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Delirium in the Hospital--Susie Curtis

posted Aug 12, 2014, 1:55 PM by Kevin Hauck

Delirium:

Definition: Delirium is an acute cognitive disorder.  It must have an acute onset and consist of problems of inattention and disorganized thinking with fluctuating mental status.  Very importantly it is reversible.  Though delusions, hallucinations, problems of orientation, and sleep/wake disturbances may be part of the syndrome they are not necessary for the syndrome to be present.

Delirium is incredibly pervasive, present in 1-2% of people in the community, in 6-56% of hospitalized patients and up to 87% of ICU patients.  In one study at Monte it was present in 15% of patients and up to 80% of our ICU patients.

Causes:  Many things contribute to the development of delirium.  They can be remembered using this helpful pneumonic. DELIRIUMS.

Drugs –iatrogenic/withdrawal

Eyes, ears, environment –does the patient wear glasses? Need a hearing aid?  Is there a window in the room? A clock? A calendar?

Low 02 states, Low reserves (frailty)

Infection

Retention – Urinary retention and constipation in the elderly

Immobility – Is the patient restrained?  Cannot ambulate due to lines and tubes (catheters?)

Under-hydration

Metabolic causes – hypo/hypernatremia, hyper/hypoglycemia, hypo/hyperkalemia

Severity of illness or organ dysfunction

Keep in mind, delirium can often be the first sign that one of the above disorders is occurring! 

Delirium also leads to longer ICU/hospital admissions, more time on ventilator support, more discharges to institutions in patients that originally from home, more in hospital deaths, and of course more cost to the hospital.

Diagnosis: The CAM-ICU is a validated scoring system to screen for delirium in all our patients.  It is important to use this as patients often may not appear delirious on first interaction.  The score is below.  (Dr. Hsieh also has very helpful pocket carts with the CAM-ICU scoring system on them).

When in the ICU, or on the floors, on every patient you must ask 4 important questions.  What is the patient’s current RASS?  What is the patient’s target RASS? (Patients are often over sedated.  A ventilated patient should be awake and alert if they are to be extubated.)  Is the patient delirious? (Use the CAM-ICU score.)  Is the patient on sedatives?


Prevention:

30-40% of episodes of hospital delirium are preventable!

-Make sure patients have their hearing aids or glasses if they require them. 

-Make sure the room has a window if possible, a working clock and a calendar with the correct day. 

-Assess fluid status, do not allow patients to become dehydrated.

-Support normal sleep/wake cycles (avoid those 3am labs!)

-Early mobility!  Make sure patients are not restrained by lines or tubes (or restraints) when avoidable.  Order PT/OT as soon as possible.  Studies on early PT in ICUs shows it not only reduces time spend delirious, it reduces ICU and hospital stay length.  Dr. Hsieh showed us that our ICUs own work in early PT has reduced delirium by 16% and reduced hospital length of stay time by 4 days!

Treatment: Always start with non-pharmacologic strategies.  Everything done above to prevent delirium can also be done to treat it.  Also assess medications.  Is the patient on a medication that may be making them delirious (hallucinogens, stimulants, anticholinergics in the elderly), if so stop the medication.  Could the patient be withdrawing from a medication?  Keep in mind that patients on versed drips can withdraw if it is stopped suddenly.  Treat withdrawal  appropriately if it is a consideration.

Only when all of the above fail consider Haldol (but remember to first check the QTc!)

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