What Is ICU Psychosis?
ICU delirium: symptoms and recovery
When an individual finds themselves in an intensive care unit (ICU), this typically entails at least a temporary loss of mobility and independence, as well as a disturbance to one’s daily routine and sleep schedule. Due to the environmental factors associated with being admitted to a critical care unit, individuals sometimes experience a phenomenon known as “ICU psychosis.” This can be more accurately described as “ICU delirium” and usually involves symptoms like confusion, lethargy, slow motor function, agitation, and hallucinations. In most cases, ICU delirium subsides when patients leave the hospital, but some may experience lasting effects for which therapy with a licensed professional may be helpful.
What is ICU psychosis and what are its hallucinations?
ICU psychosis can be seen as a mental health condition experienced by critically ill patients who have been admitted to an intensive care unit. In general, this condition isn’t frequently discussed or widely known by the general public. This could be because the term “ICU psychosis” is largely considered an outdated phrase that can be more accurately referred to as “delirium.”
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines delirium as “an impairment in attention and awareness that develops over a relatively short time interval that is associated with additional cognitive deficits.” Delirium often includes symptoms such as confusion, disorientation, and hallucinations, where patients may see, hear, or feel things that are not present.
This is a serious condition and ICU delirium can be a common occurrence for individuals in the ICU, with 20% to 70% of hospitalized individuals in the ICU experiencing this condition. There’s typically an even greater likelihood (approximately 80%) of ICU psychosis or delirium occurring in patients on mechanical ventilation.
Overview of ICU psychosis and confusion
Delirium can also be called an “acute confusional state” or “acute brain failure.” While there are generally three main types of delirium observed in individuals experiencing the condition, only two of these are typically observed in patients in the ICU.
Symptoms of ICU psychosis: Confusion, agitation, disorientation, and hallucinations
Hyperactive delirium, which isn’t commonly seen in ICU patients, typically involves symptoms like restlessness, agitation, and hallucinations. In many cases, psychotic symptoms can interfere with an individual’s care.
Meanwhile, hypoactive delirium tends to be associated with confusion, decreased response time, lethargy, slowed motor function, and other symptoms. Hyperactive delirium may account for approximately 24.5% to 43.5% of ICU delirium cases.
Frequency of ICU delirium
Mixed delirium is usually the most common type of ICU psychosis, involving a combination of elements of both hyperactive and hypoactive delirium. Mixed delirium is estimated to account for 52.5% of cases.
Types of delirium
If an individual is experiencing symptoms of delirium while in an intensive care unit, early detection can be helpful in ensuring one’s mortality and morbidity rates are not affected, although updated research may be needed. If one is experiencing a particularly severe case of ICU delirium, pharmacological measures might be a necessary option to explore.
What causes ICU psychosis?
Individuals experiencing delirium induced by ICU admission have likely developed a type of environmental delirium. When a patient is in the ICU, they usually have an increased likelihood of experiencing certain environmental factors, such as sleep deprivation, excessive noise, poor communication, separation from family and loved ones, and a lack of mobility.
Patients are often in an intensive care unit due to a traumatic situation or emergency scenario, and many wake up in the ICU with no recollection or immediate explanation as to how they got there. This sort of confusion can be another factor contributing to the development of ICU delirium.
Risk factors for ICU delirium
Older age
Older patients are more susceptible to ICU delirium due to age-related changes in brain function and a decreased ability to cope with the stressors associated with an ICU environment.
Substance misuse
Individuals with a history of substance abuse, including alcohol and recreational drugs, are at a higher risk of developing ICU delirium. Substance misuse can alter brain chemistry and impair cognitive function, making it harder for patients to manage the stresses of critical care.
Severe illness, sedation, and the onset of disorientation
Patients with severe or terminal illnesses may be more prone to ICU delirium due to the complexity and intensity of their medical conditions. The underlying severity of their health issues can contribute to cognitive impairments and increase the likelihood of experiencing delirium.
