Understanding Delirium in Patients in the Intensive Care Unit

Podcast Transcript

Raed Dweik, MD:

Hello and welcome to the Respiratory Inspirations podcast. I'm Raed Dweik, chairman of the Respiratory Institute at the Cleveland Clinic. This podcast series of short, digestible episodes is intended for patients and families, and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical illness, sleep, infectious disease, and related disciplines. We will share with you information that will help you take better care of yourself and your loved ones. I hope you enjoy today's episode.

Abhijit Duggal, MD:

Welcome to our podcast. I am Dr. Abhijeet Duggal. I'm the vice chair for research for the Department of Pulmonary Critical Care and Infectious Diseases in the Integrated Hospital Care Institute. I'm also the vice chair for the Department of Critical Care. Today, we have Dr. Heather Torbic as our guest. We will be talking about delirium. Dr. Torbic.

Heather Torbic, PharmD:

Thank you for having me today. I am a medical ICU clinical pharmacy specialist at the Cleveland Clinic. I trained at Northeastern University and Boston Medical Center Brigham Women's Hospital. And, I'm also the program director of our critical care pharmacy residency program. I’m happy to be here today speaking about delirium.

Abhijit Duggal, MD:

Thank you so much for joining us, Dr. Torbic. So, Dr. Torbic, what is delirium?

Heather Torbic, PharmD:

It's a great question. And, I think that there are still a lot of unknowns. But, ultimately, it's a state of confusion. Patients with delirium are often going to appear confused. They'll have difficulty paying attention. They may become aggressive or withdrawn. And, essentially, act differently than they normally do at baseline. They may have a change in their sleeping habits, may experience hallucinations and be confused about what's going on around them. And, I think the most important thing to distinguish is that delirium is not dementia in that delirium usually occurs suddenly and can clear up typically in a few days to weeks, whereas dementia is more so a permanent condition.

Abhijit Duggal, MD:

Thank you very much. Now, in our daily lives, people hear about delirium all the time. How common is this diagnosis?

Heather Torbic, PharmD:

That's another tough question to answer because the current incidents range anywhere from 45 to 87%. The challenge with diagnosing delirium is that we have a number of different scoring tools. It may go underrecognized. We have different severity of illness. We have different ICU patient populations. And so, there's a lot of variability in the numbers that are reported for the actual incidents of delirium. But, we do know that it is quite common and can occur in up to half of patients who do experience a stay in the ICU.

Abhijit Duggal, MD:

That's good to know. So, what are the common risk factors that really predispose someone to develop this diagnosis of delirium?

Heather Torbic, PharmD:

So, I kind of would break it into two different pieces. One is just baseline risk factors that a patient may have before even coming in to the ICU. So, actually having preexisting dementia does predispose patients to delirium. Patients of older age, if they have a history of hypertension or alcoholism or other illicit substance use, those things at baseline already predispose patients to increased risk of delirium while they're in the ICU.

And then, there's things that happen to patients once they actually are admitted. So, if they have low oxygen levels, if they have an infection, if they're experiencing pain especially if the pain is undertreated. Other medications that we provide to patients while they're in the ICU can also increase the risk of delirium. And then, also, withdrawal from medications that maybe they were on at home. Or some of the substances that they were using at baseline can also increase the risk of delirium. So, there's a number of factors that play into whether or not a patient will even develop delirium. But there are certainly things that we know would predispose them to a greater risk.

Abhijit Duggal, MD:

That's a very extensive list. So, you mentioned briefly that, you know, this is a diagnosis that can sometimes be difficult to diagnose. How do clinical specialists diagnose this disease process, usually?

Heather Torbic, PharmD:

Right now, we have a couple of validated scoring tools that our clinicians or nurses will ask patients, almost silly sounding questions, at the bedside to try to understand if they're confused or understanding what's going on in the environment. The questions are typically asked every eight to 12 hours. And so, the challenge with the assessment tool, also, is that we're only evaluating patients at those specific time points. And, as I mentioned previously, it's kind of a condition that waxes and wanes, and patients may go in and out of delirium. So, it is difficult for us to diagnose, especially if we're only checking with the scoring tools a couple of times a day.

Abhijit Duggal, MD:

That's good. Good to know. So, Dr. Torbeck, you know, you said that, you know, this is a diagnosis that can really affect a lot of patients coming into the hospital, especially coming into the intensive care unit. Is there any way that we can prevent the diagnosis of delirium in our patients?

Heather Torbic, PharmD:

Although there's nothing that we can truly do to prevent this, I think understanding the patient risk factors, if we already know that someone is going to be predisposed to having delirium, those are patients that I would monitor more closely and try to limit those medications that may increase risk of delirium, monitor patients more closely. The biggest thing that we can do is actually nonpharmacologic intervention. So, making sure the patient maintains a good sleep-wake cycle. We mobilize patients. We reorient them if they are confused. We bring in hearing aids and eyeglasses if those are things that the patient uses at home so that they can see and hear what we're doing around them. And then, of course, minimizing medications, as I mentioned, that would increase their risk of delirium. There's no medication that we can give to patients to prevent delirium. But there are certainly a number of medications that we can reduce to try to prevent delirium in that way.

Abhijit Duggal, MD:

Any comment about some common medications that perhaps can cause delirium in patients?

Heather Torbic, PharmD:

Yeah, I think the biggest medications that we're using in the ICU that are most closely linked to delirium are some of the medications that we use for sedation. So, some of our benzodiazepines and some of the other medications that we're using to help with providing either mechanical ventilation or doing procedures on patients. Although, those medications are important to make sure that patients are comfortable while they're undergoing some of these complicated procedures. And we want to try to also limit those medications because they are linked to increased risk of delirium. So, it's finding that balance between making sure that patients are comfortable but also minimizing those medications.

