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Evidenced Based Clinical PaperErin Vitale, RN, BSNWright State University-Miami Valley College of Nursing and HealthNUR 7203Dr. Kristine ScordoIntroductionDelirium is defined as a fluctuating or acute change in mental status and inattention in conjunction with disorganized thinking or an altered level of consciousness. Although the hallmark of delirium is an attention deficit, all cognitive domains can be affected including memory, visuospatial tasks, executive function, and language. Changes in sleep-wake cycles, personality changes, hallucinations, delusion, and/or autonomic findings including heart rate and blood pressure fluctuations may be associated with delirium as well (Josephson & Miller, 2012). Delirium can present as hypoactive (quiet), mixed, or pure hyperactive (agitated) delirium. Hypoactive or mixed forms of delirium are more commonly seen than hyperactive delirium (Ely, 2005). Risk factors for delirium include patient variables, underlying acute illness, and environmental factors. Patient variables include baseline mental status, co-morbidities, hearing and vision impairments, history of alcohol or tobacco abuse, age, gender, family support, and overall health and well-being. The severity of the acute illness, multi-organ dysfunction, nosocomial infections, metabolic disturbances, associated medications, treatments, and testing completed will also influence the patient’s likelihood and severity of delirium. Environmental/iatrogenic factors include healthcare providers, sedative and analgesic use, restraints, indwelling lines or catheters, sleep deprivation, and nutrition supplied. The use of psychoactive medications, including sedatives, benzodiazepines, and analgesic use, is the greatest environmental/iatrogenic risk factor for the development of delirium (Ely, 2005; Josephson & Miller, 2012). Delirium is significant among patients in the ICU setting and has been under-recognized by healthcare providers in the past. Lack of diagnosis and recognition has been attributed to the more prevalent form of hypoactive delirium, which can be mistaken for depression, dementia, or mentation changes seen in elderly. Recently, an assessment tool known as Confusion Assessment Method (CAM)-ICU has been recognized for its specificity and sensitivity for delirium recognition at approximately 95%. CAM-ICU can be completed at the bedside and assesses for (1) change or fluctuation in baseline mental status, (2) inattention, (3) disorganized thought, and (4) an altered level of consciousness. Delirium is identified when 1 and 2 and 3 or 4 are present (Inouye, Fearing, & Marcantonio, 2009). Typically, delirium is seen more commonly in the ICU setting because of the significance of their underlying illness, advanced age, and the use of psychoactive medications for treatment compliance. Delirium in the ICU limits patients’ ability to progress with their care, including mechanical ventilation weaning and hemodynamic stability. ICU delirium is associated with increased length of stay, mortality, and morbidity, especially among the elderly. The Acute Care Nurse Practitioner (ACNP) is one of the healthcare providers diagnosing and treating ICU delirium, make delirium a pertinent topic (Josephson & Miller, 2012). The significance of ICU delirium prompts a thorough review of current research with application of the clinical findings. Review of the LiteratureA review of the literature was completed to find the greatest level of evidence applicable to ICU delirium with ACNP clinical applications. Electronic databases searched for literature included CINAHL, PubMed, and EBSCO. Manufacturer studies were excluded due to potential bias and a gray literature search was not completed, limiting the literature to published studies. Keywords used for the review of the literature included intensive care unit, CAM-ICU, delirium, elderly, and ICU. The search results included 303 articles. The criteria for article selection for review included English only, previously published, human participants, written within five years, authors that are medical professionals, and a focus of patient delirium in the ICU setting. The search produced four articles that will be reviewed in greater detail. Review of Delirium in the ICU and Subsequent Long-Term Disability Among Survivors of Mechanical Ventilation The main objective of the prospective cohort study by Brummel et al. (2014) was to identify any association between delirium in the ICU with consequential disability. The authors hypothesized that the length of time the patient experienced delirium in the ICU is related to worsening long-term disability and poor health status. The population studied included patients in the medical ICU and greater than 18 years of age. Exclusion criteria included requiring mechanical ventilation for two weeks or greater prior to the screening, status post cardiac arrest, baseline neurologic deficits, enrolled in another trial that prohibited dual enrollment, and/or unwilling to receive aggressive medical treatments. Patient’s that did not survive until time of discharge, developed severe neurologic injury, or underwent cardiac surgery were also excluded from the study. Each ICU day, a research nurse or physician evaluated the patients using the CAM-ICU for up to a 28 day assessment period. A clinical neuropsychologist, who was unaware of