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Managing Delirium in the ICU

Early treatment reduces the severity of the illness.

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Delirium is one of the common mental disorders seen in hospitalized elderly patients in intensive care. It is associated with a high mortality rate and subsequent cognitive decline. Who among us has not seen an elderly patient admitted to the ICU with normal cognitive function who becomes disoriented after just a few days?

Case Study

J.C., an 89-year-old female, is admitted to the hospital after a fall resulted in a left hip fracture. While awaiting surgery, she is placed on an orthopedic unit with telemetry monitoring. Her past medical history includes COPD, smoking, chronic kidney disease, ulcer, atrial fibrillation and osteoporosis. She lives in a senior apartment and is active in her church group.

After returning from the postanesthesia care unit, J.C. is settled in bed. She is alert and oriented with stable vital signs, and her postsurgical pain is controlled with fentanyl IV. Later that evening, she develops atrial fibrillation and shortness of breath. A "rapid response" is called and she is transferred to ICU where she is again stabilized and her heart rhythm controlled. She is increasingly agitated, confused and unable to be reoriented. To prevent her from pulling out her IV lines, nurses placed mitts on her hands and administered lorazepam .5 mg IV.

Throughout the night, J.C. continues to be combative and confused until she falls asleep. The next morning, she is alert and oriented, but she has difficulty following directions. She is lethargic and unable to eat any of her meals. Physical therapy is unable to work with her, and she is admitted to subacute rehabilitation. After making little progress, she is admitted into a nursing home.

What actions could the nursing staff have taken to prevent J.C. from deteriorating so quickly?

Mechanisms of Delirium

Delirium is a sudden onset of severe confusion that fluctuates during the course of the day and often lasts about 1 week. However, it may take several weeks to regain baseline mental function. Indications are often overlooked due to the variety of symptoms.

A patient progressing into delirium may experience changes in arousal, such as increased vigilance and hyperstimulation. Conversely, the patient may become lethargic and experience a decrease in short-term memory and recall. A patient's attention span may also appear disrupted and wandering. While some patients with delirium demonstrate hallucinations, agitation and tremors, these symptoms are not necessarily needed for a diagnosis.

Common Risk Factors

The most common risk factor for delirium is underlying brain disease. Advanced age and sensory impairments are contributing factors. Common medical conditions that precipitate delirium are fluid and electrolyte disturbances, infections, drug toxicity, metabolic disorders, shock, heart failure and hypoxemia.

Elderly individuals are especially susceptible after hip fractures or aortic surgeries. Uncontrolled pain and absence of a wall clock or glasses can be issues, as well.

Complications & Consequences

Complications associated with elderly patients admitted to the ICU can include early dislocation of hip prosthesis or wound separation due to agitation. Confusion can lead to falls and urinary incontinence. An indwelling catheter may be placed leaving the patient open for infection. Increased agitation can lead to congestive heart failure, dehydration, pneumonia, aspiration and MI. Restraints used to prevent IV lines from being pulled out can lead to posttraumatic stress disorder after discharge.

All of these consequences impact a patient's quality of life, prolong the hospital stay and increase mortality risk.

And then there are the economic consequences. It is estimated delirium costs the U.S. healthcare system $143 billion to as much as $152 billion per year. On a smaller scale, the per patient cost is estimated to be between $16,303 and $64,421. Meanwhile, nursing resources are limited, and closely monitoring patients for safety stresses an already scarce reserve.

Delirium also accounts for a longer length of hospital stay, which not only contributes to increased costs, but also morbidity and mortality for elderly ICU patients. This can lead to nursing home placements after discharge. Early treatment reduces the severity of the illness.

Pharmacological Treatment

Traditional sedatives, such as benzodiazepines, are often used in the ICU setting for agitation, anxiety and insomnia. However, certain age-related changes affect the patients' response to this drug class, because benzodiazepine receptors in the brain of the elderly are more sensitive. This may lead to a state where normal social restraints of behavior are lost and sedation, unsteadiness and memory loss are increased.

Lorazepam increases the risk of delirium in elderly ICU patients by approximately 20 percent. (Pandharipande, et al, 2006). Patients with hypoalbuminemia, dementia and chronic renal failure are at an increased risk. Haloperidol, considered to be the gold standard among antipsychotics for treatment of delirium in the elderly, may be associated with a prolonged QT interval and extrapyramidal side effects.

In terms of delirium in the elderly, newer atypical antipsychotics, such as quetiapine, risperidone and olanzapine, are said to have fewer side effects; however, prescription sleep aids, benzodiazepines and the use of meperidine for pain must be avoided for elderly ICU patients. Still, consistent pain control is imperative.

What Nurses Must Know

Identifying and treating the underlying cause of delirium is important. Nurses should be observant for atypical symptoms of delirium such as lethargy, low levels of motivation and sluggishness. A psychiatry consult should be obtained for suspected delirium.

Screening tools such as CAM (confusion assessment method) or the NEECHAM Confusion Scale can be helpful in identifying non-intubated patients at risk. The CAM tool is a series of nine observations made by the nurse evaluating the patient. Scoring is based on an algorithm. The NEECHAM Confusion Scale is similar, further measuring physiological conditions such as oxygenation. It is scored using points.

Basic principles of treating delirium include avoiding causative factors, identifying and treating acute illness, providing restorative care to prevent further decline, and controlling disruptive behavior. Frequent rounds, for example, could have alerted the nursing staff to J.C.'s progression into delirium. Once in ICU, alternative medications could have been started by psychiatry, thus avoiding further complications of benzodiazepines.

References for this article can be accessed at http://www.nursing.advanceweb.com/. Click on Resources, then References.

Christine Bloodgood is a critical care nurse at Riverview Medical Center, Redbank, NJ.


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On October 21,2010, I was for no reason and with no mercy gunshot on my face by a 17 year old man. One of the bullet 's fragment broke my Carotid artery. My son did not wait for the ambulance he bring me to the hospital as soon as could. When we got the Grant hospital, already all my blood was lost. I died. I was dead for at least 4 minutes. However,the resuscitation techniques that doctors performed, were successfully. Then, I was 10 days in ICU with terrible delirium, horrible panic and hallucinations. I feel hopeless, with a extremely fear. For days, or moments, I was paranoiac and others moments, or days, I was schizophrenic. It was the most terrible experience that I had in my life. One month later I was in home and two month later I was again at Franklin University. I passed my first two classes with A I never more had that experience. I have wrote all the kind of feelings, visions, and thoughts that I have while I was in delirium. Thank you.

Josefina Sanchez-MenendezJune 28, 2011
Columbus , OH



This was a very informative article. I did not realize the damaging affects on both patients and hospital budgets that mismanagement of deliruim can cause. Great topic, great article. Kudos!

Christy Sambolin,  RNNovember 12, 2010
NJ




     

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