Non-Pharmacological Treatment and Anti-Psychotic Medication in Reducing Psychosis in the ICU
Despite the great milestones that have been made in the treatment of critically ill patients, clinical psychosis is still one of the greatest barriers in ensuring success. In fact, a significant number of patients who experience psychosis while in ICU never fully recover. Categorized with disturbances in cognition, hallucinations, impaired insight, and delusions, psychosis is a term that describes defects in normal behavior. Delirium, which is one of the major psychosis problems that occurs in ICU patients, has symptoms such as disturbance in cognition, perception, and consciousness. It is a serious ailment, and its effects normally result in long-term sequelae, especially cognitive and functional decline. In light of this, this paper aims at investigating and evaluating the best treatment for between non-pharmacological and anti-psychotic in reducing psychosis in patients who are in the ICU.
Keywords: Delirium, Non-Pharmacological, Anti-psychotic, ICU
Non-Pharmacological Treatment and Anti-Psychotic Medication in Reducing Psychosis in the ICU
Clinical psychosis is one of the leading cause of mortality in ICU patients. While great efforts are been made in understanding and treating this serious ailment, doctors are normally faced with a challenge of identifying the most appropriate treatment approach between non-pharmacological and anti-psychotic medication. Until recently, delirium in the ICU was referred to as clinical psychosis. Psychosis, a term that refers to defects in normal behavior, is a syndrome characterized by disturbances in cognition, hallucinations, impaired insight, and delusions. Although this condition is reversible, often it is always undiagnosed by the healthcare officers. This disease is highly prevalent in intensive care unit patient occurring in 20%-50% of non-intubated patients and 60-80% of patients who are receiving medical ventilation. Worse still, patients who experience deliriums have a higher mortality rate, as well as higher hospital bills.
Delirium is normally presented with symptoms of hyperactive, hypoactive, and mixed delirium. Hyperactive delirium refers to a state of restlessness and agitation, hypoactive delirium is characterized by reduced activity, lethargy, and apathy. Finally, mixed delirium normally has symptoms of both hyperactive and hypoactive delirium, which occur intermittently. Whereas hyperactive delirium is easy to recognize, hypoactive and mixed delirium are often unrecognized (Fernandez, Arthur, & Fleming, 2013). Worse still, delirium is common in the hypoactive and mixed case than in the hyperactive status. As a result, there is usually a high chance of under treatment for hypoactive and mixed delirium. Moreover, patients with hypoactive delirium can often be misdiagnosed as suffering from depression.
Use of Medication in Management of Delirium
In a review of a research done by Pandharipande et al. it was found that sedatives and analgesics have an increased risk factor for patient’s transition to delirium. In the review, one hundred and ninety eight ICU mechanically ventilated patients showed that lorazepam was a risk factor in their daily transition to delirium. This analysis was conducted using a Markov regression (Mattar, Chan, & Childs, (2013). Nonetheless, other sedatives and analgesics such as midazolam, propofol, fentanyl, and morphine did not have any significant effect towards the transition to delirium. However, they still had a trend towards being significant.
Similarly, sedatives and analgesics showed to have a high-risk factor in patients admitted to trauma ICU (TICU) and surgical ICU (SICU). In particular, midazolam showed to be a strong risk factor in the transition to delirium. However, opiates such as fentanyl showed increased chances in the development of delirium to SIVU patients’ but not in the TICU. In addition, morphine showed a lower risk of delirium. As a result, the research was inconclusive on the impact of opiates as a risk factor for delirium.
In a review of a research done by Agarwal et al. of eight two burns patients who were admitted in ICU, benzodiazepines were found to be a risk factor in the development of delirium. However, contrary to the results found in the research by Pandharipande et al., methadone and opiates were found to have a protective effect since they lowered the chances of getting delirium (Mattar, Chan, & Childs, (2013). Nevertheless, the sample size used by Agarwal et al. was small and could have led to the differences in the research findings.
A review of a research conducted by Milbrandt et al., 2005 found that haloperidol was associated with a decrease in mortality rates among mechanically ventilated ICU patients. In the study, 83 patients received haloperidol while 906 others did not. The 989 patients who remained mechanically ventilated for 48 hours were evaluated for mortality and the length of stay in ICU. Overly, the outcomes showed there was no significant difference in the length of stay in the ICU (Mattar, Chan, & Childs, (2013). However, haloperidol use was linked to a reduction in mortality as compared to non-haloperidol use.
