Non-Pharmacologic Management of Delirium:

An ABCDEF Approach

Michele C. Balas PhD, RN, APRN-NP, CCRN-K, FCCMCenter of Excellence in Critical and Complex Care

The Ohio State University College of Nursing

Columbus, Ohio, USA

Disclosures:

Dr. Balas has received research funding from the Alzheimer’s

Association, the Robert Wood Johnson Foundation, the UNMC

College of Nursing and the John A. Hartford Foundation. She

has no industry related conflicts of interest regarding the

content of this presentation.

• Identify potentially modifiable risk factors for delirium

• Explore the evidence-based ABCDEF bundle & other non-

pharmacologic interventions aimed at reducing delirium &

improving outcomes for patients and families experiencing

an acute illness

Objectives

Kaukonen JAMA 2014;311:1308-16

Critically ill with sepsis

Critically ill non-sepsis

Mortality from Critical Illness is Decreasing

Adjusted Odds Ratio

2.01.00.4

2000

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Year of ICU Admission

‘08‘99 ‘05‘00 ‘04‘01 ‘03‘02 ‘07‘06

200,000

0

100,000

150,000

250,000

50,000

Iwashyna J Am Geriatric Soc 2012;60:1070-77

Long-term Survivors from Severe Sepsis

Number of New

Survivors

Year in which patient reached survivorship

3-Year Survivors

5-Year Survivors

Wunsch JAMA 2010; 303: 849-856

Society of Critical Care Medicine, Critical Care Statistics in the United States, 2012

Annually

Adults Survive a Critical Illness

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40-70%Cognitively

Impaired

Jackson AJRCCM 2010; 182: 183

Girard Crit Care Med 2010; 38: 1513

Wolters Intensive Care Med 2013; 39: 376

Pandharipande, et al. NEJM 2013;269:1306-1316

Latronico Lancet Neurol 2011; 10: 931

60-80%Physically

Impaired

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10-30%Mental Health

Impairments

Davydow DS Intensive Care Med 2009;35:796-809

Davydow DS Psychosom Med 2008;70:512-9

Wunch H JAMA 2014;311:1133-42

Jackson JC Lancet Respir Med 2014;2:369-79

Post-Intensive Care Syndrome (PICS)

Needham Crit Care Med 2012; 40: 502-09

Elliott Crit Care Med 2014;42:2518-2526

Cognitive Impairments

Mental Health Impairment

Physical Impairments

Psychological Symptoms

Managing Emotions (Grief)

Quality of Life (Death)

Needham Crit Care Med 2012; 40: 502-09

Elliott Crit Care Med 2014;42:2518-2526

Family Post-Intensive Care Syndrome (PICS-F)

Financial Implications

Creditor MC Ann Intern Med 1993;118:219-23

Krumholz HM NEJM 2013;368:100-2

Not Just the Critically Ill

Similarities to Cancer Literature

Acute survivorshipTime when a person is being diagnosed &/or in treatment for cancer

Extended survivorshipTime immediately after treatment is completed, usually measured in months

Permanent survivorshipA longer period of time, often meaning that the passage of time since treatment is measured in years

American Society of Clinical Oncology. Cancer.Net. 2015. http://www.cancer.net/survivorship. Accessed November 10, 2015.

?

Low mobility is common in the hospital

100

0

60

40

80

20

Day 1

12P

Day 2

12A

Day 3

12A

Day 4

12A 12P 11P12P12P

Mean

Percent

of Time

Lying

Sitting

Standing/Walking

Brown J Am Geriatric Soc 2009;57:1660-1665

N=45

ICU-Acquired Weakness & Mortality

Ali N, et al. Am J Respir Crit Care Med 2008;178:261-8

Quartiles of MRC Score

20

30

10

0

29.4%

1 2 3 4

In-hospital

Mortality

(%)

Weakest Strongest

9.1%

4.2% 6.2%

40

P=0.001

N=136

1. Delirium = inattention

2. Develops over a short period of time, represents an acute

change from baseline & fluctuates in severity

3. Additional cognitive domain involved

4. Not occurring during coma

American Psychological Association Diagnostic and Statistical Manual of Mental Disorders 2013, 5th Ed.

