Delirium Presentation Web

7/27/2019 Delirium Presentation Web

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Delirium in critical illness



Delirium

An acute medical condition

Common in UK critical care patients

Serious adverse outcomes

Bedside diagnosis

May be first sign of a new infection

Pathological not psychological



Delirium

Disturbance of consciousness

Acute change in mental status

Fluctuating course – worse at night

Develops over short time, hours to days

Impaired attention

Disorganised thinking



Delirium motoric types

Hyperactive – psychomotor agitation

Hypoactive – psychomotor lethargy and

sedation, appears quiet & co-operative BUTwith inattention and disorganised thinking.

Mixed – fluctuating hypo/hyperactive

symptoms



“Acute brain dysfunction”

Prevalence of up to 80% quoted in ITU

100 ITU surgical patients:

69% with deliriumLonger ventilation & ITU stay – 4 days

Midazolam use strongest modifiable predictorPandiharipande et al. 2006 SCCM

118 ITU medical patients over 65:31% on admission.

70% during hospitalisation

McNicoll J AM Geriatri Soc. 2003;51(5):591



Pathophysiology

Neuroimaging – 42% ↓CBF, atrophy

Psychoactive drugs 3-11 fold ↑RR delirium

Related to surgery – multifactorial

Biomarkers – serum anticholinergic activity Neurotransmitters – imbalance in all

monoamines, GABA, glutamate and Ach

Sepsis: blood brain barrier breakdown ordamage by metabolic/inflammatorymediators

Yokota. Psych.Clin.Neurosci 2003, Fong. J Geront A Biol Sci Med Sci 2006, Koponen J Nerv Ment Dis 1989,Hopkins Brain Inj 2006, Chang R Neurosig 2006 Inoyue Am J Med 1999, Pandharipande Anesth 2006, MarcantonioJAMA 1994 Tune Lancet 1981, Mussi J Geriatri Psych Neurol 1999, Marcantonio J Geront A Biol Sci Med Sci 20Goyette Semin Resp CCM 2004, Sharshar ICM 2007



Delirium is often invisible

The vast majority of delirium in ICU is either

hypoactive “quiet” subtype (35%) or mixed (64%)

Very little (1%) is the pure hyperactive subtype. Older age is a strong predictor of hypoactive

delirium

Hypoactive delirium has worse outcomes

Onset: ICU day 2 (+/- 1.7)

How long: 4.2 (+/- 1.7) days Ely et al JAMA 2001;286:2703-2710 Ely et al CCM 2001;9:1370-1379

Peterson et al JAGS 2006 in press McNicholl JAGS 2003;51:591-598



Risk factors

Host factors Acute illness Iatro/environ

Elderly Severe sepsis Sedative/analges

Co-morbidities ARDS Immobilisation

Pre-existing

cognitive impair

MODS TPN

Hearing/vision

impairment

Drug OD or

illicit drugs

Sleep

deprivation

Neurological dis Nosocomial inf. Malnutrition

Alcohol/smoker Met. disturbance Anaemia



Precipitating factors

INFECTION

Hyponatraemia

Temperature

Maintenance of arterial pressure

Glucose

Benzodiazepines Hypoxia, hypercarbiaVaquero et al. Sem in Liver Dis. 2003;32:59-69



Medications cause delirium

Different drugs implicated in different studies

Benzodiazepines, esp. lorazepam

?related to dose Corticosteroids

Morphine

Maybe propofol and fentanyl AnticholinergicsPandharipande et al. Anesth;104(1):21-26,2006Dubois ICM 2001;27:1297-1304,

Marcantonio. JAMA, 1994;272:1518-1522, Gadreau J of Clin Onc. 23(27):6712-6718



Does it matter?After adjusting for age, gender, race, pre-existing

comorbidity & cog impairment, ICU diagnosisand severity of illness

3 fold higher rate of death by 6 months 1.6 fold increase in ICU costs.

Longer hospital stays

Nearly 10x rate cognitive impairment on

discharge. 1 in 3 survivors with delirium develop cognitive

impairment.

Institutionalisation



Does it matter?

