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Delirium in the

Neurologically Injured

presented by: Vera W. Bryant DNP, ARNP, ACNP-BC, CCRN, CMC, CNRN, SCRN

Neuro Critical Care Nurse Practitioner - BHM

Fifth Annual Baptist Health South FloridaMiami Neuro Nursing Symposium 2017

Financial Disclosure

• Financial relationships – none

• Product endorsements – none

• Financial gains – none ☺

Learning Objectives

• Review the syndrome of delirium and the subtypes

• Examine some of the etilogies of delirium

• Learn some of the most common risks factors

• Focus on ways to assess, prevent and treat delirium symptoms

Delirium

• What is it?

• Why is it important?

• What causes it?

• Who is at risk?

• Can it be prevented?

• How is it treated?

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Why Delirium?

• Common problem

• Serious complications

• Under recognized

• Preventable

Common

Serious Under-recognized

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Preventable

Definition

Delirium is a nonspecific organic syndrome which is characterized by an acute onset of altered level of consciousness with a fluctuating course in orientation, memory, thought or behavior.

American Psychiatric Association. Diagnostic and statistical manual of mental

disorders. 5th ed. Washington, DC: American Psychiatric Press; 2013.

Terminology

• “De liro”

• “Phrenitis”

• Like does not mean same

• DSM-V criteria

DSM-V Criteria

• Disturbance in attention

• Develops over a short period of time

• There is an additional disturbance in cognition

• Not explained by another disorder

• Evidence that the disturbance is caused by a medical condition

American Psychiatric Association. Diagnostic and statistical manual of mental

disorders. 5th ed. Washington, DC: American Psychiatric Press; 2013.

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Delirium Subtypes

Hyperactive 10%

Increased psychomotor activityRestlessnessEasily distractedHallucinationsAgitation / CombativenessConfusion

Hypoactive 50%

Reduced alertnessLethargicQuietWithdrawnSluggishConfusionDecreased motivation

Mixed 40%Features periods of both hyperactive and hypoactive symptoms

Why is it important?

Epidemiology

• Prevalent delirium

11 – 25% of hospitalized patients will have delirium on admission

Intensive Care Medicine. 2007;33(1):66-73.Neurology. 2011;76:993-999.Best Practice and Research Clinical Anaesthesiology. 2012;26(3):277-287.

Epidemiology

• Incident delirium

29 – 31% of hospitalized patients admitted without delirium will develop delirium

Intensive Care Medicine. 2007;33(1):66-73.Neurology. 2011;76:993-999.Best Practice and Research Clinical Anaesthesiology. 2012;26(3):277-287.

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Epidemiology

• Consequences (economic / functional)

−$64 Billion annually in USA

−Higher associated mortality

−Longer hospitalizations

−Decreased QOL

− Increased risk of institutionalization

Nature Reviews Neurology. 2009;5(4):210-220.Archives of Internal Medicine. 2008;168:27-32.Best Practice and Research Clinical Anaesthesiology. 2012;26(3):277-287.Critical Care Medicine. 2013;41(1):263-306 Stroke. 2012;43:645-649

What causes it?

Pathophysiology

• Neurotransmitter imbalance

• Inflammation

• Impaired oxidative metabolism

• Altered BBB permeability

Journal of Neurology. 2004;251:171-178Innovations in Clinical Neuroscience. 2011;8(10):25-34Stroke. 2012;43:645-649

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Who is at risk?

