Nonpharmacologic interventions improve outcomes.
By Amy Karon
Preventing delirium in the ICU doesn’t have to involve sophisticated medical interventions. Doubling the length of family visiting hours halved rates of ICU delirium, according to one study. And twice-daily occupational therapy cut the risk of ICU delirium even more dramatically when added to standard preventive measures, such as avoiding restraints and benzodiazepines, according to another trial.
The studies, published in Critical Care Medicine in June and the Journal of Critical Carein February, respectively, are part of promising recent work on nonpharmacologic strategies to prevent or curtail delirium in critically ill patients. Such innovations are greatly needed, because delirium portends longer ICU stays and worse outcomes and affects up to half of ICU patients, including up to 80% of those on ventilators.
“In general, the greatest impact on ICU delirium has been seen with bundles of care, rather than any single-therapy intervention,” said Carrie Goodson, MD, MHS, a pulmonary and critical care medicine fellow at Johns Hopkins University School of Medicine in Baltimore.
The ABCDEF bundle (Awakening and Breathing Coordination to free patients from sedation and mechanical ventilation, Choosing drugs to reduce risk of delirium, Delirium management, Early mobility and Exercise, and Family engagement) has the strongest evidence to date, she said. Implementing the bundle significantly increased the odds of survival and reduced the risk of acute brain dysfunction, including delirium and coma, among more than 6,000 ICU patients at seven community hospitals in California, according to findings in the February 2017 Critical Care Medicine.
Hospitalists whose ICUs have already implemented ABCDEF can consider additional steps to reduce and prevent delirium among ICU patients, Dr. Goodson and other experts said. These include strategies to support normal circadian rhythms, alertness, cognition, and motor function.
Focus on sleep
ICU delirium is multifactorial, but studies have repeatedly implicated lack of sleep as a major factor. “Patients complain of poor sleep in the ICU so frequently that I feel physicians become desensitized to it,” Dr. Goodson said.
Nighttime disturbances and light exposure disrupt normal circadian rhythms, erode sleep, and contribute to both hypoactive and hyperactive forms of delirium, experts said. “It is not uncommon for a patient with delirium to develop increased agitation during nighttime and then be totally drowsy during daytime,” said Rodrigo Cavallazzi, MD, a pulmonologist and critical care specialist at University of Louisville School of Medicine in Louisville, Ky. Such patients often receive no natural light during the day and are overexposed to artificial light at night, he said. “When I identify that, I try to break that cycle.”
Patients often sleep poorly in the ICU even when they’re sedated and look asleep, according to John Devlin, PharmD, a professor of pharmacy at Bouve College of Health Sciences at Northeastern University and a critical care pharmacist at Tufts Medical Center, both in Boston.
He recommends a protocolized approach to sleep hygiene for all ICU patients: Dim the lights, turn bedside alarms down or off, close doors, and schedule assessments, diagnostic tests, and lab draws for after 6 a.m. Also offer earplugs, eye masks, and headphones with music to help patients fall asleep. “If the ICU team, particularly the bedside nurse, rigorously follows this protocol, it can be very effective,” Dr. Devlin said.
Studies of such protocols generally report about a 50% improvement in ICU delirium, even when patients reported no or little improvement in sleep quality, Dr. Goodson said. In one study, reducing nighttime noise and light more than halved the rate of delirium in a medical-surgical ICU. Investigators reported the findings in the June 2014 Anaesthesia. In another meta-analysis of more than 800 ICU patients, placing earplugs at night reduced the risk of delirium by 39%. Those findings appeared in the May 2016 Critical Care Medicine.
It’s important to tailor sleep protocols to patients’ needs, said Dr. Devlin. “If earplugs or headphones with music are applied at night, they must be removed in the morning. Unstable ICU patients may still require assessment and diagnostic intervention during the night,” he said.