Cognitive impairment
Pre-existing cognitive impairments, as dementia or other neurocognitive disorders, can increase the risk of delirium in the ICU. These conditions can make it more difficult for patients to process new information and adapt to the ICU environment, leading to heightened confusion and disorientation.
Visual impairment
Visual impairment or blindness can contribute to ICU delirium by affecting a patient's ability to perceive and interact with their surroundings.
Infections
Infections, particularly those affecting the central nervous system, can be a significant risk factor for delirium. The body's response to infection, along with any related fever, can contribute to the development of ICU delirium.
Respiratory illnesses
Respiratory illnesses, including those that require mechanical ventilation, can be a trigger for delirium. The stress of respiratory failure, combined with the potential of low oxygen levels, can impact brain function and increase the risk of delirium in ICU patients.
How therapy and sedation can help with ICU delirium and agitation
While many individuals who experience delirium during their stay in an intensive care unit report that their symptoms go away when they leave the hospital, some severe cases of ICU delirium can have lasting effects. In these cases, seeking a pharmacological solution, such as antipsychotic medication, may be beneficial to treat symptoms like hallucinations. Please note that these medications must be prescribed by a doctor or psychiatrist, and you can communicate with them about any side effects you may be experiencing to ensure the best results.
Online therapy options for ICU psychosis and disorientation
Another potential avenue to explore is therapy. While there is no specific therapy method that has been proven to shorten the duration of delirium, the flexibility and affordability of a method like online therapy can help those who have experienced ICU delirium talk to a licensed professional from the comfort of their homes at a time that works for them.
Often, methods like cognitive behavioral therapy (CBT) can be useful in treating other mental health disorders involving psychotic symptoms, and studies suggest that online CBT can be just as effective as its in-office counterpart. However, people experiencing acute psychosis may need to seek in-person treatment.
Takeaway
Frequently asked questions
Do people recover from ICU delirium?
Recovery time for intensive care unit delirium varies from person to person, but it can take weeks to months or longer. How long it takes for these hospitalized patients to recover can depend on the extent of the condition. For example, some people may need support improving memory and thinking while others may need intense therapy like what is required for a brain injury. There is limited research into how many people recover from ICU delirium, but one older study found that, after three months, 63% of patients with ICU delirium no longer met the DSM diagnostic criteria, and 21% had completely recovered. After six months, 69% no longer met the diagnostic criteria, and 18% were fully recovered.
What causes psychosis in the ICU?
ICU psychosis is an outdated term for ICU delirium. Many factors can contribute to a patient developing ICU delirium. Some of these may include infections, alcohol withdrawal, low blood sugar, vitamin deficiencies, trauma, or low oxygen levels. Some factors may result from the condition that brought the patient to the ICU; others may come from the effects of being a patient in an intensive care unit.
Hospital delirium is common. Between 20% and 70% of hospitalized patients develop delirium; however, research has determined that ICU patients are at higher risk. In this setting, delirium occurs in about 80% of patients, including up to 83% of those on mechanical ventilation. ICU delirium is also associated with increased mortality and longer hospitalization.
In addition to mechanical ventilation, other clinical features may put someone at a higher risk of ICU delirium, including being an elderly patient or having a pre-existing cognitive impairment, depression, visual impairment, or respiratory disorder. People with multiple comorbidities or severe or terminal illnesses can be at higher risk, and some major surgeries can elevate the chances of someone developing ICU delirium. In some types of surgery, delirium may be so common that it is associated with the surgery. For example, delirium after open heart surgery is sometimes called postcardiotomy delirium.
It can be important to understand that unique factors in the ICU setting may contribute to the acute brain dysfunction of intensive care delirium. An ICU is designed to care for critically ill patients who require constant monitoring and specialized medical equipment. For example, some patients may require life-support interventions, like ventilators or ECMO machines, which are sometimes called heart-lung machines.
Whether the patient is in a coronary care unit for a heart-related condition or a transplant ICU recovering from life-saving surgery, there are a number of things about being in this intense medical environment that can cause psychological distress, including metabolic disturbances, perceptual disturbances, and psychological factors. Some of these may include deep levels of sedation, electrolyte imbalances, certain medications, sensory overload, poor sleep quality, immobility, physical or chemical restraints, lack of daylight or natural lighting, or a lack of visitors.