Predisposing Risks

• Pre-existing dementia *

• Age *

• Functional impairments *

• Severity of illness on admission

• History of ETOH abuse

• HTN

Critical Care Nurse. 2009;29:85-87Advanced Critical Care. 2011;22:225-237British Medical Journal. 2014;349:g6652

Precipitating Risks

• Infection *

• Uncontrolled pain

• Fluid / electrolyte abnormalities

• Environmental influences

• Withdrawal conditions

• Medications *

Critical Care Nurse. 2009;29:85-87Advanced Critical Care. 2011;22:225-237British Medical Journal. 2014;349:g6652

Medication Risk

• Anticholinergics

• Benzodiazepines

• Opiates

• Corticosteroids

• Tricyclic antidepressants

• H2 blockers

Critical Care Nurse. 2009;29:85-87Advanced Critical Care. 2011;22:225-237British Medical Journal. 2014;349:g6652

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Neurologically Injured

• Incidence rate: 13% to 28%

• Hypoactive is the most common

• LOS is longer

• Increase in mortality

• Coma was an independent risk factor for the development of delirium

Journal of Neurology. 2004;251:171-178 Age and Aging. 2009;38:385-389.Acta Neurologica Scandinavica. 2010;122:39-43 Stroke. 2012;43:645-649Am J Respir Crit Care Med. 2013;188(11):1331-1337.

Neurologically Injured

• Age

• Urinary retention / UTI

• Pneumonia

• Pre-existing dementia

• Sensory impairments

Stroke. 2012;43:645-649Am J Respir Crit Care Med. 2013;188(11):1331-1337.Journal of Young Pharmacists. 2017;9(2):299-302.Neuropsychiatric Disease and Treatment. 2017;13:459-465.

Neurologically Injured / Stroke

• Large anterior circulation strokes

• Hemorrhagic strokes

• Any posterior circulation strokes

• Cardio-embolic strokes

• Left hemiparesis

Journal of Neurology. 2004;251:171-178Age and Aging. 2009;38:385-389.Stroke. 2012;43:645-649Am J Respir Crit Care Med. 2013;188(11):1331-1337.

Mnemonic:

− D Drugs

− E Environment

− L Lab abnormalities

− I Infection

− R Respiratory

− I Immobility

− O Organ failure

− U Unrecognized dementia

− S Shock / Steroid / Stroke / Sleep

Adapted from: St. Louis University Geriatrics Evaluation Mnemonics Screening Tool

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Can it be prevented?

Management of Delirium

• Primary Prevention

• Secondary Prevention

Advanced Critical Care. 2011;22(3):225-237Annals of Internal Medicine. 2011;154(11):746-751.American Journal of Critical Care. 2015;24(1):48-56.

Primary Prevention- Identify patients at risk- Prevent

Secondary Prevention- Identify patients at risk- Treat- Prevent

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Assessment Screening Tools

• CAM / CAM-ICU *

• IC-DSC

• CTD

• Nu-DESC

• DOSS

Intensive Care Medicine. 2001; 27(5):859-864.JAMA. 2001;286:2703-2710. JAMA. 2004;291:1753-1762.Advanced Critical Care. 2011;22(3):225-237

Primary / Secondary Prevention

• Review the medication list

• Reduce high-risk medications

• Do not use medications to manage sleep, anxiety, mild agitation

• Reserve pharmacologic approaches for severe agitation or psychosis

Annals of Internal Medicine. 2011;154(11);746-751.Critical Care Medicine. 2013;41(1):263-306.Journal of American Geriatrics Society. 2015;63(1):142-150.

Primary / Secondary Prevention

• Enhance mobility / ROM

• Maintain nutrition / hydration

• Treat pain adequately

• Use functional aids

• Minimize risk of infection

• Sleep promotion

Advanced Critical Care. 2011;22(3):225-237Critical Care Medicine. 2013;41(1):263-306.Journal of American Geriatrics Society. 2015;63(1):142-150.

How is it treated?

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Delirium Practice Guidelines

� American College of Critical Care Medicine

� Institute for Health and Care Excellence

� American Geriatrics Society

Annals of Internal Medicine. 2011;154(11);746-751.Critical Care Medicine. 2013;41(1):263-306.Journal of American Geriatrics Society. 2015;63(1):142-150.British Medical Journal. 2017;7e013809.

