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ICU Psychosis: The Danger is Real

1 Contact Hour - 1 Pharmacology Hour
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Friday, July 1, 2022
Course Description
Participants will gain an increase in knowledge in recognizing, diagnosing, treating and preventing ICU psychosis. This activity will address differential diagnosis and pharmacological interventions regarding ICU psychosis.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    James Wittenauer (RN, MSN, MPA, RN-BC)

Outcomes

≥90% of participants will know how to prevent, recognize and treat ICU Psychosis.

Objectives

After completing this continuing education course, the participant will be able to meet the following objectives:

  1. Define ICU psychosis.
  2. List five contributing factors in developing ICU psychosis.
  3. List four signs and symptoms of ICU psychosis.
  4. List two treatments used in the management of ICU psychosis to include the medications used, the medications not used, and the non-pharmacologic treatments used.
  5. Recount three long-term implications for the patient with ICU psychosis.

Introduction

Imagine it is 5 a.m. in the medical intensive care unit. You have just finished with the morning bath, labs, and chest radiograph with your intubated patient and are going to 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 this patient 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 kindly older woman to wake with the same smile that 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, and she finally has restraints placed to keep from pulling out her intravenous line. Once the chaos has subsided, and the patient is a bit calmer, you hear the physician 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 are the contributing factors that can lead to the state, and the signs and symptoms of the disorder. We will also look at the treatment for the disorder to include the medications used and NOT used in treating ICU psychosis, as well as the non-pharmacologic treatments and the nursing implications involved in treating ICU psychosis.

ICU Psychosis Defined

ICU psychosis is often 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 history.1 Patients who suffer from ICU psychosis, are of course, in the hospital and the intensive care unit due to significant illness, by acute illness at the onset or by a chronic disease with an acute on chronic manifestation such as exacerbation of COPD. It has been noted that even after the patient recovered from the illness, there is a 60% chance that the patient will not return to their previous baseline cognitive status.1

ICU psychosis affects 60-80% of ventilated patients and 20-50% of non-ventilated patients.2 Patients suffering from ICU psychosis also have a higher chance of staying on a ventilator for a more extended period as well as having a restraint episode, an increased risk of self-extubation, and urinary catheter removal.2 Patients with ICU psychosis also are at risk for increased mortality after discharge from the hospital.2 It should also be noted that studies suggest that 50% of patients suffer from symptoms from either anxiety, depression, or post-traumatic stress disorder (PTSD) following treatment in an intensive care unit.3

There are three types of ICU psychosis4:

  • Hyperactive
  • Hypoactive
  • Mixed type with different signs and symptoms for all three types

Contributing Factors Leading to ICU Psychosis

Many factors lead to ICU psychosis, with not one of them 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. The main factors of the condition may be the result of, but are not limited to5:

  • 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 an episode of ICU psychosis. These meds include6:

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

Signs, Symptoms, and Diagnosis of ICU Psychosis

Sign and Symptoms of ICU psychosis may vary depending on the type of psychosis as well as the severity of presenting symptoms. The signs and symptoms can include7:

  • Restlessness
  • Hearing voices
  • Clouding of consciousness
  • Hallucinations
  • Nightmares
  • Paranoia
  • Disorientation
  • Agitation
  • Delusions
  • Abnormal behavior
  • Fluctuating level of consciousness, which include 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 condition.8

Diagnosing ICU psychosis can be very difficult due to the severity of the illness of the patient. In diagnosing the condition, other etiologies need to be considered first before making the diagnosis. Other conditions can mimic ICU psychosis, such as metabolic disturbances, endocrine disorders, drug toxicity, injury to the brain such as a cerebral vascular injury, a tumor, and sepsis, just to name a few.9

The disorder is diagnosed using an evaluation tool, of which there are plenty. One of the most used tools is the ICU-CAM assessment tool. This tool, which utilizes an algorithm is easy to use and is a quick way to assess for the presence of ICU psychosis. The tool is broken down into four categories, with each category scored. The first category is for the onset of signs and symptoms; if onset is a sudden change from baseline or if mental state fluctuating 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, then 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 patients' level of consciousness, which is done by the RASS scale. If the patient has any number besides 0, then the patient is CAM-Positive. If, however, the patient has a 0, then the nurse moves onto the last part. The last part assesses to see if the patient exhibits organized or disorganized thinking. This is done by asking questions that are basic, 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 amount 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.10

Treatment of ICU Psychosis

Just as there are possible causes of ICU psychosis, there are also different schools of thought on how to treat the disorder with the main objectives to keep the patient safe, return the patient to baseline cognitive functioning, and prevent or mitigate long-term effects. The treatments looked at here are not exhaustive by any means.

The first line of treatment is the use of medications to produce a calmer state in the patient. These meds may include Haldol, which is considered a first-generation antipsychotic. However, more recently, the second-generation antipsychotics such as olanzapine are gaining approval due to the lack of extrapyramidal side effects.11 The other medication that shows promise in the treatment of ICU psychosis is Melatonin and the Melatonin receptor agonist 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 intensive care unit.11

The use of Precedex shows excellent promise in the treatment of ICU psychosis in both ventilated and non-ventilated patients. The reason for 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.12 Another medication class that may prove useful, especially if the psychosis is caused by anticholinergic drugs, is cholinesterase inhibitors; an example of this class of medication is physostigmine.13

In looking at medications that may be of use in the treatment of ICU psychosis, certain medications should be avoided or discontinued in the prevention of or reduction of the symptoms. These medications to avoid are certain antibiotics, steroids, Reglan, opiates, benzodiazepines, antihistamines, and anticholinergic medications.13 The class of antibiotics that may be most associated with ICU psychosis is the cephalosporins.14 But, 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 Gaba-A, or the inhibition of monoamine oxide (MAO)15, 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 are interventions such as 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 particular note are the 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.13,16,17

