Delirium in the Intensive Care Unit: what you need to know
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Question: My father was recently in a hospital to have a heart operation. During his recovery in the Intensive Care Unit, his behavior was very strange. He seemed confused and agitated and he was even rude to my mother. My father is usually a kind and gentle man. He wasn’t acting like himself. The hospital staff said he was suffering from delirium. What is delirium and how common is it?
Answer: Delirium is very common especially for patients in a hospital’s Intensive Care Unit. Although the ICU provides special one-on-one care for patients in critical condition, the busy nature of these medical environments can sometimes contribute to the development of delirium.
As you likely observed, each patient is watched over by a nurse usually stationed at the foot of the bed. The patients are hooked up to monitoring equipment and life-support machines that often sound alarms. They also undergo frequent poking and prodding for round-the-clock medical tests.
All this commotion can prevent patients from getting adequate sleep. To further complicate matters, they are usually on heavy-duty pain medications and other sedating drugs that add to their mental fog.
And, most important, they are not well – or they wouldn’t be in the ICU in the first place.
These factors, all combined, create a kind of perfect storm that can lead to this distressing mental state.
“Delirium is very frightening for families. Your relative, who previously seemed to be totally normal, is now out of it,” says Dr. Andre Amaral, a critical-care physician at Sunnybrook Health Sciences Centre.
“It happens to about 50 per cent of our patients” in the ICU, he says, adding that the degree of delirium varies greatly from one person to the next.
Some patients experience only mild confusion or become quiet and withdrawn. Others may not be able to recognize their doctor, nurse or even their own family members and can react in a paranoid fashion.
In the worst cases, they could try to pull out their intravenous (IV) lines, pose a danger to themselves, and may need to be sedated with additional medication.
This state of confusion can fluctuate over the course of a single day. You might have noticed this pattern with your father. He may have seemed fine when you visited him in the morning. By the time you returned in the evening, he may have become very restless and agitated.
Doctors readily acknowledge they still have much to learn about what’s actually happening to the brain in these circumstances. But delirium seems to be part of overall organ dysfunction in patients who are very sick.
The chances of developing the condition increase in those who are suffering from multiple medical problems such as heart, lung and kidney failure.
“When you become critically ill, all the organ systems of your body are going through a partial shut down and the brain does the same thing. Because the brain is so complicated we don’t fully understand it,” says Dr. Brian Cuthbertson, chief of Sunnybrook’s department of critical-care medicine.
Heart patients like your father may be especially vulnerable to developing delirium. “If you have blood vessel problems around your heart you probably have similar problems in your brain,” said Dr. Shelly Dev, a Sunnybrook critical-care physician. In other words, restricted blood flow to the brain could further tax mental functions.
Even patients who are less critically ill may experience various forms of delirium. Think back to times when you’ve had a high fever. You might have felt like you were in some kind of trance.
So it’s important to keep in mind that some patients who are actually doing well in their recovery can also become delirious, says Dr. Amaral. And it is not necessarily a sign your loved one has taken a turn for the worse. In these cases, “I like to say it is a little bump on the way,” adds Dr. Amaral.
How much of this experience will patients remember after they’ve left the ICU?
“It’s hard to predict for an individual patient what they are going to remember and how unpleasant those memories are going to be,” says Dr. Dominique Piquette, another Sunnybrook critical-care physician.
“Some people recall bits of it, which are not always pleasant memories. And it is all a bit blurred,” adds Dr. Piquette. “Others have a complete blackout and don’t remember anything … which can be distressing to have lost a chunk of their lives.”
Dr. Amaral says “some people have symptoms of anxiety, stress and depression once they come out of the ICU.”
However, the good news is that family members can sometimes be extremely helpful in comforting delirious patients, says Dr. Dev.
The ICU can be an alienating place, filled with unfamiliar sights and sounds. So, hearing the voice of a loved one can be re-assuring. “I tell the families they are instrumental to healing the patient,” she says.
When patients stir to consciousness, they may not be aware they are in a hospital. “There are not many windows [in the ICU]. There is a lot of noise and a lot of things happening,“ explains Dr. Dev. “You wake up with a tube in your throat, or someone is suctioning [fluid build-up in] your lungs. It can be terrifying.”
Part of the healing involves “reorienting” the patients so they find their way out of the mental abyss. Dr. Dev provides families with the following tips for aiding the recovery process:
- “Ask them their name, where do they think they are, do they remember what’s happened. And, if they get frustrated with all the questions, remind them who you are and why they are in the hospital. ”
- Don’t be afraid to tell your loved one the true nature of their medical condition. Some families are reluctant to do so, preferring to shield the patient from more stress and worry. “It’s more frightening not to know what’s going on and have everyone say you’re fine. You start to think you’re crazy because you don’t feel fine,” says Dr. Dev.
- Help them get out of bed and walk around if, of course, they are capable of mobility. “It makes them feel more normal and less confined.”
- Bring photographs from home and have other friends and family visit if the patient is in the ICU for a long time.
- For patients who normally wear eyeglasses, or require hearing aids, make sure these items are readily available. When they can’t see or hear properly, or there is a language barrier, they face a greater risk of feeling lost and confused.
- Even having something as simple as a clock nearby enables patients to know the time and improves their grasp on the world around them
Many things can be done to minimize delirium or shorten its duration – and some of them involve family members playing active roles in helping to reorient the patient.
However, there are times when it’s not appropriate for relatives to be at the bedside – such as when hospital staff must perform certain procedures. After all, an extended family can include a wide range of relatives, notes Dr. Cuthbertson. “If you’re doing intimate washing and caring then you don’t necessarily want an uncle, or an auntie, or a child being there.”
At Sunnybrook, family members are permitted to visit ICU patients at any time of day, although they may be asked to step outside as medical circumstances dictate.
ICU visiting hours vary from one hospital to the next. If your relative is in a hospital like Sunnybrook, with an open-door policy, try to be there during morning rounds.
This is when the medical team visits all the patients in the ward, assesses them individually and puts together a daily treatment plan. The rounds provide an opportunity for you to see the physicians who have the most up-to-date information about your relative’s condition.
Keep in mind the doctors must visit numerous patients during rounds so their time is limited. If you have lots of questions, use this opportunity to make an appointment with the physician who is most responsible for your relative’s care. At that later meeting, the doctor should be able to answer your questions, including those dealing with topics like delirium.
As a general rule, the patient’s confusion and agitation will lessen as the overall medical condition becomes less critical.
“The vast majority of people will improve significantly over a period of a few days or a week as they get better,” explains Dr. Cuthbertson.
Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. His blog Personal Health Navigator is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Email your questions to AskPaul@sunnybrook.ca and follow Paul on Twitter @epaultaylor