Delirium is the Strongest Independent Predictor

of Cognitive Impairment

0 2 4 6 8 10

70

60

80

90

N=382

P=0.004 for 0 vs. 5 days of delirium

RBANS

Global

Cognitive

Score

Days of ICU Delirium

Pandharipande, et al. NEJM 2013;269:1306-1316

Pisani MA. Am J Respir Crit Care Med. 2009;180:1092-1097

Time to Death (Days)0 75 150 225 300 375 450

0

0.2

0.4

0.6

0.8

1.0

Survival

Probability

0 days

1-2 days3-4 days

5-9 days

10+ daysHR, 1.10; 95% CI, 1.03–1.18; p < .001

Delirium & Mortality

Delirium, Why We Should Care

• Increased ICU & hospital LOS

•↑ restraints & sedative medications

• Poor functional recovery

• New institutionalization

• Multiple complications

• Total $143 billion to $152 billion nationally

•l 1-year health-care costs

Predisposing Risk Factors

• Advanced age• Dementia or other forms of cognitive impairment• Functional impairments• Medical & Psychiatric comorbidities• Drug or ETOH withdrawal• Male• Sensory impairment• APO E4 polymorphism

Precipitating Risk Factors

• Acute cardiac, neurologic, pulmonary or infectious event• Surgery• Severity of illness• Fluid & electrolyte imbalances• Immobility/bed rest/restraints• Mechanical ventilation• Indwelling tubes/catheters• Sleep deprivation• Uncontrolled pain• Medications

• Anticholinergic agents, benzodiazepines, opioids, more than 3 medications added

Date of download: 7/11/2016Copyright © 2016 American Medical

Association. All rights reserved.

From: Effectiveness of Multicomponent Nonpharmacological Delirium Interventions: A Meta-analysis

JAMA Intern Med. 2015;175(4):512-520. doi:10.1001/jamainternmed.2014.7779

Meta-analysis of Delirium Incidence and Falls Eleven studies measured delirium incidence. Three randomized or matched trials and 5 non–randomized or

matched trials demonstrated significant reductions in delirium incidence. P < .001, and heterogeneity was low at I2 = 18%. Weighting was assigned according to

the inverse of the variance. Odds ratios less than 1 indicate decreased delirium incidence. Four studies examined the number of falls per patient-days.

Individually, only Stenvall et al (a randomized or matched trial) demonstrated significant reduction in the number of falls. P < .001, and heterogeneity was low at

I2 = 0%. Weighting was assigned according to the inverse of the variance. Odds ratios less than 1 indicate decreased rate of falls. NNT indicates the number

needed to treat.

A

D

E

C

F

B

ABCDEF BundleAssess, prevent, & manage pain

Both SAT & SBT

Choice of analgesia & sedation

Delirium: Assess, prevent, & manage delirium

Early Mobility & Exercise

Family Engagement & Empowerment

Balas, M.C., et al., (2015). Critical Connections. 14(4); 1, 10.

A

D

E

C

F

B

ABCDEF Team Approach

Nurse

Physician

Pharmacist

PT/OT

Respiratory

A

• Why– Incidence

– Outcomes

• How– NRS, BPS, CPOT

– Pharmacologic interventions

– Nonpharmacologic interventions

– Proxy responders

AAssess, prevent, & manage pain

Puntillo K. Am J Crit Care, 2001;10:238-251; Payen J. Crit Care Med. 2001;29:2258-2263; Gelinas C. Am J Crit Care. 2006;15: 420-27; Payen J.

Anesthesiology. 2009; 111: 1308-16 ; Chanques G. Crit Care Med. 2010;151: 711-721; Gelinas C. Int J Nursing Stud. 2011;48: 1495–1504; Puntillo K. Crit

Care Med. 2012;40: 2760-2767; Puntillo K. Am J Respir Crit Care Med. 2014; 89: 39-47

A protocol of “No Sedation”113 randomized

58 to control55 to intervention

Morphine PRNMorphine PRN

Cont. propofolHaloperidol PRN

Strom T, et al. Lancet 2010;375:475-80

6 hr propofol

Cont. propofol

Ramsay 3-4

Daily interruption

Analgosedation: ICU Length of Stay

0

Days

70

20

40

60

80

100

Patients

Remaining

in ICU

(%)

