Tackling Delirium in the Hospital Setting – FRESHRN

Let’s dig into delirium. This post and episode is part of a campaign to educate nursing students, new nurses, and seasoned nurses alike on delirium. It’s one of those things that has evolved dramatically in the literature over the years, but practice changes are slow to catch up. A bunch of episodes will drop soon on the topic across different nursing podcasts and to stay up to date on them, click here.

Note: This post was compiled with the help of Kali Dayton, DNP RN, a fierce advocate for changing the culture around how we manage and treat delirium. To see check out her full list of resources and website, please click here.

I recorded a podcast episode version of this post, to listen to it, simply click play below.

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If you’d prefer to watch a video of this content, click play below!

Delirium Definition

Hospital-acquired delirium, also known as nosocomial delirium, is a form of delirium that develops during a patient’s stay in a hospital. Delirium is a sudden onset of confusion, disorientation, and fluctuating levels of consciousness, often accompanied by agitation or lethargy. In hospital-acquired delirium, these symptoms are not present upon admission but emerge during the course of the hospital stay.

Several factors can contribute to the development of hospital-acquired delirium. Let’s discuss them in two sections. Modifiable risk factors and non-modifiable.

Non-Modifiable Risk Factors

• Age: Older adults are more susceptible due to age-related changes in the brain and decreased cognitive reserve.
• Pre-existing cognitive impairment or dementia: Patients with these conditions are at a higher risk.
• Polypharmacy: The use of multiple medications can increase the risk of delirium, particularly if they have sedative or anticholinergic effects.
• Medical conditions: Severe illness, infections, or metabolic imbalances can predispose patients to delirium.
• Surgery: Postoperative delirium is common, particularly in older patients and those with pre-existing cognitive impairment.

Modifiable Risk Factors

• Environmental factors: Disruption of normal sleep patterns, lack of natural light, lack of mobility, Lack of social interaction or familiar faces and sensory deprivation can contribute to the development of delirium

Prevention and management of hospital-acquired delirium involve identifying and addressing modifiable risk factors, providing appropriate medical care, and implementing non-pharmacological interventions such as ensuring proper sleep hygiene, orientation, and social interaction. Early recognition and treatment of delirium are crucial to minimize its duration and potential complications.

A Powerful Case Study

76-year-old man with a history of bipolar disorder and lithium use and alcohol abuse. He lives at home with his wife and works as a delivery driver. He had had a prolonged period of sobriety and then had a relapse and was attempting to withdrawal again at home. He arrived to the ED already suffering delirium tremens and it was unclear when his last drink was. He was combative in the ED and was loaded with 16mg of lorazepam.

On the floor, he was started on an lorazepam CIWA protocol with scheduled diazepam. You can see over the next 4 days that the doses decreased even down to 2mg of lorazepam and 10mg of diazepam for that day. Then the doses started to creep back up.

Five days later his doses have increased and he receives 14 mg of lorazepam and 15 mg of diazepam in 24 hours. This is 9 days after admission. On the EMAR, the indication for each lorazepam dose is charted as for “Agitation”.

This is likely about 11+ days after his last drink. Is he still in ETOH withdrawal?

Timeline/Window of Withdrawal

What is likely going on here?

• Benzodiazipine-induced delirium with agitation being treated with lorazepam

For the following three days he remained on the CIWA protocol and continues to receive lorazepam and diazepam for “agitation”. He is too sedated to mobilize and becomes profoundly comatose. On days 11 and 12 days after admission, he was on BIPAP for respiratory suppression/altered mental status. The next day he was intubated on a PEEP 5/30%, febrile with a new leukocytosis, and severely delirious with a RASS +1.

What likely happened?

• Oversedation and weakness from 12 days of bedrest leading to aspiration pneumonia while on BIPAP
• Delirium

What should be the treatment for him now?

