ICU Psychosis: The Danger is Real

Imagine it is 5 a.m. in the medical intensive care unit (ICU). You have just finished with the morning bath, labs, and chest radiograph with your intubated patient and will see your other patient and start her morning bath and labs. This patient is an older woman battling pneumonia, and you have been caring for her for the past two days. She is due for transfer to the intermediate care unit later in the day. As you walk into the room, you expect the kind older woman to wake with the same smile she has had for the past two mornings. However, upon waking her, she starts to scream obscenities and yells for you to get out of her room. As you try to calm her down, she tries to punch you as you come near her bed. Upon hearing the commotion, the other staff members go into the room and attempt to calm her down; this only agitates her more. She finally has restraints placed to keep her from pulling out her intravenous line. Once the chaos has subsided and the patient is a bit calmer, you hear the healthcare provider talking with one of the residents about the patient developing ICU psychosis.

ICU psychosis? Just what is ICU psychosis? Is it a real sickness, or is it just an invented name to describe when an intensive care patient does not get enough sleep? In this series, we will look at the state of ICU psychosis, what it is, what the contributing factors are that can lead to the state, and the signs and symptoms of the disorder. We will also look at the treatment for the disorder, including the medications used and NOT used in treating ICU psychosis, as well as the non-pharmacologic treatments for this disorder. The nursing implications involved in treating ICU psychosis will also be reviewed.

According to Welker (2022), ICU psychosis is often defined as a cluster of psychiatric symptoms and may be referred to as delirium. The disorder itself is defined as an acute dysfunction of the brain that presents with psychiatric symptoms in a patient without any known history of mental health disorders. Patients who suffer from ICU psychosis are in the hospital and ICU due to significant illness (acute illness at the onset or by chronic disease with an acute or chronic manifestation, such as exacerbation of COPD). The disorder itself has a financial effect on the healthcare system as it comprises an extra toll of $164 billion per Palakshappa and Hough (2021). It has been noted that even after the patient recovers from the illness, there is a 60% chance that the patient will not return to their previous baseline cognitive status (Brummel & Girard, 2013). The disorder has the potential to affect 20-70% of hospitalized patients, according to Ali and Cascella (2022). ICU psychosis can affect up to 83% of ventilated patients (Ali and Cascella, 2022) and 20-50% of non-ventilated patients (Demler, 2018). Patients suffering from ICU psychosis also have a higher chance of staying on a ventilator for a more extended period, having a restraint episode, and an increased risk of self-extubation and urinary catheter removal (Demler, 2018). Patients with ICU psychosis may also be at risk for increased mortality after discharge from the hospital, with higher mortality from the hypoactive type per Mart et al. (2021). It should also be noted that recent studies suggest that 13% of patients have post-traumatic stress disorder (PTSD) following treatment in an ICU per Askari Hosseini et al. (2021).

There are three types of ICU psychosis (Royal Papworth Hospital, 2022):

• Hyperactive
• Hypoactive
• Mixed type with different signs and symptoms

Many factors lead to ICU psychosis, with not one being more dominant than the other but rather a mixture of all factors leading to the presenting issue. There are differing theories as to the cause of ICU psychosis. According to Vyveganathan et al. (2019), the main factors of the condition may be the result of but are not limited to the following:

• Age
• Presence of dementia
• Acuity of illness
• Presence of hearing or a visual impairment
• Hypertension
• Renal disease or impairment
• Smoking
• Diagnosis of sepsis
• Use of vasopressors
• Renal replacement therapy
• Acute respiratory distress syndrome
• Presence of urinary catheters
• Abnormal bilirubin levels
• Abnormal urea levels
• Use of restraints
• Absence of daylight exposure
• Lack of clocks in the patient room

Certain medications may contribute to ICU psychosis. Per Hayhurst et al. (2016), these meds include the following:

• Analgesics and sedatives such as:
  • Lorazepam
  • Morphine
  • Midazolam
  • Meperidine
• Phenergan
• Benadryl
• Cyclobenzaprine, due to its anticholinergic properties
• Certain steroids
• Administration of dopamine

Signs and symptoms of ICU psychosis may vary depending on the type of psychosis and the severity of presenting symptoms. The signs and symptoms can include the following (Welker, 2022):

• Restlessness
• Hearing voices
• Clouding of consciousness
• Hallucinations
• Nightmares
• Paranoia
• Disorientation
• Agitation
• Delusions
• Abnormal behavior
• Fluctuating level of consciousness, which includes aggressive or passive behavior

Of all three types of ICU psychosis, the hypoactive form is the hardest to diagnose due to the passive nature of the condition (Farkas, 2018).

Diagnosing ICU psychosis can be very difficult due to the severity of the patient's illness. In diagnosing the condition, other etiologies must be considered before making the diagnosis. Other conditions can mimic ICU psychosis, such as metabolic disturbances, endocrine disorders, drug toxicity, and injury to the brain, such as a cerebral vascular injury, a tumor, and sepsis, to name a few.