14 21 28

Intervention (n=55)

Control (n=58)

Strom T, et al. Lancet 2010;375:475-80

p=.03

ICU stay reduced by 9.7 days

B• Why

– Incidence

– Outcomes

• How

– Daily safety screen &

success/failure criteria

– Importance of RT & RN

coordination

– Opt out method

BBoth SATs &

SBTs

Ely E. N Engl J Med. 1996;335:1864-9; Riker R. (SAS) Crit Care Med. 1999; 27:1325-9; Kress J. N Engl J Med. 2000;342:1471-7; Sessler C. (RASS) Am J

Respir Crit Care Med. 2002, 166:1338-44; Ely E. (RASS) JAMA. 2003;289:2983-91; Girard T. Lancet. 2008;371:126-34; Strøm T. Lancet. 2010;375:475-80;

Shehabi Y. Am J Respir Crit Care Med. 2012;186:724-31; Balas M. Crit Care Med. 2013;42:1024-36; Klompas M. Am J Respir Crit Care Med. 2015;191:292-

301.

ABC—study design

336 randomized

168 to control168 to intervention

Daily SBT

Daily SAT

Daily SBT

1 year follow-up 1 year follow-up

Girard TD, et al. Lancet 2008;371:126-34

Coordinated SAT+SBT approach is associated

with a 14% reduction in mortality at 1 year.

Patients

Alive (%)

Girard TD, et al. Lancet 2008;371:126-34

00

20

40

60

80

100

60 12

0

18

0

24

0

30

0

36

0Days

p=.01

NNT to save 1 life: 7

SAT+SBT (n=167)

Usual Care+SBT (n=168)

C

• Why

– Incidence

– Outcomes

• How

– Rounding

– Target sedation score

– Pharmacist driven

CChoice of

analgesia &

sedation

Riker R. Crit Care Med. 1999; 27:1325-9; Kress J. N Engl J Med. 2000;342:1471-7.; Sessler C. Am J Respir Crit Care Med. 2002, 166:1338-44; Ely E. JAMA.

2003;289:2983-91; Girard T. Lancet. 2008;371:126-34; Strøm T. Lancet. 2010;375:475-80; Shehabi Y. Am J Respir Crit Care Med. 2012;186:724-31; Bassett

R. (IHI ABCDE Collaborative) Jt Comm J Qual Patient Saf. 2015;41:62-74.

Shehabi Y, et al. AJRCCM 2012;186:724-731

100

Deep Sedated (RASS -3 to -5)

Light Sedated (RASS -2 to +1)

Every deep sedation increases

the risk of death at 6 months

0 30 60 90 120 150 180Days

75

Patients

Alive

(%)

0

25

50

p=0.048

N=251

Targeted Level of Consciousness

Choose Target Level of Consciousness

Assess Actual Level of Consciousness

Modify Treatment so Actual = Target

D

DAssess, Prevent,

&

Manage Delirium

• Why– Incidence

– Outcomes

• How– CAM ICU, ICDSC

– Nonpharmacologicinterventions

– Pharmacologic interventions

Ely E. JAMA. 2001;286:2703-2710; Bergeron N. Intensive Care Med. 2001;27:859-864; Dubois M. Intensive Care Med. 2001;27:1297-1304; Ely E. Intensive

Care Med. 2001;27:1892-1900; Ely E. JAMA. 2004;291:1753-1762; Pisani M. Am J Respir Crit Care Med. 2009;180:1092-1097; Shehabi Y. Crit Care Med.

2010; 38:2311–2318; Schweickert W. Lancet. 2009;373:1874-1882; Needham D. Arch Phys Med Rehabil. 2010;91:536-542;’ Colombo R. Minerva Anestesiol.

2012;78:1026-1033; Balas M. Crit Care Med. 2013;42:1024-1036; Kamdar B. Crit Care Med. 2013;41:800-809

Inouye SK Arch Intern Med. 2001;161:2467-2473.

Devlin JW Crit Care Med. 2007;35:2721-2724.