In a systematic review that was conducted to find the effectiveness of the use of dexmedetomidine an adjuvant to benzodiazepine-based therapy when decreasing the severity of delirium caused by alcohol withdrawal among ICU patients, dexmedetomidine was found to be a more effective than benzodiazepine-based therapy. While the use of benzodiazepine is effective in treating alcohol dependents who are experiencing withdrawal syndromes, this method is often ineffective for ICU patients due to the imbalance in the inhibitory and excitatory neurotransmitters. The research used a three-step strategy and included studies published since 1997. Databases such as Ovid/Medline, Cochrane, Joanna Biggs Institute and others were used in the data collection process. Overly, a meta-analysis of three studies using CIWA showed a decrease in the CIWA scores. The confidence interval (C) was ‐6.24 to ‐4.16, p <0.0001 while the weighted mean difference (WMD) was -5.2. Similarly, the RASS scores indicated an improvement with the use of the adjunct treatment with dexmedetomidine as compared to using benzodiazepine-based therapy alone.
Due to the various negative effects associated with pharmacological treatment, various non-pharmacological approaches have been established to address the emotional needs that lead to the development of ICU delirium. Overly, these tactics are aimed at addressing the sensory, cognitive, and emotional factors. On the sensory factors, massage therapy is mainly used to treat chronic pain by stimulating the A-δ nerve fibers, which inhibit pain transmission. Cognitive factors work through the use of sensory and procedural information and behavioral techniques to distract individuals from the pain (Rhonda, Maria, Venita, 2011). Specific methods include music therapy, cognitive behavioral techniques, biofeedback, and muscle relaxation. Finally, emotional techniques aim at promoting a positive attitude on the patient on their ability to overcome the ailment. This method uses tactics such as stress management, CBT, and putting the patient in an environmentally friendly environment.
The use of non-pharmacological treatment, in particular, the relaxation training was found to be effective at reducing headache intensity. A review of a research that was conducted to evaluate the effectiveness of non-pharmacological pain management in relieving chronic pain for children and adolescents found that mixed models of psychological treatment were effective in reducing anxiety related pain. Eight studies were conducted to analyze the effectiveness of relaxation training program on headaches. A self-reported 6-point Likert scale was used to measure the effectiveness of the relaxation training.
Finally, an analysis of the use of relaxation training over the use of medication showed a significant reduction in the headache sum. On the contrary, relaxation training did not show any reduction in the use of medication when used for over a period of three weeks (Xue, Watts, & Robertson, 2012). A biofeedback treatment was found to be effective at reducing headache symptoms that had occurred for more than a year. Finally, two studies reported a positive reduction in pain when using cognitive behavioral therapy for over six months. In particular, the studies combined cognitive therapy with sessions of muscle stimulation, muscle relaxation training, and meditation. The studies showed a significant decrease of (p<0.0001) in post-test depression score and (p<0.05) in the anxiety score after six months (Joanna Briggs Institute, 2010). As a result, it was concluded that a mixed model of psychosocial treatment was effective in reducing anxiety related to recurrent pain in ICU patients.
A review of a research conducted by Colombo, Corona, Praga, Minari, Giannotti, and Castelli, 2012 found that patients in ICU experience a lot of sleep disruption. In particular, mechanically ventilated patients experience prolonged bed rest, heavy sedation that normally lead to ICU weakness and delirium. (Hu, Jiang, Chen, Zeng, Chen, Li, Huining, & Evans, 2015). However, the use of physical and occupational therapy in the earliest days have been proved to result in a reduction in sedative-related immobility and reduced incidence of delirium (Gornmesall, Larkin, Lopez, & Aromataris, 2012). Moreover, patients normally wake up to a strange environment without previous recollection of their previous days, weeks, or even months, which is extremely confusing (Dabrow, Renee, & Susan, 2015). In light of this, education and orientation training are essential in enabling them to establish a connection with their current environment.
