Critical Care - Critical Care Delirium

What is delirium?

Delirium is a name for acute confusion. The patient who is delirious is often experiencing a world that makes no sense to us, but is very real to them.

For instance:

• They may not know they are in hospital
• Think they can see frightening animals
• Think they have been kidnapped
• Think staff are only pretending to be nurses
• They try to make sense of the noises around them and create a different explanation for them, so for instance if another patient is upset, they may think someone is being tortured

The main point is that the patient is absolutely convinced about the reality of the confused world they are in. It can be terrifying for them and very worrying for relatives.

Often a patient who is delirious will still recognise friends and family, although they will not generally believe their reassurances. They will usually want to get out of bed and be taken home. Patients with delirium can find it very difficult to understand or retain information - so even if they appear to understand what is happening, or may be joining in a conversation, it is unlikely they will remember what has just been said to them.
 
Delirium can also fluctuate, one minute you will be having a normal conversation and the next they will say something that makes no sense.

Delirium can show itself in two ways – either obvious to onlookers or hidden. Some patients can be very agitated and upset, which is stressful and upsetting for relatives and nursing staff who are trying to keep a patient safe. Usually, most delirium is quiet and not obvious to staff and relatives and may make patients very sleepy.

Delirium is a condition of extremes - patients either don’t sleep at all or they sleep all the time, they are continually restless, or they remain absolutely still. Whatever it looks like, delirium is a sign that the brain is not working properly because the patient is very ill.

Why does delirium develop?

Delirium is very common in critical care because the patients are so ill. It can be caused by:

• Infection
• The drugs we need to give patients to keep them comfortable
• Kidney failure
• Lung failure
• Heart failure

Some patients are more likely to get delirium, such as:

• Older patients
• Those who have become a bit forgetful
• Those who are already on medicines before critical care
• Those who have liver problems
• Patients who are dying
• Patients on ventilators

It does not take much to make these patients delirious - even a simple water infection would cause it.

I think my relative or friend might have Delirium

It can be difficult to tell if an intensive care patient has delirium, as they are often sedated and there may not be any obvious signs.

A patient may not be able to talk to us to tell us what they are experiencing - either because they are sedated or because they are on a ventilator (breathing machine) either with a face mask or a tracheostomy (where a tube has been put through a hole in the patient’s neck).

In critical care we try to find out if a patient has delirium, but we can only do this with patients who we can wake up enough to get them to squeeze our hands. We test for delirium by doing a short concentration test and we can do this test every day.

If you think your relative or friend has delirium or is not quite themselves, then please let the nurse or doctor know.

What can I do to help the patient with delirium?

There are ways you can try to help patient with delirium, such as:

• Talk to the patient, hold their hand and reassure them
• Tell them regularly that they are in hospital
• If the patient is sedated, and you are not sure what to talk about, try reading a book or a newspaper to them. They may find your voice comforting
• Keeping a diary of events can help them understand what happened afterwards

We will try to help patients with delirium by doing things such as:

• Trying to establish a day/night routine for the patient to help normal sleep
• Trying to get them mobile even if it is just sitting on the edge of the bed
• Trying to get them off the ventilator and cut down sedation
• Sometimes using medicines to reduce the symptoms of delirium

How long does delirium usually last?

It is usually only temporary - a few days to a week. Sometimes, it can last longer and may take several weeks to completely clear. Even once the patient is no longer delirious, it may take some time for them to work out what really happened to them and what was imaginary.

Does it have any lasting effects on your health?

Delirium is a serious event, which we expect to get better as patients recover. However, in some patients, delirium is associated with problems after critical care.

They are less likely to do as well as patients who don't get delirium, though this could be because patients who are very ill, often get delirium. Some can have long-term problems with brain function, for example concentration or memory.

Where can I get help? Are there any support organisations?

ICUsteps is a charity for ex-ICU patients and relatives. They have information on their website and have support groups in some areas.

In summary

Delirium is a temporary but distressing condition for patients and relatives. If you have any concerns about your relative, or would like more information, please do talk to the staff and they will try to help.