Guideline Recommendations

• Recommend to avoid medication classes that may induce delirium

• Recommend routine monitoring of delirium using validated assessment tools

• Recommend the implementation of nonpharmacological interventions

Guideline Recommendations

• Recommend use of antipsychotics only in patients that are severely agitated or distressed and are posing substantial harm to self and others

• Recommend using the lowest dose of medication for the shortest period of time

Guideline Recommendations

• Do NOT recommend the use of sedatives in the treatment of delirium, except in cases of drug and alcohol withdrawal

• Do NOT recommend the use of antipsychotics to prevent delirium

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Guideline Recommendations

• Recommend early mobilization

• Recommend thiamine should be considered in all patients with delirium

General Treatment

• Identify, remove and treat underlying cause(s)

• Non-pharmacologic measures

• Pharmacologic measures

−Antipsychotics (Neuroleptics)

−Sedatives

Annals of Internal Medicine. 2011;154(11);746-751.Critical Care Medicine. 2013;41(1):263-306.Journal of American Geriatrics Society. 2015;63(1):142-150.

Pharmacologic Treatment

• Typical antipsychotics

−Haloperidol

• Dose: Not specified

• Risks: QT prolongation, EPS, NMS

• Benefits: Low frequency of sedation, respiratory depression and hypotension

Annals of Internal Medicine. 2011;154(11);746-751.Critical Care Medicine. 2013;41(1):263-306.Journal of American Geriatrics Society. 2015;63(1):142-150.

Pharmacologic Treatment

• Atypical antipsychotics

−Olanzapine

−Quetiapine

−Risperidone

• Dose: Not specified

• Risks: Drowsiness, decreased risk of QT prolongation and EPS

• Benefits: As effective as haloperidol

Annals of Internal Medicine. 2011;154(11);746-751.Critical Care Medicine. 2013;41(1):263-306.Journal of American Geriatrics Society. 2015;63(1):142-150.

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Pharmacologic Treatment

• Sedatives

−Benzodiazepines

−Propofol

• In Trials

−Dexmedetomidine

−Gabapentin

Annals of Internal Medicine. 2011;154(11);746-751.Critical Care Medicine. 2013;41(1):263-306.Journal of American Geriatrics Society. 2015;63(1):142-150.

Key Learning Points

• Delirium is a multifactorial syndrome with predisposing and precipitating risk factors

• Delirium can be diagnosed with high sensitivity and specificity

• Prevention should be the goal

• If delirium occurs, treat the underlying cause(s)

• Always try non-pharmacologic approaches first, and then low dose antipsychotics

Summary

• Nurses play an important role in the assessment, recognition, prevention and treatment of delirium in their patients.

• Therefore, it is important to expand the knowledge about delirium to improve identification, management -- and most importantly outcome. ☺

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of Critical Care. 2015;24(1):48-56.

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Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nature Reviews Neurology. 2009;5(4):210-220.

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Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. One-year healthcare costs associated with delirium in the elderly population. Archives of Internal Medicine. 2008;168:27-32.

Maneeworg J, Maneeton B, Maneeton N, Vaniyapong T, Traisacathit P, Sricharoen N, et al. Delirium after a traumatic brain injury: Predictors and symptom patterns. Neuropsychiatric Disease and

Treatment. 2017;13:459-465.

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ReferencesNaidech AM, Beaumont JL, Rosenberg NF, Mass MB, Kosteva AR, Ault ML, et al. Intracerebral hemorrhage and delirium symptoms. American Journal of Respiratory and Critical Care Medicine. 2013;188(11):1331-1337.

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Critical Care. 2011;22(3):225-237.

Shi Q, Presutti R, Selchen D, Saposnik G. Delirium in acute stroke. Stroke. 2012;43:645-649.

Vasilevskis EE, Han JH, Hughes CG, Ely EW. Epidemiology and risk factors for delirium across hospital settings. Best Practice & Research

Clinical Anaesthesiology. 2012;26(3):277-287.