• Mobility, family, sleep hygiene, avoid deliriogenic medications

Outcome

His care team did not have that culture or training, so he remained sedated and immobilized on propofol for the next 6 days. Even after extubation, he spent an additional 8 days in the ICU with severe delirium/altered mental status and severe ICU acquired weakness. During his time in the ICU, he developed 2 stage two ulcers on the bridge of his nose and on his sacrum. He spent 16 days on the med/surg floor being seen by psych who insisted in their notes that this was likely severe acute delirium. He developed a CAUTI and was again treated for sepsis. He was finally transferred to a rehab facility still delirious and unable to walk.

• Total of 6 weeks in the hospital, 2 hospital acquired infections, two pressure injuries, preventable intubation with 6 days of MV, lots of work treating delirium, attempting to re-mobilize, turning q 2, etc.
• Traumatizing delirium, cognitive impairments, high risk of not returning home, high risk of readmission to the hospital with a new hospital acquired infection from the care facility, etc.

Scary Stats

• 81% of intubated patients develop delirium- is it really all down to critical illness or is this so high because of what we give them (sedatives) when they are intubated? (18)
• Delirium doubles the risk of dying in the hospital (12), triples the risk of dying 6 months after discharge (13), and risks are still high 1 year after discharge (14).
• For every 1 day of delirium, there is a 10% increased risk of death. (13)
• Not just confusion, but usually vivid, gruesome, and graphic realities often far worse than the ICU that cause deep psychological trauma and is a root cause of post-ICU PSTD. (15)
• Delirium is the strongest predictor of length of stay- no matter the diagnosis, severity, comorbidities, etc. (16)
• Delirium increases length in the ICU by almost 5 days and almost 7 days on the medical floor. (17)
• Delirium doubles the nursing hours required for care (20).
  • It increases:
    • Risk of workplace violence (21)
    • Line and tube removals (22)
    • Unplanned extubation by 11 times (23)
    • increases time on the ventilator (19)
    • Healthcare costs by 39% (24)
• Effects continue after the hospital:
  • “post-ICU Dementia”- Delirium survivors have a 120x greater risk of long-term cognitive impairments (25)
  • ⅓ of delirium survivors have PTSD (26)
• The ABCDEF Bundle decreases delirium by 25-50% – depending on the level of compliance (27)
• The less sedation is given, the more patients are mobilized, the more they connect with their families- the less delirium they develop.

Cross Department Considerations

How do our practices impact the rest of the hospitalization/workload/risk for others?

A bolus in the ED can result in a mess of agitation/delirium/comatose for floor/ICU to deal with. Then they usually continue that pattern of responding to the emergence agitation with more Ativan. Thus, locking and loading patients into the rollercoaster ride of delirium and bolus benzos and all the sequelae that follows.

ICU sedation- mess of delirium and weakness sets acute floors/stepdown/rehab for continuous turning, fall risk, line/tube removals, agitation, stress, prolonged stays, etc.

Acute care floor sedating with ativan/antipsychotics—> impedes mobility, causes delirium —> oversedation leads to intubation, prolonged stay sets up for hospital-acquired infections, septic shock, ICU stay, etc.

ICU sedates and immobilizes patients, then extubates them and sends them to the floor. They are weak with poor secretion clearance/airway protection/dyphragm dysfunction and at high risk of aspiration and/or inadequate ventilation. They are still struggling with hyperactive or hypoactive delirium and are difficult to manage and end up receiving more sedatives on the floor. They are laborious and dangerous to mobilize, so they continue in bed and develop pneumonia, pressure injuries, CAUTI, etc. — they end up back in the ICU.

Remember: The ABCDEF bundle reduces ICU readmission by 46%, primarily because it decreases delirium by 25-50%.

How We View Delirium

Something else to deal with that makes our job harder, so we often cope with memes/humor/jokes about sedation. I personally believe this is the result of being exposed to trauma in the ICU as a caregiver. I highly recommend this resource to dive deeper into finding healthier ways to cope with the pain that is a natural byproduct of working as a nurse.

Making light of deep sedation and intubation dehumanizes our patients, and our beliefs about sedation play a role in decision making that drastically impacts the fellow human beings we’re caring for.