the patients’ clinical course, assessed their overall functional status at three and twelve months post hospital discharge. Out of the 187 patients initially enrolled, 54 died during the inpatient stay and an additional 7 were excluded, with the remaining 126 patients eligible. Follow up was completed in 80 patients at 3 months, and 62 patients at the 12 month follow up. Patient characteristics that completed follow up included mean age 61, 48% female, 52% male, mean 12 years of education, mean 5 days of mechanical ventilation, and 50% admitting diagnosis of sepsis and/or acute respiratory distress syndrome (ARDS). Limitations for the study includes the patients were not assessed for delirium after they left the ICU and were transferred to additional units, potentially skewing their total number of delirium days. Additional limitations include the small population size, patient reported measures of functioning rather than objective evaluation, and lack of pre-ICU assessment (Brummel et al., 2014). The major finding of the study was the duration of delirium in the ICU was independently linked to increased odds of acute disability. The newly acquired disability was measured by activities of daily living (ADL) and overall awareness of their changes in function following the first year post hospital discharge. The study demonstrated the importance of recognizing the duration of the delirium, not just the presence of delirium in the ICU. Clinical implications for the role of the ACNP include recognizing that the total number of ICU delirium days may predispose the patient to worsening long term outcomes. The findings prompt the practitioner for closer evaluation of delirium, increased delirium assessment frequency, and implementing appropriate interventions to shorten the delirium duration length. The findings highlight the long-term consequences of ICU delirium, making delirium identification and management of upmost importance (Brummel et al., 2014). Review of Fluctuations in Sedation Levels May Contribute to Delirium in ICU Patients Svenningsen et al. (2013) main objective of the study was to explore the significance of inconsistent sedation levels and the incidence of delirium in the ICU. The prospective cohort study was completed at three multidisciplinary ICUs. Patient sedation levels were assessed utilizing the Richmond Agitation and Sedation Scale (RASS) and delirium was assessed using the CAM ICU tool. The authors hypothesized that significant changes in sedation levels would promote patient delirium. Significant changes were defined as greater than two levels of RASS from two sequential assessments. Patient inclusion criteria were ages greater than 18 and admitted to the ICU. Exclusion criteria consisted of ICU admission less than 48 hours, language barriers, and inability to communicate due to previous brain damage. If the patient was readmitted to the ICU after transfer or discharge less than 24 hours previously, both ICU stays counted as one. If the readmission was greater than 24 hours post discharge or transfer, only data from the first ICU admission was utilized. ICU practices and staffing was consistent between the three ICU facilities. The population studied included a total of 640 patients, 221 defined as delirium negative and 419 delirium positive based on the RAAS and CAM-ICU assessments. The mean age of patients’ delirium negative was 59.8, 54% men, 46% women, with an average of 11 intubated days. The mean age of patients’ delirium positive was 65.5, men 62%, women 38%, with an average of 26 intubated days. Additionally, the patients with delirium positive were in the ICU for 8 days compared to delirium negative of 3 days (Svenningsen et al., 2013). Limitations of the study include lack of focus on opiates for pain control versus sedation requirements. Additionally, more detailed information regarding the specific medications used would be assistive for clinical applicability. For example, the reader cannot ascertain the dosages of the medications used, or frequency of the bolus doses. A major study finding was midazolam was associated with fewer delirium incidences than propofol. Additionally, the study supports that ICU delirium is related to the length of stay. The study supports the authors’ hypothesis that major changes in sedation are associated with delirium. The authors also considered the presence of delirium positive patients (65% of the total group studied) to be significant and surprising (Svenningsen et al., 2013). The findings could be applied clinically for the ACNP role by supporting previous evidence that ICU delirium has a strong relationship with the length of stay. Recognizing the relationship prompts the practitioner to do CAM-ICU and RASS assessments to facilitate patient progression and recognition of ICU delirium. Based on the study results, additional research will be required to support whether continuous infusion of sedation, bolus infusion of sedation, or no sedation will ultimately be the most beneficial for patient outcomes. Review of The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) for the Diagnosis of Delirium: a Systematic Review and Meta-Analysis of Clinical Studies The systematic review completed by Gusmao-Flores, Salluh, Chalhub, & Quarantini (2012) main objective was to assess the current evidence of the CAM-ICU and ICDSC accuracy for diagnosing delirium in the ICU setting. The