The disorder is diagnosed using an evaluation tool, of which there are plenty. One of the most used tools is the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) assessment tool; this tool, which utilizes an algorithm, is easy to use and is a quick way to assess the presence of ICU psychosis. The tool is broken down into four categories, with each category scored. The first category is for signs and symptoms, if the onset is a sudden change from baseline or if the mental state fluctuates over twenty-four hours. If there is a sudden onset, the nurse records the score and moves on to part two. If the onset is not sudden, the patient is considered CAM-Negative. The second category is assessing to see if the patient can pay attention by having the patient squeeze the nurse's hand when the letter A is heard while the nurse spells out S-A-V-E-A-H-A-A-R-T. If the patient makes two or fewer errors, the patient is CAM-Negative, but if the patient has greater than two errors, the nurse moves on to part three. The third part assesses the patient's level of consciousness, which is done using the Richmond Agitation Sedation Scale (RASS). If the patient has any number besides 0, then the patient is CAM-Positive. If the patient has a 0, the nurse moves on to the last part. The last part assesses whether the patient exhibits organized or disorganized thinking. This assessment asks basic questions, and the patient responds with a solid answer. Examples of the questions are:

• "Does a stone float on water?"
• "Are there fish in the sea?"
• "Does one pound weigh more than two?"
• "Can you use a hammer to pound a nail?"

After the questions, the nurse makes a simple command of the patient to "Hold up this many fingers" (the nurse holds up two fingers). If the patient performs the command successfully, the nurse tells the patient to hold the same number of digits with the other hand.

If the patient makes 0-1 errors, the results are CAM-Negative. If the patient makes more than one error, the patient is considered CAM-Positive (Crimi & Bigatello, 2012).

Just as there are possible causes of ICU psychosis, there are also different schools of thought on treating the disorder with the main objectives of keeping the patient safe, returning the patient to baseline cognitive functioning, and preventing or mitigating long-term effects. The treatments looked at here are not exhaustive by any means.

The first line of treatment is medications to produce a calmer state in the patient. These meds may include Haldol, which is considered a first-generation antipsychotic. However, more recently, second-generation antipsychotics such as olanzapine are gaining approval due to the lack of extrapyramidal side effects (Cascella et al., 2019) and that the rate of hypotension is lower than that of other medications used (Liu et al., 2023). The other medication that shows promise in treating ICU psychosis is melatonin and the melatonin receptor agonist called ramelteon. These medications have been shown to reduce the incidence of ICU psychosis by helping to regulate the sleep-wake cycle that is so often out of rhythm when in the ICU (Cascella et al., 2019).

The use of Precedex shows excellent promise in the treatment of ICU psychosis in both ventilated and non-ventilated patients; this promise is possibly due to Precedex producing both a sedative and analgesic effect, thereby decreasing the need for medications such as morphine and benzodiazepine class drugs connected with ICU psychosis (McLaughlin & Marik, 2016). Another medication class that may prove useful, especially if anticholinergic drugs cause psychosis, is cholinesterase inhibitors; an example of this class of medication is physostigmine (Arumugam et al., 2017).

In looking at medications that may be of use in the treatment of ICU psychosis, certain medications should be avoided or discontinued to prevent or reduce the symptoms. These medications to avoid are certain antibiotics, steroids, Reglan, opiates, benzodiazepines, antihistamines, and anticholinergic medications (Arumugam et al., 2017). The class of antibiotics most associated with ICU psychosis is cephalosporins (Grahl et al., 2018). However, cephalosporins are not the only class of antibiotics that may cause delirium. Beta-lactams, carbapenems, metronidazole, macrolides, fluoroquinolones, oxazolidinones, and sulfonamides may also cause delirium. The reason for the antibiotics as the cause can range from toxicity, supratherapeutic levels, antagonistic action of gamma-aminobutyric acid type A (GABAA), or the inhibition of monoamine oxide (MAO), with the symptoms of the psychosis resolving once the antibiotic is discontinued.

The non-pharmacologic treatment of ICU psychosis includes measures that are labeled as multicomponent. These measures include orientation, engaging the patient in therapeutic activities and pet therapy, assisting with early mobilization, hearing/vision assistance, ensuring proper sleep, rehydration, and physical therapy. Of note are things like the presence of a clock in the patients' room, ensuring their glasses or hearing aids are there, and aiding in a sound sleep by the reduction in ambient noise will go a long way in the reduction of and prevention of ICU psychosis (Arumugam et al., 2017).

The long-term effects of ICU psychosis cannot be overstated. There is evidence to support that patients suffering from ICU psychosis are at risk of increased stay in the ICU as well as the hospital, increased health care costs of that hospitalization by 20%, long-term anxiety, depression, PTSD, cognitive impairment, and even death while hospitalized (Vasilevskis et al., 2018). The problem is so important because the healthcare team needs to realize that while the patient is now out of intensive care and possibly going home, that patient may still suffer from issues they did not have before coming to the ICU. These issues can affect not only the quality of life but also the duration of that patient's life. There is a condition known as Post-intensive Care Syndrome; this condition is being recognized with its treatment and post-ICU support groups being started to help ICU patients recover from the ordeal of not only being in an ICU but surviving critical illness and PTSD, anxiety, and depression that occurs as a result (Radigan, 2018).

Just as there is treatment for ICU psychosis, there is also the means to prevent the disorder. New research is demonstrating how healthcare providers can prevent the development of the disorder. According to Kang et al. (2023), while non-pharmacological measures such as aromatherapy, massage, and music improve sleep and family involvement, exercise cognitive stimulation improves delirium, and light and noise blocking was shown to help improve sleep and prevent delirium. Other measures against ICU psychosis are the promotion of extended visitation of family and loved ones of patients in the ICU per Rosa et al. (2017) and early mobilization per Nydahl et al. (2023).

In closing, ICU psychosis is not only a severe problem in the short term for the patient. It is a problem affecting patients and their quality and quantity of life, their families, the healthcare system, and the public. Healthcare providers owe it to their patients to be vigilant in the early diagnosis and treatment of ICU psychosis.

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