Assessment and Management of Delirium Across the Life Span

Delirium is an acute change in consciousness that is accompanied by inattention and either a change in cognition or perceptual disturbance.¹  Patients can have hyperactive delirium (agitation, restlessness, attempting to remove catheters, and/or emotional lability), hypo-active delirium (flat affect, withdrawal, apathy, lethargy, and/or decreased responsiveness), or a combination of both.¹  Delirium affects up to 80% of patients in the intensive care unit (ICU), and it is estimated that ICU costs associated with delirium equal between $4 billion and $16 billion annually in the United States.^2–6 

This form of acute brain dysfunction is associated with increased length of ICU and hospital stays, time receiving mechanical ventilation, mortality, and long-term cognitive impairment.^7–9  Despite this high prevalence and the adverse outcomes, delirium in the ICU goes undetected and, thus, untreated in scores of patients.¹⁰  Iatrogenic risk factors are often modifiable and are referred to as precipitating factors.^3,11 

1. Evaluate patients for potential risk factors for delirium, including a review of medications. [level B]

2. Assess all critically ill patients for delirium by using validated tools. [level B]

3. Create strategies to decrease delirium risk factors, including early progressive mobility. [level B]

   
   

4. Collaborate with providers to administer benzodiazepines cautiously, developing strategies to give only what is needed. [level C]

5. Use antipsychotic medications cautiously, monitoring for prolongation of QTc. [level C]

6. Collaborate with the interprofessional team to prevent and manage delirium. [level D]

7. Involve family in nonpharmacological management strategies. [level C]

1. Pediatrics. Risk factors for delirium in critically ill children are understudied, with one single-center prospective report¹²  currently available. Large-scale, multisite research is needed to further discern the risk factors for delirium specific to the pediatric ICU population. Current risk factors associated with the diagnosis of delirium in the pediatric ICU include

   • Presence of developmental delay

   • Need for mechanical ventilation

   • Age 2–5 years

2. Adults and Older Adults. Risk factors for delirium in critically ill adults are consistently reported as older age, preexisting dementia, hypertension, pre-ICU emergency surgery or trauma, high severity of illness, mechanical ventilation, metabolic acidosis, delirium on the prior day, coma, and multiple organ failure.¹³ 

Although immobility has not been reported as a risk factor for the development of delirium in the ICU, it has been reported in non-ICU cohorts.¹⁴  Researchers in recent studies^15,16  have reported that early mobility in critically ill patients results in not only improved physical function, but also improved cognitive function, reducing the duration of delirium by 2 days. “Early” is defined by these protocols as within the first 3 days of the ICU stay and focuses on progressive mobility pathways, starting with passive range-of-motion exercises and progressing to active range-of-motion exercises, sitting on the side of the bed, and ambulating as tolerated.¹⁷  Mobilize ICU patients early, whenever feasible, to reduce the incidence and duration of delirium and improve physical outcomes.¹⁸ 

Sedative use has been the only consistently identified modifiable risk factor for ICU delirium.

• Benzodiazepines. Benzodiazepines are an independent risk factor for the transition to delirium.^19,20  Use of benzodiazepines is not suggested for ICU patients with delirium unrelated to alcohol or benzodiazepine withdrawal.¹⁸ 

• Dexmedetomidine. Two recent studies, “Maximizing Efficacy of Targeted Sedation and Reducing Neurological Dysfunction (MENDS)” and “Safety and Efficacy of Dexmedetomidine Compared with Midazolam (SEDCOM),” showed a significant reduction in delirium duration in patients receiving dexmedetomidine when compared with benzodiazepines (lorazepam and midazolam, respectively).^21,22  Both studies used dexmedetomidine at higher doses and for longer durations than the current Food and Drug Administration (FDA) labeling approval, which is a maximum dose of 0.7 mcg/kg per hour for a 24-hour duration. Patients sedated with dexmedetomidine have a lower prevalence of delirium than do patients sedated with benzodiazepines, along with other improved outcomes (eg, duration of mechanical ventilation, ICU length of stay).¹⁸ 

• Opioids and propofol. The data concerning opioids are difficult to interpret, because some studies show a dose-dependent relationship, while other studies indicate no relationship between the use of these drugs and development of delirium in the ICU.^3,19,23–25  Only 1 study has explicitly addressed propofol, and those researchers report no significant relationship between propofol and ICU delirium.^20,24  More research is needed with both propofol and opioids to fully understand their relationship to the development and duration of delirium.

