Assessing Patients With Altered Level of Consciousness.

Patients with alterations in level of consciousness are among the most difficult to assess, so knowledge of how to assess these patients is important for tracking trends and identifying changes. This article discusses methods used to assess patients admitted with an altered level of consciousness and describes the neurological assessment of and potential causes for altered level of consciousness. Identifying and understanding certain examination findings enable faster recognition and intervention for life-threatening neurological events, directly impacting outcomes for neurologically compromised individuals.

Relationship between in-hospital angiotensin converting enzyme inhibitors and Angiotensin receptor blockers administration and delirium in the cardiac ICU.

OBJECTIVES: Delirium may be associated with neuroinflammation and reduced blood-brain barrier (BBB) stability. ACE Inhibitors (ACEIs) and Angiotensin Receptor Blockers (ARBs) reduce neuroinflammation and stabilize the BBB, thus slowing the progression of memory loss in patients with dementia. This study evaluated the effect of these medications on delirium prevalence. METHODS: This was a retrospective study of data from all patients admitted to a Cardiac ICU between 1 January 2020-31 December 2020. The presence of delirium was determined based on the International Classification of Diseases (ICD) 10 codes and nurse delirium screening. RESULTS: Of the 1684 unique patients, almost half developed delirium. Delirious patients who did not receive either ACEI or ARB had higher odds (odds ratio [OR] 5.88, 95% CI 3.7-9.09, P < .001) of in-hospital death and experienced significantly shorter ICU lengths of stay (LOS) (P = .01). There was no significant effect of medication exposure on the time to delirium onset. CONCLUSIONS: While ACEIs and ARBs have been shown to slow the progression of memory loss for patients with Alzheimer's disease, we did not observe a difference in time to delirium onset.

Impact of risk for severe COVID-19 illness on physical activity during the pandemic.

BACKGROUND: Precautions to mitigate spread of COVID-19 such as the closing of exercise facilities impacted physical activity behaviors. Varied risks for severe COVID-19 may have influenced participation in regular physical activity to maintain precautions. OBJECTIVE: Describe differences in the amount and intensity of physical activity between adults at high versus low risk for severe COVID-19 illness during the pandemic. We hypothesized that over 13 months, 1) high-risk adults would have greater odds of inactivity than low-risk adults, and 2) when active, high-risk adults would have lower metabolic equivalent of task minutes (MET-min) than low-risk adults. METHODS: This longitudinal observational cohort study surveyed U.S. adults' demographics, health history, and physical activity beginning March 2020 using REDCap. Using self-report, health history was assessed with a modified Charlson Comorbidity Index and physical activity with the International Physical Activity Questionnaire. Repeated physical activity measurements were conducted in June, July, October, and December of 2020, and in April of 2021. Two models, a logistic model evaluating physical inactivity (hypothesis 1) and a gamma model evaluating total MET-min for physically active individuals (hypothesis 2), were used. Models were controlled for age, gender, and race. RESULTS: The final sample consisted of 640 participants (mean age 42.7 ± 15.7, 78% women, 90% white), with n = 175 categorized as high-risk and n = 465 as low-risk. The odds of inactivity for the high-risk adults were 2.8 to 4.1 times as high than for low-risk adults at baseline and 13 months. Active high-risk adults had lower MET-min levels than low-risk adults in March (28%, p = 0.001), June (29%, p = 0.002), and July of 2020 (30%, p = 0.005) only. CONCLUSIONS: Adults at high risk of severe COVID-19 illness were disproportionately more likely to be physically inactive and exhibit lower MET-min levels than adults at low risk during the early months of the COVID-19 pandemic.

Supervised deep learning with vision transformer predicts delirium using limited lead EEG.

As many as 80% of critically ill patients develop delirium increasing the need for institutionalization and higher morbidity and mortality. Clinicians detect less than 40% of delirium when using a validated screening tool. EEG is the criterion standard but is resource intensive thus not feasible for widespread delirium monitoring. This study evaluated the use of limited-lead rapid-response EEG and supervised deep learning methods with vision transformer to predict delirium. This proof-of-concept study used a prospective design to evaluate use of supervised deep learning with vision transformer and a rapid-response EEG device for predicting delirium in mechanically ventilated critically ill older adults. Fifteen different models were analyzed. Using all available data, the vision transformer models provided 99.9%+ training and 97% testing accuracy across models. Vision transformer with rapid-response EEG is capable of predicting delirium. Such monitoring is feasible in critically ill older adults. Therefore, this method has strong potential for improving the accuracy of delirium detection, providing greater opportunity for individualized interventions. Such an approach may shorten hospital length of stay, increase discharge to home, decrease mortality, and reduce the financial burden associated with delirium.

