this is one the leading health problem in hospital areas ICU delirium

2. Objectives
 At the end of this presentation, students will be able to
know about:
 ICU Psychosis (Delirium)
 Causes of ICU Psychosis
 Clinical Manifestation of ICU Psychosis
 Diagnosing ICU Psychosis
 Management Of ICU Psychosis
 Prognostic Significant of ICU Psychosis

3. ICU Delirium
 Delirium is an acute organic mental syndrome
characterized by
 Disturbance of consciousness
 Cognitive impairment
 Disorientation
 Decreased or increased psychomotor activity
 Disordered sleep-wake cycle,
 Fluctuation in presentation.

4.  Delirium is the most common psychiatric
syndrome found in the general hospital setting
especially in Critical Care units and thus referred
as “ICU Psychosis”.
 Terms that used interchangeably for ICU psychosis
are “ICU syndrome”, “ICU Delirium”, “acute brain
failure”, “acute confusional state”, “toxic
encephalopathy” and “organic brain syndrome".

5. Causes

6. Environmental Causes
 Sensory deprivation: A patient being put in a room that
often has no windows, and is away from family, friends, and all
that is familiar and comforting.
 Sleep disturbance and deprivation: The constant
disturbance and noise with the hospital staff coming at all
hours to check vital signs, give medications, etc.
 Continuous light levels: Continuous disruption of the
normal biorhythms with lights on continually (no reference to
day or night)
 Stress: Patients in an ICU frequently feel the almost total loss
of control over their life.
 Lack of orientation: A patient's loss of time and date.

7.  Medical monitoring: The continuous monitoring of the
patient's vital signs, and the noise monitoring devices
produce can be disturbing and create sensory overload.
 Inappropriate staff communication: (medical slang,
treating the patient as if he were hearing impaired,
gossip, conferences about other patients and lack of
contact) is particularly distressing to patients.
 Immobilization
 Monotonous and unfamiliar ICU Environment
 Bewildering array of tubes, cables, monitors and alarms

8. Medical Causes
 D Drugs
 E Eyes, ears, and other sensory deficits (Poor hearing
and vision)
 L Low O2 states (e.g. heart attack, stroke, and
pulmonary embolism)
 I Infection
 R Retention (of urine or stool)
 I Ictal state
 U Under-hydration/under-nutrition
 M Metabolic causes (DM, Sodium abnormalities)
 (S) Subdural hematoma

9.  The mnemonic for the Causes of Delirium is I
WATCH DEATH
 (Infections, Withdrawal, Acute metabolic
encephalopathy, Trauma, central nervous
system (CNS) pathology, Hypoxia, Deficiencies,
Endocrine disorders, Acute vascular
insufficiency, Toxins and drugs, Heavy metals)
Medical Causes

10. Others
 Pain which may not be adequately controlled in an
ICU
 Medication (drug) reaction or side effects
 Prolonged Ventilation

11. Clinical Manifestation
 The symptoms vary greatly from patient to patient, onset is
usually rapid
 Extreme excitement
 Anxiety, Restlessness
 Hallucinations
 Nightmares
 Paranoia
 Disorientation
 Agitation
 Delusions
 Fluctuating level of consciousness which include aggressive
or passive behavior

12. Diagnosis
 The diagnosis of ICU psychosis or Delirium
can be made only in the absence of a known
underlying medical condition that can
mimic the symptoms of ICU psychosis.

13.  Delirium assessment tools, such as the Intensive
Care Delirium Screening Checklist (ICDSC) and
the Confusion Assessment Method for the ICU
(CAM-ICU) allow non-psychiatric physicians and
nurses to diagnose delirium in ICU patients
rapidly and reliably, even when the patient cannot
speak because of endotracheal intubation.
Diagnosis

14. Management

15. Non Pharmacological Management
 Continuity of health care personal
 Clear concise communication
 Repeated verbal reminders of time, place and person
 Clock, calendar, TV, newspaper, radio readily accessible
as a means of orientating in time
 Simplify the environment, single room when available,
reduce noise levels and remove unnecessary equipment
 Adjust lighting according to day and night cycle.

16.  Keep familiar objects
 Flexible visiting hours
 Allow maximum periods of uninterrupted sleep
 Encourage mobilization and increase activity levels
 Relaxation techniques like music therapy and
massage may also help.
 Family members, familiar objects, and calm words
may help.
Non Pharmacological Management

17. Pharmacological Management
 The treatment of ICU psychosis clearly depends on the
cause(s).
 A first step is a review of the patient's medications.
 Dehydration is remedied by administering fluids.
 Infections must be diagnosed and treated.
 An antipsychotic agent such as haloperidol is commonly
used.
 Olanzapine and respiridone have been used as they are less
sedating and have fewer side effects

18. How to Prevent ICU Psychosis
 Using more liberal visiting policies
 Providing periods for sleep
 Minimizing shift changes in the nursing staff caring for a
patient,
 Orienting the patient to the date and time
 Asking the patient if there are any questions or concerns
 Talking with the family to obtain information regarding
religious and cultural beliefs
 Even coordinating the lighting with the normal day-night
cycle, etc

19. Prognostic Significance
 Increase the Risk of Mortality
 Increase long term cognitive impairment
 Increase ICU and Hospital Stay (up to 10 extra days)
 Increase Cost
 Increase time on vent
 Increase Re-intubation
 Self extubation
 Removal of catheter