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for Medical Professionals — ABCDEFs of Prevention and Safety

Terminology and Mnemonics

Over 25 different terms have been used to describe the spectrum of cognitive impairment in the ICU including: ICU psychosis, ICU syndrome, acute confusional state, septic encephalopathy and acute brain failure. The Diagnostic and Statistical Manual of Mental Disorders (DSM IV) officially defines delirium as a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time (hours to days) and fluctuates over time.

The three motoric subtypes of delirium are hyperactive, hypoactive, and mixed. Medical and nursing literature often refers to patients with hyperactive delirium as having ICU psychosis. The neurology literature generally uses the term “delirium” to refer almost exclusively to hyperactive patients and “acute encephalopathy” as a synonym for hypoactive delirium. We recognize that patients in the ICU develop the spectrum of 3 delirious states (hyper, hypo, and mixed). For general purposes within this web site, we will use the term “delirium” to indicate the spectrum of these states and will make distinctions between these motoric subtypes whenever possible with regard to etiology, clinical outcome, and treatment.


THINK

What to THINK about when delirium is present

T Toxic Situations
CHF, shock, dehydration
Deliriogenic meds (Tight Titration)
New organ failure, e.g, liver, kidney
H Hypoxemia
I Infection/sepsis (nosocomial), Immobilization
N Nonpharmacological interventions
Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation
K K+ or Electrolyte problems

* Adapted with permission from: Marta Render, MD – Veteran Affairs In-patient Evaluation Center (IPEC)


Dr. DRE (Disease remediation, Drug Removal, Environmental modifications)

Strategies to consider when delirium is present

Dr Diseases (Sepsis, COPD, CHF)
DR Drug Removal (SATs and stopping benzodiazepines/ narcotics)
E Environment (Immobilization, sleep and day/night, hearing aids, glasses)

DELIRIUM (S)

Differential diagnosis for patients with Delirium
(Remember: delirium usually has more than one cause)

D Drugs
E Eyes, ears, and other sensory deficits
L Low O2 states (e.g. heart attack, stroke, and pulmonary embolism)
I Infection
R Retention (of urine or stool)
I Ictal state
U Underhydration/undernutrition
M Metabolic causes (DM, Post-operative state, Sodium abnormalities)
(S) Subdural hematoma

* Adapted from: Saint Louis University Geriatrics Evaluation Mnemonics Screening Tools (SLU GEMS). Developed or compiled by: Faculty from Saint Louis University Geriatrics Division and St. Louis Veterans Affairs GRECC.


DELIRIOUS

D Drugs (continuous drips, Na+, Ca+, BUN/Cr, NH3+)
E Environmental factors (hearing aids, eye glasses, sleep/wake cycle)
L Labs (including Na+, K+, Ca+, BUN/Cr, NH3+)
I Infection
R Respiratory status (ABGs-PaO2 and PCO2)
I Immobility
O Organ failure (renal failure, liver failure, heart failure)
U Unrecognized dementia
S Shock (sepsis, cardiogenic)/Steroid

ICU DELIRIUM (S)

Mnemonic for risk factors and causes of ICU DELIRIUM (S).

Iatrogenic exposure Consider any diagnostic procedure or therapeutic intervention or any harmful occurrence that was not a natural consequence of the patient’s illness
Cognitive impairment Preexisting dementia, or MCI or depression
Use of restraints and catheters Reevaluate the use of restraints and bladder catheters daily
Drugs Evaluate the use of sedatives (e.g. benzodiazepines or opiates) and medications with anticholinergic activity.
Consider the abrupt cessation of smoking or alcohol.
Consider withdrawal from chronically used sedatives.
Elderly Evaluate patients older than 65 years with greater attention
Laboratory abnormalities Especially hyponatremia, azotemia, hyperbilirubinemia, hypocalcemia and metabolic acidosis
Infection Sepsis and severe sepsis.
Especially urinary, respiratory tract infections.
Respiratory Consider respiratory failure (PCO2 greater than 45 mmHg or PO2 less than 55 mmHg or oxygen saturation less than 88%).
Consider causes such as COPD, ARDS, PE*
Intracranial perfusion Consider presence of hypertension or hypotension.
Consider hemorrhage, stroke, tumor
Urinary/faecal retention Consider urinary retention or faecal impaction, especially in elderly and in postoperative patients
Myocardial Consider myocardial causes: myocardial infarction, acute heart failure, arrhythmia
Sleep and Sensory deprivation Consider the alterations of the sleep cycle and sleep deprivation.
Consider the non availability of glasses (poor vision).
Consider the non availability of hearings devices (poor hearing).