Abhijit Duggal, MD:

And, you had mentioned the sleep-wake cycle. Can you comment a little bit about that?

Heather Torbic, PharmD:

Sure. So, of course, an ICU is a very busy place. And, we don't do a good job of delineating between morning and night, especially because there's oftentimes active things going on at all hours of the day in an intensive care unit. So, we have to try to do the best that we can by making sure that patients know when it's daytime and when it's nighttime. And, keeping them in a normal sleep-wake cycle if we can do that. So, keeping blinds open in the room, turning off the lights at night, keeping the curtains closed at night to try to minimize noise, are good practices that we can have to try to maintain that sleep-wake cycle.

Abhijit Duggal, MD:

That's very good. So, you mentioned that we don't have any effective medications to prevent delirium. How about treating delirium? How do we really treat delirium in these patients?

Heather Torbic, PharmD:

Yeah. Unfortunately, we're in the same boat with treatment of delirium as well. There have been a number of medications that have been studied for the treatment of delirium. Some examples are anti-psychotics or neuromodulating medications. But, unfortunately, there's not a lot of great data associated with them actually providing a benefit in terms of treatment. And they are associated with adverse effects that we need to be cognizant of. And so, we do try to avoid using them for treatment in these settings. So, again, going back to the management strategies that I mentioned previously in prevention, with nonpharmacologic interventions, those are going to be our most successful tools in treating delirium. So, getting patients back onto a schedule, reorienting them, using hearing aids and eyeglasses, minimizing deliriogenic medications, and trying to prevent as much as we can to get them back into a normal sleep-wake cycle and normal rhythm.

Abhijit Duggal, MD:

Thank you for that answer. So, why do we care about delirium so much? Like, what are the potential negative consequences of delirium on our patients?

Heather Torbic, PharmD:

I mean, I think aside from the just difficulty of a patient going through delirium and having to go through that period of time where they are confused, and having your loved ones watch patients in that state, there's also long-term consequences of delirium. So, patients with delirium end up needing more sedation and often have longer durations on mechanical ventilation or other life-saving supportive measures, which then translates to longer ICU stays, longer hospital stays, and ultimately higher mortality. We know that there's also long-term cognitive impairment in patients who experience delirium. And they may never return to baseline given some of these consequences. The other thing to watch out for is patients may experience post-traumatic stress disorder from this experience, or chronic depression following their ICU admission. And so, there's a lot of downstream effects from developing delirium in the ICU.

Abhijit Duggal, MD:

So, it seems like, you know, we have significant long-term consequences associated with delirium. So, do people need to be mindful of these consequences once a patient is even discharged from the hospital?

Heather Torbic, PharmD:

Yeah. I think it's important to educate patients and their families on some of the consequences following an ICU admission. There's a number of post-ICU care programs across the country that are looking at helping patients specifically who have had long and complicated ICU stays. And, these clinics are developed to help patients and their families work through some of these complications, making sure that they're set up with physical therapy, the right oxygen setup, going through their medication list following an ICU discharge to make sure that there's no medications on their list that they no longer need that could be contributing to some of these long-term consequences. And, making sure that medications are dosed appropriately, that there's no drug interactions. So, there's a lot of post-ICU care that can happen to help with the transition from the ICU. But I think it's important for families and patients to know that there could be these consequences, but there are programs out there that can help support the transition from an ICU stay.

Abhijit Duggal, MD:

Thank you so much for that answer. So, talking about all of this, like, you know, there seems to be a significant burden associated with delirium in our patients, especially in the intensive care unit. I'm sure a lot of our listeners are thinking about how they can help their loved ones, thinking of both while they are in the hospital and once they get discharged. Is there any way that families and friends can help patients in terms of delirium?

Heather Torbic, PharmD:

Friends and families are probably the biggest tool that we have against delirium in the ICU. It's so helpful for friends and family to be at the bedside to help reorient patients when they are confused, speaking to them calmly, talking to them about the day and the date, the time of day. Talking about friends and family. Trying to normalize the ICU stay as much as possible. Bringing in some of those things, like I mentioned, eyeglasses and hearing aids to help them interact better with the ICU care team. Decorating their room with calendars or posters, family pictures, familiar items that may remind them of home and make the ICU stay a little bit more comfortable for them. Using the TV or radio to provide the patient with TV shows or movies or music that they like to listen to, to try to create a more calming environment.

And then, I think also if the patient does develop delirium, being there to help calm them and introducing some of these non-pharmacologic interventions. It's often much better for a patient to be reoriented with someone they know rather than someone from the ICU staff that they're less familiar with. So, family and friends play a huge role in preventing and managing delirium in the ICU.

Abhijit Duggal, MD:

Perfect. That was a really informative session talking about the impact of delirium for our ICU patients. Any major thoughts, anything we have not discussed that you would like to talk about in terms of people knowing about both prevalence and consequences of delirium?

Heather Torbic, PharmD:

I think the biggest thing to know, especially from a patient and family standpoint, is understanding that this can happen. There's nothing that the patient has done wrong if this does develop. It's a very common consequence of an ICU stay and critical illness, especially the more sick a patient is, the more likely they are to develop delirium. Then also understanding that there's a way out of it, too. It may take a few days or weeks for that to occur. But it's important to stay patient and continue working with physical therapy and the ICU teams to help reorient the patient and get them back to baseline.

Abhijit Duggal, MD:

So, we talked about delirium in this episode. And, hopefully, it was extremely informative for all our listeners. Thank you for your time, Dr. Torbic.

Heather Torbic, PharmD:

Thank you.

Raed Dweik, MD:

Thank you for listening to this episode of the Respiratory Inspirations podcast. For more stories and information for the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @raeddweikmd.