In the absence of a validated tool, delirium goes undetected by both physicians and nurses in more than 65% of ICU patients.^10,26–28  Reports underscore the need for systematic utilization of standardized assessment tools, which is in concert with the recommendations from both national and international guidelines.^18,29–31  Recent Society of Critical Care Medicine guidelines recommend all adult ICU patients be routinely assessed for delirium.¹⁸  Routine assessment reduces the likelihood of delirium going undetected and consequently untreated. ICU delirium assessment tools are available for both adults and children.

1. Pediatrics. The Pediatric Confusion Assessment Method for the ICU (pCAM-ICU for ages ≥ 5 years),³²  Cornell Assessment of Pediatric Delirium (CAP-D for ages 1–17 years),³³  and the Pediatric Anesthesia Emergence Delirium Scale (PAED, for ages 1–17 years)³⁴  are valid and reliable tools for assessing delirium in pediatric ICU patients. A PreSchool Confusion Assessment Method for the ICU (psCAM-ICU) for children 6 months to 5 years of age also has been validated for use.³⁵ 

2. Adults and Older Adults. The Confusion Assessment Method for the ICU (CAM-ICU)^36,37  and the Intensive Care Delirium Screening Checklist (ICDSC)³⁸  are the most valid and reliable tools to assess delirium in adult and older adult ICU patients.¹⁴  Implementation of both tools has been described; both have high accuracy and favorable compliance, and each requires minimal education.^39–43 

1. Fundamentally, prevention and management strategies for children and adults should focus first on disease-related interventions. The Society of Critical Care Medicine suggests identification of the cause as the first step in delirium management.¹⁸  The following THINK mnemonic may be helpful in determining the cause when delirium is present:

   • Toxic situations

     • Congestive heart failure, shock, dehydration

     • Deliriogenic medications (tight titration of sedatives)

     • New organ failure (eg, liver, kidney)

   • Hypoxemia

   • Infection/sepsis (hospital-acquired), Immobilization

   • Nonpharmacological interventions (Are these being neglected?)

     • Hearing aids, glasses, sleep protocols, music, noise control, ambulation

   • K⁺ or electrolyte problems

2. Additional Management Strategies for Older Adults

   • Older adults are likely to have more non-modifiable risk factors for delirium upon presentation to the hospital. Mitigation of modifiable risk factors becomes extremely important.

   • Additional nonpharmacological interventions to prevent and manage delirium in critically ill older adults include, but are not limited to^{18,29–31,44} 

     • Avoid malnutrition

     • Avoid use of restraints

     • Discontinue or remove all unnecessary catheters, tubes, and equipment

     • Keep environment calm and uncluttered; avoid overstimulation

     • Consider “camouflaging” catheters and tubes

     • Early and frequent mobilization and participation in activities of daily living

     • Treat pain

     • Provide cognitively stimulating activities adapted for patient

1. No drug has been approved by the FDA to treat delirium in children or adults.

2. Pediatric. No guidelines for pharmacological treatment of delirium in children are currently available. In single-center retrospective studies,^45,46  atypical antipsychotic administration (ie, olanzapine, risperidone, quetiapine) appeared to be effective and safe for managing delirium in children. Further prospective and placebo-controlled studies of pharmacological treatment of critically ill children with delirium is required to determine the efficacy of those drugs.

3. Adults and Older Adults. Current clinical practice guidelines for critically ill adults state that no published evidence indicates that treatment with haloperidol reduces the duration of delirium in adult ICU patients; however, atypical antipsychotics may reduce the duration of delirium.¹⁸  In the past, clinical practice guidelines have recommended antipsychotics as the medication class of choice for delirium, yet very little evidence exists to support this internationally adopted treatment.^47–49  Review of the literature reveals few placebo-controlled investigations on the efficacy of antipsychotic agents for the treatment of ICU delirium. Two such studies^50,51  demonstrated no difference in antipsychotic treatment versus placebo. Another pilot study⁵²  indicated that treatment with quetiapine may reduce delirium duration. These studies are the first steps in understanding the best pharmacological treatment; however, larger trials are needed to confirm these findings in order to systematically direct the choice for delirium treatment.

