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Delirium and Dementia in the Intensive Care Unit Increasing Awareness for Decreasing Risk, Improving Outcomes, and Family Engagement

Jennifer Volland, DHA, RN, CPHQ, NEA-BC, FACHE; Anna Fisher, DHA, CDP; Diane Drexler, MBA, BSN, RN, FACHE

Longer stays in the intensive care unit (ICU) can be an opportunistic

battlefield where not only is the length of stay longer, but also there is

increased time that lapses with the potential for a patient fall, nosocomial

infection, urinary tract infection, and other untoward events (http://

oig.hhs.gov/oei/reports/oei-06-09-00090.pdf ; ASHRM Forum.

2014;Q3:10-14). As such, the push has become for shorter lengths of

stay whenever possible. Delirium and dementia are 2 conditions that the

ICU clinician must remain diligent in monitoring for status changes.

Delirium poses the threat of longer-term undesirable outcomes and is a

potential inherent risk in the care delivered. It rises to the level of a medical

emergency that can be deadly but, when caught early, can be treated and

resolved (Science Daily, September 16, 2013). Setting expectations with

families, providing adequate education, and involving them in a holistic

view of patient-centered care can help toward the detection of differences

that may occur from an ICU stay. Interventions the ICU clinician can take

for increasing self, patient, and family awareness to decrease risk and

improve outcomes and ways to deepen family engagement in these

populations are explored with practical applications.

Keywords: Assessment, Delirium, Dementia, Documentation errors,

Family engagement, ICU psychosis, Implications of extended ICU stay,

Improved outcomes

[DIMENS CRIT CARE NURS. 2015;34(5):259/264]

An intensive care unit (ICU) visit is a stressful time for patients and families. Added to the depersonalization of a hospital gown, unpredictability through changing of routines, and uncertainty of self-preservation, a patient is

tossed into a state of disempowerment. Medications become administered by a nurse that had been independently taken at home, privacy can become compromised with changing from a home-like setting to a group environment, and often

DOI: 10.1097/DCC.0000000000000133 September/October 2015 259

Delirium and Dementia in the ICU

the stay invokes a sense of decreased resilience and power- lessness. Families often feel just as much at a loss, watching their loved one fight for survival with foreign tubes and lines attached to various body parts, monitors that occasionally chime with information they are unable to decipher, and various pumps at the bedside that take space and are a con- tinual reminder of the severity of their loved one’s condition.

For patients who have shorter durations in the ICU, there is a time of celebration upon arrival to a general medical-surgical floor as a stepping stone and indicator of positive recovery.While the patient may not always achieve his/her original level of ability or health, the transition marks a clearer path of a successful discharge to either a facility or home. Longer stays in the ICU can be an opportunistic battlefieldwhere not only is the length of stay longer, but also there is increased time that lapses with the potential for a patient fall, nosocomial infection, urinary tract infection, and other untoward events.1,2 As such, the push has become for shorter lengths of stay whenever possible not only for finan- cial considerations but also for the clinical implications.2

An essential part of nursing within the critical care set- ting is conducting neurological and cognitive functioning assessments.3 Watching for a status change becomes a priority under the ever-watchful nurse’s eye. A cognitive as- sessment can be difficult because of individual circumstancesV the nonresponsive patient, verbally challenged patient, and the sedated patient as examples. At times overlooked is the occurrence or potential for delirium, when the primary focus of treatment is the reason for admission. Delirium affects 12.5 million patients and costs $152 billion every year.4

Delirium poses the threat of longer-term undesirable out- comes and is a potential inherent risk in the care delivered. It rises to the level of amedical emergency that can be deadly; however, when caught early, it can be treated and resolved.5

With the aging population at risk of increasing frailty, de- lirium will contribute to long-term morbidity and mortality.4

Less commonlymentioned to families andmanaged as a potential outcome is the risk of delirium and dementia that can occur secondary to a patient’s time spent in the ICU. Actively engaging the patient and family in their care involves not only a patient’s physical state, but also his/her cognitive capacity and what could occur after the ICU stay.