Spronk PE Intensive Care Med. 2009;35:1276-1280.

van Eijk MM Crit Care Med. 2009;37:1881-1885.

Delirium is missed in 3 out of 4 cases if a screening

tool is not used.

Missed DeliriousMissedMissed

Hyperactive

2%

Hypoactive

43%

Peterson, et al., J Am Geriatr Soc 2006; 54: 479-84

Mixed

54%

Clinical Subtypes of Delirium

Step 1-Routinely administer valid & reliable delirium screening instruments

• CAM, CAM-ICU, ICDSC, etc.

• Frequency of assessments

• Teaching strategies

• Common errors

Screening: Implementation Strategies

• UTA drama• Case-based scenarios

1

– Before-and-after case studies – Strategy increased usage of the ICDSC by 70% and accuracy of assessment by 54%

• Spot-checking2,3

– Systematic comparison of users with expert raters – Identifies areas for fine tuning education

• Get it into the water– Incorporate delirium into hospital nursing orientation

1. Devlin JW Crit Care. 2008;12(1):R19.2. Pun BT Crit Care Med. 2005;33(6):1199-1205.3. Soja SL Intensive Care Med. 2008;34(7):1263-1268.

Step 2-Consider differential diagnosis & recognize potential for coexistence

• Pain, anxiety, dementia, depression

Step 3- Perform history & physical exam

• History-Baseline status• Medication review

– OTC & ETOH• Physical exam

– VSS, O2 sat, neuro exam, I & O• Laboratory other diagnostic tests

• CBC, electrolytes, renal function test, UA, LFTs, serum drug levels, ABGs, chest X-ray, EKG, cultures

• EEG & CSF rarely helpful

Step 4-Discontinue unnecessary drugs

• Anticholinergics• Anticonvulsants• Antidepressants (anticholinergic only)• Antihistamines (anticholinergic only)• Antiparkinsonian agents

• Antipsychotics

• Barbiturates

• Benzodiazepines

• Chloral hydrate

• H2-blocking agents

• Opioid analgesics (esp. meperidine)

Step 5- Use non-pharmacologic interventions

• Recognize, remove, or reverse of the underlying cause of delirium

• Prevent/correct– Electrolyte disturbances

– Hypoxia

– Infections

– Hemodynamic instability

• Implement fall, aspiration, & safety precautions

Step 5- Use non-pharmacologic interventions• Call bell, close proximity

• DC unnecessary lines/tubes/equipment

• Distraction/activity belts

• Adequate lighting/reduced noise

• Clocks/calendars/pictures

• Avoid physical restraint use– Restraints are indicated only if other

nonrestrictive measures have failed & if behavior puts self or others at risk for harm

• Provide 1:1 care/supervision

Step 5- Use non-pharmacologic interventions

• Provide glasses, hearing aids, &/or other assistive devices

• Favor mobilization/avoid immobilization– Limit the use of tubes & catheters, IVs, &

other devices that “tether” patient

• Assist with ADLS

• Encourage activities that limit anxiety

• Reorient

Reorienting ICU Patients• Before-after observations in 214 ICU patients• Interventions:

– Night environment, music therapy, visual cues (clock)– Reorientation with 5 W’s and 1 H

• Who? Who are you? Who is the nurse/physician?• What? What happened?• Where? Where are you/we?• Why? Why did it happen?• How? How did it happen? And what is the illness progression?

• Result: Delirium incidence reduction – Pre 35% vs. post 22%

Colombo R Minerva Anestesiol. 2012;78:1026-1033.

Step 5- Use non-pharmacologic interventions

Communication-Patient• Provide a way of communicating

needs

• Use reality orientation, repeat information as necessary, explain the situation, environment, & equipment

• ALL BEHAVIOR HAS MEANING!

