What is Delirium?
Delirium is a common clinical syndrome characterized by:Inattention
Acute cognitivedysfunction
Pathophysiology: Disruption of neurotransmission (drug action, inflammation, acute stress response)
Delirium: Think rapid onset, inattention, clouding of consciousness (bewildered), fluctuation
Dementia: Think gradual onset, intellectual impairment, memory disturbance, personality/mood change, no conscious clouding
HyperactivePatient may be combative with agitation that may
require sedation (is diagnosed more frequently).
Subtypes of Delirium
HypoactivePatient may be quiet and even peaceful, despite
cognitive impairment. More difficult to assess.
MixedCombination of both types
Why monitor for Delirium?
• 50-80% of ventilated patients develop delirium• 20-50% of lower severity ICU patients develop
delirium• Over 40,000 ventilated patients are delirious
every day• Delirium leads to increased mortality, longer
hospital stay, poorer recovery, higher costs of healthcare, long-term neurocognitive problems.
Ely EW JAMA 2001;286,2703-2710Ely EW CCM 2001;29,1370-79
ICU Delirium: The Canary in the Coal Mine
Under recognized form of organ dysfunction
3-fold increase in mortality at 6 months
Each DAY a patients is delirious = 10% INCREASE in risk of death
Delirium in the ICUClinical Value of RASS/CAM-ICU Measurement
Stimulates thinking of Rx:
– Delirium recognition is a Burglar Alarm for us (early sign of danger)
– Forces us to consider treatable causes earlier– Utilize nonpharmacologic interventions– Do NOT automatically link delirium monitoring with
a specific drug treatment
www.ICUdelirium.org
Educational Delirium Website
A Two Step Approach to Assessing Consciousness
Step 1 Level of Consciousness (arousal): RASS
Step 2 Content of Consciousness (delirium): CAM-ICU
Step 1: LOC Assessment
Assess for arousal
Step 1: Arousal Assessment (RASS)
+3
+2
+1
0
- 1
- 2
- 3
- 4
- 5
Richmond Agitation-Sedation Scale (RASS)
Step 2: Content Assessment
Assess for Delirium
Confusion Assessment Method for the ICU (CAM-ICU)
Feature 1: Acute change or fluctuating course of mental
status
And
Feature 2: Inattention
And
Feature 3: Altered level of consciousness
Feature 4: Disorganized Thinking
Or
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1Ely, et. al. CCM 2001; 29:1370-1379.4Ely, et. al. JAMA 2001; 286:2703-2710.5
Feature 1: Alteration/Fluctuation in Mental Status
Is the pt different than his/her baseline mental status?
OR
Has the patient had any fluctuation in mental status in the past 24 hours (eg fluctuating RASS, GCS, previous delirium assessments, etc)
Present: If either question is YES.
Feature 1: Alteration/Fluctuation in Mental Status
Common Questions: • What if you do not know the patient’s baseline?
– Assume normal unless you have red flags that make you suspicious
– Red Flag: patient came from institution• What about dementia?
– Ask family “What could she/he do prior to this illness?”
Feature 2: Inattention
Screening for Attention– two options
Letter “A” test Letters: S A V E A H A A R T (or numbers)Say 10 letters (or numbers) and instruct the patient to
squeeze on the letter “A” (or on a certain number) PicturesSimilar test with pictures (instructions are in picture packets)
Feature 2: Inattention
1. Attempt Letters first.
2. If pt is able to perform the Letter test you are sure of the results, you are done with Inattention test.
3. If pt is unable to perform the Letter test or you are unsure of the results, use the Pictures.
If you perform both tests, use the Pictures result to determine if inattention is present.
Inattention Present : If >2 errors
Feature 2: Inattention
• What if the patient only squeezes once and then falls back to “sleep”? or What if the patient is too hyperactive/combative to participate in squeezing?– Remember what you are assessing—Attention – This patient is inattentive
• If you have to explain the directions more than twice, start to be suspicious for inattention
If either Feature 1 or 2 are absent,
Stop
Overall CAM-ICU is Negative
If Features 1 and 2 are present,
Proceed
to Feature 3
Feature 3: Alt Level of Consciousness
Any LOC other than Alert.
Present: If the Actual RASS score is anything other than “0” (zero).
You have already done this assessment. It was the first thing you did when you
walked in the room!
Feature 4: Disorganized Thinking
Yes/No Questions (Use either Set A or Set B) :
Set A Set B
1. Will a stone float on water? 1. Will a leaf float on water?2. Are there fish in the sea? 2. Are there elephants in the sea?3. Does one pound weigh more than 3. Do two pounds weigh two pounds? more than one pound?
4. Can you use a hammer to pound a nail? 4. Can you use a hammer to cut wood?
Note: Use whatever form of communication that works (nodding, hand squeezing, blinking, etc).
Feature 4: Disorganized Thinking
Command
Say to patient: “Hold up this many fingers” (Examiner holds two fingers in front of patient) “Now do the same thing with the other hand” (Not repeating the number of fingers).
