Delirium is an abnormal state of mind characterized by cerebral dysfunction with fluctuation of the mental status, disorganized thinking, changes in the levels of consciousness, and inattention. The basic features of delirium patients are altered levels of consciousness and cognitive impairment. Other symptoms include hallucinations, sleep disturbances, emotional disturbances, and abnormal psychomotor behavior. There are two classifications; hyperactive and hypoactive delirium. Hyperactive delirium mainly has the features of hallucinations and delusions, while hypoactive delirium is associated with confusion and sedation; therefore, it is often misdiagnosed in ICU patients (Barr et al., 2013).
Delirium in ICU patients has serious adverse effects. It causes an increase in the length of hospitalization, increased cases of mortality in the ICU, and cognitive impairment can persist even after discharge from the critical care unit. It is, therefore, essential for the early detection and management of delirium in these patients. Some of the risk factors for delirium consist of pre-existing dementia, history of alcohol intake, and hypertension. Other risk factors are increased severity of the illness, coma, and treatment with benzodiazepines. Critical patients who are under mechanical ventilation have a higher prevalence of developing delirium when treated with benzodiazepines compared with dexmedetomidine (Barr et al., 2013).
As stated earlier, early detection and monitoring of adult critically ill patients for delirium is vital. Healthcare professionals have to identify treatable and modifiable risks that can cause or exacerbate delirium in a patient. Routine monitoring of all patients for delirium enables the clinicians to detect and treat delirium, improving the patient outcomes. The journal recommends two delirium assessment tools out of the five, as they have high specificity and sensitivity in detecting delirium adult patients against the criteria provided for by the American Psychiatric Association. According to the journal, it recommends the two as they can identify and monitor delirium in adult ICU patients who are either on or off mechanical ventilation. These tools include; Confusion Assessment Method for the ICU (CAM- ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) (Barr et al., 2013).
The journal goes further to recognizes several measures that can be employed to prevent delirium in these patients while in the unit to improve the patient’s outcome. The measures are categorized as either pharmacologic or non-pharmacologic, with the later more preferred as studies show they are more beneficial to the patient. The journal does not recommend the use of antipsychotics such as haloperidol for prophylactic use in ICU adult patients to prevent delirium or in patients at risk of torsades de pointes. It also suggests the need to avoid the use of benzodiazepines in critical patients diagnosed with delirium that is unrelated to withdrawal from alcohol or benzodiazepine; rather, the clinician may prescribe dexmedetomidine. The journal also does not recommend the use of rivastigimine to lessen the extent of delirium in an ICU patient (Barr et al., 2013).
The highly recommended non-pharmacological ways to prevent delirium include; regular monitoring of delirium in patients and early mobilization, which helps to decrease the development and length of the duration of delirium. Early mobilization in the ICU has also shown to decrease the reduction of ICU stay and increase days the patient is on mechanical ventilation. Another measure that is recommended is the promotion of sleep in critically ill patients. Healthcare providers can promote this by controlling light and noise levels in the unit as well as clustering of procedures done to the patients to reduce sleep disturbance allowing for longer sleep intervals. Other measures include encouraging communication to the patient, including repeated reorientation, providing visual and hearing aids, the use of non-verbal music, maintaining systolic blood pressure above 90 mmHg and oxygen saturations above 90%, and lastly treating the underlying infections and metabolic derangements (McFeely, 2015).
In conclusion, delirium in critically ill patients can be prevented and treated. Early detection and routine monitoring with assessment tools such as CAM- ICU and ICDSC are emphasized as they help to detect even hypoactive delirium, which is common in ICU patients but often misdiagnosed (McFeely, 2015). The overall goal of the prevention of delirium is to avert patient mortality and improve patient outcomes.
References
Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gélinas, C., Dasta, J. F., … American College of Critical Care Medicine. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine, 41(1), 263–306. https://doi.org/10.1097/CCM.0b013e3182783b72
McFeely, J. E. (2015, May 1). Assessment, Prevention, and Treatment of Delirium in the ICU. Retrieved July 14, 2020, from www.reliasmedia.com website: https://www.reliasmedia.com/articles/135368-assessment-prevention-and-treatment-of-delirium-in-the-icu