DELIRIUM IMPLICATIONS OF AN ICU STAY Delirium has been noted as a risk for the elderly popu- lation with an ICU stay. However, the realization that delir- ium occurs within the ICU is more pervasive than had been traditionally thought. Initial estimates placed the prevalence of ICU delirium around 40% through use of the Confusion Assessment Method (CAM) as an assessment tool.6,7 With advancement to theCAM-ICUas a tool for detectingdelirium, rates have increased to 87% of ICU patients becoming delirious during some point during their stay, and 83% of

mechanically ventilated patients experience delirium.8,9

Today, delirium is considered to be 1 of the most frequent complications in the ICU.10,11 Despite the prevalence of delirium, the diagnosis is often missed.

A diagnosis of delirium using the CAM instrument re- quires acute onset, fluctuating course, inattention, and dis- organized thinking or altered level of consciousness.12 The most common subtype of delirium is hypoactive, with the patient appearing subdued, lethargic, stuporous, or coma- tose. As a result, it is important for the full clinical team inclusive of nurses to be waking a ‘‘sleeping’’ patient dur- ing daily rounding to assess level of consciousness.13

With nearly 70%of the elderly having delirium during their hospitalization, it is a complication that needs pro- active monitoring by the ICU nurse combined with family education. Implication for the ICU setting is that the inci- dence rate approaches one-third of individuals who have onset of a delirium episode during their ICU stay. Post- ICU delirium may be attributable back to the dynamics of the ICU environment if it occurs briefly after transfer to a lower level of care.14 As part of the patient transition to the lower level of care, any events of delirium should be reported as part of the hand-off process for outcome moni- toring and ongoing assessment. Not only is delirium an important aspect to closely track within the hospital set- ting, family and caregivers need to understand the impor- tance of a patient having an episode of delirium during his/her stay. Mortality rates of patients who experience delirium while hospitalized range from 22% to 76%, and at 1 year, this percentage remains at 35% to 40%.15

THE LINKAGE OF CRITICAL ILLNESS, ICU DELIRIUM, AND LONG-TERM COGNITIVE IMPAIRMENT Longer episodes of delirium in the hospital setting are as- sociated with declines in thinking and memory, and delir- ium has been associated with atrophy, inflammation, and other brain changes.16 At 3 months after heavy sedation, 40% of individuals exhibit cognitive test scores equivalent to those of individuals with moderate traumatic brain in- jury, and 26% of individuals exhibit scores similar to indi- viduals withmild Alzheimer disease. Further out in duration, at 1 year after heavy sedation, 34% of individuals have scores equivalent to some level of brain injury, and 24%of individuals have scores similar to those of individuals with Alzheimer disease.16 The impact of ICU delirium after hospitalization can be pervasive and persistent.

DEMENTIA IMPLICATIONS OF AN ICU STAY Up to 75% of patients discharged from the ICU setting show signs of dementia and nearly a third will demonstrate symptoms similar to Alzheimer disease.16,17 Individuals with ICUstays are at high-risk long-termcognitive impairment

260 Dimensions of Critical Care Nursing Vol. 34 / No. 5

Delirium and Dementia in the ICU

independent of age (many that become impacted are in their 30s and 40s).16,18 This has been further underscored with patients who had heavy sedation in the ICU experienc- ing an impact on brain function up to a year after hospital discharge. Drug-induced comas similarly can have a negative impact with lengthening the time of delirium, which places the patient at increased risk of dementia.16 To help mitigate this concern, physicians at Vanderbilt University suggest con- trolling for pain and ensuring comfort, then not including a deeper level of sedation.16 In a study of 25386 Medi- care patients, 17.8% developed dementia in the years fol- lowing an ICU episode. Individuals tended to have an infection or sepsis or neurological dysfunction such as anoxic brain damage, encephalopathy, and transient mental disor- ders or received acute dialysis for nonYkidney failure.19