Relationship between angiotensin-converting enzyme inhibitors and angiotensin receptor blockers prescribing and delirium in the ICU-A secondary analysis.

BACKGROUND: Studies suggest Angiotensin-Converting Enzyme inhibitors (ACEI) and Angiotensin Receptor Blockers (ARB) may slow the decline of memory function in individuals with mild to moderate Alzheimer's disease by regulating migroglial activation and oxidative stress within the brain's reticular activating system. Therefore, we evaluated the relationship between delirium prevalence and being prescribed ACEI and ARB in participants admitted to the intensive care units (ICU). METHODS: A secondary analysis of data from two parallel pragmatic randomized controlled trials was performed. ACEI and ARB exposure was defined as being prescribed an ACEI or an ARB within six months prior to the ICU admission. The primary endpoint was the first positive delirium assessment based on Confusion Assessment Method for the ICU (CAM-ICU) for up to thirty days. RESULTS: A total of 4791 patients admitted to the medical, surgical, and progressive ICU and screened for eligibility for the parent studies between February 2009 and January 2015 from two level 1 trauma and one safety net hospital in a large urban academic health system were included. Delirium rates in the ICU were not significantly different among participants with no exposure to ACEI/ARB (12.6%), or exposure to ACEI (14.4%), ARB (11.8%), or ACEI and ARB in combination (15.4%) in six months prior to the ICU admission. Exposure to ACEI (OR = 0.97[0.77, 1.22]), ARB (OR = 0.70 [0.47, 1.05]), or both (OR = 0.97 [0.33, 2.89]) in six months prior to ICU admission was not significantly associated with odds of delirium during the ICU admission after adjusting for age, gender, race, co-morbidities, and insurance status. CONCLUSIONS: While the impact of ACEI and ARB exposure prior to the ICU admission was not associated with the prevalence of delirium in this study, further research is needed to fully understand the impact of antihypertensive medications on delirium.

Relationship Among Clinically Obtained Biomarkers of Inflammation, Hypercoagulability, and Macrophage Activation, and Delirium in Critically Ill Patients With COVID-19.

Critically ill patients with COVID-19 experience high rates of delirium and coma. Whether delirium occurs through novel mechanisms in COVID-19 is not known. We analyzed the relationship among biomarkers of inflammation (C-reactive protein [CRP]), hypercoagulability (d-dimer), and lung macrophage activation (ferritin), and the primary composite outcome of delirium/coma next day. We also measured associations between biomarkers and next day delirium and coma independently, and delirium severity. DESIGN: Retrospective, observational cohort study. SETTING: ICUs at two large, urban, academic referral hospitals. PATIENTS: All consecutive adult patients admitted to the ICU from March 1, 2020, to June 7, 2020, with COVID-19 with clinical biomarkers and delirium assessments performed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Daily concentrations of CRP, d-dimer, and ferritin were obtained. Coma (assessed by Richmond Agitation-Sedation Scale) and delirium (assessed by Confusion Assessment Method for the ICU/Confusion Assessment Method for the ICU-7) were measured bid. A cohort of 197 ICU patients with COVID-19 were included. Higher d-dimer (odds ratio [OR], 1.57; 95% CI, 1.17-2.12; p < 0.01) and ferritin quartiles (OR, 1.36; 95% CI, 1.02-1.81; p < 0.01) were associated with greater odds of the composite outcome of delirium/coma next day. d-dimer was associated with greater odds of next day delirium (OR, 1.49; 95% CI, 1.14-1.94; p < 0.01) and coma independently (OR, 1.52; 95% CI, 1.08-2.14; p = 0.017). Higher ferritin quartiles were associated with greater odds of next day delirium (OR, 1.33; 95% CI, 1.04-1.70; p = 0.026) and coma independently (OR, 1.59; 95% CI, 1.14-2.23; p < 0.01). Higher CRP quartiles were associated with coma (OR, 1.36; 95% CI, 1.03-1.79; p = 0.030) and delirium severity the next day (ß = 0.30; se, 0.07; p ≤ 0.01). CONCLUSIONS: Our hypothesis-generating study found d-dimer and ferritin were associated with delirium/coma the following day, as well as delirium and coma independently. CRP was associated with next day coma and delirium severity. Larger studies to validate these results are needed.

