Delirium may present as changes in behaviour: Cognitive function - changes in concentration, responsiveness, confusion Perception - hallucinations, delusions Physical function - changes in mobility, movement, restlessness, agitation, appetite, sleep Social behaviour - lack of cooperation, withdrawal, altered communication, mood change.
These fit in with the pattern of delirium described above, in that there are of acute onset and fluctuating.
A full clinical history and assessment is important, but it is well recognised that delirium can be difficult to detect, especially in its hypoactive form. The use of a validated assessment tool can improve the sensitivity of detecting delirium. Examples:
Intensive care delirium screening checklist
CAM-ICU Not possible if patient is deeply sedated of unconscious. There is a stepped flowchart looking at:
Acute change/fluctuating course in their normal mental status
Inattention errors -
“squeeze my hand every time I say the letter A”
More than 2 errors is abnormal
RASS - alert and calm () is normal
Questions designed to elicit this - does a stone float on water
Screening of high risk patients should be undertaken to ensure that it isn’t missed. This will include essentially every patient on ICU.
Non pharmacological interventions
Ensure good communication
Get family involved
Minimise changes in staff
Clock and calendar
Minimise movement between sites
Cognitively stimulating activities
Mobilise as able
Detect and treat pain
Assess for infection
Reverse sensory impairment e.g. glasses, hearing aids
Ensure medication review to minimise impact
Identify and treat cause Consider similar, serious medical conditions:
Intracranial pathology e.g. infection
Reorientate Consider involving family/friends Optimise preventative measures If needed, Low dose sedatives - olanzapine/haloperidol Only if other efforts have failed
Communication with family is also important. Can be very upsetting for family.
Incidence & Complications
30-60% of ICU patients 60-80% of ventilated patients Undetected in ⅔
Complications include an increased risk of:
Long term neuropsychological disease
Prolonged ICU and hospital stay
Cognitive impairment can be in 50% of these patients at 12 months after their ICU delirium episode. This may be reflected in increased care needs following an episode. Mortality is increased by a factor of 3.2 at 6 months.