Sepsis can present a significant longer-term issue for the elderly. It has been estimated that the risk factor of sepsis may be responsible for up to 20000 new cases of dementia per year in individuals older than 65 years.20 Short-term mental problems are also indicative of a potential predis- position to dementia during the first 3 years after hospital- ization with an ICU stay. The risk associated with dialysis for nonYkidney failure appears to be time dependent, with the windowmost at risk occurring up to the first 6months. Postoperative delirium was also associated with longer- term impairment.While not a direct cause, certain diseases or illnesses may increase the risk of dementia or ‘‘unmask’’ previously undiagnosed dementia.19

Individuals who received a diagnosis of dementia prior to ICU hospitalization are also at risk of poorer outcomes. More than half of patientswith preexisting dementia develop delirium during the hospital stay. Without early detection, this frail population has faster declines in both physical and mental health. Patients with dementia who develop de- lirium in the hospital setting have a 25% greater chance of dying within 30days.21

The condition delirium superimposed dementia (DSD) has been drawing greater attention. Common causes of DSD are infections, dehydration, and medication changes. Nearly one-third of patients who acquire DSD are dehydrated.21

Dehydration is a status that can be easily monitored in the ICU for appropriate interventions. The nurse canmake an impactful difference.

Delirium superimposed dementia is a significant cost to the health care system, directly impacts an individual’s quality of life, and has been linked with higher rates of patient morbidity. Patients with DSD incur approximately 4 additional hospital days than do patients with dementia who do not develop DSD. Individuals with DSD also exhi- bit reduced physical and mental ability upon hospital dis- charge than do their peers without delirium and at follow-up visits 1 month later. In addition, patients with DSD have higher morbidity rates within a month after hospital dis-

charge.21 A reduction of 1-day hospitalization for DSD patients would reduce health care costs by $20 million per year. This places DSD among the frontrunners of dia- betes and heart disease for overall costs.5

DIFFERENTIATING BETWEEN DELIRIUM, DEMENTIA, AND DOCUMENTATION Deliriummust be differentiated from other conditions that may cause acute confusion. Items to consider is whether the acute confusion is due to a primary neurologic condi- tion (such as dementia), psychotic disorder, neurovascular insult, or a complication of a systemic illness.22 The presen- tation of delirium can be multifaceted. It has an acute onset; often fluctuates during the course of the day; results in inattention or decreased ability to focus, sustain, or shift attention; produces changes in cognition or may result in perceptual disturbances; may result in a change in con- sciousness; and has evidence that the cause is directly relat- able to a medical condition.

Using DELIRIUM as an acronym helps the ICU nurse remember the risk factors. John Hopkins has discovered that a diagnosis is missed in more than 50% of cases. The most common causes that they monitor for are dementia; electrolyte disorders; lung, liver, heart, kidney, brain; infec- tion; rx (prescription) drugs; injury, pain, stress; unfamiliar environment; metabolic.23

Dementia is usually typified by a progressive decline in memory over a duration of time that often spans months to years. This can be difficult to determine if the patient presents to the hospital without family to inquire about the patient’s history.22 Lewy body dementia can appear similar in some respects to delirium, such as fluctuating symptoms and hallucinations. However, patients with dementia gene- rally have intact attention and alertness.24 Delirium and dementia are significantly interrelated. In a recent study, the proportion of individuals who experienced episodes of delirium was 14.7% in Alzheimer disease, 34.4% in vas- cular dementia, and 31.8% in dementia with Lewy bodies. The frequency of delirium varies with each dementia type. It is important to note that delirium decreases activities of daily living and exaggerates behavioral and psychological symptoms of dementia.25

Different terms are used interchangeably at times with delirium. These can include ICU psychosis, acute mental status change, acute confusion, and postoperative psychosis. While labeling deliriummay help to promote the appropriate care measures that need to be taken by a nurse, delirium is a medical diagnosis. When communicating with medical staff, it is important to relay the findings as well as the problems, so an accurate patient diagnosis can be made.