Nonpharmacological Cognitive Impairment Prevention Interventions in Older Adults Undergoing Cardiac Surgery: A Systematic Review.

BACKGROUND: More than 1 million individuals undergo cardiothoracic surgery for coronary artery bypass graft or valve repair/replacement annually in the United States. There is an increased risk of developing serious cognitive impairment post cardiothoracic surgery. Pharmacological interventions and surgical techniques were associated with improvements in cognitive function in previous systematic reviews. However, a gap in the literature exists regarding how nonpharmacological interventions can mitigate cognitive impairment in adults undergoing cardiac surgery. OBJECTIVE: The aim of this study was to explore the effectiveness of nonpharmacological interventions to reduce the detrimental effects of cardiac surgery on cognitive function in patients after cardiothoracic surgery. METHODS: CINAHL, MEDLINE, PubMed, EMBASE, PsycINFO, and Web of Science databases were searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from January 2011 to February 2022. RESULTS: Nineteen studies were included in this review. Researchers defined cognitive impairment differently across studies. Various interventions were used to reduce cognitive impairment post cardiothoracic surgery, with the most common being remote ischemic limb conditioning. The interventions used to reduce cognitive impairment were heterogeneous in outcomes, measurements, and time of assessment, but only 2 interventions were associated with a reduction in cognitive impairment. CONCLUSIONS: This review is a unique synthesis of the quality of interventions that address broader components of cognition. Researchers used various interventions to reduce cognitive impairment; the outcomes, instruments, and time interval for measurements were heterogeneous. Researchers should conduct future studies at multiple time intervals, using a comprehensive measure of cognitive impairment to better understand the impact of cognitive impairment interventions postoperatively.

Delirium detection using GAMMA wave and machine learning: A pilot study.

Delirium occurs in as many as 80% of critically ill older adults and is associated with increased long-term cognitive impairment, institutionalization, and mortality. Less than half of delirium cases are identified using currently available subjective assessment tools. Electroencephalogram (EEG) has been identified as a reliable objective measure but has not been feasible. This study was a prospective pilot proof-of-concept study, to examine the use of machine learning methods evaluating the use of gamma band to predict delirium from EEG data derived from a limited lead rapid response handheld device. Data from 13 critically ill participants aged 50 or older requiring mechanical ventilation for more than 12 h were enrolled. Across the three models, accuracy of predicting delirium was 70 or greater. Stepwise discriminant analysis provided the best overall method. While additional research is needed to determine the best cut points and efficacy, use of a handheld limited lead rapid response EEG device capable of monitoring all five cerebral lobes of the brain for predicting delirium hold promise.

Minimizing Post-Intensive Care Syndrome to Improve Outcomes for Intensive Care Unit Survivors.

TOPIC: Post-intensive care syndrome is a collection of symptoms that more than half of patients who survive a critical illness, and their family caregivers, experience after the illness. Those symptoms include weakness/ fatigue, sleep disturbances/insomnia, cognitive dysfunction, posttraumatic stress disorder, other mental health conditions, and a lack of effective coping strategies. CLINICAL RELEVANCE: To minimize the risk of a patient developing post-intensive care syndrome, intensive care unit nurses must adopt practices that reduce the severity of disability and optimize patient outcomes. They must also advocate for patients who need additional expert care. PURPOSE: To describe interventions that critical care nurses can implement to minimize a patient's risk for post-intensive care syndrome. CONTENT COVERED: This article describes patients who have a high risk of developing post-intensive care syndrome and interventions that are within nurses' purview.

Rapid Handheld Continuous Electroencephalogram (EEG) Has the Potential to Detect Delirium in Older Adults.

