Paranoia, Delusions, Hallucinations: Symptoms of ICU Delirium

This content is sponsored by MedStar Washington Hospital Center

Being admitted to a hospital intensive care unit (ICU) can be troubling no matter what the reason. Sometimes the medication used in treatment or just the environment can lead to another problem called ICU delirium.

ICU delirium is an acute condition where a patient experiences sudden, intense confusion that can include inattention, disorganized thinking, hallucinations, confusion and paranoia, said Dr. Matthew Schreiber, associate director of the medical ICU at MedStar Washington Hospital Center, who also specializes in pulmonary disease/critical care medicine.

“It’s often the consequence of another disease, but it’s important to recognize delirium as its own condition requiring its own plan of care,” Dr. Schreiber said.

There are many causes for delirium, Dr. Schreiber said. Some medications have an association with delirium and the ICU itself can lead to delirium as well.

“Imagine dealing with night after night of an environment with 24-hour lights, beeping, and interruption. While those things are happening as part of a plan to treat somebody, after days of this stimulation it can impacts a patient’s mental status leading to delirium,” Dr. Schreiber said.

Patients with ICU delirium can’t maintain focus and have disorganized thinking. In more extreme situations, they can be confused by their surroundings and see and hear things that aren’t there.

Delirium is a condition that comes and goes, Dr. Schreiber explained. “It can be there at 6 a.m., gone at noon, back again at 7 p.m., and gone at 2 a.m. The ongoing fluctuations like that are a key component,” he said. That’s why it’s important for hospital staff to perform assessments for delirium on patients, he added.

It may be difficult to tell if someone is delirious by looking at them or speaking with them, so there is a specific assessment to determine if the patient has had a change in their level of calmness or sedation. Also tested is the patient’s attentiveness or ability to focus and their thought process.

Hospital staffers test patients’ ability to focus by seeing whether they can appropriately follow instructions for a simple task 10 times. Then, to measure disorganized thinking, they ask patients questions with obvious answers, such as: Can you hit a nail with a hammer?; Is a mouse bigger than a giraffe?; Is ice cream cold?

Dr. Schreiber says ICU delirium is common and hospital staffers check patients regularly.

“We check every patient in the ICU every single day and when diagnosed, delirium can significantly change our plan of care.”

If a patient tests positive for delirium, doctors may decide to get rid of a sedative, alter medications or look more closely for signs that something else is wrong.

It’s not yet clear what exactly leads to ICU delirium, however the older a person is, or the more ill a person gets, the more likely they are to have delirium, Dr. Schreiber said. Also, people who have a history of dependence on chemical substances or are who are on a ventilator machine are more likely to develop delirium.

“Whether if any one of those things are the absolute cause or not is hard to say,” Dr. Schreiber said. “It’s really something we should be looking for in every patient.

An “ABCDEF bundle” is used with ICU patients to potentially help them avoid long-term complications with ICU delirium. The acronym stands for assess and address pain; both a spontaneous breathing and spontaneous awakening trial; choice of medication; delirium: check for it; early mobilization activity; and family engagement and involvement.

“Long term, patients that have had delirium are shown have more cognitive and functional issues as well as an increased chance for death at 6 months,” Dr. Schreiber said, adding that it’s crucial to mitigate that type of long-term damage from delirium.

To read more about ICU delirium and recommendations from Dr. Schreiber in his podcast, click here.

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