Delirium and Dementia in the Intensive Care Unit DQ

Longer stays in the intensive care unit (ICU) can be an opportunistic

battlefield where not only is the length of stay longer, but also there is

increased time that lapses with the potential for a patient fall, nosocomial

infection, urinary tract infection, and other untoward events (http://

oig.hhs.gov/oei/reports/oei-06-09-00090.pdf ; ASHRM Forum.

2014;Q3:10-14). As such, the push has become for shorter lengths of

stay whenever possible. Delirium and dementia are 2 conditions that the

ICU clinician must remain diligent in monitoring for status changes.

Delirium poses the threat of longer-term undesirable outcomes and is a

potential inherent risk in the care delivered. It rises to the level of a medical

emergency that can be deadly but, when caught early, can be treated and

resolved (Science Daily, September 16, 2013). Setting expectations with

families, providing adequate education, and involving them in a holistic

view of patient-centered care can help toward the detection of differences

that may occur from an ICU stay. Interventions the ICU clinician can take

for increasing self, patient, and family awareness to decrease risk and

improve outcomes and ways to deepen family engagement in these

populations are explored with practical applications.

Keywords: Assessment, Delirium, Dementia, Documentation errors,

Family engagement, ICU psychosis, Implications of extended ICU stay,

Improved outcomes

[DIMENS CRIT CARE NURS. 2015;34(5):259/264]

An intensive care unit (ICU) visit is a stressful time for patients and families. Added to the depersonalization of a hospital gown, unpredictability through changing of routines, and uncertainty of self-preservation, a patient is

tossed into a state of disempowerment. Medications become administered by a nurse that had been independently taken at home, privacy can become compromised with changing from a home-like setting to a group environment, and often

DOI: 10.1097/DCC.0000000000000133 September/October 2015 259

Delirium and Dementia in the ICU

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

the stay invokes a sense of decreased resilience and power- lessness. Families often feel just as much at a loss, watching their loved one fight for survival with foreign tubes and lines attached to various body parts, monitors that occasionally chime with information they are unable to decipher, and various pumps at the bedside that take space and are a con- tinual reminder of the severity of their loved one’s condition.

For patients who have shorter durations in the ICU, there is a time of celebration upon arrival to a general medical-surgical floor as a stepping stone and indicator of positive recovery.While the patient may not always achieve his/her original level of ability or health, the transition marks a clearer path of a successful discharge to either a facility or home. Longer stays in the ICU can be an opportunistic battlefieldwhere not only is the length of stay longer, but also there is increased time that lapses with the potential for a patient fall, nosocomial infection, urinary tract infection, and other untoward events.1,2 As such, the push has become for shorter lengths of stay whenever possible not only for finan- cial considerations but also for the clinical implications.2

An essential part of nursing within the critical care set- ting is conducting neurological and cognitive functioning assessments.3 Watching for a status change becomes a priority under the ever-watchful nurse’s eye. A cognitive as- sessment can be difficult because of individual circumstancesV the nonresponsive patient, verbally challenged patient, and the sedated patient as examples. At times overlooked is the occurrence or potential for delirium, when the primary focus of treatment is the reason for admission. Delirium affects 12.5 million patients and costs $152 billion every year.4

Delirium poses the threat of longer-term undesirable out- comes and is a potential inherent risk in the care delivered. It rises to the level of amedical emergency that can be deadly; however, when caught early, it can be treated and resolved.5

With the aging population at risk of increasing frailty, de- lirium will contribute to long-term morbidity and mortality.4

Less commonlymentioned to families andmanaged as a potential outcome is the risk of delirium and dementia that can occur secondary to a patient’s time spent in the ICU. Actively engaging the patient and family in their care involves not only a patient’s physical state, but also his/her cognitive capacity and what could occur after the ICU stay.

DELIRIUM IMPLICATIONS OF AN ICU STAY Delirium has been noted as a risk for the elderly popu- lation with an ICU stay. However, the realization that delir- ium occurs within the ICU is more pervasive than had been traditionally thought. Initial estimates placed the prevalence of ICU delirium around 40% through use of the Confusion Assessment Method (CAM) as an assessment tool.6,7 With advancement to theCAM-ICUas a tool for detectingdelirium, rates have increased to 87% of ICU patients becoming delirious during some point during their stay, and 83% of Delirium and Dementia in the Intensive Care Unit DQ

mechanically ventilated patients experience delirium.8,9

Today, delirium is considered to be 1 of the most frequent complications in the ICU.10,11 Despite the prevalence of delirium, the diagnosis is often missed.

A diagnosis of delirium using the CAM instrument re- quires acute onset, fluctuating course, inattention, and dis- organized thinking or altered level of consciousness.12 The most common subtype of delirium is hypoactive, with the patient appearing subdued, lethargic, stuporous, or coma- tose. As a result, it is important for the full clinical team inclusive of nurses to be waking a ‘‘sleeping’’ patient dur- ing daily rounding to assess level of consciousness.13

With nearly 70%of the elderly having delirium during their hospitalization, it is a complication that needs pro- active monitoring by the ICU nurse combined with family education. Implication for the ICU setting is that the inci- dence rate approaches one-third of individuals who have onset of a delirium episode during their ICU stay. Post- ICU delirium may be attributable back to the dynamics of the ICU environment if it occurs briefly after transfer to a lower level of care.14 As part of the patient transition to the lower level of care, any events of delirium should be reported as part of the hand-off process for outcome moni- toring and ongoing assessment. Not only is delirium an important aspect to closely track within the hospital set- ting, family and caregivers need to understand the impor- tance of a patient having an episode of delirium during his/her stay. Mortality rates of patients who experience delirium while hospitalized range from 22% to 76%, and at 1 year, this percentage remains at 35% to 40%.15

THE LINKAGE OF CRITICAL ILLNESS, ICU DELIRIUM, AND LONG-TERM COGNITIVE IMPAIRMENT Longer episodes of delirium in the hospital setting are as- sociated with declines in thinking and memory, and delir- ium has been associated with atrophy, inflammation, and other brain changes.16 At 3 months after heavy sedation, 40% of individuals exhibit cognitive test scores equivalent to those of individuals with moderate traumatic brain in- jury, and 26% of individuals exhibit scores similar to indi- viduals withmild Alzheimer disease. Further out in duration, at 1 year after heavy sedation, 34% of individuals have scores equivalent to some level of brain injury, and 24%of individuals have scores similar to those of individuals with Alzheimer disease.16 The impact of ICU delirium after hospitalization can be pervasive and persistent. Delirium and Dementia in the Intensive Care Unit DQ