BACKGROUND: Delirium-related biochemical derangements lead to electrical changes that can be detected in electroencephalographic (EEG) patterns followed by behavioral signs and symptoms. Studies using limited lead EEG show a large difference between patients with and without delirium while discriminating delirium from other causes. Handheld rapid EEG devices may be capable of detecting delirium before symptom onset, thus providing an objective physiological method to detect delirium when it is most amenable to interventions. OBJECTIVE: The aim of this study was to explore the potential for rapid EEG to detect waveform pattern changes consistent with delirium status. METHODS: This prospective exploratory pilot study used a correlational design and mixed models to explore the relationships between handheld portable EEG data and delirium status. RESULTS: While being under powered minimized opportunities to detect statistical differences in EEG-derived ratios using spectral density analysis, sleep-to-wake ratios tended to be higher in patients with delirium. CONCLUSIONS: Limited lead EEG may be useful in predicting adverse outcomes and risk for delirium in older critically ill patients. Although this population is at the highest risk for mortality, delirium is not easily identified by current clinical assessments. Therefore, further investigation of limited lead EEG for delirium detection is warranted.

Understanding Disorders of Consciousness: Opportunities for Critical Care Nurses.

BACKGROUND: Disorders of consciousness are powerful predictors of outcomes including mortality among critically ill patients. Encephalopathy, delirium, and coma are disorders of consciousness frequently encountered by critical care nurses but often classified incorrectly. OBJECTIVE: To provide a greater understanding of disorders of consciousness and to provide standardized assessments and nursing interventions for these disorders. METHODS: A literature search was conducted by using the terms consciousness, mental status, awareness, arousal, wakefulness, assessment, disorders of consciousness, delirium, encephalopathy, coma, vegetative state, and minimal consciousness. Articles were published in the past 10 years in CINAHL and PubMed. Articles were excluded if they were not in English or directly related to caring for patients with a disorder of consciousness. The remaining 142 articles were evaluated for inclusion; 81 articles received full review. RESULTS: A disorder of consciousness signifies that the threshold for compensation has been surpassed with potentially irreversible damage. Altered thalamocortical interactions and reduced cortical activity impair communication networks across the various parts of the brain, causing a disturbance in consciousness. DISCUSSION: The cue-response theory is a model that describes the process and impact of nursing care on recovery from acute brain injury. Appropriate standardized assessments and interventions must be used to manage altered levels of consciousness in critically ill patients. CONCLUSIONS: Paying close attention to neurological changes and monitoring them with standardized assessments are critical to implementing early measures to prevent complications.

Increasing the Effectiveness of Targeted Temperature Management.

TOPIC: Targeted temperature management and therapeutic hypothermia are essential components of the multimodal approach to caring for compromised patients after cardiac arrest and severe traumatic brain injury. CLINICAL RELEVANCE: The continuously evolving science necessitates summation of individual facets and concepts to enhance knowledge and application for optimally delivering care. Targeted temperature management is a complex therapy that requires fine-tuning the most effective interventions to maintain high-quality targeted temperature management and maximize patient outcomes. PURPOSE: To describe the underlying pathophysiology of fever and the importance of manipulating water temperature and of preventing and treating shivering during that process. CONTENT COVERED: This article discusses nursing considerations regarding the care of patients requiring targeted temperature management that are necessary to improve patient outcomes.

Hospital value-based purchasing: How acute care advanced practice nurses demonstrate value.

ABSTRACT: Hospital value-based purchasing (HVBP) is a budget neutral initiative from the Centers for Medicare & Medicaid Services designed to adjust the hospital payment system based on health care quality data. Hospital value-based purchasing is designed to promote improved clinical outcomes and better patient experience in the acute care setting. Advanced practice registered nurses (APRNs) in the acute care setting are instrumental to the success of health care institutions under the current payer model in the United States health care system. When APRNs use their advanced knowledge and leadership skills to champion quality improvement and patient experience projects, they may increase financial reimbursement within the HVBP system, thus demonstrating value to the health care institution. Four basic steps could help APRNs demonstrate value to the organization, understand the standard, evaluate your performance compared with the standard, identify opportunities, and implement projects or participate in projects. This article provides a broad overview of the HVBP structure and describes how APRNs can positively influence performance measures, thereby potentially increasing hospital reimbursement.

Calming the Agitated Patient: Providing Strategies to Support Clinicians.

