Dec 5, 2018
ICU delirium is a state of agitation or confusion that can affect as many as 80 percent of patients who are admitted to the intensive care unit. Dr. Matthew Schreiber explains this condition and how we reduce the risk for our patients.
TRANSCRIPT
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thanks for joining us today. We’re talking to Dr. Matthew Schreiber, associate director of the Medical ICU and an attending physician in Pulmonary Disease/Critical Care Medicine at MedStar Washington Hospital Center. Welcome, Dr. Schreiber.
Dr. Matthew Schreiber: Thank you for having me.
Host: Today we’re talking about ICU delirium, a sudden and intense confusion that can include hallucinations, delusions, and paranoia. So, Dr. Schreiber, what can cause ICU delirium?
Dr. Schreiber: What can cause it is really the focus of a lot of research right now and the list of things is very, very long. We know that medications have an association with delirium. Some of the things that historically have been used in the ICU to help treat a patient also have risks that are now being identified, like delirium. Additionally, the ICU as an environment itself can lend to having delirium because imagine in your normal job, or your normal life, with a newborn child or something else, if you become sleep deprived, the next day you’re a little bit foggy and a little bit less focused, and imagine dealing with night after night of a twenty-four-hour lights on, beeping environment where things are happening because they need to happen to treat somebody. After days of that, it also impacts a patient’s mental status and can lead to delirium. On top of that, delirium is really a very specific disease. It’s not dementia, it’s not pain, it’s not agitation -- those things might look really similar, but what delirium is, is it’s an end organ failure, meaning the brain, in response to other things going on. And we don’t have a model to say A causes B, but we know delirium happens based on a diagnostic criteria—a series of questions and kind of a test, if you will, to say if someone’s delirious or not. But we can’t necessarily chalk it up to ‘if we could just do this one thing we’d be able to get rid of it.’ It’s a…it’s a sign of a disease, but it is its own condition and its own disease and its own thing on its own.
Host: That’s fascinating. So, the brain can actually die from overstimulation?
Dr. Schreiber: It’s interesting that you put it that way, ‘cause that’s somewhat of what’s being shown in some research. If you parallel this to something like sepsis. Sepsis is the whole body responding to an infection in one place. So, lots of people get urinary tract infections, but some people, their body’s inflammation and that’s the body’s response to it, they end up septic from that same urinary tract infection. The brain sees all the same blood as everywhere else in the body, so even though somebody might have low blood pressure or troubles breathing because of an infection down in their lower extremities or again, that urine, the lungs were an innocent victim. Here the brain is an innocent victim to whatever the illness is because of all the things circulating around in the body causing end organ damage. To come back to what you said about the brain dying, there actually are some studies coming out of Vanderbilt where they’ve done MRIs on people who were diagnosed as having delirium during an ICU stay. Six months later the brain actually looks different when compared to people who were just as sick but for whatever reason their body didn’t end up having delirium, so something physical is happening there.
Host: So, we’re talking visual, and auditory and physiological symptoms. What would be some of the indications that a person has delirium as opposed to another condition?
Dr. Schreiber: So, it’s important to point out that those kinds of things you brought up are what a lot of people think of when they think of delirium, but delirium really is more nuanced than that. It’s got a couple of clinical tests that can be done at the bed side to help make the diagnosis, but they’re all consistent in what they are. Delirium is a condition that waxes and wanes, meaning it comes and goes. Dementia is something that comes on and gradually happens over years and doesn’t necessarily just get better. Delirium is something that can be there at 6 AM, and gone at noon and back again at 7 PM and gone at 2 AM and so the ongoing fluctuations like that are a key component. The second part is inattention. The patient just can’t maintain focus. And so, we test that by seeing if they can just do something that we’re asking them to do, uh, ten times. You know, some of them being in the affirmative, meaning do it, and some of them not, meaning we say something and they’re not supposed to do it, but if they can’t maintain focus for those, that’s inattention, and that’s the second component. And the last part is disorganized thinking. You might just call it confusion. But the way that we test for this when it comes to disorganized thinking is we ask questions to a patient that really should have no question of what’s right and wrong. Things like, is ice cream cold? Is a mouse bigger than a giraffe? Can you hit a nail with a hammer? And when somebody has delirium, questions like that still become difficult for them to answer even though they sound like something anyone should be able to get right. Really, it’s hard to tell without actually doing the test. There are people who can be completely oriented, can tell you the date, where they are, their name and be delirious. And there are people who can be disoriented or have dementia or have changes in their ability to respond because of a stroke and not be delirious. So, it really does come back to those key things of waxing and waning mental status, so it’s changing throughout the day, inattention, and disorganized thinking.
