An acute medical condition.
Common in UK critical care patients.
Serious adverse outcomes.
Bedside diagnosis.
Maybe the first sign of a new infection.
Pathological, not psychological.
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Delirium in critical illness.
1. Delirium in critical illness
Presented by
Khaled Mahmoud Azab Mohamed
Emergency medicine registrar
Aseer Central Hospital
2010
2. 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
3. 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
4. Delirium motoric types
Hyperactive – psychomotor agitation
Hypoactive – psychomotor lethargy and
sedation, appears quiet & co-operative BUT
with inattention and disorganised thinking.
Mixed – fluctuating hypo/hyperactive
symptoms
5. “Acute brain dysfunction”
Prevalence of up to 80% quoted in ITU
100 ITU surgical patients:
69% with delirium
Longer ventilation & ITU stay – 4 days
Midazolam use strongest modifiable predictor
Pandiharipande 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
6. 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 or
damage by metabolic/inflammatory
mediators
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, Marcantonio
JAMA 1994 Tune Lancet 1981, Mussi J Geriatri Psych Neurol 1999, Marcantonio J Geront A Biol Sci Med Sci 20
Goyette Semin Resp CCM 2004, Sharshar ICM 2007
7. 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
8. 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
9. Precipitating factors
INFECTION
Hyponatraemia
Temperature
Maintenance of arterial pressure
Glucose
Benzodiazepines
Hypoxia, hypercarbia
Vaquero et al. Sem in Liver Dis. 2003;32:59-69
10. Medications cause delirium
Different drugs implicated in different studies
Benzodiazepines, esp. lorazepam
?related to dose
Corticosteroids
Morphine
Maybe propofol and fentanyl
Anticholinergics
Pandharipande 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
11. Does it matter?
After adjusting for age, gender, race, pre-existing
comorbidity & cog impairment, ICU diagnosis
and 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
12. 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
13. Delirium and death
In 275 medical ITU patients
Independent predictor 6 month mortality:
34% with delirium v. 15% without p=0.03
After adjusting for covariates
Hazard ratio death: 3.2 (CI 1.4 – 7.7)
203 general medical patients
Adj. relative mortality risk 1.8
Median survival 510 days v. 1122 days
Rockwood Age & Aging 1999;28(6):551-6, Ely et al JAMA 2004;291:1753-1762
14. Dementia after delirium
203 patients, 38 with delirium – 22 with
dementia, 16 without. 32 month follow up.
Incidence of dementia 5.6% per year without
delirium, 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
15. Medical ITU patients
11 of 34 patients neuropsychologically
impaired.
Generally diffuse but primarily areas of
psychomotor speed, visual & working
memory, verbal fluency and visuo-
construction.
Clinically significant depression in 36%
these patients.
Jackson CCM 2005;31(4):1226-1234
16. 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 simple
multiplication problems.”
17. 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
18. 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
19. 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.
20. The Assessment tool!
Feature 1: Acute onset of mental status
changes, or Fluctuating course.
Feature 2: Inattention
AND
AND
Feature 3: Disorganised
thinking
Feature 4: Altered level of
consciousness
OR
21. CAM-ICU
Sedation level at least eye-opening to voice with or
without eye contact.
Feature 1: is patient different from baseline?
Or: any fluctuations in mental status 24/12?
Feature 2: looking for inattention – ASE letters, if
unclear status – ASE pictures using hand squeeze.
If both positive:
Feature 3: Disorganised thinking, a) 4 questions – 2
or more incorrect responses is positive. b) Holding
up fingers.
Feature 4: Altered conscious level i.e. drowsy +
22. 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