Agitation is a symptom of many medical and psychiatric disorders that can manifest along a spectrum of severity. Agitation often delays treatment onset, potentially impacting morbidity and mortality, and may require emergency interventions. Management of acute agitation centers around three main goals: early recognition and treatment of the underlying etiology, rapid control of the behavior, and prevention of harm to the patient and personnel. Nurses should increase use of validated techniques, including frequent and sufficient reality orientation, validation therapy, and strategies that improve the individual's quality of life.

Engaging Bedside Nurse in Research and Quality Improvement.

Nurses are expected to participate in research and scholarly inquiry; despite ongoing attempts, the practice-research gap continues to be fraught with significant barriers. System strategies have not addressed concerns at the individual nurse level. Given the implications on quality and safety, focusing on identification of individual nurse strategies should be an important focus of attention for nursing leaders and researchers. This article seeks to describe barriers, potential solutions, and implications for nurse leaders.

Delirium Screening of Patients on a Neuroscience Step-Down Unit.

This project aimed to identify patients who had experienced a stroke and were at risk for delirium earlier, and implement evidence-based protocols to reduce overall length of stay and mortality. Nurses were motivated to perform screening and implement strategies that benefit patients who had experienced acute stroke. Results suggest early identification and treatment of delirium, use of prevention strategies, and treatment of the underlying etiology can improve patient outcomes and reduce cost of care.

Using a Behavioral Response Team on Non-Psychiatric Nursing Units.

Negative behaviors often are directed toward nursing staff in verbal or physical assaults. Nursing staff on non-psychiatric units may not be prepared to manage such situations and need additional support. Behavioral Emergency Response Teams (BERTs) have been effective in supporting nursing staff faced with patients exhibiting these behaviors.

A Review of Neuronal Pathways Associated With Consciousness.

ABSTRACT: INTRODUCTION: Accurate communication of information regarding fluctuations in level of consciousness is critical. It is, important for nurses to understand terms related to consciousness to appropriately assess and implement plans of care. CONTENT: Although the neurobiology of consciousness is complex and multifaceted, consciousness can be conceptualized as having 2 distinct but interrelated dimensions: arousal and awareness. The different levels of consciousness are thought to fall on a continuum ranging from being fully awake to coma. CONCLUSION: This article focuses on the terms of consciousness, awareness, and arousal along with nursing implications where appropriate.

Delirium Tremens in the Older Adult.

INTRODUCTION: Caring for patients experiencing alcohol withdrawal syndrome can be challenging. Patients 65 and older are at increased risk for alcohol withdrawal syndrome related complications. The higher prevalence of co-morbidities, including cognitive impairment, longer drinking history and greater sensitivity to alcohol withdrawal syndrome treatment are the result of decreased ability of the brain to adapt to stressors such as illness, trauma, or surgery. DELIRIUM TREMENS: Symptoms may appear earlier from the last drink and present with a wide range of symptoms. The most effective interventions require high-quality nursing care delivery to prevent, decrease the severity and shorten the duration of delirium. NURSING IMPLICATIONS: Strategies that help minimize these challenges starts with obtaining the patient's selfreport of their alcohol use history. Nurses should be diligent in their monitoring for signs of active alcohol withdrawal. Screening and assessment tools such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised should guide pharmacological management. To support nurses in identifying delirium tremens, this manuscript seek to describe the underlying pathophysiology, key assessment components and nursing management of delirium tremens in the older adult.

Sedation selection to reduce delirium risk: Why dexmedetomidine may be a better choice.

ABSTRACT: In 2018, the Society of Critical Care Medicine published the Pain Agitation Delirium Immobility and Sleep Disruption guidelines that recommend protocol assessment-based pain and sedation management. Since the publication of these guidelines, multiple studies and meta-analyses have been conducted comparing sedative options in the Intensive Care Unit (ICU) setting including dexmedetomidine and propofol. Sedatives are on a continuum when it comes to delirium risk. Propofol, like benzodiazepines, causes changes in sleep patterns by suppressing the rapid eye movement sleep stage not seen with dexmedetomidine, worsening the ICU patient's already poor sleep quality. This reduction in sleep quality increases the risk of delirium. As patient advocates, advanced practice nurses play a vital role in minimizing risk of patient harm. Sedative use and management are areas of opportunity for nurses to minimize this risk. When sedatives are needed, daily sedation vacations should be conducted to re-evaluate the minimum required dose. These practices can reduce sedation risks for delirium and allow for bedside screening and early detection.