ICU Psychosis and its nursing

management
 Introduction

 The brain is one of the most prevalent organs

involved of sepsis
 Acute confusional states (delirium)
- 10 to 60% of the older hospitalized population
- 60 to 80% of patients in the intensive care
 Go unrecognized by the managing physicians
and nurses in 32 to 66% of cases
 Introduction cont..

 The international ‘Surviving Intensive Care’ 2002

Roundtable Conference
- future investigations in neurocognitive
abnormalities is strongest recommendation
 Delirium :
- a marker of end-organ damage
- a promoter of other organ system dysfunction
 Levels of Conciousness

 Awake: aroused and aware

 Somnolent: easily aroused and aware

 Stuporous: aroused with difficulty, impaired

awareness

 Comatose: unarousable and unaware

 Vegetative state: aroused but unaware

 Delirium :

 - one of the strongest predictors of prolonged

cognitive impairment and mortality
 More than 25 terms refer to Delirium :
- Subacute befuddlement, ICU psychosis, acute brain
dysfunction, encephalopathy of critical illness, toxic
confusional state, confusion or neurologic
impairment
 Monitoring sedation and diagnosing
delirium in the ICU

 2002 guidelines of the Society of Critical Care

Medicine (SCCM)
- all critically ill patients be simultaneously
monitored for level of sedation and for delirium
 First step : assess a patient’s level of
consciousness/sedation
 Second step : assess the brain’s function
 Delirium: prevalence and subtypes

 Prevalence of delirium in ICU cohort studies :

20%, 70%, or 80%
 Unrecognized by the clinician as many as 66
to 84% of patients
- fewer interactions and less time spent in direct
patient care
 Hypoactive, hyperactive (<5%) and mixed
delirium
 Delirium: pathophysiology and etiology

 Brain inflammatory response :

- production of cytokines, cell infiltration, and tissue
damage
 Local inflammation in the brain :
- necrosis factor-α, interleukin-1β, and interferon-γ
- development of multiple organ dysfunction
syndrome, its resolution, or both
 Pathophysiology cont…

 Three of the neurotransmitter systems

- dopamine, γ-aminobutyric acid (GABA), and
acetylcholine
 Dopamine :
- increases the excitability of neurons
 GABA and acetylcholine :
- decrease neuronal excitability
 Endotoxin, cytokines, hypoxemia, inadequate
cerebral perfusion, metabolic derangements,
mechanical ventilator, sedative and analgesic
medications
 Risk factors for delirium

 The risk factors can be divided into three

categories:
1. host factors
2. the acute illness itself
3. iatrogenic or environmental factors
 Benzodiazepines, narcotics, and other
psychoactive drugs : 3 to 11 times
 Sedative and analgesic medications
Etiology of Delirium
Etiology of Delirium (II)
CAM ICU SCORE

1. Acute Onset or Fluctuating Course Absent Present

acute change in mental status from baseline? OR did the abnormal behavior fluctuate
during the past 24 hours?
2. Inattention Absent Present
Did the patient have difficulty focusing attention as evidenced by scores less than 8 on
either the auditory or visual component of the Attention Screening Examination (ASE)?

3. Disorganized Thinking Absent Present

Does the patient have disorganized or incoherent thinking as evidenced by incorrect
answers to 2 or more of the following 4 questions and/or demonstrate an inability to follow
commands?
Questions (Alternate Set A and Set B): 2 sets of logic questions (does a stone float? Does a
leaf float?)

4. Altered Level of Consciousness Absent Present

Is the patient’s level of consciousness anything other than alert (e.g. vigilant, lethargic or
stuporous)
Alert: Looks around spontaneously, fully aware of environment, interacts appropriately.
Vigilant: Hyperalert.
Lethargic: Drowsy but easily aroused. Unaware of some elements in the environment, or no
appropriate spontaneous interaction with interviewer. Becomes fully aware and appropriate with
minimal noxious stimulation.
Stupor: Becomes incompletely aware with strong noxious stimulation. Can be aroused only by
vigorous and repeated stimuli. As soon as stimulus removed, subject lapses back into unresponsive
state.

Overall CAM ICU Score:

If 1 + 2, and either 3 or 4 is present, patient has delirium. Yes No
 ICU psychosis-Clinical manifestation

The cluster of psychiatric

symptoms of ICU psychosis
include:

 extreme excitement,  paranoia,

 anxiety  disorientation,
 restlessness,  delusions,
 hearing voices,  abnormal behaviour,
 clouding of consciousness,  fluctuating level of
 hallucinations, consciousness which include
 agitation aggressive or passive behavior.

