SCCM Resource Library-New Directions in Delirium Therapy

Video Transcription

Good morning. My name is Christiane Perme and I am a physical therapist at the Houston Methodist Hospital in Houston, Texas.  First of all, I would like to thank the organizing committee for the invitation. It's a great honor for me to have the opportunity to present at this congress today and share  some of my clinical experiences about delirium with all of you. Today, I'm going to be talking about physical therapy and its impact on delirium.  I have no potential financial interests to report and I'm going to start by talking a little bit about my clinical experience with delirium and that is because I have been a  physical therapist practicing in an intensive care unit for the past 30 years. So basically, this is the only clinical setting that I have worked in the past three decades  and I have had an opportunity to care for hundreds of patients during delirium. Now this is a picture that I want to share with you of one of the first patients that  I can remember that I mobilized out of bed on mechanical ventilation with delirium. That was in the early 1990s and what I would like to kind of bring your attention to is  the interdisciplinary communication in order to provide safe care to patients like that. As a physical therapist, there's no way I could possibly do this alone.  So again, having a multidisciplinary team working with those patients to ensure safety, it's very important.  Now delirium, we all know that it's associated with very long-term cognitive and functional deficits.  We also know that the evidence suggests that improved outcomes will occur if we do have early, goal-directed, multi-component, multi-interventional, and multidisciplinary approach.  Having said that, physical therapy in ICU is just one of the key non-pharmacological strategies for both the prevention and the treatment of delirium.  Now it's very interesting that I just said how important physical therapy is for the prevention and treatment of delirium.  However, in this article published in 2016, it's about the association of sleep quality, delirium, and sedation status with daily participation in physical therapy in the ICU.  What this study shows us is that in 327 consecutive patients in a single academic medical ICU,  the results of physical therapy participation on the following day was not associated at all with the perceived sleep quality.  So that means that even if the patients did not sleep very well, they were able to participate with therapy.  However, there was a negative association with continuous sedation infusions, opioid boluses, and delirium, which means that even though the physical therapy really helped  the patients, the patients with delirium were less likely to be able to participate in physical therapy.  So now I would like to kind of bring your attention to the relationship between the physical activity and delirium.  Physical function is vital to maintain an independent life, and we all know that. And we also know that the delirium and physical function are closely related.  In this picture, I'm going to be able to share with you the relationship between physical activity and delirium in three different time points, before, during, and after delirium.  So before delirium, what we need to understand is that there are predisposing factors like impaired physical function and low physical activity that can, you know, lead to delirium,  as well as precipitating factors like immobility and physical restraints that could also lead to delirium.  Now, during delirium, the patients usually show some degree of motor symptoms of delirium. That's why we understand that patients could have a hypoactive or a hyperactive delirium.  In addition to that, another aspect that should be of great concern to all of us is that during delirium, patients have a persistent risk for falls.  After delirium, what happens is that there will be some degree of functional decline associated with delirium, as well a certain degree of disability associated with this  functional decline.  I think that this picture really helps us illustrate really this kind of how close the relationship is between physical activity and delirium.  So now, moving on to physical therapy in ICU. This is nothing new. I know that in the past decade, there's a lot of initiatives to increase the mobility,  increase physical therapy in ICU, but this concept has been around for close to 50 years. Here I'm presenting two references, one in 1972 in the Physical Therapy Journal and the  other one in 1975 in the Chest Journal, both of them really talking about the importance of early mobility of these patients in the ICU, particularly in mechanical ventilation,  and the amazing benefits of such intervention. When we talk about rehab interventions provided by physical therapists in ICU, we know now  that they are safe and feasible, and there are some references that I included. Also, these interventions are associated with decreased duration of mechanical ventilation,  shorter ICU and hospital length of stay, decreased mortality, as well as improved physical and cognitive outcomes, and I also included a couple of references there that relate to  this information. So now going into clinically, what rehab interventions are mostly used by physical therapists in ICU, we could offer those patients in-bed mobility.  So that could be like range of motion exercises, turning side to side, sitting on the side of the bed, and even active exercises using elastic bands or using weights.  