These are things that happen to the patient
• Insults
• Often Iatrogenic
• Baseline Precipitating Delirium

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Framework for Risk
Precipitating Stimulus
Baseline Vulnerability
High
Noxious
Low
Mild/None
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Framework for Risk
Precipitating Stimulus
Baseline Vulnerability
High
Noxious
Low
Mild/None
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Framework for Risk
Precipitating Stimulus
Baseline Vulnerability
High
Noxious
Low
Mild/None
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Framework for Risk
Precipitating Stimulus
Baseline Vulnerability
High
Noxious
Low
Mild/None
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Framework for Risk
Precipitating Stimulus
Baseline Vulnerability
High
Noxious
Low
Mild/None
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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 2001271892-900 Ely EW JAMA
2001286,2703-2710 Ely EW CCM 200129,1370-79 McNi
coll L, JAGS 200351591-98
Bergeron N, ICM 200127859-64 Thomason J, AJRCCM
2003167A968 Ely EW CCM 200432106-112 Peterson
et al, AJRCCM 2003167A968
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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 2001286,2703-2710
• Ely EW CCM 200129,1370-79

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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 200432106-112 2 Bergeron, ICM
200127859-64 3 Ely EW JAMA 2001286,2703-2710 4
Ely EW CCM 200129,1370-79 5 Inouye, Am J Med
1999106565-573 6 Lawlor, Arch Intern Med
2000160786-794 7 McCusker, Arch Intern Med
2002162457-463
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In-Hospital Mortality
Delirium On Admission
Develop Delirium
Postop Delirium

• Acute MI

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4-13
22-76
10-26
Arch Intern Med 2002162(4)457-63 Am J
Psychiatry 1999156(5 Suppl)1-20 JAMA
1994271(2)134-9 NEJM 19953351857-63 www.ahrq.g
ov
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Delirium Monitoring in ICUs - 1999
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Delirium Monitoring in ICUs - 2007
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Morandi et al, Intensive Care Med 2008
Morandi et al, Intensive Care Med 2008
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The biggest problem is that doctors are focused
only on the organs that got patients into the
hospital, ignoring newly acquired brain problems
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Delirium Pathophysiology
Flacker, et al. Gerontol. Bio Scie 1999 54A
B239-B246
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Delirium Pathophysiology
Flacker, et al. Gerontol. Bio Scie 1999 54A
B239-B246
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Monitoring and Support of Organ Dysfunction
Cardiovascular
Pulmonary
Renal
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• How do you monitor for brain failure (i.e.
  delirium)?

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Triad of Neurologic Monitoring
Arousal SAS, RASS, MAAS
Delirium CAM-ICU
Consciousness Wakefulness Content
Physiological Brain Activity BIS-EEG, ERP, P300
Plum and Posner Diagnosis of Stupor and Coma
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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)

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Richmond Agitation-Sedation Scale(RASS)

• 4 Combative
• 3 Very agitated
• 2 Agitated
• 1 Restless
• 0 Alert /calm
• -1 Drowsy eye contact gt10 sec
• -2 Light sedation eye contact lt10 sec
• -3 Moderate no eye contact
• -4 Deep physical stimulation required
• -5 Unarousable no response even with physical

Verbal Stimulus
Physical Stimulus
Sessler CN, et al. AJRCCM 2002 1661338-1344.
Ely et al, AJRCCM 2001163A954
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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. 20032892983-2991

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Ely EW, JAMA 20032892983-91
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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)

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