Increased ICU LOS 8 vs. 5 days

Increased Hosp. LOS 21 vs. 11 days

Increased time on vent 9 vs. 4 days

Higher costs $22 000 vs. $13 000

3 fold increased risk of death

Poss. incrd longterm cognitive impairment Ely ICM 2001;27,1892-1900, Ely JAMA 2004;291:1753-1762, Lim SM, CCM 2004;32:2254-2259,

Milbrandt E, CCM 2004;32:955-962, Jackson Neuropsychology Review 2004;14:87-98



Delirium and death

In 275 medical ITU patients

Independent predictor 6 month mortality:

34% with delirium v. 15% without p=0.03After adjusting for covariates

Hazard ratio death: 3.2 (CI 1.4 – 7.7)

203 general medical patientsAdj. relative mortality risk 1.8

Median survival 510 days v. 1122 daysRockwood Age & Aging 1999;28(6):551-6, Ely et al JAMA 2004;291:1753-1762



Dementia after delirium

203 patients, 38 with delirium – 22 with

dementia, 16 without. 32 month follow up.

Incidence of dementia 5.6% per year withoutdelirium, 18.1% with.

Relative risk of death adjusted incr 1.8 +

significantly shorter median survival time

Rockwood et al, Age and aging 1999;28:551-556



Medical ITU patients

11 of 34 patients neuropsychologicallyimpaired.

Generally diffuse but primarily areas of psychomotor speed, visual & workingmemory, verbal fluency and visuo-construction.

Clinically significant depression in 36%these patients.

Jackson CCM 2005;31(4):1226-1234



Delirium and outcome

40 year old ARDS ICU survivor college graduate

“I have been out of hospital and trying to get on with

my life for the past 2 years. I have trouble with people’s names that I have worked with for years.

I can’t remember where I put things at home. I

can’t help my children with their homework

because I can’t remember how to do simplemultiplication problems.”



Neurological monitoring

Level of sedation.

Drugs are given with specific agreed

target of effect.Screen for delirium

Confusion assessment method for the ICU

CAM-ICU, sensitivity/specificity 95%V. high inter-rater reliability

Ely et al CCM;29:1370-1379, 2001, Ely et al JAMA;286:2703-2710, 2001



Delirium screening

CAM-ICU –

4 features

Altered mental status

Inattention; Indentify As in 10 letter spoken sequence

SAVE A HAART

Disorganised thinking

Altered level of consciousness

ICDSC – 8 items

Over one shift. 4 or more = delirium

Ely JAMA 2001, Bergeron ICM 2001



CAM-ICU Incorporates 4 key features from

definition of delirium, 1 minute to do

1. Change in mental status from baseline or

fluctuating course.

2. Inattention

3. Disorganised thinking

4. Altered level of consciousness

Needs 1 & 2 with either 3 or 4.



The Assessment tool!Feature 1: Acute onset of mental

status changes, or Fluctuating course.

Feature 2: Inattention

AND

AND

Feature 3: Disorganisedthinking

Feature 4: Altered level ofconsciousness

OR



CAM-ICU

Sedation level at least eye-opening to voice with orwithout eye contact.

Feature 1: is patient different from baseline?

Or: any fluctuations in mental status 24/12?

Feature 2: looking for inattention – ASE letters, ifunclear status – ASE pictures using hand squeeze.

If both positive:

Feature 3: Disorganised thinking, a) 4 questions – 2or more incorrect responses is positive. b) Holdingup fingers.

Feature 4: Altered conscious level i.e. drowsy +



Management:

treat cause(s) & reduce risks Treat underlying infection and CCF

Correct metabolic disturbance & hypoxia

Frequent reorientation of patient Goal directed sedation/analgesia &/or daily

wakeup.

Stop ventilator each day to test readiness

Early mobilisation

Attention to optimising sleep patterns Inouye. NEJM 1999;340(9):669



Management

Pharmacological therapyAntipsychotics:

Haloperidol: dopamine receptor

antagonist D2, variable sedationside effects: torsades de pointes (QTc)

extrapyramidal.

Newer atypicals: Olanzepine, QuetiapineBenzodiazepines:

Deliriogenic, alcohol withdrawal.



Haloperidol

1950 shortly after chlorpromazine

D2 blockade mesolimbic pathways

Blockade in nigrostriatal pathway – EPS

Fewer vasomotor, cardiac central effects

60% bioavailability

Metabolised by oxidative dealkylation

Various dose schedules

2.5mgs to 5mgs starting dose



Delirium and Negative outcome

Cause-and-effect? Systemic infections & injury ► brain

dysfunction generation of CNS

inflammatory response ►Production ofcytokines, cell infiltration & tissue damage.

CNS immune activation accompanied by

peripheral production of TNF, interleukin 1& interferon δ contributing to MOF.

Bergeron Critical Care 2005;9:R375-381



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