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Introduction
Delirium is common in patients admitted to the intensive care unit (ICU) and can affect them in many ways. This leaflet is for people with a loved one in the ICU. It aims to explain what delirium is, what causes it and what strategies can help to manage it.
What is ICU delirium?
Delirium is a word we use to describe a state of confusion in ICU patients. It may come and go, and vary from hour to hour or from day to day. Sometimes it continues after the patient has left the ICU. Delirium is assessed and monitored in ICU because it can affect people for some time after their ICU stay and can be associated with an increased risk of longer term health problems and outcomes.
Delirium can affect ICU patients of any age but is particularly common for older patients. In the ICU, delirium causes patients to have a reduced awareness of their surroundings or to imagine they are in a different situation.
Patients with delirium may experience frightening or distressing hallucinations (see or hear things that exist in their mind but not in reality) and delusions (a clearly false belief). For example, patients may not be aware they are in hospital, may think that they have been kidnapped and that staff are trying to hurt them or believe that they or people close to them have died. These experiences can appear very real to patients and may cause them to feel fearful and isolated.
Patients with delirium may behave in ways that are not usual for them. They may appear anxious, agitated, or have less energy than usual and they may find it difficult to concentrate on, understand or remember information given to them. Delirium can change quickly so that one moment the patient is able to join in a conversation normally and the next moment they are confused.
Delirium can be distressing for both patients and their loved ones – please speak to a member of staff if you need to.
Types of ICU delirium
Delirium can present in different ways:
Hyperactive delirium
Patients can appear agitated, restless, upset or anxious. They may speak quickly or loudly, respond negatively or aggressively, or seem paranoid. It is common for patients with hyperactive delirium to have a disrupted sleep pattern (being awake at night and asleep in the day) and to give confused answers.
Hypoactive delirium
Hypoactive delirium is harder to identify. Patients may appear drowsy and move less than usual for them; however, patients are commonly sedated on ICU, and this will also affect level of alertness and movement. Some patients with hypoactive delirium can become quiet and withdrawn from conversation, and therefore may take more time to respond to you. If eating orally, there may also be changes in appetite (not eating as much as usual).
Mixed delirium
Patients with mixed delirium will present with hyperactive delirium symptoms some of the time and hypoactive delirium symptoms at the other times.
Causes of ICU delirium
When a patient is critically unwell, many parts of the body can be affected including the brain. Delirium is a sign that the brain is not working as usual. Factors that can contribute to ICU delirium are:
- Infections
- Medication or changes in medication
- Sleep disturbance
- Nutrition disturbances
- Co-morbidities (previous alcohol and drug intake, previous cognitive issues)
- Pain
- Disorientation – waking up in a different environment
Monitoring and management of ICU delirium
For patients who are awake enough, their delirium state will be monitored by staff every day using the Confusion Assessment Method in ICU (CAM-ICU). If you think your loved one has delirium because they are acting differently from normal or appear very upset, please let the staff know to see if they can help.
There is no specific treatment for delirium. ICU staff will try to minimise causes of delirium (e.g. by ensuring effective pain management, trying to maintain day/night routine) and to implement delirium management strategies if needed (e.g. using orientation boards, promoting early mobilisation). However, unfortunately it is not always possible to prevent delirium from occurring. For patients on ventilators (breathing support machines), at least two out of three will experience delirium.
Measures used to keep everyone safe
Patients experiencing delirium may not know what is happening to them and their actions may present a danger to themselves or others. For example, they may try to pull out their lines (drips and tubes attached to them), keep trying to get out of bed or hit out at staff and visitors who they think are trying to hurt them. Occasionally, it may be necessary to use physical restraints - such as mittens, or short-acting sedative medication - to keep patients, staff and visitors safe.
A temporary Deprivation of Liberty Safeguards (DoLS) process may need to be followed, which allows the hospital to legally treat the patient until they regain capacity to make decisions for themselves. The patient’s next of kin with be kept fully informed in this situation.
What can you do to help?
Your knowledge about your loved one is valued by the ICU staff caring for them and your contributions to delirium care are very important. The following are strategies that can help manage delirium in ICU patients:
Provide comfort and reassurance
- Speak calmly and use simple words and phrases.
- Acknowledge your loved one’s experiences and empathise with how they are feeling. Try not to reinforce any delusions or hallucinations (e.g. by going along with them).
- Try reassuring your loved one that they are safe and being looked after.
- Try holding hands / stroking their hair - sometimes experiencing familiar touch can help patients to experience something “real” when their mind is elsewhere.
Help orientate the patient
- Explain to your loved one that they are in Frimley Park or Wexham Park Hospital.
- Tell your loved one the day, date, time, month and year. Show them the orientation board (please alert staff if one is not already provided and you think it would be useful) and encourage them to read aloud the day, date, month, year and place. If possible, encourage your loved one to practise writing these details down.
- Your loved one may find it hard to believe or understand you when you try to reassure and orientate them - this is because the hallucinations, dreams and delusions often feel very real. Patients with delirium also find it difficult to retain information. You may need to repeat the reassurance and orientation each time you visit.
Distraction
- Try distracting your loved one if they are attempting to pull out attachments or get out of the bed, for example by showing photos, talking about family, asking them to talk about something, reading a newspaper or favourite book to them, etc.
Providing factual information
- Add entries to your loved one’s ICU diary if they have one (ask staff if you are unsure) - the diary entries can be helpful later when your loved one is making sense of their experiences whilst on the ICU.
Bring important items from home
- If your loved one usually wears glasses and/or hearing aids, it is important that they continue to use these whilst on the ICU to enable them to interact with people and the environment effectively.
- Encouraging your loved one to wear their own clothes rather than hospital gowns can be helpful.
- Items that might bring comfort and connect your loved one with their life outside the ICU can be helpful, for example photos, music, familiar smells, favourite blankets etc.
- It is useful for staff to know as much information about your loved one as possible with details such as any specific routines (e.g. spraying lavender on the pillow / listening to prayers / doing relaxation before sleep, etc), when they need to wear glasses, any likes and dislikes. There is space in the front of the ICU diary to write this information.
How long does delirium last?
Delirium is person-specific and the duration can vary. It is usually temporary and will last from a few days to a week. Sometimes it can last longer and may take several weeks to completely resolve. Delirim does not always settle when a patient leaves the ICU and may continue after. Even after the delirium has resolved it may take some time for the patient to process their experiences on the ICU and to understand what was real and what was imagined. If any concerns arise then please do speak with the ICU team.
Does delirium have any lasting effects?
Delirium should get better as patients improve and recover from their critical illness. Some patients who experience delirium have longer-term problems with brain function, for example concentration or memory – these difficulties usually improve over time, but it can take up to 18 months. If you have any concerns, then please do speak with the ICU team.
Further sources of information
The following websites provide information about ICU delirium.
Contact details
Please speak with the staff caring for your loved one if you have any questions or concerns about delirium. If your loved one is already discharged from ICU, please feel free to contact the Critical Care Rehabilitation and Follow Up (CCRFU) team using the following email address:
- Frimley Park Hospital: fhft.
icufollowupfph @nhs.net - Wexham Park Hospital: fhft.
wphicufollowup @nhs.net
Contact us
If you have any queries relating to this information, please contact the Intensive care medicine service.
About this information
Service:
Intensive care medicine
Reference:
MM/005
Approval date:
30 July 2024
Review date:
1 July 2027
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Important note
This page provides general information only. It is developed by clinical staff and is reviewed regularly every 3 years for accuracy. For personal advice about your health, or if you have any concerns, please speak to your doctor.