In a review of nursing documentation, when patients had DSD, the word ‘‘confusion’’ (eg, patient remains plea- santly confused) was often used. Use of this word with the

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dementia patient may serve as a flag for the ICU nurse that events beyond confusionmay be occurring with the patient. Another error that has been noted in nursing documenta- tion is for nurses to intermingle ‘‘alert’’ with ‘‘oriented’’ when making notations in the nursing notes. Remaining diligent in assessing alertness as distinct from orientation to time, place, and person is a critical element of monitor- ing for delirium and dementia and any deterioration in condition (Figure).

In older patients, the ability for nurses to discern be- tween delirium and dementia is lacking. Often in nurse docu- mentation, delirium features are misinterpreted as dementia or other similar cognitive impairments. Noting specific be- haviors are important for purposes of nurse charting.While nursing documentation may be accurate describing a pa- tient’s level of orientation, often what is written is not to the level of specificity needed for communicating mental status to other health care professionals.27 Recommendations to improve communication and documentation include using terms on the CAM/CAM-ICU tool and mental assessment tools for delirium recognition and facilitating a proper assess- ment in the acute care environment.27,28

EFFECTIVE NURSING INTERVENTIONS FOR DELIRIUM The first step to mitigating delirium in the ICU is under- standing the risk factors and events that can precede an episode. Risk factors that the nurse should be watching for

include a patient’s age older than 65years, dehydration, dementia, functional dependence or immobility, infection at hospital admission, malnutrition, multiple comorbidities, multiple medications, chronic renal or hepatic impairment, severe illness/admission to an ICU, and vision or hearing impairment.22 Addressing 6 risk factors can reduce the incidence of deliriumby up to 33%,which include cognitive impairment, sleepdeprivation, dehydration, immobility, vision impairment, and hearing impairment.22,29 Precursors that the nurse should be aware of include electrolyte abnormal- ities; environmental factors such as excessive noise, inter- rupted sleep, or unnecessary stimuli; hypoxia, hypoglycemia, or ischemia; medications (particularly anticholinergics, nar- cotics, and sedative-hypnotics); neurologic disorders such as stroke or seizure; pain; sleep deprivation; surgery; the patient having a urinary catheter; and withdrawal from alcohol, illicit drug use, or benzodiazepines.22,30

Effective treatment of delirium requires addressing the underlying root causes. The ICU nurse should assess respi- ratory status, ensure adequate oxygenation is being provided, evaluate and bring to the attention of the physician any symptoms consistent with myocardial or cerebrovascular ischemia, and monitor the patient’s hydration status.22 Ad- ditional interventions that hospitals are adopting to help mitigate cognitive impairment in the ICU include a focus on lighter sedation, increasing patient awareness of night and day, having patients both mentally and physically active as soon as possible in their recovery, and waking

Figure. Delirium versus dementia. Source: Shapiro and Mervis.26

262 Dimensions of Critical Care Nursing Vol. 34 / No. 5

Delirium and Dementia in the ICU

patients regularly to evaluate ability to wean from the ven- tilator.16,17 Suggested ways to accomplish this include offer- ing brain-boosting games for the patient to actively engage in during their time in the ICU and ensuring visual distinctions between day and night in the patient’s environment.17 Cog- nitive rehabilitation should coincide with the timing of physical rehabilitation with patients and families prepared both physically and mentally to leave the hospital.16

The involvement of family and friends has been noted as an important element to both patients and their loved ones as part of their hospitalization.31 Educating family members about the issues associated with extended ICU stays, encouraging their verbalization of date and time in conversations with the patient, keeping window shades open during the day, and using low lighting in evening hours are ways to help their loved one staymentally active in the ICU and avoid a false diagnosis of Alzheimer disease.17 Simple family interventions can also include bringing a patient’s eyeglasses, hearing aids, and comfort items from home.18