authors performed a systematic search of MEDLINE, SciELO, CINAHL, and EMBASE databases for articles that evaluated the performance of the two delirium assessment tools.Nine studies assessing CAM-ICU and four studies assessing ICDSC were included in the systematic review. Two of the thirteen studies evaluated both delirium assessment tools concurrently. The nine CAM-ICU studies had 969 patient participants and the ICDSC studies had 391 patient participants. All of the studies were conducted in the ICU and all but one used methodology for diagnostic tool evaluation. Two of the nine CAM-ICU studies were multicenter evaluations with a mixed population (medical, surgical) of critically ill patients. Two studies only evaluated patients that were mechanically ventilated, while the remaining studies included non-ventilated patients. One of the nine studies exclusively studied stroke patients, with and without mechanical ventilation. Main characteristics of the CAM-ICU studies include a range of 38-181 patients per study, between the years of 2001-2012, with delirium diagnosed in 16-55% of the patient population. Main characteristics of the ICDSC studies include a range of 59-126 patients, between the years 2001-2011, with delirium diagnosis in 15-46% of the patient population. One of the four studies evaluating the ICDSC was a multicenter study and all four studies were mixed populations (medical, surgical, cardiac). Two of the four studies suggested different cutoffs for the ICDSC tool for delirium diagnosis, which resulted in an improvement in the sensitivity with a decrease in the specificity. The limitations of the study include the mixed population and having mechanically vented patients and non-mechanically vented patients. The findings would be more applicable if all of the patients did or did not require ventilation and were from the same patient setting (cardiac, medical, surgical, or neurologic ICU) (Gusmao-Flores, Salluh, Chalhub, & Quarantini, 2012).Overall, the sensitivity and specificity for the CAM-ICU was 80% and 95.9% compared to 74% and 81.9% for the ICDSC tool. The major findings of the systematic review include support of the use of CAM-ICU and ICDSC as delirium screening tools. The authors recommend the use of the CAM-ICU as a diagnostic tool given its high specificity (Gusmao-Flores, Salluh, Chalhub, & Quarantini, 2012). Based on the authors’ findings, the CAM-ICU would be applied by the ACNP to clinical practice for screening and diagnosing of delirium. The ACNP role includes educating staff and peers on how to follow the CAM-ICU algorithm to ensure the tool was being used effectively. Appropriately recognizing and diagnosing delirium is the first step of patient care to minimize negative patient outcomes. Review of The Pharmacologic Treatment of Intensive Care Unit Delirium: A Systematic Review A systematic review by Bathula & Gonzales (2009) was completed with the main objective to evaluate pharmacologic interventions available for the treatment and/or prevention of delirium. The authors searched OVID Medline, PubMed, Cochrane Central Register of Controlled Trials, and CINAHL for clinical trials assessing pharmacological interventions. The authors searched for randomized control trials that assessed pharmacological interventions for the management or prevention of delirium, including placebo use. Exclusion criteria included patients less than 18 years of age, patients with history or current Axis 1 disorders, and those with potential alcohol induced delirium. Review studies were further narrowed by evaluation of the title, abstract, and methodological quality to a total of thirteen studies. Characteristics of the included studies can be divided into the four studies that focused on pharmacological management of delirium and nine studies that were trying to prevent delirium through pharmacologic interventions. The studies focused on pharmacological management included medical patients, surgical patients, and one study that focused solely on AIDS patients. The ages ranged from 39-65 and treatment length varied from 5-7 days. Compared pharmacological interventions included haloperidol, chlorpromazine, lorazepam; haloperidol, risperidone; amisulpride, quetiapine; and haloperidol, olanzapine. The studies focused on pharmacological prevention included medical, cardiac, and surgical patients. The ages ranged from 60-79 and treatment length was the length of a non-cardiac surgery to 28 days. Pharmacological interventions completed during the studies reviewed included donepezil placebo, haloperidol placebo, citicoline placebo, dexmedetomide, lorazepam, diazepam, flunitrazepam, pethidine, pethidine placebo, risperidone placebo, gabapentin placebo, and nitrous oxide plus oxygen administration. Overall, more male patients were found in the studies and there was a greater amount of patients with surgical needs. Limitations of the study include that patients with baseline mental deficits were included which can make delirium assessment challenging, there was lack randomization processes and blinding techniques, and the studies reviewed included a variety of pharmacological interventions with diverse patient populations. Including a variety of pharmacological interventions and having diverse patients in the studies reviewed limit universal recommendations (Bathula & Gonzales, 2009). Major findings include that patients had no significant