D e l i r i u m i n t h e N e u ro In t en si ve C are U n it Joseph B. Haymore,
MS, ACNP-BC
a,b,
*, Nikhil Patel,
MD, MBA
c
KEYWORDS Delirium Inattention Altered level of consciousness Validated tools Assessment KEY POINTS Delirium in the neuro intensive care unit (ICU) affects as many as 10% to 48% of patients. There are few studies looking specifically at the neuro ICU patient population and delirium; thus, nurses rely on general ICU data to make evidence-based decisions. Delirium cannot be addressed without also monitoring pain, sedation, and agitation using validated tools. The Confusion Assessment Method for the ICU and the Intensive Care Delirium Screening Checklist are the validated delirium assessment tools recommended by national guidelines.
Delirium is a common, serious, and life-threatening complication in the intensive care unit (ICU). Nurses should assess their patients for delirium risk factors, appropriately assess for and manage pain and sedation or agitation, and monitor for the emergence of delirium with all patients. To properly assess and monitor for this critical patient safety condition, nurses must use appropriate, validated assessment tools and not rely solely on clinical observations and judgment. Delirium is in many ways similar to acute kidney injury (AKI). The modern ICU nurse and clinical team is aware that their patients are at high risk of AKI, with 20% to 50% of the patients having some degree of AKI during their time in the ICU.1 By being aware of which patients are at risk for AKI, avoiding interventions that put the patient at increased risk, regularly monitoring renal function, and intervening early when signs of renal end-organ dysfunction are noticed, the clinical team will improve that patient’s likelihood of either not developing AKI or having a limited course with full recovery. Delirium is also common, affecting 20% to greater than 80% of ICU patients. Delirium is an acute brain injury, a manifestation of end-organ dysfunction or damage owing to a combination of the patient’s own
Disclosures: None. a Neurocritical Care Unit, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD, USA; b University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD 21201, USA; c Department of Neurology, University of Maryland School of Medicine, 620 West Lexington Street, Baltimore, MD 21201, USA * Corresponding author. E-mail address: [email protected] Crit Care Nurs Clin N Am 28 (2016) 21–35 http://dx.doi.org/10.1016/j.cnc.2015.11.001 ccnursing.theclinics.com 0899-5885/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
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risk factors and the effects of acute illness. Many patients with delirium recover and have few if any long-term complications. However, some will experience long-term, often permanent cognitive impairment, namely, chronic brain failure. The ICU nurse should view the acutely ill patient as being at risk for any end-organ dysfunction (eg, lung, heart, skin) and routinely monitor the patient based on the best available evidence. Delirium in the neuro ICU setting is an especially challenging condition. Most patients admitted to a neuro ICU have some degree of brain dysfunction due to an illness, condition, or trauma. Because delirium is an acute brain injury, it can be difficult to determine whether the patient’s behavior is because of her hemorrhage, stroke, meningitis, or other factor, or that she is developing an additional brain dysfunction in the form of delirium. It is this difficulty with teasing out delirium from the primary brain dysfunction that most of the research into delirium in the ICU has been conducted in the medical, surgical, and cardiothoracic ICU settings. Therefore, the majority of the information in this article is pertinent to all ICUs. The data specific to the neuro ICU setting are discussed when available. This article discusses what delirium is and who is at risk, and reviews the process of monitoring patients in the ICU for delirium. The appropriate assessment tools for each step of the monitoring process are described. WHAT IS DELIRIUM?
