Il delirium nei reparti ad alta intensività

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1 PSICOGERIATRIA: IL DELIRIUM NEI DIVERSI SETTING Il delirium nei reparti ad alta intensività Giuseppe Natalini Terapia Intensiva Fondazione Poliambulanza Brescia

2 L'anziano in Terapia Intensiva Rapporto Progetto PROSAFE Anno %

3 le risposte della tecno-medicina al delirium

4 La dimesione del problema 20% 1 65% 1 15% 1 Giornate di degenza con delirium: 6% (10% 1 ) Wøien H et al. The incidence of delirium in Norwegian intensive care units; deep sedation makes assessment difficult. Acta Anaesthesiol Scand 2012; online Oct 17. 1) dati personali

5 Durata degenza Ely EW et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291: Thomason JW et al. Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients. Crit Care 2005; 9:R375-81

6 mortalità Shehabi Y, Riker RR, Bokesch PM, Wisemandle W, Shintani A, Ely EW. Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients. Crit Care Med 2010; 38: ly EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, Inouye SK, Bernard GR, Dittus RS. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004; 291:

7 Danni cognitivi a lungo termine Girard TD, Jackson JC, Pandharipande PP, Pun BT, Thompson JL, Shintani AK, Gordon SM, Canonico AE, Dittus RS, Bernard GR, Ely EW. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med 2010; 38:

8 In sintesi... Il delirium in Terapia Intensiva: È frequente Aumenta degenza Aumenta mortalità Disturbi cognitivi a lungo termine

9 Il trattamento del delirium

10 Skrobik YK et al. Olanzapine vs haloperidol: treating delirium in a critical care setting. Intensive Care Med 2004; 30: Devlin JW et al. Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, double-blind, placebo-controlled pilot study. Crit Care Med 2010; 38:

11 van Eijk MM et al. Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: a multicentre, double-blind, placebo-controlled randomised trial. Lancet. 2010; 376:

12 Prevenire il delirium I FARMACI

13 Wang W et al. Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: a randomized controlled trial. Crit Care Med 2012; 40:731-9

14 Girard TD et al. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: The MIND randomized, p lacebocontrolled trial. Crit Care Med 2010; 38:

15 Prevenire il delirium INTERVENTI NON FARMACOLOGICI

16 Salluh JI et al. Delirium epidemiology in critical care (DECCA): an international study. Crit Care 2010;14: R210 Pandharipande P et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology 2006;104):21-6 Ely EW et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004; 291:

17 van den Boogaard M et al. Development and validation of PRE-DELIRIC (PREdiction of DELIRium in ICu patients) delirium prediction model for intensive care patients: observational multicentre study. BMJ 2012;344:e420

18 Van Rompaey B et al. Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care 2009;13:R77

19 Van Rompaey B et al. Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care 2009;13:R77

20 Strategia di riorientamento Colombo R et al. A reorientation strategy for reducing delirium in the critically ill. Results of an interventional study. Minerva Anestesiol 2012; 78:

21 Strategia di riorientamento Colombo R et al. A reorientation strategy for reducing delirium in the critically ill. Results of an interventional study. Minerva Anestesiol 2012; 78:

22 Strategia di riorientamento Età: HR 1.03, [95% CI: ], p=0.001 Midazolam + oppioide: HR 2.15, [95% CI: ], p=0.02 Riorientamento: HR 0.50, [95% CI: ], p=0.03 Colombo R et al. A reorientation strategy for reducing delirium in the critically ill. Results of an interventional study. Minerva Anestesiol 2012; 78:

23 Rispetto del sonno notturno Van Rompaey B et al. The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlledtrial in intensive care patients. Crit Care 2012; 16:R73

24 Terapia fisica ed occupazionale precoce Esercizi assistiti o indipendenti in posizione supina Mobilizzazione attiva nel letto Partecipazione nelle Activities of Daily Living Esercizi per l'indipendenza funzionale Trasferimento letto-poltrona Deambulazione assistita Schweickert WD et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373:

25 Terapia fisica ed occupazionale precoce Schweickert WD et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373:

26 Terapia fisica ed occupazionale precoce Schweickert WD et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373:

27 Prevenzione del delirium in Terapia Intensiva o I farmaci sono inutili o dannosi o Sono efficaci gli interventi non farmacologici: o Riposo notturno o Strategie di riorientamento o Terapia fisica ed occupazionale precoce

28 le risposte della tecno-medicina al delirium