Delirium

What is Delirum?

(Álvarez et al., 2017; Balas et al., 2012; González et al., 2009; Ista et al., 2014; Peterson et al., 2006; Slooter et al., 2020)

Delirium is a (A) disturbance in attention and awareness, over a (B) short period of time (hours to days) that is a change from baseline and fluctuates in severity over the day. There can also be (C) additional changes in cognition. These changes in A & C can’t be explained by other pre-existing or known neurocognitive disorders.

There is evidence from exam findings/testing “that the disturbance is a direct physiologic consequence of another medical condition, substance intoxication or withdrawal (i.e. because of a drug of abuse medication), or exposure to a toxin, or is because of multiple etiologies.” (Slooter et al., 2020).

Delirium is a significant and frequent problem for patients in the ICU. Incidence is as high as 45-87% in mechanically vented and 20-56% in non-vented elderly patients (Álvarez et al., 2017; Balas et al., 2012). A cohort study of 542 patients showed that duration of delirium directly impacts survival with an 11% increase in mortality for every 48 hours that delirium persists (González et al., 2009).

  • Hyperactive delirium is the easiest type to recognize. These patients will be restless, behavioral, and anxious with the potential for rapid mood swings or hallucinations. These patients might often resist care.

  • Patients with hypoactive delirium may be inactive or have reduced activity. They tend to be sluggish, drowsy, or in a daze. These patients may not interact with family or others. This type of delirium is also referred to as “quiet delirium” and tends to unrecognized or misdiagnosed as sedation or depression. Often these are the patients who we’re told “aren’t ready yet” for therapy. But these are the perfect patients to work and try to engage with.

  • Patients with mixed delirium, with have symptoms involved in both types of delirium. Your patient may quickly switch back and forth from being restless and sluggish.

  • “The term acute encephalopathy refers to a rapidly developing (over less than 4 weeks, but usually within hours to a few days) pathobiological process in the brain.” (Slooter et al., 2020). Acute encephalopathy can lead to delirium, lower levels of consciousness, or coma, all of which are changes in baseline function.

Risk Factors

(Palacios-Ceña et al., 2016; Ramírez Echeverría et al., 2022)

Risk factors for delirium include: pre-existing cognitive impairment, advanced age, mechanical ventilation, untreated pain, sedative medications, sleep deprivation, multisystem illness, and prolonged immobilization.

*Many critically ill patients require some form of sedative medication while in the ICU which is shown to increase delirium.

Role of OT

(Álvarez et al., 2017; Deemer et al., 2020)

It has been estimated that a majority of delirium cases are preventable with the use of environmental aids (hearing aids and glasses), appropriate day/night rhythm, and participation in early mobility and rehabilitation (Álvarez et al., 2017). Furthermore, it has been shown that ICU patients who participated in an OT-specific treatment protocol to address delirium showed improved cognition, function, and delirium (Álvarez et al., 2017).

Role of OT addressing cognition

  • Improve cognition, memory, sleep hygiene, and maintain function in the ICU

  • Be sure you are thinking about the other 23 hours of the day, when you are not there actively working with the patient. It is important that there is carryover of these strategies outside of therapy.

  • Evidence supports the use of non-pharmacologic interventions for delirium management, including cognitive interventions including Cognitive Training, Cognitive Stimulation, and Cognitive Rehabilitation

    • Cognitive Training: goal to maintain or restore cognitive functions. Would use repeated tasks that focus on cognitive domains. Tasks that fall within this category would include tasks resembling ADL, adapting/modifying tasks to meet the patients needs/current level, utilizing spaced information retrieval, and memory activities (i.e., digit span, memory tasks, picture guess)

    • Cognitive Stimulation: goal to maintain or restore cognitive functions. Engage the patient in activities and discussions that improve cognition and social function. Tasks that fall within this category would include reality orientation, reminiscent therapy, memory training, and recreational activities.

    • Cognitive Rehabilitation: goal to improve function in everyday tasks. This encompasses a more individual approach to improve function and improve residual cognitive abilities. Tasks that fall within this category would include the development and integration of new strategies to overcome cognitive challenges (i.e., the use of memory aids such as calendars or diaries).

Evaluation & Treatment

Evaluation: It is important to screen for delirium. The goal is to prevent delirium not just treat it after it occurs. Assessments that can be used include the CAM-ICU or the AM-PAC applied cognitive inpatient short form.

