Gina Johnson
Delirium is a type of confusion that occurs when the brain becomes overwhelmed. It is often associated with older adults (≥65 years old) in intensive care units (ICUs) and can lead to adverse long-term cognitive, physical, and mental health impairments, as well as early death. Sleep deprivation and delirium are closely linked, with shared clinical characteristics, risk factors, and neurochemical abnormalities. Poor sleep quality, especially during hospitalization, can hinder self-care and recovery, increasing the risk of falls, functional impairment, institutionalization, and even death. While the exact mechanism is not fully understood, it is believed that disruptions in sleep/wake cycles can contribute to delirium, and this relationship is more pronounced in older adults. Therefore, improving sleep quality is recommended as a strategy to reduce the risk of delirium.
| Characteristics | Values |
|---|---|
| Risk factors for delirium | Age, illness severity, orientation, ability to perform simple word or math tests, sleep deprivation, restraints, certain drugs, recent brain surgery, seizures, encephalitis, dehydration, immobility, visual impairment, cognitive impairment, hearing impairment, unmanaged pain, social isolation, end-of-life factors |
| Interventions to reduce delirium risk | Eliminating or substituting deliriogenic medications, revising nighttime routines to avoid interruptions, prescribing melatonin, consults with occupational and speech/language therapists, removing bladder catheters, increasing mobility, improving sleep quality, adjusting mechanical ventilation settings, non-pharmacological interventions, antipsychotics |
| Sleep disturbances and delirium | Coexist, may cause and/or worsen each other, adverse outcomes associated with both in hospital settings, shared characteristics, risk factors, and neurochemical abnormalities |
| Medications and delirium | Sedatives and hypnotics can cause sleep disturbances and are risk factors for delirium, dexmedetomidine associated with decreased incidence of delirium compared to benzodiazepines, GABA agonists, benzodiazepines, and propofol are commonly used for sedation in critically ill patients, opioids may decrease the risk of delirium in patients experiencing pain |
| Delirium characteristics | Confusion, hyperactivity, agitation, aggression, hypoactivity, sleeping during the day, hallucinations, delusions, loss of "filter", reduced facial expressions, reduced responsiveness, apathy, sluggishness, diminished interest in surroundings or self-care |
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What You'll Learn
Sleep deprivation is a risk factor for delirium
Sleep deprivation and delirium are closely linked. Delirium is a type of confusion that occurs when the brain becomes overwhelmed. It is often preventable, and its risk factors can be mitigated. Sleep deprivation is a significant contributor to delirium, and the two conditions frequently coexist.
In a study, 12.6% of patients with an average age of 67 had delirium on hospital admission, and 5.6% developed the condition during their stay. The risk factors for delirium include age, illness severity, orientation, and cognitive ability. Sleep deprivation is a common issue for elderly patients, and it can lead to delirium. In addition to sleep deprivation, the use of physical restraints and certain drugs can also increase the risk of delirium in this demographic.
The Hospital Elder Life Program (HELP) assessed six risk factors for delirium: dehydration, sleep deprivation, immobility, visual impairment, cognitive impairment, and hearing impairment. The program implemented non-pharmacological interventions, such as warm milk, back and shoulder rubs, and relaxing music to improve sleep quality and reduce the need for sedatives. These interventions not only reduced the use of sedative drugs but also lowered the incidence of delirium.
Additionally, certain medications commonly used in ICUs, such as GABA agonists, benzodiazepines, propofol, lorazepam, and midazolam, are known to adversely affect sleep architecture by decreasing slow-wave sleep (SWS) and reducing REM sleep. These medications are also strong independent risk factors for delirium. In contrast, sedation with dexmedetomidine has been shown to result in less delirium compared to other commonly used sedatives.
The relationship between sleep deprivation and delirium is complex and bidirectional, with adverse outcomes observed in hospital settings. Poor sleep quality during hospitalization, especially in older adults, can hinder participation in self-care and rehabilitation activities, increasing the risk of falls, functional impairment, and early death. While the exact mechanism is not fully understood, it is believed that dysregulation of neurochemicals such as acetylcholine and dopamine, which are important for sleep regulation, may play a role in the development of delirium.