Misinformation impedes evidence-based practices and continues disconnect between what we see at the bedside and patient experience.

“Why, in 2023, are hundreds of thousands of people laughing about the loss of human connection, communication, dignity, autonomy, identity, career, relationships, quality and quantity of life? Why don’t we understand we are joking about torturing vulnerable human beings that have entrusted their lives and loved ones in our care?”

Kali Dayton, DNP RN

Fast Facts

These facts were provided by Kali!

• Nursing is an evidence-based discipline. Is the evidence guiding our sedation practices?
  • Early deep sedation is an independent predictor of mortality. (1)
  • For every 1 mg of Ativan there is a 20% increased risk of delirium (3)
  • For every 1 mg of Versed there is a 7-8% increased risk of delirium (4)
  • 5mg/hrx 24 hrs x 7% = 840% increased risk
  • Benzodiazepines increase mortality (5)
• Sedation is NOT sleep. Propofol and benzodiazepines disrupt brain activity and PREVENTS REM cycle. We are causing lethal and inhumane sleep deprivation. (6)
• Mechanical ventilation is NOT an automatic indication for sedation. (7)
• Continuous sedation comes with high risks (8)
  • Patients are already vulnerable and at high risk of delirium- why do we automatically destine them to have delirium when we have proven tools to avoid this lethal, damaging, and tortuous condition?
  • Continuous and especially deep sedation is essential during exceptions such as intracranial hypertension, status epilepticus, inability to oxygenate with movement (severest ARDS or cardiogenic shock), etc.
  • Are we running vasopressors to compensate for sedation that is usually unwarranted? There is no evidence to support increasing risk of ICU acquired weakness with vasopressors solely to support the use of sedation.
• The ABCDEF bundle is not just a checklist to require more charting, starting and stopping sedation.
  • The goal is to “produce patients who are more awake, cognitively engaged, and physically active, which ultimately serves to facilitate patient autonomy and the ability to express unmet physical, emotional, and spiritual needs.” (9)
    • —– Is that our vision, or is it to have all intubated patients comatose, unresponsive, and immobile?
  • PADIS guidelines: Pain, Agitation, Delirium, Immobility, Sleep Disruption: Is automatically starting sedatives and opioids on every patient really practicing the PADIS guidelines?
    • Pain is best assessed when patients can report it. Agitation is best addressed when we can assess the root cause of it/prevent delirium. Delirium is best prevented when we avoid deliriogenic medications that are not needed. Immobility is inevitable when we automatically sedate. Sleep is disrupted when sedation is given. (10)

Awakening Trials/ Sedation Vacation

• What is the objective of awakening trials? – to take a quick break and assess for stroke? Or to truly assess for resolution of indications for sedation (ICH, seizure, ability to oxgyenate with movement, etc) with the goal of turning sedation OFF.
• Are RNs taught and supported in performing successful awakening trials?
  • Respond with connection, communication, addressing pain, family involvement, OT for cognitive integration/mobility, PT involved for mobility
  • If we continue to deeply sedate in response to agitation, then we end up with patients that are sedated because they’re intubated and intubated because they’re sedated.
    • This increases workload, halts bedflow, increases complications such as VAP, HAPI, CAUTI, CLABSI, etc.- all creating a worse experience for patients, families, and staff.
• Are we only doing “sedation vacations” to do quick breathing trials only once ventilator settings are minimal? What is the evidence to support that? Why do ventilator settings guide our sedation practices? There is NO evidence to support that cultural training.
• Main reason for “failed” sedation “vacation” is agitation. – are we assessing and addressing the CAUSE of agitation, or are we masking it by resuming sedation?
• How do we know if they’re in pain, scared, lost in alternative realities, need to have a bowel movement, need to communicate, etc if we run back to deep sedation?
• A top cause of agitation is delirium. Does it make sense to respond to delirium with deliriogenic medication that are likely the cause of delirium?
• Are 5am awakening trials really appropriate? – Dark room, lone RN that is busy at the end of their shift, etc.