Treatment: Specific treatment ideas and recommendations will be similar to other patient populations but an overall goal would be to help the patient create a routine and engage in “normal” activities. Ideas could include

  • Speaking clearly and repeat cues as needed. Avoid bombardment of stimulation

  • Reorientation: Orient and verbalize correct orientation 3 times. Reorientation should occur frequently

  • Engage in discussion/talk to the patient about familiar topics, family/friends

  • Incorporate family and friends as able (phone calls, recorded messages)

  • Provide their glasses and/or hearing aides

  • Decorate the room with familiar items

  • Play the patient’s favorite music

  • Coma arousal/stimulation for lower-level patients

  • Assistive Technology & Communication: figure out a reliable communication method (high tech: eye gaze, iPads; low tech: yes/no response, SPEACS-2 program)

Possible Barriers

  • Receiving appropriate OT orders. If the team consulting OT as needed?

  • The patients medical complexity

  • Timing of intervention 

  • Sensitive family responses. Does the family understand delirium or what is going on with their family member?

  • Provider support for interventions. Do team members understand the role of OT? Do they know the benefits for early intervention for delirium management?

  • The environment. Can the environment be  

  • appropriate intervention in appropriate environment

References

Álvarez, E. A., Garrido, M. A., Tobar, E. A., Prieto, S. A., Vergara, S. O., Briceño, C. D., & González, F. J. (2017). Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: A pilot randomized clinical trial. Journal of Critical Care, 37, 85–90. https://doi.org/10.1016/j.jcrc.2016.09.002

Balas, M. C., Vasilevskis, E. E., Burke, W. J., Boehm, L., Pun, B. T., Olsen, K. M., Peitz, G. J., & Ely, E. W. (2012). Critical care nurses’ role in implementing the “ABCDE Bundle” into practice. Critical Care Nurse, 32(2), 35–48. https://doi.org/10.4037/ccn2012229

Deemer, K., Zjadewicz, K., Fiest, K., Oviatt, S., Parsons, M., Myhre, B., & Posadas-Calleja, J. (2020). Effect of early cognitive interventions on delirium in critically ill patients: A systematic review. Canadian Journal of Anesthesia/Journal Canadien d’anesthésie, 67(8), 1016–1034. https://doi.org/10.1007/s12630-020-01670-z

González, M., Martínez, G., Calderón, J., Villarroel, L., Yuri, F., Rojas, C., Jeria, Á., Valdivia, G., Marín, P. P., & Carrasco, M. (2009). Impact of delirium on short-term mortality in elderly inpatients: A prospective cohort study. Psychosomatics, 50(3), 234–238. https://doi.org/10.1176/appi.psy.50.3.234

Ista, E., Trogrlic, Z., Bakker, J., Osse, R. J., van Achterberg, T., & van der Jagt, M. (2014). Improvement of care for ICU patients with delirium by early screening and treatment: Study protocol of iDECePTIvE study. Implementation Science, 9(1), 143. https://doi.org/10.1186/s13012-014-0143-7

Palacios-Ceña, D., Cachón-Pérez, J. M., Martínez-Piedrola, R., Gueita-Rodriguez, J., Perez-de-Heredia, M., & Fernández-de-las-Peñas, C. (2016). How do doctors and nurses manage delirium in intensive care units? A qualitative study using focus groups. BMJ Open, 6(1), e009678. https://doi.org/10.1136/bmjopen-2015-009678

Peterson, J. F., Pun, B. T., Dittus, R. S., Thomason, J. W. W., Jackson, J. C., Shintani, A. K., & Ely, E. W. (2006). Delirium and its motoric subtypes: A study of 614 critically ill patients. Journal of the American Geriatrics Society, 54(3), 479–484. https://doi.org/10.1111/j.1532-5415.2005.00621.x

Ramírez Echeverría, M. de L., Schoo, C., & Paul, M. (2022). Delirium. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK470399/

Slooter, A. J. C., Otte, W. M., Devlin, J. W., Arora, R. C., Bleck, T. P., Claassen, J., Duprey, M. S., Ely, E. W., Kaplan, P. W., Latronico, N., Morandi, A., Neufeld, K. J., Sharshar, T., MacLullich, A. M. J., & Stevens, R. D. (2020). Updated nomenclature of delirium and acute encephalopathy: Statement of ten Societies. Intensive Care Medicine, 46(5), 1020–1022. https://doi.org/10.1007/s00134-019-05907-4