Delirium – What’s Old Is New Again

History – What We Learned

Back in the day, we thought delirium was a natural outcome of patients being in the ICU. We did what we needed to keep patients safe, including sedation and restraints in the ICU. We restricted family visitation to avoid distressing our patients or interrupting our workflow. We thought having the patient's family in our environment, especially when we were providing care, increased the risk of litigation.

That thinking was SO last millennium. We learned through research that:

• ICU delirium is not benign; it is associated with increased length of stay (LOS), in-hospital mortality risk and long-term cognitive impairment.
• We could modify elements of our patient care that could reduce delirium, such as lighter sedation targets and early mobility rather than benzodiazepines and restraints.
• Families at the bedside were actually good for patients and staff in most instances. There was no increase in litigation by incorporating them into our environment and care.

Current Research – Where We Are Now

Then came COVID-19. Patients began having an increase in delirium again. Initially, we thought the virus might have a direct impact on the brain, causing delirium. Additionally, because of the virus's infectious nature and increasing demand for acute care, healthcare providers reverted to previous ways of providing that care. Benzodiazepines were in demand and frequently used because patients were in isolation, proned and required sedation to maintain mechanical ventilation, and there were shortages of propofol. In addition, all visitation by families and significant others was curtailed to prevent the spread of the virus. In effect, patients spent a lot of time alone, upside down, in a world that was foreign to them.

Our colleagues at Vanderbilt University who have done so much work in delirium research and outcomes initiated a study to determine if there were additional contributors to delirium incidence in these acutely ill patients. This multicenter, retrospective study was conducted in 14 countries and 69 facilities, and enrolled 2,000+ ICU patients who were being treated for COVID-19 and were routinely screened for the presence of delirium. Over 80% of the patients were in a coma for a median of 7 days, and 55% had delirium for a median of 3 days. This duration is double what we have seen for acute brain dysfunction in non-COVID-19 patients with ARDS. Risk factors associated with next-day delirium included:

• Older age
• Higher SAPS II scores
• Male sex
• Smoking or alcohol abuse
• Vasopressor use
• Invasive mechanical ventilation use
• Opioid infusions and restraints

However, the two strongest predictors for delirium were benzodiazepine use and lack of family visitation (either in person or virtually); both are modifiable risk factors.

An accompanying editorial in Lancet Respiratory Medicine reminds us that &'available evidence-based practice outside the context of COVID-19 should form the basis of the approach to delirium management.'

Questions to Ask Yourself

• Am I evaluating sedation needs every day through the use of daily awakening trials?
• Am I able to maintain a sufficient level of sedation using medications other than benzodiazepines?
• Is there a way to incorporate family in care, even if I use video on an iPad?
• How can I use ABCDEF bundle components when caring for these patients in an already stressed ICU environment?
• Can we ask the family to bring in a poster with pictures and stories to post to personalize the patient for us? It may be difficult for staff to connect with patients who are frequently proned, and thereby faceless. A poster could facilitate the connection.

Additional AACN Resources

• AACN Practice Alert: Assessment and Management of Delirium Across the Life Span"
• AACN Blog: Pediatric Delirium: Combating Brain Dysfunction"
• AACN Webinar: Guideline Update: Bundle up for Pain, Agitation, and Delirium"

How are you managing delirium in your patients?

AACN and Linda Bell sincerely thank Brenda Pun, DNP, RN, FCCM, for her contributions to the content included in this blog.