• Listen to & observe behavior

• Acknowledge feelings & fears

Step 5- Use non-pharmacologic interventions

Communication-Staff• Walking rounds & mental status exam

with off-going care provider

• Delirium screenings at least once a shift

• Conduct multidisciplinary rounds

• Provide for continuity in care

• Rapid response for challenging situations

Step 5- Use non-pharmacologic interventions

Communication-Family• Interview caregivers & family to determine

patients’ baseline behavior & methods to relieve anxiety & depression

• Involve & inform SO of patients change in mental status (provide emotional support)

• Encourage visits by family/friends (may be helpful to call in family 24/7)

Step 5- Use non-pharmacologic interventions

• Nonpharmacologic sleep promotion

Sleep Abnormalities

• More time in light sleep• Less time in deep sleep• More sleep fragmentation

Friese R. Crit Care Med. 2008;36:697-705.

Weinhouse GL, Watson PL. Crit Care Clin. 2009;25:539-549.

There is little evidence that sedatives in the ICU restore

normal sleep

Boosting Sleep Quality

• Optimize environmental strategies

– Day/night variation, reduce night interruptions, noise reduction

• Avoid benzodiazepines (↓ SWS & REM)

• Consider dexmedetomidine (↑ SWS)

• GABA receptor agonists (eg, zolpidem)

• Sedating antidepressants (eg, trazodone) or antipsychotics

• Melatonin

– Pilot: may improve sleep quality of ICU COPD patients

Weinhouse GL, Watson PL. Crit Care Clinics. 2009;25:539-549.

Faulhaber J, et al. Psychopharmacology. 1997;130:285-291.

Shilo L, et al. Chronobiol Int. 2000;17:71-76.

Effect of Common Sedatives & Analgesics on Sleep There is little evidence that administration of sedatives inthe ICU achieves the restorative function of normal sleep

• Benzodiazepines

↑ Stage 2 NREM↓ Slow wave sleep (SWS) and REM

• Propofol

↑ Total sleep time without enhancing REM ↓ SWS

• Analgesics

Abnormal sleep architecture• Dexmedetomidine

↑ SWS

Weinhouse GL, et al. Sleep. 2006;29:707-716.Nelson LE, et al. Anesthesiology. 2003;98:428-436.

Differences in BOLD activities/NREM sleep (fMRI)

Contribution of Sedative-Hypnotic Agents to Delirium Via Modulation of the Sleep Pathway

Sanders RD, Maze M. Can J Anesth. 2011;58:149-156.

E

• Why– Incidence

– Outcomes

• How– Daily safety screen &

success/failure criteria

– Importance of team coordination

– PT/OT driven

EEarly mobility

& exercise

Thomsen G. Crit Care Med. 2008;36:1119-24; Schweickert W. Lancet. 2009;373:1874-82; Pohlman M. Crit Care Med. 2010;38:2089-94.; Needham D. Arch

Phys Med Rehabil. 2010;91:536-42; Morris P. Am J Med Sci. 2011;341:373-7; Hopkins R. Phys Ther. 2012;92:1518-23.; Lord R. Crit Care Med. 2013;41:717-

24; Kayambu G. Crit Care Med. 2013;41:1543-54; Kayambu G. Intensive Care Med. 2015;41:865-74; Miller M. Ann Am Thorac Soc. Epub 2015.

More patients who received early PT+OT were functionally

independent at hospital discharge

1005028211470

0

20

40

60

80

Hospital Days

Proportion of

patients with

functional

independence at

hospital discharge

(%)

Usual Care (n=49)

Early PT+OT (n=55)

p = 0.048

Schweickert, Lancet 2009; 373: 1874-82

F

• Why– Patient & family-centered

care

– Safety

• How– Flexible visiting hours

– Family presence during codes

– Rounding

– Unit design

FFamily

engagement & empowerment

Scheunemann L JAMA 2003; 290: 1166- 1172; Azoulay E Intv Care Med 2003; 29: 1498-1504; McDonagh J Crit Care Med 2004; 32:1484-1488; Azoulay E

Crit Care Med 2004; 32: 1832- 1838; Curtis R Am J Respir Crit Care Med 2005; 171: 844–849; Stapleton R Crit Care Med 2006; 34: 1679- 1685; Norton S Crit

Care Med 2007; 35: 1530- 1535; Lautrette A N Engl J Med 2007; 356: 469- 478; Zier L Crit Care Med 2008; 36: 2341- 2347

ABCDEs: Processes of Care

ABCDE Process Measures

Pre –

ABCDE

(Ntot = 146)