Host: So, it sounds like different populations of people, different conditions for which they’re hospitalized in the ICU, can cause varying levels of delirium symptoms. Is there a particular risk factor an individual might have that would make, say me as opposed to you, more susceptible?
Dr. Schreiber: That has been shown. So, the older a person gets, the more likely they are to have delirium. The more ill the person is when they first come into the hospital, the more likely they are to have delirium. People that have a history of dependencies on different chemical substances, whether it’s things like alcohol or illicit drugs or even prescription medications, are more likely to have delirium. Whether if any one of those things is the absolute risk or not, hard to say. But it’s something we really should be looking for in every patient. It’s also important to say this is not just an ICU thing. It’s where a lot of it happens, in fact eight out of 10 people who end up on a breathing machine will have delirium at some point in their hospital stay. But half the people who never end up on a breathing machine can still be that way, and even just regular admissions to the hospital, what we call the medical/surgical floors or wards—up to a quarter of those people will have delirium during their stay, at some point.
Host: So, this is a fairly common thing. How many cases would you estimate that you see at MedStar Washington Hospital Center in a year?
Dr. Schreiber: Hundreds. I think the better way to put it is how many people every day do we see having delirium? We…we make it part of our rounds. It’s something that the nurses do every single shift, is do a test - we call it a Cam ICU, confusion and agitation method in the ICU, to look at that series of questions. Has their mental status changed? We ask people, to basically squeeze my hand or blink your eyes or stick out your tongue. Whatever they can do when I say the letter A, and then I spell out ‘save a heart,’ and heart is spelled wrong, it’s s a v e a h a a r t, and if they get more than two of those wrong, then we move on to disorganized thinking and ask them those simple yes, no questions, and can they follow a command. And if they can’t follow two separate commands and answer questions without more than two errors altogether, that’s delirium. We check every patient in the ICU every single day, and when we find it, then that can actually change our plan of care. Do we need to be more aggressive getting rid of a sedative? Do we need to change that to something else, even if it, you know, we’re not sure it’s going to be as effective to help maintain a level of comfort. Or, is it a sign that something’s going wrong? You know, when a patient’s in the hospital and has a fever, everyone says “oh, we need to figure out why that patient has a fever.” If someone was normal yesterday and delirious today, that’s another sign that the brain is raising a red flag maybe something’s going on and that might be the first sign of an infection or a complication.
Host: Is this something that patients have ever brought up in themselves and say, you know, “doctor, I just don’t feel right?” Or is this something that family members can also watch out for? Or caregivers? What’s their role?
Dr. Schreiber: The patient’s usually not aware because it’s affecting their brain and so that level of noticing ‘hey, I’m different’ is one of the risk factors of the condition. Family see it, they just not necessarily know what to call it. Why is my loved one not themselves? Why did they act like they didn’t know who I was? And the worry is, is this dementia? Is this permanent? Is—have they had a stroke? Is there something going on? Is it any number of things? They don’t necessarily come up and say, ‘I think my loved one’s delirious.’ But when we get those kind of questions, like ‘she was talking out of her mind this morning’ or ‘she couldn’t remember something I said to her fifteen minutes ago’ or something like that, those are red flags to that disorganized thinking.
Host: Is there anything that a patient or a family member can do to decrease the risk for delirium?