What if patients still can’t sleep despite all these measures and adequate pain control? Then Dr. Devlin recommends considering a low-dose, nonbenzodiazepine sleep aid. If patients are fearful or have bothersome hallucinations, a low dose of haloperidol or quetiapine might be warranted, he said. “If the patient has delirium and moderate to severe agitation not related to pain, then dexmedetomidine should be considered, given that recent data suggests that its use may improve sleep and help reduce delirium.”
Promoting alertness and orientation during daytime hours also helps prevent delirium, according to recent research. In a meta-analysis of six trials, giving patients music, clocks, calendars, and frequent orienting messages (who, what, when, where, and why) led to markedly lower rates and durations of delirium compared with usual ICU care. Light therapy also shows some promise, although trials of this intervention were imperfectly designed and yielded mixed results, reviewers wrote in the May 2017 Nursing in Critical Care.
Another promising area of research is cognitive stimulation—”essentially using games to exercise the brain,” said Dr. Goodson. For example, ICU patients can be offered notebooks and asked to play number games, match symbols, or draw. When patients practiced these activities twice daily for five days along with occupational therapy, early mobilization, upper-extremity exercises, and hair brushing and other activities of daily living, they had only a 3% incidence of delirium compared to 20% in a group assigned to standard care, researchers reported in the February 2017 Journal of Critical Care.
Family members also can help prevent delirium, as long as their presence does not increase anxiety or interfere with sleep, Dr. Devlin said. In addition to the benefits found from extending visiting hours, another randomized trial of ventilated and unventilated adults in the ICU showed that patients who listened to prerecorded, orienting messages from family members once an hour during waking hours had two-thirds fewer days of delirium than patients who received standard care. Recorded messages from strangers cut delirium less markedly (by about a third), researchers wrote in the July-August 2017 Heart & Lung.
Experts’ experiences support these findings. “We had an elderly lady with delirium who would respond to her daughters completely differently than the health care personnel, and would have good days, delirium-free days, when her daughters were around,” said Babar Khan, MBBS, medical director of the Critical Care Recovery Center and associate professor at Indiana University School of Medicine in Indianapolis. “This is anecdotal, as we were also employing other delirium management strategies concomitantly. But the difference in this patient’s behavior with and without family members was remarkable. For the elderly, the presence of family members can help reduce delirium.”
Leading and motivating
Many ICUs have added at least a few nonpharmacologic measures to their delirium prevention protocols. But success hinges on adherence, which tends to vary widely. Without a strong example from physician leaders, ICU staff may disengage and conclude that nonpharmacologic measures don’t work, experts said.
Changing the environment and culture of the ICU “is truly a multidisciplinary team effort, in which every member of the ICU staff plays an important role,” said Dr. Goodson. Physicians contribute by educating other clinicians, patients, and families on the importance and relevance of new interventions, she said. “Nurses are unlikely to feel motivated to mobilize patients and monitor for delirium if physicians never ask for this information or make any changes to the plan based upon it.”
Dr. Devlin echoed her comments, noting that if ICU physicians seem not to support a delirium prevention protocol, other team members soon will put less effort into following it. Instead, hospitalists should “act as champions for their patients” by asking about adherence during rounds and team huddles, Dr. Khan said. Hospitalists can also assess barriers to use and help troubleshoot problems, Dr. Devlin added.
Involving the entire ICU team in efforts to prevent and curtail delirium also helps motivate staff. For example, nurses can recognize early warning signs of ICU delirium, while ICU pharmacists can identify risky medication interactions during bedside consults, Dr. Cavallazzi said. “Sometimes patients will become less agitated and confused once a feeding tube is removed,” he added. “I have had cases where our speech therapist and dietitian made a huge difference by recognizing that a patient was ready to eat by mouth.”
Recognizing accomplishments also improves the chances that they will happen again, Dr. Goodson added. “Celebrating successes, such as successfully managing a mildly agitated patient through nonpharmacologic versus pharmacologic treatment or ambulating a mechanically-ventilated patient is an important motivator that physicians should not pass up the chance to use.”
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