differences in efficacy and tolerability when comparing first and second generation antipsychotics. Inconsistent findings were noted, with some studies recommending reduction of delirium symptoms with haloperidol, others recommending donepezil, and one study recommending cholinergic precursors. One consistent finding noted in several studies was that antipsychotics improved delirium symptoms, with no specific agent being superior. Despite not finding one antipsychotic agent to be superior, the review supports the recommendations by American Psychiatric Association and the Society of Critical Care Medicine by recommending Haldol as the first line agent for the treatment of ICU delirium. Recommendations were given for the use of CAM-ICU as an assessment and diagnosis tool and utilization of non-pharmacological techniques such as promoting sleep and frequent reorientation. Clinical applications of the study for the ACNP include use of antipsychotics, specifically haloperidol, for pharmacologic management of delirium in addition to non-pharmacologic management. The ACNP can encourage optimization of a sleep-wake cycle with supportive family visits to minimize delirium symptoms without the use of pharmacologic treatment (Bathula & Gonzales, 2009). Concerns in the ElderlyThe elderly patient population presents the ACNP a distinctive set of challenges in ICU delirium management. With advanced age, the elderly patient has compromises in every organ system making them predisposed to infection, acute illness, and chronic health conditions. Additionally, the geriatric patient has pharmacokinetic and pharmacodynamics changes present requiring diligence by the practitioner when managing their pharmacological and medical care. The geriatric patient is at greater risk for poor health status prior to the hospital admission and presence of co-morbidities, further raising the likelihood of delirium development. Due to the multiple delirium risk factors often present in elderly patients, the precipitating event to cause delirium may be considered a low level insult. Non-pharmacological interventions that can be completed to reduce the risk of ICU delirium in the geriatric patient include treating pain while avoiding polypharmacy, promoting appropriate sleep cycles, avoiding excess noise and light, providing their glasses and hearing aids, and re-orientation as needed (Milbrandt & Angus, 2009). Optimizing nutrition and physical independence can be crucial at preventing delirium in the ICU for the elderly patient. If pharmacological therapy is required, avoidance of benzodiazepines, high dose opioids, and anticholinergics should be completed to reduce the occurrence of delirium and complications (Smith, 2012). SummaryDelirium is recognized as a common complication in the ICU setting. Recognizing the risk factors for ICU delirium in conjunction with use of the available assessment tools can help the practitioner to diagnose ICU delirium in a timely manner. Recognition of ICU delirium can prompt the ACNP and healthcare team to implement non-pharmacological and pharmacological interventions. The significance of poor long term patient outcomes demonstrates the importance of delirium management. Delirium demands an interdisciplinary approach by healthcare providers given the illnesses multifactorial nature. Future research will further clarify areas of improvement for management and care of the ICU delirium patient (Ely, 2005; Milbrandt & Angus, 2009). ReferencesBathula, M., & Gonzales, J. (2009). The pharmacologic treatment of intensive care unit delirium: A systematic review. Annals of Pharmacotherapy, 47(9), 1168-1174. Retrieved from EBSCOhost. Brummel, N., Jackson, J., Pandharipande, P., Thompson, J., Shintani, A., Dittus, R., &…Girard, T. (2014). Delirium in the ICU and subsequent long-term disability among survivors of mechanical ventilation. Critical Care Medicine, 42(2), 369-377. Retrieved from EBSCOhost. Ely, E?(2005). Chapter 62. Delirium in the Intensive Care Unit.?In?Hall J.B., Schmidt G.A., Wood L.H.?(Eds),?Principles of Critical Care, 3e.?Retrieved March 30, 2014from, D., Salluh, J., Chalhub, R., & Quarantini, L. (2012). The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies. Critical Care, 16(4), 1-10. Retrieved from EBSCOhost. Inouye, S. K., Fearing, M. A., & Marcantonio, E. R.?(2009). Chapter 53. Delirium.?InHalter J.B., Ouslander J.G., Tinetti M.E., Studenski S, High K.P., Asthana S?(Eds),Hazzard's Geriatric Medicine and Gerontology, 6e.?Retrieved April 01, 2014?from, S., & Miller, B. L.?(2012). Chapter 25. Confusion and Delirium.?In?Longo D.L., Fauci A.S., Kasper D.L., Hauser S.L., Jameson J, Loscalzo J?(Eds),Harrison's Principles of Internal Medicine, 18e.?Retrieved March 30, 2014?from, E. B., & Angus D. C.?(2009). Chapter 19. Critical Care.?In?Halter J.B., Ouslander J.G., Tinetti M.E., Studenski S, High K.P., Asthana S?(Eds),?Hazzard's Geriatric Medicine and Gerontology, 6e.?Retrieved April 01, 2014?from, B. (2012). Delirium issues in elderly surgical patients. AORN Journal, 96(1), 75-85. Retrieved from EBSCOhost. Svenningsen, H., Egerod, I., Videbech, P., Christensen, D., Frydenberg, M., & Tonneson, E. (2013). Fluctuations in sedation levels may contribute to delirium in ICU patients. Acta Anaesthesiologica Scandinavica, 57(3), 288-293. Retrieved from EBSCOhost. ................
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