I WATCH DEATH

Differential Diagnosis of Delirium.

Infection HIV, sepsis, Pneumonia
Withdrawal Alcohol, barbiturate, sedative-hypnotic
Acute metabolic Acidosis, alkalosis, electrolyte disturbance, hepatic failure, renal failure
Trauma Closed-head injury, heat stroke, postoperative, severe burns
CNS pathology Abscess, hemorrhage, hydrocephalus, subdural hematoma, Infection, seizures, stroke, tumors, metastases, vasculitis, Encephalitis, meningitis, syphilis
Hypoxia Anemia, carbon monoxide poisoning, hypotension, Pulmonary or cardiac failure
Deficiencies Vitamin B12, folate, niacin, thiamine
Endocrinopathies Hyper/hypoadrenocorticism, hyper/hypoglycemia, Myxedema, hyperparathyroidism
Acute vascular Hypertensive encephalopathy, stroke, arrhythmia, shock
Toxins or drugs Prescription drugs, illicit drugs, pesticides, solvents
Heavy Metals Lead, manganese, mercury

Reference


COCOA PHSS

Differentiating Delirium from Dementia

  Delirium Dementia
Consciousness Decreased or hyper alert
"Clouded"
Alert
Orientation Disorganized Disoriented
Course Fluctuating Steady slow decline
Onset Acute or sub acute Chronic
Attention Impaired Usually normal
Psychomotor Agitated or lethargic Usually normal
Hallucinations Perceptual disturbances
May have hallucinations
Usually not present
Sleep-wake-cycle Abnormal Usually normal
Speech Slow, incoherent Aphasic, anomic difficulty finding words

* Adapted from: Saint Louis University Geriatrics Evaluation Mnemonics Screening Tools (SLU GEMS). Developed or compiled by: Faculty from Saint Louis University Geriatrics Division and St. Louis Veterans Affairs GRECC.


Understanding international differences in terminology for delirium and other types of acute brain dysfunction in critically ill patients.

Abstract

Background: Delirium (acute brain dysfunction) is a potentially life threatening disturbance in brain function that frequently occurs in critically ill patients. While this area of brain dysfunction in critical care is rapidly advancing, striking limitations in use of terminology related to delirium internationally are hindering cross-talk and collaborative research. In the English literature, synonyms of delirium such as the Intensive Care Unit syndrome, acute brain dysfunction, acute brain failure, psychosis, confusion, and encephalopathy are widely used. This often leads to scientific ‘‘confusion’’ regarding published data and methodology within studies, which is further exacerbated by organizational, cultural and language barriers.

Objective: We undertook this multinational effort to identify conflicts in terminology and phenomenology of delirium to facilitate communication across medical disciplines and languages.

Methods: The evaluation of the terminology used for acute brain dysfunction was determined conducting communications with 24 authors from academic communities throughout countries/regions that speak the 13 variants of the Romanic languages included into this manuscript.

Results: In the 13 languages utilizing Romanic characters, included in this report, we identified the following terms used to define major types of acute brain dysfunction: coma, delirium, delirio, delirium tremens, délire, confusion mentale, delir, delier, Durchgangs-Syndrom, acute verwardheid, intensivpsykose, IVA-psykos, IVA-syndrom, akutt konfusion/ forvirring. Interestingly two terms are very consistent: 100%of the selected languages use the term coma or koma to describe patients unresponsive to verbal and/or physical stimuli, and 100% use delirium tremens to define delirium due to alcohol withdrawal. Conversely, only 54% use the term delirium to indicate the disorder as defined by the DSM-IV as an acute change in mental status, inattention, disorganized thinking and altered level of consciousness. Conclusions: Attempts towards standardization in terminology, or at least awareness of differences across languages and specialties, will help cross-talk among clinicians and researchers.