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Sedatives and sleep architecture
Sleep disturbances and delirium often coexist, and while a cause-and-effect relationship has not been established, they can likely cause and/or worsen each other. Commonly used sedatives are known to cause abnormalities in sleep architecture and are also known risk factors for delirium. Therefore, exposure to these medications should be minimised, especially in ICU patients, where mechanical ventilation settings should be adjusted to optimise patient-ventilator synchrony.
Sedatives such as propofol and dexmedetomidine have been found to have comparable positive effects on sleep architecture, shifting sleep patterns towards normal in most, but not all, patients. Light sedation with these drugs has been shown to increase the amount of stable sleep and decrease the number of wake intrusions. However, in around 25% of patients, sedation failed to improve sleep.
Benzodiazepines, another commonly used sedative, have been shown to adversely affect sleep architecture by decreasing slow-wave sleep (SWS) and reducing REM sleep. They may also affect sleep by inhibiting melatonin synthesis in the pineal gland. Lorazepam and midazolam, the most commonly used benzodiazepines in the ICU, are strong independent risk factors for delirium.
Opioid analgesics are also commonly used in conjunction with sedatives in ICU patients to decrease pain and aid sedation. They suppress REM sleep and SWS in a dose-dependent manner. Despite these effects on sleep architecture, opioids may improve sleep and decrease the risk of delirium in patients experiencing pain.
Chronic use of sedative-hypnotics has been shown to be detrimental to sleep regulation, disrupting sleep architecture and reducing the time spent in deep sleep (N3) and REM sleep, while increasing light sleep (N2). This may contribute to the link between sedative-hypnotic use and cognitive impairment in older adults.
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The role of melatonin
While a direct causal relationship between sleep deprivation and delirium has not been established, sleep disturbances and delirium frequently coexist and are likely to cause and/or worsen each other. Sleep disorders and delirium are connected, and this is evident in the current preventive strategies for delirium. The Hospital Elder Life Program (HELP) tested by the Yale Delirium Prevention trial assessed six risk factors (dehydration, sleep deprivation, immobility, visual impairment, cognitive impairment, and hearing impairment) at the time of hospital admission. When one of these risk factors was determined to be present, targeted interventions were implemented, including a nonpharmacologic sleep protocol. This protocol not only reduced the need for sedative and hypnotic drugs but also lowered the incidence of delirium.
Melatonin, a pineal gland hormone, has been found to play a crucial role in reducing the risk of delirium in certain patients. It has hypnotic, anti-inflammatory, and neuroprotective effects and is known to modulate the circadian rhythms, sleep, and neurotransmitters. Melatonin disorders and related sleep-wake cycle disturbances are thought to be contributing factors to delirium. Melatonin induces sedation, lowers sedative consumption, and improves average hours of night sleep while reducing fragmented sleep.
Several studies have examined the influence of melatonin on delirium prevention in hospitalized patients. One meta-analysis of 18 studies involving 2137 patients found that melatonin significantly reduced the incidence of delirium in hospitalized medical patients. However, the effectiveness of melatonin in reducing delirium in surgical and intensive care unit (ICU) patients has been less consistent, with some studies showing a reduction in risk for these patients and others showing no significant effect. The greatest benefit of melatonin was observed in reducing the risk of post-operative delirium (49%) and ICU delirium (34%).
Overall, melatonin has been shown to be effective in preventing delirium, especially in hospitalized medical patients, and its role in other patient populations is the subject of ongoing research. Its ability to regulate sleep, modulate circadian rhythms, and provide neuroprotection makes it a promising intervention for reducing delirium risk.
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Non-pharmacological interventions
Sleep deprivation and delirium are closely linked, with shared clinical characteristics, risk factors, and neurochemical abnormalities. Acetylcholine and dopamine, which are important neurochemicals in the regulation of sleep and wakefulness, are dysregulated in people with delirium. Non-pharmacological interventions are recommended to reduce the risk of delirium in patients with sleep disturbances.