• Patient gets credit only if able to successfully complete the entire command
Feature 4: Disorganized Thinking
Present: If there is >1 error for the combined questions + command.
• Notes: – If pt is unable to move both arms, for the second
part of the command ask patient “Add one more finger”.
– If patient is unable to move arms at all (quadriplegic), then feature 4 is present if patient misses more than 1 question.
Confusion Assessment Method for the ICU (CAM-ICU)
Feature 1: Acute change or fluctuating course of mental
status
And
Feature 2: Inattention
And
Feature 3: Altered level of consciousness
Feature 4: Disorganized Thinking
Or
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1Ely, et. al. CCM 2001; 29:1370-1379.4Ely, et. al. JAMA 2001; 286:2703-2710.5
Case Studies
Case #1: Mr. Icy
45 y/o man, lawyer with no previous memory or attention problem
Dx: DKA, IntubatedIn the past 24hrs the RASS scores have been -3 to +1. Step 1: Arousal AssessmentCurrently: Awake and moving around restless in bed, but
not aggressive. RASS = +1
What do we do next?
Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
- Feature 2:
Letters = 4 errors
- Feature 3:
RASS = +1
- Feature 4
Pos Neg
Feature 1
Feature 2
Feature 3
Feature 4
Case #1: Mr. Icy
Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
Other RASS Scores: -3 +1
- Feature 2:
Letters = 4 errors
- Feature 3:
RASS = +1
- Feature 4
Pos Neg
Feature 1
X
Feature 2
X
Feature 3
X
Feature 4
Is this patient
delirious??
Case #1: Mr. Icy
Case #2 Mrs. Dapple75 y/o femaleDx: Severe pneumonia requiring prolonged mechanical
ventilation and difficulty weaningIn past 24 hours: RASS scores -3 to -1
Step 1: Arousal AssessmentEyes closed, but awakens to voice; maintains eye contact for
>10 secondsRASS = -1
What do we do next?
Step 2: CAM-ICU- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 1 error
- Feature 3
- Feature 4
Pos Neg
Feature 1
Feature 2
Feature 3
Feature 4
Case #2 Mrs. Dapple
Step 2: CAM-ICU- Feature 1:
Is he at his MS baseline?
Fluctuation?
RASS Variance: 2
- Feature 2:
Letters = 1 error
- Feature 3
- Feature 4
Pos Neg
Feature 1
X
Feature 2
X
Feature 3
Feature 4
Is this patient
delirious??
Case #2 Mrs. Dapple
Case # 3 Miss Universe
Miss Universe was successfully extubated from the Vent at 0800. All sedation and analgesia had been stopped earlier in the AM. Yesterday evening and last night she had periods of agitation with a documented RASS range of -1 to +3.
Step 1: Arousal Assessment Pt alert and calm. RASS = 0
What do we do next?
Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you aren’t sure
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4
Pos Neg
Feature 1
Feature 2
Feature 3
Feature 4
Case #3: Miss Universe
Step 2: CAM-ICU
- Feature 1: Is she at her MS baseline? Fluctuation? RASS Variance = 4- Feature 2: Letters = 3 errors, but you
aren’t sure. Pictures = 4 errors- Feature 3: RASS = 0- Feature 4
Pos Neg
Feature 1
X
Feature 2
X
Feature 3
X
Feature 4
Case #3: Miss Universe
Do you need to
do Feature 4??
Step 2: CAM-ICU
- Feature 1: Is she at her MS baseline? Fluctuation?- Feature 2: Letters = 3 errors, but you aren’t
sure. Pictures = 4 errors- Feature 3: RASS = 0- Feature 4: Answered half the questions wrong Unable to perform 2-step command 3 errors
Pos Neg
Feature 1
Feature 2
Feature 3
Feature 4
Case #3: Miss Universe
Step 2: CAM-ICU
- Feature 1: Is she at her MS baseline? Fluctuation?- Feature 2: Letters = 3 errors, but you aren’t
sure. Pictures = 4 errors- Feature 3: RASS = 0- Feature 4: Answered half the questions wrong Unable to perform 2-step command 3 errors
Pos Neg
Feature 1
X
Feature 2
X
Feature 3
X
Feature 4
X
Case #3: Miss Universe
Is this patient
delirious??
What if Miss Universe had gotten all 4 of her
questions right?
Step 2: CAM-ICU
- Feature 1: Is she at her MS baseline? Fluctuation?- Feature 2: Letters = 3 errors, but you aren’t
sure. Pictures = 4 errors- Feature 3: RASS = 0- Feature 4: Answered all 4 questions correct Unable to perform 2-step command 1 error
Pos Neg
Feature 1
X
Feature 2
X
Feature 3
X
Feature 4
X
Case #3: Miss Universe
Is this patient
delirious??
Case # 4 Mr. Bubble
Mr. Bubble works as a traveling salesman, and has been fully independent until admission. He is admitted with acute pancreatitis. His sedatives were turned off 30 minutes ago for a Spontaneous Awakening Trial (SAT).