All patients receiving antipsychotics (haloperidol or any of the atypical antipsychotics) should be routinely and systematically monitored for side effects, especially QT prolongation. Guidelines suggest withholding antipsychotic agents in patients at risk for arrhythmia (eg, baseline QT prolongation, history of torsades de pointes, administration of concomitant medications known to prolong QT interval).¹⁸ 

Rivastigmine, a cholinesterase inhibitor, is not superior to placebo for the treatment of ICU delirium. A large European trial was stopped prematurely because of increased mortality in the rivastigmine group.⁵³ 

The FDA has issued an alert that atypical antipsychotic medications (second-generation antipsychotic agents such as olanzapine, risperidone, quetiapine) are associated with mortality risk among older patients, and another analysis indicated that haloperidol use had an even higher mortality risk in non-ICU older patients than did atypical antipsychotics.⁵⁴ 

Several reviews^55–57  have described the idea of implementing a core model of care that combines multiple evidence-based practice strategies subsequently incorporated into routine daily care for the purpose of improving overall outcomes for patients and allowing a systematic reduction in the modifiable risk factors for delirium. The ABCDEF bundle includes spontaneous awakening and breathing trial coordination, careful sedation choice, delirium monitoring, early progressive mobility and exercise, and family engagement and empowerment. The intent of combining and coordinating these individual strategies is to “(1) improve collaboration among clinical team members and the family, (2) standardize care processes, and (3) break the cycle of oversedation and prolonged ventilation, which appear causative to delirium and weakness.”⁵⁵ 

The ABCDEF bundle is a helpful paradigm for critical care nurses to consider when implementing strategies to improve patient care as a means to reduce modifiable delirium risk factors and improve quality of life for patients and their families. Studies evaluating the effectiveness and safety of the bundle have reported reductions in duration of mechanical ventilation, delirium incidence, and length of stay along with increases in the occurrence of mobilization—all with no significant increased risk of adverse events.^16,58,59  Components of the ABCDEF bundle are

• Assess and manage pain

• Both awakening and breathing trials (Wake up and Breathe protocol)

• Choice of sedation and analgesia (attention to these medications)

• Delirium assessment and management

• Early progressive mobility

• Family engagement and empowerment

  • Consider having patients’ family members keep an intensive care diary, which can reduce the new onset of posttraumatic stress disorder following critical illness.⁶⁰ 

  • Family members can be helpful in preventing, recognizing, and mitigating delirium. Family and friends can help ICU patients by using the following techniques:

    • Communication: use simple words, be concrete, and take your time

    • Remind patient of day, date, surroundings

    • Talk about family and friends

    • Address patients’ concerns (eg, bills, pets, work)

    • Bring glasses or hearing aids

    • Decorate the room with familiar items that may be reminders of home

    • Encourage patient to perform range-of-motion exercises at discretion of clinical staff

  • Keep in mind that critical illness affects patients and their support system. It is important to recognize needs of the patient’s family as well as needs of the patient. Family needs may include education, social and emotional support, and access to helpful resources. Education should include expectations for the patient during and after critical illness (eg, post–intensive care syndrome, posttraumatic stress disorder, depression). Last, encourage family members to attend to basic personal needs without guilt.

Ensure consistent practice for delirium assessment: at least once per shift or with each change of caregiver, assess delirium for all critically ill patients, using a validated tool (eg, CAM-ICU, ICDSC, or pediatric assessment tool).

Support collaboration with the interprofessional team to decrease benzodiazepine use, including titration strategies (eg, sedation scale, targeted sedation protocols, and daily awakening trials) or use of alternative sedatives (eg, dexmedetomidine or propofol).

Develop a protocol that incorporates early progressive mobility and exercise for all critically ill patients. Involve the patient’s family in mobility as indicated.

Review and update policies allowing patients’ families to be present with patients.

1. Contact a clinical practice specialist for additional information: go to www.aacn.org then select Practice Resource Network.

2. See www.ICUdelirium.org for materials about delirium teaching and implementation of assessment tools, including downloadables and videos.

3. See www.ICULiberation.org for information on implementation of the 2013 Clinical Practice Guidelines for the management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit.