What is the recommended treatment for Intensive Care Unit (ICU) psychosis?

Treatment of ICU Psychosis (Delirium)

For ICU psychosis (delirium), the recommended first-line treatment is a multicomponent, nonpharmacologic intervention focused on reducing risk factors, improving cognition, and optimizing sleep, mobility, hearing, and vision, rather than routine use of antipsychotic medications. 1

Understanding ICU Delirium

ICU psychosis, more accurately termed ICU delirium, is associated with:

• Increased mortality 1
• Prolonged ICU and hospital length of stay 1
• Post-ICU cognitive impairment 1

Treatment Algorithm

First-Line Approach: Multicomponent Nonpharmacologic Interventions

Implement a bundle of interventions including:

1. Cognitive Orientation Strategies:

   • Regular reorientation
   • Cognitive stimulation
   • Use of clocks and calendars
   • Familiar personal items

2. Sleep Optimization:

   • Minimize light and noise
   • Cluster patient care activities
   • Decrease nighttime stimuli
   • Promote normal day-night cycles 1

3. Sedation Management:

   • Maintain light levels of sedation
   • Use analgesia-first sedation approach
   • Implement daily sedation interruption 1
   • Avoid benzodiazepines when possible 1

4. Early Mobilization:

   • Implement early rehabilitation/mobilization whenever feasible
   • This reduces both incidence and duration of delirium 1

5. Sensory Optimization:

   • Enable use of hearing aids and eyeglasses
   • Reduce sensory deprivation 1

Second-Line Approach: Pharmacologic Interventions

Pharmacologic agents should not be used routinely for ICU delirium, but may be considered in specific circumstances:

1. For significant distress or harmful agitation:

   • Short-term use of haloperidol or atypical antipsychotics may be warranted
   • Discontinue immediately after resolution of distressing symptoms 1
   • Monitor for QT prolongation with antipsychotics 1

2. For mechanically ventilated patients with agitation preventing weaning/extubation:

   • Consider dexmedetomidine rather than benzodiazepines 1
   • Particularly useful for delirium unrelated to alcohol or benzodiazepine withdrawal 1

3. Medications to avoid:

   • Do not use rivastigmine 1
   • Avoid routine use of statins for delirium treatment 1
   • Avoid antipsychotics in patients with QT prolongation, history of Torsades de Pointes, or on other QT-prolonging medications 1

Special Considerations

• Risk factor modification: Address pre-existing dementia, hypertension, alcoholism, and high illness severity, which are associated with increased delirium risk 1

• Medication management: Benzodiazepines may increase delirium risk and should be avoided except in alcohol or benzodiazepine withdrawal 1

• Monitoring: Use validated tools like CAM-ICU or ICDSC to routinely monitor for delirium 1

• Family involvement: Include family in reorientation efforts and care planning 1

Implementation Strategy

The ABCDEF bundle has shown significant benefits:

• A: Assessment and treatment of pain
• B: Both spontaneous awakening and breathing trials
• C: Choice of sedation
• D: Delirium monitoring and management
• E: Early mobility
• F: Family engagement 1

Consistent implementation of this bundle is associated with reduced mortality and more ICU days without coma or delirium 1.

Pitfalls to Avoid

• Overreliance on pharmacologic interventions without addressing environmental and modifiable risk factors
• Using benzodiazepines as first-line sedatives in patients at risk for delirium
• Failing to monitor for delirium regularly using validated tools
• Continuing antipsychotics beyond resolution of acute symptoms
• Neglecting sleep promotion and day-night cycle maintenance

By implementing these evidence-based strategies, ICU delirium can be effectively managed with a focus on improving patient outcomes including mortality, length of stay, and long-term cognitive function.