Step 1: Arousal Assessment Eyes closed, moves head to verbal stimulation, no eye
contactRASS = -3
What do we do next?
Step 2: CAM-ICU
- Feature 1: Is he at his MS baseline? Fluctuation?- Feature 2: Letters= no squeeze for any letters - Feature 3: RASS = -3- Feature 4:
Pos Neg
Feature 1
Feature 2
Feature 3
Feature 4
Case #4: Mr. Bubble
Step 2: CAM-ICU
- Feature 1: Is he at his MS baseline? Fluctuation?- Feature 2: Letters= no squeeze for any letters - Feature 3: RASS = -3- Feature 4:
Pos Neg
Feature 1
X
Feature 2
X
Feature 3
X
Feature 4
Case #4: Mr. Bubble
Is this patient
delirious??
Confusion Assessment Method for the ICU (CAM-ICU)
Feature 1: Acute change or fluctuating course of mental
status
And
Feature 2: Inattention
And
Feature 3: Altered level of consciousness
Feature 4: Disorganized Thinking
Or
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1Ely, et. al. CCM 2001; 29:1370-1379.4Ely, et. al. JAMA 2001; 286:2703-2710.5
Stop and THINK
Do any meds need to be stopped or lowered?
• Especially consider sedatives
• Is patient on minimal amount necessary?
– Daily sedation cessation– Targeted sedation plan– Assess target daily
• Do sedatives need to be changed?
• Remember to assess for pain!
Toxic Situations• CHF, shock, dehydration• New organ failure (liver/kidney)
Hypoxemia
Infection/sepsis (nosocomial), Immobilization
Nonpharmacologic interventions• Hearing aids, glasses, reorient,
sleep protocols, music, noise control, ambulation
K+ or electrolyte problems
Consider antipsychotics after evaluating etiology & risk factors
Nonpharmacologic Interventions
• Environmental changes (e.g. noise reduction)
• Sensory aids (e.g. hearing aids, glasses)• Reorientation and stimulation• Sleep preservation & enhancement• Exercise and mobility
RASS (N/D & reason if not done)
CAM-ICU Feature 1(MS change or fluctuation)
Absent Present
CAM-ICU Feature 2(Inattention)
Absent Present
CAM-ICU Feature 3(Altered LOC)
Absent Present
CAM-ICU Feature 4(Disorganized thinking)
Absent Present
Overall CAM-ICU1 + 2 + [3 or 4] = CAM-ICU+
Negative Positive UTA (RASS -4/-5 only) Not done: ________
Brain Road Map for Rounds(Script for Interdisciplinary Communication)
Skipping any of these steps could leave the clinical team wanting more information!
Investigate (Ask these questions) Report (only takes 10 seconds)
Where is the patient going? Target sedation score (RASS, SAS, etc)
Where is the patient now?Actual sedation score (RASS, SAS, etc)Delirium assessment (CAM-ICU, ICDSC, etc)
How did they get there? Drug exposures
Case Study - Day 1Female, age 61
Hx: hypertension
CC: altered mental status, pneumonia
Dx: Septic shock, ARDS, acute renal failure
Vent settings: A/C rate 16, TV 400, PEEP 14, FiO2 70%
Infusions: Levophed 8 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF
Assessment: Target RASS -3, actual RASS +1 to +2, displaying vent asynchrony, CAM-ICU positive, bilateral rhonchi, pulses present
Drugs: Receiving intermittent boluses of fentanyl and midazolam
What next?
Review your Road MapReport:
Action:What do you do now?
Where is the patient going? Target sedation score: RASS -3
Where is the patient now?Actual sedation score: RASS +1 to +2Delirium: CAM-ICU positive
How did they get there? Drug exposures: Intermittent fentanyl & midazolam
Case Study – Day 3
Vent settings: AC rate 16, TV 400, PEEP 6, FiO2 40%
Infusions: propofol 40 mcg/kg/hr, Levophed 4 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF
Drugs: Intermittent fentanyl for analgesia
Assessment: Target RASS -1, actual RASS -3, CAM-ICU positive, not breathing over vent set rate, bilateral rhonchi, pulses present, moving extremities spontaneously
What next?
Review your Road MapReport:
Action:What do you do now?
Where is the patient going? Target sedation score: RASS -1
Where is the patient now?Actual sedation score: RASS -3Delirium: CAM-ICU positive
How did they get there?Drug exposures: Propofol infusion 40 mcg/kg/min & intermittent fentanyl for pain
Case Study – Day 5Vent settings: Pressure support 5, PEEP 5, 40% and tolerating spontaneous breathing trial
Infusions: Levophed/vasopressin off, insulin gtt, IVF, propofol off
Septic shock resolved, passed SAT/SBT
Assessment: Target RASS 0, actual RASS 0, CAM-ICU positive, lungs clear, moves all extremities
What next?
Review your Road MapReport:
Action:What do you do now?
Where is the patient going? Target sedation score: RASS 0
Where is the patient now?Actual sedation score: RASS 0Delirium: CAM-ICU positive
How did they get there? Drug exposures: No sedatives/analgesics in the past 24h