In short, patients become temporarily psychotic. The

symptoms vary greatly from patient to patient. The onset of
ICU psychosis is usually rapid, and is upsetting and
frightening to the patient and family members.
 Prognostic significance of delirium

 In non-ICU populations, delirium is associated

with :
- 25 to 33% in-hospital mortality
- prolonged hospital stay
- 3 times the likelihood of discharge to a nursing
home
- predictor of outcome of death or nursing home
placement
- an increased risk for dementia
 Primary prevention and nonpharmacologic
approaches

 In 852 general medical patients, age >70

→primary prevention of delirium resulted in a
40% reduction in development of delirium
 Prevention cont…
 The protocol focused on optimization of risk factors :
- repeated reorientation of the patient by trained
volunteers and nurses
- provision of cognitively stimulating activities for the
patient three times per day
- nonpharmacologic sleep protocol to enhance
normalization of sleep/wake cycles
- early mobilization activities and range of motion
exercises
 Prevention cont…

- timely removal of catheters and physical restraints

- institution of the use of eyeglasses, magnifying
lenses, hearing aids, earwax disimpaction
- early correction of dehydration
 Family involvement
 It is important to teach family members of the
fluctuating course of delirium as well as how they
can detect delirium
 Pharmacologic therapy

 Used only after adequate attention has been given

to the correction of modifiable contributing
factors
 Delirium could be a manifestation of an acute,
life-threatening problem
 Benzodiazepines :
- not recommended for the management
of delirium
- elderly patients with dementia → increased
confusion and agitation
 Pharmacologic therapy cont…

 No drugs have been approved by the United

States Food and Drug Administration for the
treatment of delirium
 SCCM guidelines : haloperidol as the drug of
choice
 Haloperidol
- does not suppress the respiratory drive
- works as a dopamine receptor antagonist by
blocking the D2 receptor
- treatment of positive symptoms
- produces a variable sedative effect
 Pharmacologic therapy cont…

 In the non-ICU setting :

- starting dose of haloperidol is 0.5 to 1.0 mg,
repeated doses every 20 to 30 minutes
 In the ICU setting :
- starting dose → 5 mg every 12 hours, 20 mg/day
 Once calm, the patient can usually be treated with
much lower maintenance doses of haloperidol
 Recommends:
 mild anxiety – 0.5 to 2mg

 Moderate – 5-10mg

 severe 10-20mg
 Pharmacologic therapy cont…
 Newer ‘atypical’ antipsychotic agents
(e.g., risperidone, ziprasidone, quetiapine, and
olanzapine)
→ may also prove helpful for delirium
 Adverse effects
- hypotension, acute dystonias, extrapyramidal
effects, laryngeal spasm, malignant hyperthermia,
glucose and lipid dysregulation, dry mouth,
constipation, and urinary retention
- immediately life-threatening
→ torsades de pointes
 Nursing Management-prevention

 The primary goal is to correct any imbalance, restore

the patient's health, and return the patient to normal
activities as quickly as possible.
 using more liberal visiting policies,
 providing periods for sleep,
 protecting the patient from unnecessary excitement,
 minimizing shift changes in the nursing staff caring
for a patient, orienting the patient to the date and
time
 Nursing Management-prevention

 Reviewing all medical procedures with an

explanation about what to expect,
 Asking the patient if there are any questions or
concerns,
 Talking with the family to obtain information
regarding religious and cultural beliefs, and
 Coordinating the lighting with the normal day-night
cycle, etc.
 ICU Psychosis- Nursing Management

 The treatment of ICU psychosis depends on the cause(s).

 The actual cause of the psychosis involves many factors, and many
issues will need to be addressed to relieve the symptoms.
 A first step is a review of the patient's medications. The physician in
charge of the patient can review each of the patient's medications to
determine if they may be influencing the delirium.
 Family members, familiar objects, and calm words may help
 Sleep deprivation may be a major contributing factor. Therefore,
providing a quiet restful environment to allow the patient optimal sleep
is important.
 Controlling the amount of time visitors are allowed to stimulate the
patient can also help.
 ICU Psychosis- Nursing Management

 Dehydration is remedied by administering fluids.

 Heart failure requires treatment with digitalis.
 Infections must be diagnosed and treated.
 Sedation with anti-psychotic agents may help.
 Haloperidol
Does "ICU psychosis" really exist? Justic M.
Crit Care Nurse. 2000 Jun;20(3):28-37;

Many patients are at risk. Prevention of delirium should always be foremost,

including recognition of patients at high risk, minimal use of causative medications,
and treatment of physiological conditions
When prevention fails, early diagnosis and treatment. The potential adverse
outcomesof delirium are well documented. These include increased mortality;
Increased length of stay; reduced level of functioning in the elderly, which often
leads to placement in a nursing home; and stress response syndrome after
Hospitalization.
The value of nursing in preventing delirium is evident
Nurses provide early detection and coordinate with other members
of the healthcare team to initiate a plan of care that includes prompt treatment
of delirium to reduce the signs and symptoms, duration, and potential adverse
sequelae of this disorder.
Nursing interventions are designed to enhance patients‘
cognitive status, sense of security, safety, and comfort. Nurses are instrumental in
providing appropriate choices, doses, and administration of medications and in
recognizing side effects. Use of medications ordered to treat delirium is often
left to nurses' discretion because the orders specify that the drugs should be
given as needed. Finally, nurses are the ones who recognize the need for additional
assistance via psychiatric consultations or for more intensive observation and
Management of patients to ensure quality care.
 Conclusion

 Critically ill patients are at great risk for the

development of delirium in the ICU
 Delirium : prolonged length of stay and higher
6-month mortality rates
 CAM-ICU : a valid, reliable, quick, and easy to
use serial assessment tool
 Routine delirium monitoring by the SCCM
clinical practice guidelines on sedation and
analgesia
 Improving both cognitive and noncognitive
outcomes
THE END