Delirium is a behavioral syndrome that includes an altered level of consciousness (LOC), difficulty maintaining attention, and a change in cognition or perception. The onset is acute (hours to days) and has a fluctuating course that might include periods of lucid, normal mental functioning. The behavior must be owing to a medical condition, use of a medication or other substance (ie, alcohol or recreational drugs), or withdrawal from a medication or substance, but not owing to a primary psychiatric condition (Table 1).2 Delirium Motor Subtypes
Patients with delirium may be consistently hyperactive or agitated (5 days) Indwelling urinary catheters Admission through the emergency department Admission through transfer from another facility or unit Trauma Invasive procedures Pain Surgery Isolation Poor quality sunlight Physical restraints Data from Refs.14,22–24
Delirium in the Neuro ICU
delirium 77% to 87% of the time. The PRE-DELIRIC uses 10 risk factors (age, Acute Physiology And Chronic Health Evaluation [APACHE]-II score, admission group, coma, infection, metabolic acidosis, use of sedatives and morphine, urea concentration, and urgent admission) to predict the likelihood of developing delirium. All of the data needed for the PRE-DELIRIC are available within 24-hours of admission in a typical ICU. This tool has been studied rigorously and validated across multiple ICU settings (medical, surgical, trauma, and neuro) and in multiple countries in Australia and multiple countries in Europe. However, there is an important caveat for using the PRE-DELIRIC in the neuro ICU setting. Of the patients studied in the development and validation of this tool, only 16% (n 5 784/4880) were in a neurocritical care setting. Further research is needed before this tool can be widely used in the neuro ICU. Steps 2: Pain Assessment
Pain is very common in the ICU, with as many as 50% of the patients experiencing pain at rest and up to 80% during routine care.16 Poorly controlled pain (undertreated or overtreated) can both trigger the emergence of delirium and potentially interfere with monitoring, leading to a delay in detection and intervention. The American Association of Critical-Care Nurses and the Society of Critical Care Medicine have published guidelines calling for routine monitoring of pain, using patient self-reporting of pain when possible.17,18 Both organizations recommend using a validated behavioral pain scale to assess when a patient is unable to effectively self-report. The tools that they recommend are the Behavioral Pain Scale and the Critical-Care Pain Observation Tool (Tables 3 and 4 respectively). These tools are a structured method of observing the patient at rest and also assessing her response to stimulation, and should be used with all routine assessments and when there is a suspicion of pain (eg, changes in activity, change in vital signs). Step 3: Level of Consciousness—Sedation–Agitation Assessment
The next important step is to assess the patient’s LOC. Consciousness has 2 major components, arousal and content. If a patient does not have an adequate level of arousal, then consciousness cannot emerge. This level of arousal is described along a continuum
Table 3 Behavioral Pain Scale (BPS) Assess
Description
Score
Facial expression
Relaxed Partially tense Totally tense Grimace
1 2 3 4
Movements of upper limbs
Relaxed Partially flexed Totally flexed Totally contracted
1 2 3 4
Mechanical ventilation
Tolerating movements Coughing, but tolerating during most of the time Fighting the ventilator Impossible to control the ventilator
1 2 3 4
Total range (higher number 5 more pain)
3–12
From Payen J, Bru O, Bosson J, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med 2001;29(12):2258–63; with permission.
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Table 4 Critical Care Pain Observation Tool (CPOT) Assess
Description
Label
Score
Facial expression
No muscular tension observed Presence of frowning, brow lowering, orbit tightening, and levator contraction All of the above facial movements plus eyelid tightly closed
Relaxed, neutral
0
Tense
1
Grimacing
2
Does not move at all (does not necessarily mean absence of pain) Slow, cautious movements, touching or rubbing the pain site, seeking attention through movements Pulling tube, attempting to sit up, moving limbs/not following commands, striking at staff, trying to climb out of bed
Absence of movements
0
Protection
1
Restlessness
2
No resistance to passive movements
Relaxed
0
Resistance to passive movements Strong resistance to passive movements, inability to complete them
Tense, rigid
1
Very tense or rigid
2
Alarms not activated, easy ventilation Alarms stop spontaneously Asynchrony: blocking ventilation, alarms frequently, activated
Tolerating ventilator
0
Talking in normal tone or no sound Sighing, moaning Crying out, sobbing
Talking in normal tone or no sound Sighing, moaning Crying out, sobbing
Body movements
Muscle tension Evaluate with passive flexion and extension of upper extremities
Compliance with the ventilator (intubated patients)
or Vocalization (nonintubated patients)
Total range (higher number 5 more pain)
Coughing but tolerating 1 Fighting ventilator 2
0 1 2 3–12
From Ge´linas C, Fillion L, Puntillo K. Item selection and content validity of the Critical-Care Pain Observation Tool for non-verbal adults. J Adv Nurs 2008;65(1):203–16; with permission.