Education and training programs in the hospital setting can also be useful. Hospital staff education programs and focusing on caregiver-patient interactions have the benefit of reducing the duration of the delirium episode, reducing the length of stay required for patients who have delirium, and increasing mortality rates.22,32 Nurses on average are becoming older (mean age, 46 years).33 During their nurs- ing educational years, information about how to best treat delirium and knowledge about the condition as a disorder was a new concept. Training programs that focus on de- lirium can benefit all generations of nurses, to improve their ability to communicate clearly about this condition and conduct a proper assessment.

EFFECTIVE NURSING INTERVENTIONS FOR DEMENTIA Intensive care unit nurses can enrich the environment for patients with dementia. An easy intervention that engages the family is having reminiscent or ambient music played in the patient’s room. Research has shown that music can be beneficial for patients with dementia and can trigger memories of the past.34 Offering welcoming kits for patients is another method of making the patient feel more involved through offering mind-stimulating activities. This is sim- ilar in concept to providing a hospital welcome kit, which often includes a toothbrush and toothpaste. Activities that are adapted to patients with dementia are provided as a ‘‘kit.’’ These kits could include 2 to 3 simple inexpensive items that the patient can use at the bedside with an instruc- tion sheet for the family. Examples include cards, poker chips, and shapes.35

An alternate option to the dementia ‘‘kits’’ is to develop a dementia cart that is located within the ICU. Potential

items include simple books, jigsaw puzzles with different levels of difficulty, paper and colored pencils, and simple board games with instructions to the family and loved ones onways to engage the patient.35 This cost-alternative method of providing activities for the patient and their family provides an additional resource for caregiver empowerment in a setting that often is associated with stress and turmoil. The activities can support a sense of normalcy to the indi- vidual and their loved ones within a setting that they are often unfamiliar. Through the use of items on the cart, fam- ilies maymore readily detect changes that occur within the ICU environment, and they become a vital and active part of the patient’s care.

Differentiating between delirium and dementia can be a challenge for all providers but especially so in the ICU environment where patients often face greater limitations because of their illness. What was once thought to be an infrequent occurrence has been brought to greater lightwith the advancement of assessment tools such as theCAM-ICU. Nurses need to remain diligent in their nursing assessment, using behavioral examples in documentation andmaintain- ing the rigor of the nursing process when doing cognitive assessments. Accurate identification is a product of knowing both the risk factors and events that can preclude an epi- sode. While delirium presents differently than dementia, patient-centered care involves family education of behav- iors they can be monitoring for upon discharge that may occur. Patients with dementia are at higher risk of delir- ium, and keeping a watchful eye on this population for further declines is important for a patient’s overall quality of life, reducing unnecessary length of stay, and preventing avoidable health care costs. While the ICU environment is fraught with processes that disempower patients and their families, involving them to a deeper level in the care preven- tion of delirium is an active way to give back some control during what often is experienced as a stressful time and setting.

Acknowledgments The authors acknowledge National Research Corpo- ration, Hillcrest Health System, and Yavapai Regional Medical Center for their ongoing support and focus on excellence in patient-centered care delivery.

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ABOUT THE AUTHORS

Jennifer Volland, DHA, RN, CPHQ, NEA-BC, FACHE, is vice

president of Program Development at National Research Corporation,

Lincoln, Nebraska.

Anna Fisher, DHA, CDP, is director of Education and Quality at

Hillcrest Health Services, Bellevue, Nebraska.

Diane Drexler, MBA, BSN, RN, FACHE, is chief nursing officer at the

Yavapai Regional Medical Center, Prescott, Arizona.

The authors have disclosed that they have no significant relationship with, or

financial interest in, any commercial companies pertaining to this article.

Address correspondence and reprint requests to: Jennifer Volland, DHA