April 1, 2014
“Dale Needham and colleagues in the MICU have radically scaled back the use of sedation; many more patients now remain awake to read, visit with family and perform physical therapy.”
Up to 80 percent of mechanically ventilated patients in the intensive care unit experience delirium, says Johns Hopkins critical care specialist Dale Needham. Whether their confused or agitated state is caused by sedation medications, disrupted sleep or electrolyte imbalances, the longer they have it, he says, the higher their risk of enduring problems with memory and thinking. With advances in medicine, rehab and technology, notes Needham, many changes are happening in the ICU, and “addressing delirium is being recognized as very important.”
Increasingly, mobility has been demonstrated to improve delirium, even in the ICU setting. Indeed, says Needham, new practice guidelines from the Society of Critical Care Medicine recommend early mobility as one of six evidence-based steps to improve patient outcomes. “As we address delirium through better-quality sleep and adjusting medications,” he says, “additional physical and mental stimulation can make a huge difference. I’ve seen it happen time and time again.”
Often mistaken for dementia or depression, particularly in older patients, delirium famously disrupts sleep cycles, says Dorianne Feldman, medical director of Johns Hopkins Hospital’s comprehensive inpatient rehabilitation program. “For many patients, day becomes night.”
To counter that effect, R. Samuel Mayer and his colleagues advocate regular daytime mobility so that by evening, patients are tired and more likely to sleep better. Progressive mobility and positioning, including elevating the head of the bed, active range-of-motion exercises, sitting and ambulation, at least three times a day, he says, can accelerate recovery.
A recent quality improvement project focused on improving sleep and cognition among 300 patients in the Johns Hopkins Hospital medical ICU validates this approach. Needham and his colleagues found that daytime interventions to help promote normal circadian rhythms and nighttime sleep were associated with reducing delirium in the ICU. Other strategies included adjusting medications, raising window blinds, preventing excessive daytime napping and encouraging early rehabilitation while still on life support. The rehab team is now applying what has been learned in the ICU to patients on the inpatient rehabilitation unit.
In most cases, Mayer says, delirium is reversible, “but it requires a skilled team to help manage the patient.” To that end, for the past four years, experts across disciplines—psychiatry, nursing, critical care and rehabilitation—have convened for a monthly, hospital-wide meeting to address delirium.
Sometimes, says Mayer, choices need to be weighed in each case. “If the culprit is an infection,” he says, “we should start antibiotics, but other medications that contribute to delirium, like benzodiazepines, should be carefully reviewed to ensure that they are not causing this state of “brain failure.”
Incorporating daytime physical rehabilitation regularly from the onset of hospitalization, stress Needham and Mayer, hastens recovery. “Within about two weeks,” says Mayer, “we can get most of these patients oriented, moving and feeling better, and they’re no worse for the wear.”