from coma, to sedated, to awake and alert, to agitated, to combative and violent. The nurse needs to be aware of where her patient is along this continuum for multiple reasons. If her patient needs sedation, she must make sure that the patient is appropriately sedated. Maintaining a patient with the lightest level of sedation needed is clearly associated with earlier liberation from mechanical ventilation, fewer nosocomial infections, and a reduction in post ICU psychological and cognitive impairment.18 The use of validated sedation–agitation tools along with daily interruptions of sedation has been shown to reduce the amount and duration of use of sedative medication across multiple settings.
Delirium in the Neuro ICU
The other important reason to appropriately monitor LOC is that an altered LOC is a defining characteristic of delirium. If a patient has an unexplained fluctuation in LOC, he may be developing delirium. The American Association of Critical-Care Nurses and Society of Critical Care Medicine recommend using the Richmond Agitation–Sedation Scale (RASS) and the Riker Sedation–Agitation Scale (SAS; Tables 5 and 6 respectively). Table 5 Richmond Agitation–Sedation Scale (RASS) Score Classification
Descriptor
Motor Subtype
LOC
4
Combative
Hyperactive
Altered
3
Very agitated
2
Agitated
1
Restless
Overtly combative or violent; immediate danger to staff Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff Frequent nonpurposeful movement or patient– ventilator dyssynchrony Anxious or apprehensive but movements not aggressive or vigorous
—
Not altered
0
Alert and calm — 1
2 3 4
5
Hypoactive Altered Not fully alert, but has sustained (>10 s) awakening, with eye contact, to voice Light sedation Briefly (
MS, ACNP-BC
a,b,
*, Nikhil Patel,
MD, MBA
c
KEYWORDS Delirium Inattention Altered level of consciousness Validated tools Assessment KEY POINTS Delirium in the neuro intensive care unit (ICU) affects as many as 10% to 48% of patients. There are few studies looking specifically at the neuro ICU patient population and delirium; thus, nurses rely on general ICU data to make evidence-based decisions. Delirium cannot be addressed without also monitoring pain, sedation, and agitation using validated tools. The Confusion Assessment Method for the ICU and the Intensive Care Delirium Screening Checklist are the validated delirium assessment tools recommended by national guidelines.
Delirium is a common, serious, and life-threatening complication in the intensive care unit (ICU). Nurses should assess their patients for delirium risk factors, appropriately assess for and manage pain and sedation or agitation, and monitor for the emergence of delirium with all patients. To properly assess and monitor for this critical patient safety condition, nurses must use appropriate, validated assessment tools and not rely solely on clinical observations and judgment. Delirium is in many ways similar to acute kidney injury (AKI). The modern ICU nurse and clinical team is aware that their patients are at high risk of AKI, with 20% to 50% of the patients having some degree of AKI during their time in the ICU.1 By being aware of which patients are at risk for AKI, avoiding interventions that put the patient at increased risk, regularly monitoring renal function, and intervening early when signs of renal end-organ dysfunction are noticed, the clinical team will improve that patient’s likelihood of either not developing AKI or having a limited course with full recovery. Delirium is also common, affecting 20% to greater than 80% of ICU patients. Delirium is an acute brain injury, a manifestation of end-organ dysfunction or damage owing to a combination of the patient’s own
Disclosures: None. a Neurocritical Care Unit, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD, USA; b University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD 21201, USA; c Department of Neurology, University of Maryland School of Medicine, 620 West Lexington Street, Baltimore, MD 21201, USA * Corresponding author. E-mail address: [email protected] Crit Care Nurs Clin N Am 28 (2016) 21–35 http://dx.doi.org/10.1016/j.cnc.2015.11.001 ccnursing.theclinics.com 0899-5885/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
22
Haymore & Patel
