How to end quiet suffering in the intensive care unit? Identifying and treating hypoactive delirium

Kotfis, K., Mesa, P. & Ely, E.W. How to end quiet suffering in the intensive care unit? Identifying and treating hypoactive delirium. Intensive Care Med (2024). https://doi.org/10.1007/s00134-024-07534-0

Summary of "How to End Quiet Suffering in the Intensive Care Unit? Identifying and Treating Hypoactive Delirium"

Abstract

Hypoactive delirium, characterized by decreased movement and arousal, is the most common and challenging motor delirium subtype to recognize. It is associated with higher mortality, longer hospital stays, and long-term cognitive impairments. The incidence varies widely (11–89%) depending on the population, clinical context, and detection method. It is particularly common among the elderly, ICU patients, those with prior cognitive impairment, and at end-of-life. Delirium, while typically reversible, can lead to long-term cognitive and functional impairments, suggesting it may be classified as an acquired brain injury (ABI).

Introduction

Hypoactive delirium presents a significant diagnostic and clinical challenge due to its overlap with dementia and depression. It manifests as lethargy, apathy, and withdrawal from external stimuli. Delirium may cause invisible ABI, and its severity is comparable to moderate traumatic injury or mild Alzheimer's disease. Fig. 1 delineates hypoactive delirium within the spectrum of acute encephalopathy.

Diagnosis

Diagnosing hypoactive delirium is difficult because its symptoms overlap with other conditions such as dementia and depression. It is often diagnosed with a positive Confusion Assessment Method for the ICU (CAM-ICU) and a Richmond Agitation-Sedation Scale (RASS) score of zero or less. Other assessment tools include the Bush-Francis Catatonia Rating Scale (BFCRS), Delirium Rating Scale (DRS), Memorial Delirium Assessment Scale (MDAS), and CAM-ICU-7. Differential diagnosis should rule out conditions like negative symptoms of psychotic illness, akinetic mutism, locked-in syndrome, status epilepticus, severe neurocognitive impairment, or apathy.

Assessment Tools

Various tools can facilitate the diagnosis of hypoactive delirium:

• Electroencephalogram (EEG): Shows a less integrated network in the alpha band and generalized slowing, distinguishing it from dementia or depression.
• Blood Biomarkers: Increased levels of C-reactive protein, tumor necrosis factor-alpha, and interleukin-6 may aid diagnosis.
• Neuroimaging: Reveals structural and functional predictors of delirium, such as brain atrophy and reduced cerebral blood flow.

Management

Management focuses on prevention and the use of the ABCDEF bundle, promoting an "awake and walking" ICU culture. Current evidence suggests:

• Prevention: Light sedation and early mobility improve long-term cognitive outcomes.
• Pharmacologic Interventions: No evidence-based pharmacologic treatment for delirium. Reducing exposure to GABAergic drugs is crucial. Antipsychotics are not typically recommended but may be considered for psychotic symptoms or sleep cycle dysregulation. Melatonin and ramelteon show promise in reducing the duration of delirium.
• Non-Pharmacologic Interventions: Establishing an active culture of lighter sedation or no sedation and early mobility.

Take-Home Message

Hypoactive delirium's duration predicts higher mortality rates, longer hospital stays, higher costs, and higher rates of acquired dementia. Key to managing hypoactive delirium includes awareness, timely diagnosis, preventive measures, and promoting an "awake and walking" ICU.

ACCESS FULL ARTICLE HERE

Watch the following video on "Anything new in ICU delirium?" by Dr. Wes Ely

Discussion Questions

1. What are the primary challenges in diagnosing hypoactive delirium in ICU patients, and how can these be addressed?
2. How does the implementation of the ABCDEF bundle impact the incidence and outcomes of hypoactive delirium in ICU patients?
3. What are the potential benefits and limitations of using non-pharmacologic interventions, such as early mobility and reduced sedation, in managing hypoactive delirium?

Javier Amador-Castañeda, BHS, RRT, FCCM, PNAP

Interprofessional Critical Care Network (ICCN)