A review of a multicomponent research conducted by Inouye et al., which targeted sleep deprivation, immobility, disorientation; and visual and hearing impairment showed that there was a 40% reduction in delirium when the interventions were made (Rivosecchi, Smithburger, Svec, Camplbell, & Kane-Gill, 2015). Similarly, a research that was conducted by Marcantonio et al., achieved an 18% reduction in delirium when he introduced a protocol that entailed a geriatric consultation early in the patient’s surgical hip fracture (Xue, Watts, & Robertson, 2012). Overly, combinations of use of various non-pharmacological healthcare methods, as well as medications, have been found to be effective in increasing the healing treatment. Therefore, there is a need to train ICU nurse on the best intervention policies for each case.
While both non-pharmacological and anti-psychotic medications have been found to be effective in the treatment and management of ICU delirium, the former appears to be the most appropriate. To begin with, these intervention practices are low-risk, low-cost, and have proved to be extremely beneficial. Nonetheless, there is a huge challenge in determining the right strategy for its implementation. Moreover, since most anti-psychotic medications have been found to be effective, the use of an evidence-based medical approach with a combination of non-pharmacological methods is the most effective. Consequently, ICU nurses should have a multidisciplinary team to assist them in determining the most appropriate intervention strategy.
Colombo R, Corona A, Praga F, Minari C, Giannotti C, Castelli A, et al. (2012) A reorientation strategy for reducing delirium in the critically ill. Results of an interventional study. Minerva Anestesiol. 78 (9):1026–33.
This research is informed by the fact that in most cases, ICU patients normally wake up into a strange environment with different noises, settings, and various physical and mental pain. Therefore, this paper aims at evaluating the impact of having a timely reorientation of ICU patients to their new world in order to minimize the risks of delirium. Further, it makes a conclusion on both the effectiveness and the most appropriate strategy that health care officers should use to minimize instances of delirium among these patients.
Dabrow, W., Renee, G., & Susan, W. (2015). The use of dexmedetomidine as an adjuvant to benzodiazepine‐based therapy to decrease the severity of delirium in alcohol withdrawal in adult intensive care unit patients: a systematic review. JBI Database of Systematic Reviews and Implementation Reports. 3 (1), 224-252.
This article evaluates on the effectiveness of using dexmedetomidine as an adjuvant to benzodiazepine‐based therapy to minimize the impacts of delirium caused by withdrawal symptoms on alcohol dependent individuals. Importantly, this paper evaluates on the use of an alternative medication and its effectiveness in treating critically ill patients. In addition to this, the paper gives an important analysis on the need for using an evidence-based approach to make healthcare decisions such as when to use alternative medicines. Moreover, it also checks on the effectiveness of using a combination of both pharmacological and non-pharmacological treatment methods.
Fernandez, R., Arthur, B., & Fleming, R. (2013). Effect of doll therapy in managing challenging behaviors in people with dementia: A systematic review protocol. JBI Database of Systematic Reviews & Implementation Reports, 11 (9), 120-132.
The article reviews on the effectiveness of using doll therapy, which is a nonpharmacological approach in managing dementia and delirium in critically ill patients. On one side, it evaluates the comfort and attachment brought by presence of toys in an individual’s room. Moreover, it also checks if there is an attachment brought by the person always having a toy around him. Basically, the therapy is based on visual therapy. On the other hand, it also evaluates if the presence of a doll makes the person to feel undermined or too sick to recover, which could negatively affect his/her treatment.
Gornmesall, J., Larkin, D., Lopez, V., & Aromataris, E. (2012). Non-pharmacological interventions for cancer-related fatigue in men treated for prostate cancer. JBI Best Practice, 16 (12), 1-4.
This article evaluates on the impact of non-pharmacological methods in treating men who have prostate cancer. Specifically, this research reviews on the effectiveness of nonpharmacological treatments in minimizing the pain and distresses experienced by individuals with cancer. Individual with cancer normally experience excruciating pain in the treatment process such as chemotherapy, as well as from the disease itself. Moreover, it also checks on the sustainability and availability of this method in improving the quality of life of these individuals when undergoing the treatment, when they are recovering, and finally after full recovery.
Hu, R., Jiang, X., Chen, J., Zeng, Z., Chen, Y., Li, Y., Huining, X., & Evans, W. (2015). Non-drug treatments for promoting sleep in adults in the intensive care unit. Cochrane Database of Systematic Reviews, 10 (8808), 1-111.