risk factors and the effects of acute illness. Many patients with delirium recover and have few if any long-term complications. However, some will experience long-term, often permanent cognitive impairment, namely, chronic brain failure. The ICU nurse should view the acutely ill patient as being at risk for any end-organ dysfunction (eg, lung, heart, skin) and routinely monitor the patient based on the best available evidence. Delirium in the neuro ICU setting is an especially challenging condition. Most patients admitted to a neuro ICU have some degree of brain dysfunction due to an illness, condition, or trauma. Because delirium is an acute brain injury, it can be difficult to determine whether the patient’s behavior is because of her hemorrhage, stroke, meningitis, or other factor, or that she is developing an additional brain dysfunction in the form of delirium. It is this difficulty with teasing out delirium from the primary brain dysfunction that most of the research into delirium in the ICU has been conducted in the medical, surgical, and cardiothoracic ICU settings. Therefore, the majority of the information in this article is pertinent to all ICUs. The data specific to the neuro ICU setting are discussed when available. This article discusses what delirium is and who is at risk, and reviews the process of monitoring patients in the ICU for delirium. The appropriate assessment tools for each step of the monitoring process are described. WHAT IS DELIRIUM?
Delirium is a behavioral syndrome that includes an altered level of consciousness (LOC), difficulty maintaining attention, and a change in cognition or perception. The onset is acute (hours to days) and has a fluctuating course that might include periods of lucid, normal mental functioning. The behavior must be owing to a medical condition, use of a medication or other substance (ie, alcohol or recreational drugs), or withdrawal from a medication or substance, but not owing to a primary psychiatric condition (Table 1).2 Delirium Motor Subtypes
Patients with delirium may be consistently hyperactive or agitated (5 days) Indwelling urinary catheters Admission through the emergency department Admission through transfer from another facility or unit Trauma Invasive procedures Pain Surgery Isolation Poor quality sunlight Physical restraints Data from Refs.14,22–24
Delirium in the Neuro ICU
delirium 77% to 87% of the time. The PRE-DELIRIC uses 10 risk factors (age, Acute Physiology And Chronic Health Evaluation [APACHE]-II score, admission group, coma, infection, metabolic acidosis, use of sedatives and morphine, urea concentration, and urgent admission) to predict the likelihood of developing delirium. All of the data needed for the PRE-DELIRIC are available within 24-hours of admission in a typical ICU. This tool has been studied rigorously and validated across multiple ICU settings (medical, surgical, trauma, and neuro) and in multiple countries in Australia and multiple countries in Europe. However, there is an important caveat for using the PRE-DELIRIC in the neuro ICU setting. Of the patients studied in the development and validation of this tool, only 16% (n 5 784/4880) were in a neurocritical care setting. Further research is needed before this tool can be widely used in the neuro ICU. Steps 2: Pain Assessment
Pain is very common in the ICU, with as many as 50% of the patients experiencing pain at rest and up to 80% during routine care.16 Poorly controlled pain (undertreated or overtreated) can both trigger the emergence of delirium and potentially interfere with monitoring, leading to a delay in detection and intervention. The American Association of Critical-Care Nurses and the Society of Critical Care Medicine have published guidelines calling for routine monitoring of pain, using patient self-reporting of pain when possible.17,18 Both organizations recommend using a validated behavioral pain scale to assess when a patient is unable to effectively self-report. The tools that they recommend are the Behavioral Pain Scale and the Critical-Care Pain Observation Tool (Tables 3 and 4 respectively). These tools are a structured method of observing the patient at rest and also assessing her response to stimulation, and should be used with all routine assessments and when there is a suspicion of pain (eg, changes in activity, change in vital signs). Step 3: Level of Consciousness—Sedation–Agitation Assessment
The next important step is to assess the patient’s LOC. Consciousness has 2 major components, arousal and content. If a patient does not have an adequate level of arousal, then consciousness cannot emerge. This level of arousal is described along a continuum
Table 3 Behavioral Pain Scale (BPS) Assess
Description
Score
Facial expression
Relaxed Partially tense Totally tense Grimace
1 2 3 4
Movements of upper limbs
Relaxed Partially flexed Totally flexed Totally contracted
1 2 3 4
Mechanical ventilation
Tolerating movements Coughing, but tolerating during most of the time Fighting the ventilator Impossible to control the ventilator
1 2 3 4
Total range (higher number 5 more pain)
3–12
From Payen J, Bru O, Bosson J, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med 2001;29(12):2258–63; with permission.