(Nvent = 93)

Post –

ABCDE

(Ntot = 150)

(Nvent = 94)

P

A SAT performed 53% 71% 0.04

B SBT performed 71% 84% 0.03

C Used Benzodiazepines 62% 51% 0.06

D% time CAM-ICU

documented every 8 hoursNA 50% NA

E Out of bed anytime 48% 66% 0.002

Balas MC Crit Care Med 2014;42:1024-36

ABCDE Bundle: Outcomes

Balas MC Crit Care Med 2014;42:1024-36

Outcome

Before

ABCDEs

(n=146)

After

ABCDEs

(n=150)

P

Ventilator-free days (out of 28) 21 24 0.04

Ever delirious 62% 49% 0.02

ICU days with delirium 50% 33% 0.003

Ever comatose 28% 28% 0.91

ICU days with coma 2 2 0.35

ICU mortality 16% 9% 0.07

Hospital mortality (ICU + post-ICU) 20% 11% 0.04

A

D

E

C

F

B

ABCDEF Team Approach

Nurse

Physician

Pharmacist

PT/OT

Respiratory

ABCDEF Road Map(A framework for bedside rounds)

3. How did they get there?Drugs

Assistance needed for Mobility

1. Where is the patient going?Target Pain Level

Target Consciousness Level

Target Mobility Level

2. Where is the patient now?Current Pain & Consciousness Levels

Current Delirium Status

Current Mobility Level

© B

rian Slo

an via Flickr

Improved communication

Families Clinicians

Decreased family anxiety (vs. excluding family)

How do we do it?

1) Prepare family

2) Team rounds as usual

3) Plain language summary

4) Q & A

Does not take longer! (Saves time later?)

Family Engagement on Rounds

Davidson JE, www.nacq.org, 2016

“Most patients return to their primary care

physicians, who frequently don’t know to probe

into the nature of their ICU memories. And if no

one asks, patients might go years before they

admit their experience and seek help — if ever.”

“Their life is terrible, and they often end up back in

the hospital…We need to restructure critical care

to handle the needs of ICU survivors."

"Every day I wake up and I keep

thinking this is the day I'm going to

go back to my old life."

Social Worker

Physician

Nurse

Practitioners

Pharmacist

Psychologist

Case

Manager

Vanderbilt ICU Recovery Center

Aging/Pre-operative studies indicate potential benefits for

physical and cognitive function & hospital outcomes:

Exercise

Strength/ Endurance/ Flexibility

Cognitive

Cognitive stimulating activities/ Computer games

Nutritional

Supplemental nutrition in high-risk patients

“Pre”-habilitation?

O’Doherty Br J Anes 2013;110:697-84

Barnes JAMA Inter Med 2013;173:797-804

Holloway W J Nurs Rsch 2015;37:103-23

Barnes JAMA Inter Med 2013;173:797-804

Gupta Anes Clinics 2016: 34; 2641-50

Selected Additional References• Ely E. JAMA. 2001;286:2703-2710 (CAM-ICU)

• Bergeron N. Intensive Care Med. 2001;27:859-864 (ICDSC)

• Dubois M. Intensive Care Med. 2001;27:1297-1304 (Risk Factors)

• Ely E. Intensive Care Med. 2001;27:1892-1900 (LOS and Risk Factors)

• Ely E. JAMA. 2004;291:1753-1762 (Delirium Mortality)

• Pisani M. Am J Respir Crit Care Med. 2009;180:1092-1097 (Delirium Mortality)

• Shehabi Y. Crit Care Med. 2010; 38:2311–2318 (Delirium Mortality)

• Schweickert W. Lancet. 2009;373:1874-1882 (Delirium Reduction)

• Needham D. Arch Phys Med Rehabil. 2010;91:536-542 (Delirium Reduction)

• Colombo R. Minerva Anestesiol. 2012;78:1026-1033 (Delirium Reduction)

• Gusmao-Flores D. Crit Care. 2012;16:R115 (Meta-Analysis of Tools)

• Balas M. Crit Care Med. 2013;42:1024-1036 (Delirium Reduction)

• Kamdar B. Crit Care Med. 2013;41:800-809 (Delirium Reduction)