This research evaluates on the effectiveness of using nonpharmacological treatment to promote sleep in adults who are in the ICU. In most cases, patients in the ICU do not get enough sleep, which leads to increased chances of getting delirium. Moreover, the lack of sleep slows their rate of healing. In light of this, this article makes an in depth analysis on the effectiveness of the use of various nonpharmacological methods such as music therapy, noise reduction, social support, and complementary therapies to minimize sleep disturbance on ICU patients.
Mattar, I., Chan, M., & Childs, C. (2013). Risk factors for acute delirium in critically ill adult patients: A systematic review. ISRN Critical Care, 2013(910125, 1-10.
Basically, this article makes a detailed review of the various researches on the risk factors used to treat delirium in ICU patients. Specifically, the paper focuses on the effects of sedatives and analgesics risk factors. Notably, this paper provides a detailed review of the effectiveness of these medications in the treatment of various causes of ICU. In particular, the paper checks on the trauma ICU (TICU) and surgical ICU (SICU). In addition to the above, the paper evaluates on other risk factors such as old age in the treatment of ICU delirium. Consequently, this paper is able to give an in depth review of the effectiveness of each treatment approach.
Rhonda, D., Maria, M., Venita, E. (2011). Comparison of educational interventions for mental health consumers receiving psychotropic medication. Joanna Briggs Institute Reports, 2(1), 1-44.
This paper gives a review of the various medical approaches used to treat patients who have psychotropic diseases. Specifically, the paper makes an in depth review of the need for training in prevention medical overdose, misdiagnosis, under treatment, and negligence. Moreover, it checks on the effectiveness of using an evidence-based approach in the treatment of delirium using nonpharmacological methods. It also evaluates on the need of using a structured approach in the nonpharmacological treatment of patients. Basically, this approach will ensure that ICU nurses are able to identify the most appropriate method to use when treating a patient. Similarly, the use evidence-based approach in the treatment of patients will enable doctors to evaluate on the effectiveness of various medications. Further, it also evaluates the education frequency, methods, and extent of the learning in influencing the provision of high quality care.
Rivosecchi, M., Smithburger, L., Svec, S., Camplbell, S., & Kane-Gill, L. (2015). Nonpharmacological interventions to prevent delirium: An evidence-based systematic review. American Association of Critical Care Nurse, 35 (1), 39-50.
This article provides a review of the impact of nonpharmacological interventions in the treatment of delirium in ICU patients. It provides a review of researches that are in the database of MEDLINE and EMBASE. The paper makes an in-depth analysis of the effectiveness of haloperidol in the treatment of ICU delirium. Based on an evidence-based approach, the research makes a conclusion on the most appropriate intervention strategy in the treatment of this ailment. In addition, the paper evaluates the effectiveness of early mobilization in nonpharmacological approach to discuss about pain, delirium, and agitation as presented in the American College of Critical Care Medicine. Moreover, the paper discusses and reviews the importance of setting up a nonpharmacological protocol to prevent the occurrence of delirium. Specifically, the paper checks on the importance of medics understanding the risk factors and addressing these situations. Overly, this paper provides a detailed and well thought review on nonpharmacological treatment in the prevention of delirium in ICU patients.
Joanna Briggs Institute. (2010). Effectiveness of non-pharmacological pain management in relieving chronic pain for children and adolescents, Best Practice, 14 (17), 1-4.
This article reviews on the effectiveness of using both non-pharmacological and pharmacological methods in treating patients suffering from cancer. In addition, it reviews on the effectiveness of using these methods jointly depending on the severity of the chronic pain. Basically, it evaluates on cases where the pain has occurred for only a few weeks, one that has been present for less than 6 months, and one that has occurred in more than 6 months. Based on the review of the research, it is able to make a conclusion on the most appropriate treatment method.
Xue, Y., Watts, R., & Robertson, J. (2012). Non-pharmacological management of fever in otherwise healthy children. JBI Best Practice, 16(7), 1-4.
This article evaluates on the effectiveness of treating fever using pharmacological and non-pharmacological methods. In addition, it also analyzes on the rate of acceptance of the various treatment methods by parents. Therefore, it incorporates the interest of all stakeholders when analyzing the most appropriate treatment method. Finally, based on the results of the research, it is able to make a conclusion on the most appropriate treatment method.