ICU Delirium and Psychosis Treatment - Research Paper Example

?Introduction ICU delirium is one of the most challenging conditions in ICU care. There is a wide prevalence of delirium in inpatient settings (Goforth and Rao 813). It has been estimated that “10% of all inpatients will develop delirium over the course of hospitalization” (Goforth and Rao 813). Sadly, this figure increases in special population, and the estimation is that 30% of patients in ICU will develop delirium (Goforth and Rao 813). It has been found that 2 to 3 million patients suffer from delirium per year and it is one of the most frequent hospital complications in elderly people (Goforth and Rao 813). It not only prolongs the ICU and hospital stay for patients but also affects the psychological health of care givers and nurses involved in patient care by causing immense distress to them (Goforth and Rao 813). It has been estimated that the hospital costs increases by $4 billion due to delirium (Goforth and Rao 813). Moreover, the survivors of critical illness are known to develop long-term cognitive impairment due to delirium (Marik 495). This shows the severity of the problem of ICU delirium. However, treatment of ICU delirium or psychosis is not easy as the very setting and the medication used for treatment of illness are known to be the underlying causes of the ICU delirium. Hence, to treat the ICU delirium successfully, important steps are needed to be taken by medical practitioners for correct identification of underlying causes of the condition, as only the knowledge and understanding of the underlying causes can help in prevention or treatment of delirium. Definition Intensive care unit (ICU) psychosis, which was historically ascribed to the ICU environment, and was believed to be caused by ICU environment related stressors such as impaired sleep, deprivation of sunlight, disruption of circadian rhythm and sensory overload, is a common subtype of delirium (Goforth and Rao 813). The acute stress, which usually accompanies the acute illness, is known to cause altered states of consciousness, called delirium, particularly in patients admitted to the intensive care settings (Leigh and Streltzer 184). ‘ICU psychosis’ is the term used to describe the delirium with psychotic features such as visual hallucinations, paranoid delusions, and agitation (Leigh and Streltzer 184). According to Ely et al. (2001), ICU delirium can be defined as “an acute change or fluctuation in the course of patient’s mental status, plus inattention and either disorganized thinking or an altered level of consciousness” (Adam and Osborne 37). It is a medical condition “which arises over a relatively short period of time and fluctuates over the course of the day” (Goforth and Rao 813). Conditions like deficits in the ability to focus, sustain and shift attention are the manifestations of disturbance in consciousness (Goforth and Rao 813). Additionally, conditions like “reduced awareness of surrounding environment, disorientation, secondary memory, language impairments” such as dysnomia and dysgraphia, visuoconstructional impairment representing a diffuse cerebral process etc., are frequently seen in patients suffering from ICU delirium (Goforth and Rao 813). Also, conditions like misinterpretations, illusions, delusion and hallucinations, which show perceptual disturbances, are also commonly found in the patients (Goforth and Rao 813). Terms like ICU psychosis, ICU syndrome, encephalopathy, acute confusional state, organic brain syndrome, toxic psychosis, and acute brain failure, are used to describe the delirium that is generally synonymous with ICU conditions (Goforth and Rao 813). Causes According to McGuire et al., it is usually for a brief duration that the onset of symptoms appears, but it occurs rapidly (Bassett, Ames and Chiu 178). The factors like pathophysiologic changes of severe illness, postoperative metabolic disturbances, increase in use of drugs which are often toxic, and the severity of the underlying illness are associated with cause of apparent increased risk of delirium in the ICU patients (Bassett, Ames and Chiu 178). According to Kornfield et al. (1965), the early research suggested that the normal circadian rhythms in patients were disturbed due to sleep deprivation that patient suffered due to constant lighting and activity (Bassett, Ames and Chiu 178). However, according to McGuire et al. (2000), at this time, there is no evidence which supports that sleep deprivation has any role in causing delirium occurring in the ICU (Bassett, Ames and Chiu 178). Diagnosis Delirium is a medical condition and not just a behavioral problem (Page and Ely 27). Hence, delirium is a “medical diagnosis of a syndrome with specific diagnostic features” (Page and Ely 27). The diagnosis is primarily based on clinical tests and careful bedside observation (Page and Ely 27). Delirium is difficult to detect. This was evident from a research study which showed that only 35% of daily delirium was detected by nurses while doctors were able to detect only 28% (Page and Ely 27). Hence, even in patients who are calm and apparently not agitated, the routine assessment of delirium is recommended (Madan and Agarwal 663). No specific or sensitive medical test exists that can be used for the diagnosis of the ICU delirium (Goforth and Rao 815). The clinical acumen of making the diagnosis of ICU delirium cannot be replaced by the laboratory tests even though they may be confirmatory and supportive (Goforth and Rao 815). This is because clinical symptoms are less forthcoming in some cases due to mildness in delirium (Goforth and Rao 815). Even though the delirium with noticeable symptoms like hyperactive or mixed presentation are easy to diagnose, it is important to identify the hypoactive delirium as the prognosis, rehabilitation and treatment are affected more by it than other forms of delirium (Goforth and Rao 815). The clinical history and examination is the best standard criteria for delirium (Madan and Agarwal 663). However, as the critically ill and ventilated patients are not able to read and write, it is not possible to use these methods of assessment (Madan and Agarwal 663). “Therefore, other tools for the assessment of ICU delirium have been developed” (Madan and Agarwal 663). Several validated rating scales have been developed to help the medical practitioners in diagnosis of delirium (Goforth and Rao 815). To monitor the disease course and response to treatment in a better way, a regular and routine use of one