Impact of Family Involvement

• The “F” in the ABCDEF Bundle is for family engagement
• Family presence decreases rates of delirium by 88% (29)
• Family is a potent tool to prevent and treat delirium
• If we are not involving families, we are not practicing evidence-based medicine.
• Family visitation in the ICU is associated with lower psychiatric disorders following discharge (28)
• There is NO evidence to support visitation restrictions, but evidence does prove that LIBERAL visitation decreases trauma, anxiety, and overall outcomes
• Visitation restrictions (such as visiting hours and very limited numbers of visitors) are archaic practices that have proven to worsen patient experiences and outcomes.
• What role does nursing culture play in family visitation policies? Do we understand the role of families in keeping patients safe from delirium? Do we know how to utilize them in treating delirium/helping with mobility/keeping patients safe, etc.?

Take Home Messages

• Sedation isn’t sleep; they could be locked in a horrific nightmare
• There needs to be serious justification for continued deep sedation
  • ICH, seizure, ability to oxgyenate with movement, etc
• Getting patients up and out of bed while ventilated is evidence-based practice
• While getting patients OOB increases workload at that time, it decreases LOS and confusion – so if we want to be completely self-centered about this, it actually does make your job easier
• Families, even if they are frustrating, decreases rates of delirium by as much as 88% – there is no pharmacological agent that powerful!
• Finally, consider how you’d feel if you were intubated and sedated for a week in an ICU and saw on social media ICU nurses laughing and joking about how much they love restrained, intubated and sedated patients. Imagine if that was your loved one.
• Focus on modifiable risk factors. Just like you feel a duty to prevent falls and not make it more likely for physical injury, we need to do the same thing here with the brain and delirium.
  • Sleep hygiene: Ensuring patients have a quiet, comfortable environment to sleep in can help promote better sleep quality. Minimizing nighttime disruptions, such as staff visits and noise, can also be beneficial.
  • Orientation: Provide clear signage and clocks in patient rooms to help maintain their sense of time and place. Frequent reminders of the date, time, and location can also help reorient patients who are experiencing confusion.
  • Social interaction: Encourage family members and friends to visit and engage with the patient, as familiar faces can provide reassurance and promote a sense of connection. Involving patients in social activities, when possible, can also help maintain cognitive function and reduce feelings of isolation.
  • Mobility and physical activity: Encourage patients to move around and engage in light physical activity, as tolerated, to help maintain strength and mobility. This can also help reduce the risk of complications associated with prolonged bed rest, such as blood clots and pressure ulcers.
  • Structured daily routine: Establishing a consistent daily routine can help promote a sense of familiarity and stability for patients. This may include regular meal times, physical therapy sessions, and designated rest periods.
• For my next episode, I’ve got a phenomenal interview with Sarah from the Rapid Response RN podcast where we discuss:
  • A powerful experience she had as an ICU nurse dealing with delirium
  • Common mistakes new nurses make regarding delirium
  • Tidbits about new nurses working with RRT nurses

Final Thoughts About Delirium

So that about does it for delirium! Again, this episode is part of a campaign to educate students and new nurses alike on delirium. A bunch of episodes will drop next week on the topic across different nursing podcasts and to stay up to date on them, click here.

Thanks nurses, stay fresh!

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References

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31. *Sandeep, G., et al. (2019). Post-traumatic stress disorder (ptsd) related symptoms following an experience of delirium. Journal of Psychosomatic Research, 123. https://www.sciencedirect.com/science/article/abs/pii/S0022399919301837 *****
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35. Case studies
    1. https://daytonicuconsulting.com/case-studies/management-of-delirium-in-icu-improves-patient-outcomes/
    2. https://daytonicuconsulting.com/case-studies/jims-story-evidence-based-practices-reduce-icu-complications/
    3. https://daytonicuconsulting.com/case-studies/improve-icu-patient-outcomes-with-abcdef-bundle/