It can be difficult to determine delirium from other clinical conditions in the ICU setting; to be considered ICU delirium, the DSM states that the changes in cognition or psychiatric symptoms must not be attributable to another neurocognitive disorder and must not occur in a “setting of a reduced level of arousal,” like a coma or a sedative medication. Critical care medicine doctors are often unable to find an underlying cause of delirium; they thoroughly investigate whether it is caused by something that may be treatable, like an acute infection, stroke, or meningitis.
How long does ICU syndrome last?
How long it takes someone to recover from ICU syndrome depends on many factors, including their overall mental and physical health. Some people can recover completely within a few months, while others will develop chronic symptoms requiring long-term management.
How do you stop ICU delirium?
In a 2019 meta-analysis titled “Current controversies and future perspectives on treatment of intensive care unit delirium in adults,” researchers stated that haloperidol and some atypical antipsychotics have been used to treat ICU delirium “despite no support from rigorous controlled studies.” This critical review found that “large-scale studies demonstrated that antipsychotics do not significantly shorten the duration of delirium.” The authors concluded that “there are no effective pharmacological strategies in both prevention and management of established ICU-D.”
That said, research has also determined some non-pharmacological interventions that may help prevent and cure ICU delirium, including the following:
- Implementing pain and sedation protocols. This approach can include assessing pain regularly, choosing light sedation when possible, and choosing the right medications.
- Using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). This screening tool can help clinicians quickly and reliably assess mental state and determine if a patient is experiencing delirium.
- Emphasizing nonpharmacological strategies, like involving family members in care and focusing on early mobility, may help prevent ICU delirium. Other interventions that may help avoid ICU delirium include providing patients with clocks or calendars, opening the blinds, minimizing nighttime nurse interventions and other interruptions to encourage sleep, avoiding physical restraints, orienting patients to their surroundings, and providing hearing or vision aids if necessary.
How long does ICU delusion last?
ICU delusion can last weeks to months, with some people developing symptoms that can require long-term management.
How to talk to someone with ICU delirium?
When talking to someone in the ICU with delirium, speak clearly, using short, simple sentences. Reorient them frequently to their surroundings and offer gentle reassurance instead of contradicting them or arguing with them. It can also help to minimize other distractions in the environment by reducing any unnecessary noise, e.g., turning off the television.
Can ICU psychosis be permanent?
ICU delirium is usually temporary, but it can lead to long-term deficits. According to Dr. E. Wesley Ely, an intensive care specialist at Vanderbilt Medical Center, “about one-third of patients who have cognitive problems after their ICU stay fully recover, another third stay about the same after their dementia sets in, and a third continue to go downhill.”
How do you overcome ICU psychosis?
Like any stress response syndrome, ICU delirium can be challenging to overcome. While a patient is still in the ICU, the medical team may closely monitor them for changes in their mental status, like a new memory deficit or a psychotic episode, and do regular lab work, like a complete blood cell count or blood cultures, to make sure they do not have an infection or other diagnosis that may be causing the delirium. Once the person leaves the ICU and the hospital, the treatment approach may shift to therapy and other treatments for supporting memory and cognition or addressing any other symptoms the person may be dealing with long-term.
How do hospitals deal with psychosis?
Medical staff generally try to identify and treat any underlying conditions that may be contributing to acute confusional states in hospitalized patients. For example, if a patient is dehydrated, staff can ensure they have adequate fluid, or if they have an infection, they are likely to be started on antibiotics. Other interventions may include limiting interruptions overnight to encourage sleep, minimizing noise, opening the blinds, and frequently reorienting the patient to self, place, and time.
What is the prognosis for ICU delirium?
The prognosis for ICU delirium can depend on the person’s overall mental and physical health before, during, and after their hospital stay. Some people can recover completely, while others may stay the same or continue to deteriorate.
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