GUEST EDITORIAL doi: 10.1111/nicc.12033
Intensive care delirium: the new black The interest in delirium in the intensive care unit (ICU) has increased in the past 10 years. A quick Medline search yields a growing number of hits on the term ‘intensive care delirium’ from 12 in 2002 to 178 in 2012. In the 1980s and 1990s, the condition was known by other terms such as ‘intensive care syndrome’ or ‘acute confusion’. Delirium is Latin for ‘going off the plowed track’ and has been described as ‘brain failure’. It is undetermined whether ICU delirium is primarily a result of acute illness or caused by medications. The condition has been associated with adverse events such as self-extubation, prolonged hospitalization, increasing cost, cognitive decline, and death. While lighter sedation leads to fewer days with delirium, longer duration of delirium is an independent predictor of adverse outcome. Interruption in daily sedation has been shown to decrease the duration of the ICU stay, but fluctuations in consciousness related to daily awakening might precipitate delirium (Svenningsen et al., 2013). In 1980, delirium received an independent medical classification, and its clinical features were defined in 1989. Delirium in mechanically ventilated patients was formally described in 2001, when two validated tools for delirium detection became available: The Intensive Care Delirium Screening Checklist (ICDSC) and the Confusion Assessment Method for the ICU (CAM-ICU) (Bergeron et al., 2001; Ely et al., 2001). CAM-ICU is the more widely used instrument. It was conceived as a tool that was fast and easy for nurses to use. The main difference between the tools is that ICDSC does not recognize sedated patients as delirious. Without adequate screening tools, delirium might go undetected. In one study, nurses picked up only 35% of 164
delirium, and doctors 28% (Page and Ely, 2011, p.27). Delirium is a syndrome that is detected rather than diagnosed. The following clinical subtypes have been identified: hyperactive, hypoactive, and mixed type delirium. The following distribution was described in a study of critically ill patients in 2006: hyperactive (2%), hypoactive (44%), and mixed (54%) (Page and Ely, 2011, p.38). Subsyndromal delirium is a condition where the patient shows some symptoms of delirium, but not all. Most cases of delirium are quiet and hypoactive delirium is frequently mistaken for sedation, withdrawal, or depression. Patients with the hyperactive subtype display agitated behavior and experience more hallucinations and delusions than hypoactive patients, but have a better prospect of full recovery. Delirium has been reported in 20–50% of non-ventilated patients and up to 80% of mechanically ventilated ICU patients (Katz and McNeely, 2013). ICU nurses are in a key position to detect delirium, and modify the condition by careful sedation management. Studies show that ICU nurses play an important role in sedation of mechanically ventilated patients independently and in collaboration with the physicians (Egerod et al., 2013). Important issues are interdisciplinary management of sedation, pain, sleep, circadian rhythm, and early mobilization (Barr et al., 2013). Nurses need to be familiar with the long-term issues associated with over and under sedation, as they titrate sedatives according to patient requirements at the bedside. Imagine the power of nurses, who are able to control the consciousness of their patients. In some cases, nurses over-sedate the patients to compensate for under-staffing; it is easier to care for an unmoving and tranquil body, than an awake, agitated, and distressed
individual. In other situations, nurses may employ lighter sedation, paving the way for better communication and early mobilization. In a study using a protocol of no-sedation, it was necessary to have a higher than standard nurse-patient ratio (Strom et al., 2010). The increased cost of better staffing was most likely counterbalanced by the advantages of a speedier recovery and exit from ICU. Caring for alert intubated patients is likely to be common practice of future intensive care nursing, requiring nurses to further refine their communication and compassion skills. One advantage of less sedated patients is that it is easier to assess for delirium. Moreover, studies are beginning to show that the incidence of delirium decreases when patients are kept more awake and oriented. The risk of delirium is greatest at the stage when the patient is regaining consciousness, either awakening from coma or deep sedation. This is when the patient is most vulnerable and when nurses should try to avoid shifting the dose of sedation too frequently. Patients should only be sedated if there is a medical indication. Sedation disturbs the normal sleep pattern. Many ICU patients suffer sleep deprivation, which leads to delirium. In ICUs, sedation should be replaced by a goal of natural sleep and a normal circadian rhythm. More and more ICUs install dynamic lighting systems to ensure a natural day-night cycle. Studies are needed to determine the effect of lighting systems on the incidence of delirium. The most common causes of delirium in ICU have been identified as infections and medications (Page and Ely, 2011), but delirium is also precipitated by disrupted sleep and a hostile and unfamiliar environment. These are modifiable factors that are central to nursing.
© 2013 The Author. Nursing in Critical Care © 2013 British Association of Critical Care Nurses • Vol 18 No 4
Guest Editorial
Pain management is important to promote sleep and to discourage delirium. In the strategy of analgo-sedation, patients are medicated primarily for pain, and only if necessary, sedated. Mobilization increases the chances of normal sleep in the short-term and improves outcomes in the long-term. Sleep, pain management, adequate nutrition, good hydration, presence of family, and early mobilization are all key factors to reduce delirium. The familiar faces and voices of family members are not only calming to the patient, but also stimulating for patients with nothing to do. Nurses are able to promote family presence and participation in care. Family-centered care is important to the patient as well as the visitors and gives the patient a lifeline to the familiar world outside ICU. It is important to understand the patient experience in order to make improvements in ICU. In their study of nurses’ perceptions of unpleasant symptoms in mechanically ventilated and sedated ICU patients, Randen et al. (2013) found that nurses underestimated their signs and symptoms. Nurses need to recognize unpleasant symptoms and over-sedation in ICU patients to provide better care and targeted interventions. Hallucinations and delusions related to sedation and
delirium are unpleasant experiences that might lead to post-traumatic stress. Nurses have identified confusion in ICU patients for years, but it is a different matter to label the individual as delirious. Implementation of delirium screening tools has been slow to becoming standardized practice because patient screening represents a new kind of nursing in many settings. Patient screening, however, is not the opposite of caring, but an important part of safe caring. Nurses need to be educated and to understand why delirium screening is important in terms of outcomes and help to find ways to identify, predict, prevent, or modify delirium in at-risk ICU patients. Ingrid Egerod Professor, University of Copenhagen, Faculty of Health & Medical Sciences and Copenhagen University Hospital Rigshospitalet, Trauma Centre 3193, Blegdamsvej 9, DK-2100 Copenhagen O, Denmark E-mail:
[email protected]
REFERENCES Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, et al. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients
© 2013 The Author. Nursing in Critical Care © 2013 British Association of Critical Care Nurses
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