Delirium Treatment
The most important step in delirium management is early recognition. If delirium is not diagnosed, it is doubtful that any efforts will be made to reverse it. Once delirium is detected, efforts should focus on identifying the etiology. Often this can be done by assessing for the presence of known risk factors. Both prevention and treatment should focus on the minimization and/or elimination of predisposing and precipitating factors. The theoretical goals of management are to improve the patient’s cognitive status and reduce the risk of adverse outcomes such as aspiration, prolonged immobility, increased length of acute care, institutionalization, and death.
Delirium Management Protocol
Protocols and evidence-based strategies for prevention and treatment of delirium will no doubt emerge as more evidence becomes available from ongoing randomized clinical trials of both nonpharmacological and pharmacological strategies. Our group has deliberately put off publishing a delirium management algorithm because it would necessitates incorporation of “expert opinion” and thus aspects that have yet to be adequately tested or proven. However, the requests for such an approach continue to flood our experiences at national and international forums and numerous emails we receive from website visitors. Therefore, we have developed the following Sedation and Delirium Management Protocol, which basically and succinctly summarizes our approach at the current time. We want to emphasize that this approach, which is largely based on the current SCCM Clinical Practice Guidelines, (VUMC Sedation Protocol) is one which needs to be updated regularly with new data and also personalized at each medical center according to thought leaders at that center. This is not a “one-shoe-fits-all” protocol. We hope that this draft protocol helps you form your own integrated approach to CNS monitoring, sedation targeting, and delirium management in critically ill ICU patients.
Nonpharmacologic
Primary prevention is preferred; however, some degree of delirium is inevitable in the ICU. Although there are no data on primary prevention (nonpharmacologic) trials in the ICU, the data in non-ICU settings focuses on minimizing risk factors. The strategies include the following interventions: repeated reorientation of patients, provisions of cognitively stimulating activities for the patients multiple times a day, a nonpharmacological sleep protocol, early mobilization activities, range of motion exercises, timely removal of catheters and physical restraints, use of eye glasses and magnifying lenses, hearing aids and earwax disimpaction, early correction of dehydration, use of a scheduled pain management protocol, minimization of unnecessary noise/stimuli. Strategies for the prevention and management of delirium in the ICU are important areas for future investigation.Pharmacologic
The first step in pharmacologic treatment of delirium is to assess the patient’s current medications for any offending agents that may be causing or exacerbating the delirium. Inappropriate use of sedatives or analgesics may exacerbate delirium symptoms. Delirious patients may become more obtunded and confused when treated with sedatives, causing a paradoxical increase in agitation as the sedative effects wear off. In fact, benzodiazepines and narcotics that are often used in the ICU to treat “confusion” (delirium) actually worsen cognition and exacerbate the problem. A thorough review of a patient’s medications will help identify any sedatives, analgesics and/or anticholinergic drugs that may be removed or decreased in dose.There are currently no drugs with FDA-approval for the treatment of delirium. The American Psychiatric Association http://www.psych.org/psych_pract/treatg/pg/Practice%20Guidelines8904/Delirium.pdf and the Society of Critical Care Medicine clinical practice guidelines (Jacobi J, et al., Crit Care Med 2002; 30:119-141) recommend haloperidol for the treatment of delirium, though it is acknowledged that this is based on sparse outcomes data from nonrandomized case series and anecdotal reports (i.e., level C data). Haloperidol is a dopamine receptor antagonist that works by inhibiting dopamine neurotransmission, with resultant improvement in the positive symptomatology (hallucinations, agitated and combative behavior, etc) and often results in a sedative effect. Haloperidol and similar agents (e.g., droperidol) have not been extensively studied in the ICU, though they are widely used anecdotally. In addition to haloperidol, other candidate antipsychotics/neuroleptic agents (e.g., risperidol, ziprasidone, quetiapine, and olanzapine) may prove to be helpful for both hyperactive and hypoactive delirium, especially with their broader receptor affinities. Patients receiving all of these antipsychotics should be monitored for adverse side effects such as QT prolongation, arrhythmias and extrapyramidal side effects. Prospective randomized controlled trials are needed to evaluate the effectiveness and safety of these agents relative to one another.
Vanderbilt University Medical Center
Veterans Affairs TN Valley Geriatric Research Education and Clinical Center (GRECC)