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Table 4 Critical Care Pain Observation Tool (CPOT) Assess
Description
Label
Score
Facial expression
No muscular tension observed Presence of frowning, brow lowering, orbit tightening, and levator contraction All of the above facial movements plus eyelid tightly closed
Relaxed, neutral
0
Tense
1
Grimacing
2
Does not move at all (does not necessarily mean absence of pain) Slow, cautious movements, touching or rubbing the pain site, seeking attention through movements Pulling tube, attempting to sit up, moving limbs/not following commands, striking at staff, trying to climb out of bed
Absence of movements
0
Protection
1
Restlessness
2
No resistance to passive movements
Relaxed
0
Resistance to passive movements Strong resistance to passive movements, inability to complete them
Tense, rigid
1
Very tense or rigid
2
Alarms not activated, easy ventilation Alarms stop spontaneously Asynchrony: blocking ventilation, alarms frequently, activated
Tolerating ventilator
0
Talking in normal tone or no sound Sighing, moaning Crying out, sobbing
Talking in normal tone or no sound Sighing, moaning Crying out, sobbing
Body movements
Muscle tension Evaluate with passive flexion and extension of upper extremities
Compliance with the ventilator (intubated patients)
or Vocalization (nonintubated patients)
Total range (higher number 5 more pain)
Coughing but tolerating 1 Fighting ventilator 2
0 1 2 3–12
From Ge´linas C, Fillion L, Puntillo K. Item selection and content validity of the Critical-Care Pain Observation Tool for non-verbal adults. J Adv Nurs 2008;65(1):203–16; with permission.
from coma, to sedated, to awake and alert, to agitated, to combative and violent. The nurse needs to be aware of where her patient is along this continuum for multiple reasons. If her patient needs sedation, she must make sure that the patient is appropriately sedated. Maintaining a patient with the lightest level of sedation needed is clearly associated with earlier liberation from mechanical ventilation, fewer nosocomial infections, and a reduction in post ICU psychological and cognitive impairment.18 The use of validated sedation–agitation tools along with daily interruptions of sedation has been shown to reduce the amount and duration of use of sedative medication across multiple settings.
Delirium in the Neuro ICU
The other important reason to appropriately monitor LOC is that an altered LOC is a defining characteristic of delirium. If a patient has an unexplained fluctuation in LOC, he may be developing delirium. The American Association of Critical-Care Nurses and Society of Critical Care Medicine recommend using the Richmond Agitation–Sedation Scale (RASS) and the Riker Sedation–Agitation Scale (SAS; Tables 5 and 6 respectively). Table 5 Richmond Agitation–Sedation Scale (RASS) Score Classification
Descriptor
Motor Subtype
LOC
4
Combative
Hyperactive
Altered
3
Very agitated
2
Agitated
1
Restless
Overtly combative or violent; immediate danger to staff Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff Frequent nonpurposeful movement or patient– ventilator dyssynchrony Anxious or apprehensive but movements not aggressive or vigorous
—
Not altered
0
Alert and calm — 1
2 3 4
5
Hypoactive Altered Not fully alert, but has sustained (>10 s) awakening, with eye contact, to voice Light sedation Briefly (