Treatment of ICU Psychosis

The long-term effects of ICU psychosis cannot be overstated. There is evidence to support that patients suffering from ICU psychosis are at risk increased stay in the ICU as well as the hospital, increased health care costs of that hospitalization by 20%,18 long term anxiety, depression, post-traumatic stress disorder, cognitive impairment, and even death while hospitalized19,20 The reason this is so important is that the health care team need to realize, 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 have the potential to affect not only the quality of life but the duration of that patients' life as well. There is a condition known as Post Intensive Care Syndrome. This condition is being recognized with its own treatment and post ICU support groups being started to help patients that were ICU patients recover from the ordeal of not only being in an ICU but surviving critical illness and the PTSD, anxiety, and depression that occurs as a result.21

Conclusion

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

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

References

  1. Brummel NE, Girard TD. Preventing delirium in the intensive care unit. Crit Care Clin. 2013;29(1):51–65. DOI:10.1016/j.ccc.2012.10.007.
  2. Dembler, Tammie., (2018). Monitoring for Psychosis in Hospitalized Patients. US Pharm. 2018;43(11): HS-8-HS-12.
  3. Wade D, Als N, Bell V on behalf of the POPPI investigators, et al. Providing psychological support to people in intensive care: development and feasibility study of a nurse-led intervention to prevent acute stress and long-term morbidity. BMJ Open 2018;8:e021083. DOI: 10.1136/bmjopen-2017-021083.
  4. Yezdani, H. ICU Delirium - Causes, Symptoms, Diagnosis, Treatment. Med India. Updated December 30, 2016. Accessed 2/16/20. Visit Source.
  5. Vyveganathan, L., Izaham, A., Mat, W., Peng, S., Rahman, R., Manap, N., (2019). Delirium in critically ill patients: incidence, risk factors, and outcomes. Critical Care Shock, 22, (1), 25-40.
  6. Christina J. Hayhurst, Pratik P. Pandharipande, Christopher G. Hughes; Intensive Care Unit Delirium: A Review of Diagnosis, Prevention, and Treatment. Anesthesiology 2016;125(6):1229-1241. DOI: https://doi.org/10.1097/ALN.0000000000001378.
  7. Welker M. ICU Psychosis (Intensive Care Unit Psychosis). MedicineNet. Accessed February 16, 2020. Visit Source.
  8. Farkas J. Delirium. Internet Book of Critical Care (IBCC). Published November 3, 2016. Accessed may 24, 2020. Visit Source.
  9. Shin R. Delirium, Dementia, and Amnesia in Emergency Medicine. emedicine.medscape.com. Updated September 19, 2018. Accessed May 9t, 2020. Visit Source.
  10. ResearchGate. Confusion Assessment Method in the ICU. Published January 2012. Accessed on 5/9/20 for CAM-ICU Flowsheet. Visit Source.
  11. Cascella M, Fiore M, Leone S, Carbone D, Di Napoli R. Current controversies and future perspectives on treatment of intensive care unit delirium in adults. World J Crit Care Med. 2019;8(3):18-27. Published 2019 Jun 12. DOI :10.5492/wjccm.v8.i3.18.
  12. McLaughlin M, Marik PE. Dexmedetomidine and delirium in the ICU. Ann Transl Med. 2016;4(11):224. DOI:10.21037/atm.2016.05.44.
  13. Arumugam S, El-Menyar A, Al-Hassani A, et al. Delirium in the Intensive Care Unit. J Emerg Trauma Shock. 2017;10(1):37-46. DOI:10.4103/0974-2700.199520.
  14. Grahl JJ, Stollings JL, Rakhit S, et al. Antimicrobial exposure and the risk of delirium in critically ill patients. Crit Care. 2018;22(1):337. Published 2018 Dec 12. DOI:10.1186/s13054-018-2262-z.
  15. Skelly M, Wattengel B, Starr K, Sellick J, Mergenhagen K. Psychiatric adverse effects of antibiotics.www.psychiatrictimes.com. Published November 29, 2019. Accessed May 17, 2020. Visit Source.
  16. Hipp DM, Ely EW. Pharmacological and nonpharmacological management of delirium in critically ill patients. Neurotherapeutics. 2012;9(1):158-175. DOI:10.1007/s13311-011-0102-9.
  17. Fuentes, X., Breighner, C., Gobeske, K., Clson, S., Finley, K., Bowron, C., Elmer, J., Danielson, R., Park, John, (2018). Nonpharmacologic management of delirium in the medical intensive care unit (MICU). Critical Care Medicine: January 2018; 46 (1 p579doi: 10.1097/01.ccm.0000529196.49848.97.
  18. Meyfroidt, G., Smith, M. Focus on delirium, sedation, and neurocritical care 2019: towards a more brain-friendly environment? Intensive Care Med 45, 1292–1294 (2019). https://doi.org/10.1007/s00134-019-05701-2.
  19. Yongsuk, K., Sung, J., (2015). Intensive Care Unit Delirium. Korean Journal of Critical Care Medicine 2015; 30(2): 63-72.DOI. Visit Source.
  20. Vasilevskis EE, Chandrasekhar R, Holtze CH, et al. The Cost of ICU Delirium and Coma in the Intensive Care Unit Patient. Med Care. 2018;56(10):890-897. DOI:10.1097/MLR.0000000000000975.
  21. Radigan K. Post-intensive Care Syndrome: What Happens After the ICU? reliasmedia.com. Published August 8, 2018. Accessed May 24, 2020. Visit Source.