What is the best approach to manage Intensive Care Unit (ICU) psychosis?

Management of ICU Delirium (Not "ICU Psychosis")

The term "ICU psychosis" is a dangerous misnomer that should be abandoned—what clinicians observe is delirium, a medical emergency requiring systematic identification of underlying organic causes and evidence-based nonpharmacologic interventions as first-line management. 1, 2

Terminology Matters

The concept of "ICU psychosis" falsely implies a unique psychiatric syndrome caused by the ICU environment, when in reality these patients have delirium with identifiable organic causes that require prompt investigation and reversal 2. This misnomer impedes standardized communication, reduces clinical vigilance for underlying medical causes, and delays appropriate treatment 2. Delirium in the ICU is associated with increased mortality, prolonged ICU and hospital length of stay, and development of post-ICU cognitive impairment 1.

First-Line Approach: Nonpharmacologic Interventions

Early mobilization should be performed whenever feasible to reduce both incidence and duration of delirium 1. This is a strong recommendation based on solid evidence and directly impacts morbidity and mortality outcomes.

Environmental Optimization (All patients should receive):

• Optimize sleep-wake cycles by controlling light and noise, clustering patient care activities, and decreasing nighttime stimuli 1
• Provide visible clocks and calendars for reorientation 3
• Ensure adequate analgesia before administering sedatives 1, 4
• Minimize causative medications, particularly benzodiazepines 1
• Frequent patient reorientation 4

Sedation Strategy to Prevent/Reduce Delirium

Target light sedation levels using daily sedation interruption or light sedation protocols in mechanically ventilated patients 1. Light sedation reduces mechanical ventilation duration, ICU length of stay, and delirium incidence 4.

Sedative Choice Matters:

• For mechanically ventilated patients requiring sedation: Use dexmedetomidine rather than benzodiazepine infusions 1, 4
• Benzodiazepines are a risk factor for developing delirium 1
• Dexmedetomidine (loading 1 μg/kg over 10 minutes, then 0.2-0.7 μg/kg/hr) reduces delirium duration compared to benzodiazepines 1, 4
• Monitor for bradycardia and hypotension with dexmedetomidine 4
• Use analgesia-first sedation approach 1

Pharmacologic Treatment of Established Delirium

Do NOT use haloperidol or atypical antipsychotics for delirium prevention—there is no evidence they reduce incidence or duration 1.

When Delirium is Present:

• No published evidence supports haloperidol for reducing delirium duration 1
• Atypical antipsychotics may reduce delirium duration (weak evidence, grade C) 1
• Do NOT use rivastigmine—this is contraindicated 1
• Avoid antipsychotics in patients at risk for torsades de pointes (baseline QTc prolongation, medications prolonging QTc, history of this arrhythmia) 1

For Delirium Unrelated to Alcohol/Benzodiazepine Withdrawal:

Use continuous IV dexmedetomidine rather than benzodiazepine infusions for sedation to reduce delirium duration 1.

Systematic Monitoring

Routine monitoring for delirium using validated bedside instruments is recommended for all adult ICU patients 1. ICU personnel frequently underestimate delirium presence, particularly hypoactive delirium 1, 5. Validated scales should be used to objectively quantify symptoms 1.

Identify and Treat Underlying Causes

Delirium is caused by organic stressors on the central nervous system, not the ICU environment itself 2. Investigate for:

• Metabolic disturbances and electrolyte imbalances 3
• Infections 3
• Medication effects or withdrawal syndromes 1, 3
• Vascular disorders 3
• Endocrine disorders 1
• Hypoxia or other physiological derangements 5

Risk Factors to Recognize

Four baseline risk factors significantly predict ICU delirium: preexisting dementia, history of hypertension, history of alcoholism, and high severity of illness at admission 1. Coma is an independent risk factor 1.

Critical Pitfalls to Avoid

• Never use lorazepam continuous infusions in ICU patients—risk of propylene glycol toxicity 4
• Do not abruptly discontinue sedatives after prolonged use; taper over several days to prevent withdrawal 4
• Avoid dexmedetomidine loading doses in hemodynamically unstable patients 4
• Do not assume environmental factors alone cause delirium—always search for organic causes 2
• Recognize that "as needed" antipsychotic orders place inappropriate burden on nursing discretion without evidence of benefit 5