INTENSIVE CARE UNIT PSYCHOSIS

ICU psychosis is a disorder in which patients in an intensive care unit (ICU) or a similar setting experience a cluster of serious psychiatric symptoms. Another term that may be used interchangeably for ICU psychosis is ICU syndrome. ICU psychosis is also a form of delirium, or acute brain failure. Intensive Care Unit syndrome (ICU syndrome/delirium) is a well-known problem in intensive care patients. It has been shown that acute confusion or delirium, especially in elderly patients, increases the length of hospital stay, as well as mortality. The prevalence of delirium in critical care units varies considerably, ranging from 2 to 57%. The pathogenetic mechanisms of the ICU syndrome/delirium are not well understood and the matter is still controversial. However, according to the syndromes development seems to depend on a complex interaction between the patients previous psychological problems, the psychological trauma inicted by the illness, the stress induced by the environment and the ICUs treatment and care. Moreover, various physical factors related to abnormal blood biochemistry values and drugs affecting the functions of the brain appear to be important. CAUSES ICU PSYCHOSIS Predisposing factors Certain individuals are at higher risk for developing delirium. Generally accepted predisposing factors are alcoholism, drug addiction, cerebral damage, previous episodes of delirium and chronic cardiovascular, metabolic, respiratory and renal illness. Patients over 60 are more likely to develop delirium. Additional preoperative risk factors for postcardiotomy delirium include severe functional class impairment, an active and dominant personality, and depression. Environmental Causes

Sensory deprivation: A patient being put in a room that often has no windows, and is away from family, friends, and all that is familiar and comforting.

Sleep disturbance and deprivation: The constant disturbance and noise with the hospital staff coming at all hours to check vital signs, give medications, etc.

Continuous light levels: Continuous disruption of the normal biorhythms with lights on continually (no reference to day or night).

Stress: Patients in an ICU frequently feel the almost total loss of control over their life. Lack of orientation: A patient's loss of time and date. Medical monitoring: The continuous monitoring of the patient's vital signs, and the noise monitoring devices produce can be disturbing and create sensory overload.

Medical Causes

Pain which may not be adequately controlled in an ICU Critical illness: The pathophysiology of the disease, illness or traumatic event - the stress on the body during an illness can cause a variety of symptoms.

Medication reaction or side effects: The administration of medications typically given to the patient in the hospital setting that they have not taken before.

Infection creating fever and toxins in the body. Metabolic disturbances: electrolyte imbalance, hypoxia (low blood oxygen levels), and elevated liver enzymes.

Heart failure Cumulative analgesia (the inability to feel pain while still conscious) Dehydration

CLINICAL MANIFESTATIONS The time of onset of delirium depends on the disorder's etiology. In the ICU, delirium may occur as the patient emerges from coma; during or immediately after operations; or, as is most may complain of restlessness and irritability, insomnia, lethargy, kinesthetic sensations, vivid, frightening dreams and difficulty thinking. Staring at a blank wall or gendle pressure on the closed eyelids may cause formed images of people or scenery. As the disorder progresses, impairments in attention, level of consciousness, speech, thinking, perception, orientation, memory, judgment and insight become more prominent. In moderate to severe delirium, the patient may be obviously psychotic, displaying increased psychomotor activity, paranoid delusions and hallucinations (agitated delirium). Equally important is the withdrawn, mute patient with quiet delirium who is easily missed by the casual observer. Self injury by falling out of bed or attempting to escape is an all too frequent complication.

DSM III DIAGNOSTIC CRITERIA FOR DELIRIUM 1. Clouding of consciousness (reduced clarity or awareness of environment), with reduced capacity to shift, focus, and sustain attention to environmental stimuli 2. At least two of the following: perceptual disturbance: misinterpretations, illusions or hallucinations speech that is sometimes incoherent disturbance of sleep-wakefulness cycle with insomnia or daytime drowsiness increased or decreased psychomotor activity 3. Disorientation and memory impairment (if testable) 4. Clinical features that develop over a short period of time (usually hours to days) and tend to fluctuate over the course of a day 5. Evidence, from the history, physical examination, or laboratory tests of a specific organic factor judged to be etiologically related to the disturbance to over 60 are more MANAGEMENT Pre ICU prevention If ICU admission is elective, identify and treat predisposing factors if possible (by detoxification, vitamins, etc). The ICU staff should be alerted to these risk factors and to the current therapeutic regimen. Decrease surgical organic precipitating factors if possible. Diminish facilitating factors by careful preparation of the patient and family. Planned interventions and possible adverse effects, particularly delirium, should be described. A visit to the ICU and a meeting with the staff who will be involved help to orient the patient and establish a working alliance. Very anxious or obviously fearful patients stand to benefit most from this approach. It is particularly important to treat depressive disorders before admission or surgery if at all possible, because of the increased risk of morbidity and death. A dominant, active patient with a low level of anxiety does not tolerate dependency or immobilization well and must be encouraged to work with the staff to defeat his illness. ICU prevention and treatment Many of the measures described in this section are empirically based and have not been validated by controlled trials. However, newer SICUs and CCUs have reported decreased incidence of postcardiotomy delirium and improved patient reassurance by the ICU.

Staff/patient relationships: The presence of familiar staff or family members helps improve orientation, decreases anxiety about strangers and builds trust. An empathic, humane, respectful approach and direct communication decrease patient frustration and anxiety. Autonomy in self care should be encouraged as soon as it is feasible. Early recognition of delirium and psychosis: Regular use of brief, structured questionnaires to determine attention span, orientation, memory and perceptions aids diagnostic and orientating activities. Patients can be encouraged to report distressing symptoms as soon as possible. Facilitating factors: Anxiety is decreased by adequate staff/patient relationships, the presence of a trusted relative, adequate information and reassurance about symptoms and procedures, and orientating activities. Sleep deprivation may be reduced by arranging nursing, investigational and visiting schedules to provide the patient with blocks of time to reestablish more normal sleep patterns. The sensory environment can be improved by removing unnecessary machinery from the patient's immediate environment and providing familiar sounds (e.g., radio, television, conversation). Windows, natural lighting, a night light and privacy are all desirable. Eye patches should be unilateral and/or have small openings, especially in the elderly. Immobility is a major source of frustration, sensory monotony and physical complications. The patient should be mobilized as rapidly as possible. Unfortunately, the psychotic patient may have to be protected by bedsides and, at times, restraints. Orientation to time, place and people is aided by interactions with staff and the presence of familiar items, clocks, calendars and schedules all placed in the patient's sight. Pain management includes scheduling adequate amounts of analgesics, avoiding unnecessary painful procedures and using distraction and staff reassurance. Patients should be warned interventions may be painful and allowed to ventilate anger at the procedure, rather than at the nurse.

Patient communication is enhanced by an interpreter, writing tablet or alphabet board, if required. Staff should be sensitive to patients approaching them indirectly for reassurance and explanations, particularly following delirium. Psychopharmacological management: These agents should not be used to mask or ignore underlying causes of delirium. However, in more severe cases, target symptoms of psychomotor agitation, hallucinations, delusions, and autonomic arousal may be indications for drug use. Anticholinergic delirium and delirium induced by alcohol withdrawal (delirium tremens) require special mention. Neuroleptics may worsen both these conditions. Severe anticholinergic delirium is best treated with physostigmine (Antilirium) and supportive measures. Delirium tremens requires benzodiazepines and B vitamins. Haloperidol (Haldol) may be used in treatment resistant cases. Despite their more marked anticholinergic, autonomic and epileptogenic effects, phenothiazines such as chlorpromazine may be useful for patients who are refractory to haloperidol.