The Hospital Elder Life Program (HELP) tested by the Yale Delirium Prevention trial assessed six risk factors (dehydration, sleep deprivation, immobility, visual impairment, cognitive impairment, and hearing impairment) at the time of hospital admission. When one of these risk factors was identified, a dedicated team would implement a targeted intervention. The non-pharmacological sleep protocol included sips of warm milk, back and shoulder rubs, and relaxing music at bedtime. This protocol not only reduced the need for sedative and hypnotic drugs but also lowered the incidence of delirium.
Additionally, non-pharmacological interventions can include:
- Reducing the use of physical restraints, which limit mobility and add to the risk of disorientation.
- Encouraging nursing staff to walk and converse with higher-risk patients three times a day, assisting them with getting out of bed to eat meals, ensuring water is within reach, and reinforcing awareness of time by writing the date on a board in the room and using shades to distinguish day from night.
- Removing bladder catheters, which are another type of tether that limits mobility and increases the risk of disorientation.
- Adjusting mechanical ventilation settings in ICU patients to optimize patient-ventilator synchrony, as this can help improve sleep quality.
- Lowering or eliminating exposure to commonly used sedatives, which can cause abnormalities in sleep architecture and are known risk factors for delirium.
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Delirium in older adults
Delirium is a type of confusion that occurs when the brain gets overwhelmed by a combination of factors. It is often preventable and treatable. Delirium in older adults, particularly those aged 65 and above, has gained substantial attention as a common and significant health issue. This is due to the growing elderly population and the adverse consequences of delirium, such as long-term cognitive, physical, and mental health impairments, as well as increased risk of rehospitalization and premature death. Poor sleep quality, specifically sleep/wake disruption, has been identified as a key modifiable risk factor for delirium in older adults.
The relationship between sleep and delirium is complex and bidirectional, with both conditions potentially causing or exacerbating each other. Sleep disturbances and delirium often coexist, and while a causal link has not been established, they share clinical characteristics, risk factors, and neurochemical abnormalities. Acetylcholine and dopamine, crucial for regulating sleep and wakefulness, are implicated in the development of delirium when dysregulated. Additionally, certain medications commonly used in ICUs, such as GABA agonists, benzodiazepines, propofol, lorazepam, and midazolam, can increase the risk of delirium by adversely affecting sleep architecture and reducing REM sleep.
Non-pharmacological interventions are recommended to prevent and manage delirium in older adults. The Hospital Elder Life Program (HELP), tested by the Yale Delirium Prevention Trial, addressed six risk factors: dehydration, sleep deprivation, immobility, visual impairment, cognitive impairment, and hearing impairment. Their non-pharmacological sleep protocol included warm milk, back and shoulder massages, and relaxing music, which reduced the need for sedatives and lowered delirium incidence. Other general recommendations for preventing delirium include increasing mobility, social connection, and improving sleep quality.
In a hospital setting, delirium prevention strategies may include reducing the use of physical restraints, encouraging patient mobility, providing cognitive stimulation, and optimizing the sleep environment by minimizing interruptions and using melatonin supplements if necessary. Additionally, addressing pain management, ensuring adequate sensory stimulation, and maintaining natural light and sound environment can help reduce the risk of delirium in older adults. While the mechanism is not fully understood, poor sleep quality during hospitalization has been linked to adverse outcomes in this population, including hindered participation in self-care and rehabilitation, increased risk of falls, functional impairment, and premature death.
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Frequently asked questions
Sleep deprivation and delirium are closely linked, with shared clinical characteristics, risk factors, and neurochemical abnormalities. Acetylcholine and dopamine, which are important neurochemicals in the regulation of sleep and wakefulness, are believed to be dysregulated when delirious.
Delirium is a type of confusion that occurs when the brain gets overwhelmed. Risk factors include age, illness severity, orientation, ability to perform simple word or math tests, sleep deprivation, immobility, visual impairment, cognitive impairment, and hearing impairment.
Non-pharmacological interventions are recommended to reduce the risk of delirium. For example, the Hospital Elder Life Program (HELP) tested by the Yale Delirium Prevention Trial included targeted interventions such as sips of warm milk, back and shoulder rubs, and relaxing music when going to sleep. This protocol reduced the need for sedative and hypnotic drugs, which are known risk factors for delirium.