Dr. Schreiber: Absolutely. Being a familiar face, being able to redirect, being able to anchor that patient in what’s going on and help them stay focused, has been shown to help. Having things like the whiteboards in our rooms that have today’s date and today’s nurse and today’s information, help reorient the patient. Having things on the television in the room that have current, redirecting kind of issues. Not necessarily dramatic things you might see on the news, but things that let people know of what’s going on now have been shown to help. And also, letting people get the rest they need. You know, we do have an open ICU that allows visiting hours around the clock. But our goal is to let patients sleep at night and stay awake during the day. During the day, we try to be aggressive with pushing things forward as much as the patient can do and so family members can help by being encouraging for that. Helping keep the patient’s spirits up and when the patient’s saying things like “I just don’t know if I can do physical therapy today,” to ask them, “Are you sure? How about a little, but can we help you? Can we cheer you on?” You know, this is really gonna help you out by staying purposeful and active and moving forward because early mobilization and activity’s also been shown to reduce delirium.
Host: Interesting. So, walking or getting up and participating in PT?
Dr. Schreiber: Absolutely, and not just with the physical therapist. One of the things that we’ve been doing here for almost two years now in the medical ICUs is rolling out a bundle of things to help control, manage, and prevent delirium. This is called the ABCDEF bundle. It stands for assessing and addressing pain, because that’s important. When a patient is ‘quote un quote’ agitated, maybe it’s because they’re hurting, and if we can control that pain syndrome instead of just using something like a sedative, or an antipsychotic or something to calm them down, you might actually get two birds with that one stone, and reduce their risk, and help that issue. The B is for both the spontaneous awakening and breathing trial. So, people that are on a vent—mechanical ventilation, a breathing machine for life support - to every single day see, can they breathe on their own? And, if they’re really sick, they’re going to declare that they can’t because they’ll breathe fast, and you can tell within a minute. But maybe they can, because if they can breathe on their own on that machine with some settings being changed, maybe they’re ready for that to come off and you get rid of another risk factor for delirium. The awakening trial is not just saying, let’s turn down any pain or sedative medications to see where we can get the patient awake and comfortable, but literally every single day to push stop on those machines and see if the patient needs it.
That’s been studied, and by always trying to adjust to just enough for the patient what they need was considered standard of care. By doing that but also once a day pushing pause on the machines, cut the number of days of continuous medications like that, cut the number of days on the vent, shortened the ICU stay, and did nothing to raise mortality or patient harm, and so the fear of ‘Well, I can’t push stop on this medicines that going through this IV pump, the patient will hurt themselves,’ never has actually been shown. In fact, continuing it longer seems to be what hurts people. The C is the choice in those medications. Things called benzodiazepines. At home, people might know this as Xanax, is one of those examples. Ativan is another example. That family of medicines has the most research behind it to lead to delirium than anything else we know. In fact, one study showed a direct relationship of the dose that you get of medicines in this family to having delirium within a day, and it doesn’t seem like much but relatively low doses ended up having a hundred percent of people having delirium that day, so we try to avoid those whenever we can. Sometimes they’re needed. We use benzodiazepines when someone is seizing. We use them when someone’s in alcohol withdrawal. But, a lot of times you can find something else. The D is for delirium. To check it, because if you don’t look for it, you’re not going to find it. And that’s that test we call a Cam ICU. The E is early mobilization activity, which might be physical therapy, but our nurses are fantastic. You know, we can sit somebody on the edge of the bed, let them use those core muscles to dangle their feet. We can move people to a chair because the sitting position uses different muscles than laying in bed, and we walk people. And we walk people. You know, we get a physical therapist, a nurse, another nurse to help, if needed, and even if someone is still on a ventilator, still on a breathing machine, still on life support, we can walk them in the unit if they’re able, but we won’t know if we don’t check to see what they can do. And the F is family engagement and involvement. Because it is important for family members to help us help that patient in a way that we can’t. As much as I might like my patients, I will never be that familiar face that they’ve known for years and years and years, at least I hope that I’m never that face. And that’s something we can’t reproduce. And so, we do try to invite families to rounds every day. If they can’t be there, we try to call them every day, and we really do try to encourage that engagement with the patient to help them move along.
Host: Is there a risk for untreated delirium, or if somebody has it, can it resolve on its own?