of these scales is encouraged during both initial assessment and follow-up examinations (Goforth and Rao 815). “The Confusional Assessment Method (CAM), has been validated under a variety of circumstances for delirium screening” (Goforth and Rao 815). The presence of delirium is suggested through the positive response to CAM (Goforth and Rao 815). The two instruments that are validated as both, screening tools and useful in tracking changes in the severity of delirium are The Memorial Delirium Assessment Scale (MDAS) and The Delirium Rating Scale (DRS, DRS-98) (Goforth and Rao 815). As the Folstein ‘Mini-Mental Status Examination’ (MMSE) has not been validated for use in delirious states, it is of limited use even though it is commonly used clinically (Goforth and Rao 815). However, as MMSE covers a wide variety of cortical domains and the presence of delirious process is suggested through fluctuating scores, it may prove to be helpful is diagnosis (Goforth and Rao 815). Prevention The prevention of delirium can be achieved by dividing the preventive strategies in nonpharmacologic, pharmacologic and combined approaches (Madan and Agarwal 664). Since the practices ingrained in the ICU care may result in the development of delirium, developing a multidisciplinary approach to prevent the delirium can prove to be a prudent step (Azocar, Taghizadeh and Lat 93). There is evidence that through organized team efforts affecting the multiple points of patient care, the development of delirium can be prevented (Azocar, Taghizadeh and Lat 93). However, it is also important to note that the preventive measures, which were effective in preventing delirium in general patients, were found to be ineffective in preventing delirium in ICU patients (Azocar, Taghizadeh and Lat 93). This does not mean that there is no way delirium can be prevented. As the development delirium is frequently and largely caused by use of medications, identifying the deliriogenic medications and limiting/or removing their use is a logical step towards prevention of delirium (Azocar, Taghizadeh and Lat 93). Reduction in subsyndromal delirium has been achieved through the combined approach of using both, pharmacologic and nonpharmacologic methods (Madan and Agarwal 664). Delirium can be avoided if the use of psychoactive medications opioids and benzodiazepines, which are commonly used in ICU care, is targeted to achieve clinical endpoint (Azocar, Taghizadeh and Lat 93). It is also preferable to treat the underlying disease state that causes delirium (Azocar, Taghizadeh and Lat 93). Moreover, if simple interventions such as minimizing noise, frequent reorientation, normalizing sleep patterns, removing unnecessary catheters, mobilization and transfer from the ICU environment, are implemented as standard practice, then delirium can be prevented (Azocar, Taghizadeh and Lat 93). Treatment The primary goal of psychiatric intervention in the acutely medically ill patient is to facilitate the acute medical treatment (Leigh and Streltzer 184). Identifying and correcting the underlying cause while managing “the cognitive and behavioral aspects of the syndrome to maximize the patient comfort and enable neurobehavioral recovery” is the goal of delirium treatment (Goforth and Rao 815). As the medications, such as steroids, which cause the delirium, are necessary for maintaining life, the quick treatment of psychotic symptoms in delirium is not possible (Leigh and Streltzer 184). Under such circumstances, further sedation even if it means keeping the patient asleep during the acute phase of treatment, is the only thing that consultant can recommend (Leigh and Streltzer 184). Also, during the intensive care stay, the use of medications that require time to work, such as antidepressants and other drugs that may further complicate medical conditions, can be withheld to decrease the severity in psychosis (Leigh and Streltzer 184). This can also improve the cognitive functioning in the patient (Goforth and Rao 815). However, identifying the underlying medical causes and minimizing the neurobehavioral sequelae of the disorder is an essential step for effective treatment of ICU delirium (Goforth and Rao 815). Also, most commonly used and recommended drugs for management of delirium are the antipsychotic agents (Madan and Agarwal 664). It is apparent that both, conventional and atypical antipsychotic drugs are effective in treatment of delirium (Madan and Agarwal 664). Due to lack of any specific treatment for ICU psychosis, transfer out of the ICU as soon as possible is indicated for patients suffering from ICU psychosis (Leigh and Streltzer 184). It has been found that ultimately, what plays a key role in the management of ICU delirium is the team work and patient focused care (Madan and Agarwal 664). Conclusion The discussion above shows that management and treatment of ICU delirium is important for the health and safety of both, patients and the care givers. As it is evident that the environment of ICU and medications used in the ICU are the underlying cause of ICU delirium, the prevention and reduction in severity of delirium can be achieved through team work, patient centered care and planning. Hence, it becomes a duty of the care givers to increase the knowledge and understanding of the underlying causes and preventive methods of ICU delirium. This will ensure not only decrease in prevalence of ICU delirium, but also maintenance of psychological and physical health of patients and care givers. Work Cited Adam, Sheila and Sue Osborne. Critical care nursing: Science and practice. 2nd ed. Oxford, UK: Oxford UP, 2005. Print. Azocar, Ruben, J., Taghizadeh, Pouneh and Ishaq Lat. Surgical intensive care medicine. 2nd ed. Ed. John O’Donnell and Flavio Nacul. New York: Springer, 2010. Print. Bassett, Anne, Ames, David and Edmond Chiu. Psychosis in the elderly. Oxon: Taylor &  Francis, 2005. Print.   Goforth, Harold, W. and Murali Rao. The interface of neurology & internal medicine. Ed. Jose Biller. Philadelphia: Lippincott Williams & Wilkins, 2008. Print. Leigh, Hoyle and Jon Streltzer. Handbook of consultation liaison psychiatry. New York: Springer, 2008. Print. Madan, Karan and Ritesh Agarwal. Handbook of pulmonary and critical care medicine. Ed. S.K. Jindal. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd. Marik, Paul, E. Handbook of evidence based critical care. 2nd ed. New York: Springer, 2010. Print. Page, Valerie, and E. Wesley Ely. Delirium in critical care. Cambridge, UK: Cambridge UP, 2011. Print. Read More