Dr. Schreiber: Most of the time patients, as they get better clinically, as whatever got them sick in the first place gets better, they’ll start to improve. There are long term risks here though. Being delirious on its own, even when you, what we call, adjust for other things, meaning you’re doing statistics to say how much does this cause that or associate with that, and you say ‘well, I’m going to take two people who are just as sick and one’s delirious and one’s not, how does, how does this outcome change,’ delirium’s been shown to increase mortality at six months. If it’s its own process being on its own, it’s more likely to kill you, which is why it’s so important to try to prevent it with those other things like getting out of bed, and less days on the vent and less sedation. I mentioned the MRI studies a little bit earlier, that there’s something physically different happening in the brain and so, long term, patients that have had delirium tend to have more cognitive issues and functional issues and it can be something simple like more often saying ‘I was going to tell you something. I just can’t remember what that was’, but it can be life changing if now they can’t go back to work. And icudelirium.org is a fantastic website for both patients and practicing clinicians and family members and everyone else to see testimonials from patients and caregivers and hospital professionals all talking about the long-term outcomes of this condition. It can be life altering and the worst part is, if no one was ever able to say ‘hey, you had this while you’re in the hospital’ because there are plenty of places that don’t check for it every day. Even in our institution, I can’t tell you that every single unit, every single nurse, every single day, checks for this. Then they go home and wonder ‘why am I different?’ And we have a long way to go to help support people at the back end of their illness, at the back end of the ICU after they’ve left, to try to give them every opportunity to get back to being themselves.
Host: That’s really a lovely statement, I think, because yeah, I mean it’s traumatic enough being in the hospital, let alone being in the ICU after a traumatic event. Is there a certain subset, say accident victims or surgery, you know, people that had complications with surgery, that you see delirium in more often or a certain age group?
Dr. Schreiber: The older you are, the more likely you are to become delirious. As far as the disease itself, I think the literature is just not there yet from the research. It has been shown in burn ICUs, cardiac ICUs, surgical ICUs, medical ICUs, it doesn’t discriminate. What we do know is it happens far more often if you are on a breathing machine, and that’s probably a mix of both - that means you’re sicker because if you’re on a form of life support to help you breathe, that’s pretty bad. But also, what does oxygen do to you and your brain? If you’ve ever been unfortunate enough to have a family member in a neonatal ICU or if you’ve ever worked near one of those, you know that they, as…as early and aggressively as possible, try to have that baby off of oxygen because of how it can affect your eyes and other things. We always try to use it as little as possible but it has things that cause inflammation, it’s one of the effects, so could the vent itself do some of this? We don’t know. The research isn’t there yet. People who are septic - there’s some studies that say there might be more delirium in that because of the way the whole body can become inflamed, including the brain, when the body is dealing with an infection and becoming septic. But if there is one disease to do it, I don’t think we have that answer yet.
Host: Have you ever seen a very severe case of delirium turn around and what was that process like?
Dr. Schreiber: I have. I, I can distinctly remember a patient who, you’d walk past the room and looked like a normal guy. Sitting in the chair awake, watching tv, and then you’d talk to him, and you’d hear from the nurse, ‘Well, overnight we had to, you know, give him something because he was agitated, or we had to calm him down,’ you know, even if it wasn’t with the medicines. So, right there you have waxing and waning mental status. And then you’d ask questions and he would give answers that just seemed a little off, and so you’d take the next step and ask him to squeeze your fingers when you say the letter a for all those letters, and get that wrong, and then ask him these disorganized think questions and get that wrong. And then something would come out and he, he was scared because that’s what he saw and that’s what he believed was going on, and you would never know this if you didn’t ask the right questions because he would talk to you like everything’s fine, until you got into what he was perceiving and seeing. And, you know, he acted like he was actually handling it ok, and it’s not a big deal but then you realize he’s delirious and that visual hallucination was one of the things his delirium was manifesting. He ended up doing well. He left the hospital. I saw him in the clinic months later and he was trying to go back to work. He ran his own business and said he was having some trouble doing the books, so to speak, but for as close as he came to death with what brought him in, it was a remarkable improvement, just not all the way to as good as you wish you could get if you survived a life-threatening illness.
Host: Thank you for joining us today, Dr. Schreiber.
Dr. Schreiber: Oh, it’s been my pleasure! Thank you.
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