So kind of pretty aggressive exercises. We also can offer out-of-bed mobility activities. That would include the patient standing at the bedside, sitting in a regular chair, which  in this case would imply that the patient must be able to bear weight and take a few steps to the chair, and later when they are tired, to be able to safely stand up and return  to the bed. If they are not able to do that, we usually have stretcher chairs, where patients can  be lifted using overhead lift or total assistance into a stretcher chair, and then they become a chair. Also, walking would be one of the out-of-bed mobility activities.  So basically, these are interventions that are used by physical therapists. However, when you look at all of those activities, there is nothing to say that these can only  be done by a licensed physical therapist. If a patient does not have any degree of functional deficits or if they don't have any profound  weakness or something like that, I mean, these activities can be considered just routine  nursing care, and we should also encourage nurses to help those patients with those activities.  Now, in addition to the activities that I just mentioned, there are additional interventions  that are provided by physical therapists in ICU, like education for patients, family members, and nurses and doctors, respiratory therapists.  We also can provide positioning recommendations for specific needs of patients, therapeutic exercises, a large variety of ways that we can help patients improve their strength,  their mobility, and things like that, transfers training, walking re-education, chest physical  therapy, primarily with a focus on bronchopulmonary hygiene, respiratory muscle training, some places we provide wound care, and even other interventions.  So, what I want everybody to understand is that physical therapy interventions provided by physical therapies intensive care unit go beyond just walking patients on the ventilator  and just getting patients out of bed. My focus now is going to be on the safety aspects of mobilizing patients with delirium.  At the end of the day, it's all about the risks and the benefits. So, in order for us to really be successful in doing that, we must clearly understand  the benefits of mobilizing the patient at that particular time, as well as understanding the risks. Only then we can really make the right clinical decision for the patient.  I'm going to be talking a little bit about this article that was published in 2014, and  it was created by a group of experts in several countries, and what they did, they put together  some of these expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults, and the way they did that, which was  a phenomenal way of doing this, is they used the colors of a traffic light to recommend these activities.  So, the green would be a low risk of an adverse event, the yellow, a potential risk and consequences  of an adverse event, and finally, the red, significant potential risk or consequences of an adverse event.  So those colors will guide clinicians to decide about mobilizing these patients. So they do have specific recommendations for delirium, and I'm going to highlight here  that if the patients are negative for delirium, then they can be doing exercise in bed and out of bed.  If they have positive screening for delirium and they are able to follow commands, it's green for in-bed exercises, but we should proceed with a lot of caution for out of bed.  And if the patient is positive for delirium and unable to follow commands, this is in a situation where, yes, we can proceed, but we should have a lot of caution.  So I hope that this is also helpful for all of us to kind of understand that there are recommendations to mobilize patients with delirium.  Now, inside a patient's mind, I'm going to share with you a patient that I had some time ago, and this is what the nurse showed me that the patient had written when she came  to work. And this patient, which I knew quite well, that day I could tell by the look in the eyes  that there was something not right, and the patient was absolutely refusing to work with me for physical therapy.  She was on two arms restrained, trying to get out of bed, completely disoriented. And when I asked the patient, why don't you want me to help you?  You're going to feel better if I help you get up. She immediately reached out and wanted to write me something. And I said, okay, let me give you some time.  I'm going to go see another patient. Just tell me what's going on so I can understand before we try doing this. So here's what the patient wrote me.  I moved so much I made myself bleed. I thought Angie, who was his daughter, her daughter, left Matt and went to Spain with someone named Jack. Everyone wanted to kill me.  They had already killed Jerry, and the ship was sinking, and I couldn't get off.  To me, this is a very powerful message. When I am trying to convince this patient to work with me and get out of bed, that's what's going through her mind.  So basically, in this particular day for this particular patient, we were unable to do that because she was an elderly lady.  She was a very heavy lady, and she had a tracheostomy, and she was trying to pull things. So we decided that the risks were much higher than the benefits.  Here is a picture of my patient that I want to share with you, also in the early 90s. What I want you to pay attention, look at the eye expression, the facial expression.  Look at the eye. I mean, this to me, it's very important when I work with patients with delirium.  So I had to get the whole entire family to help me with this patient, and then we were able to successfully get him up and moving around a little bit in the hallway.  And now, take a look at his facial expression. So to me, that is the best indicator that how we can impact these patients. But again, like I said, it takes a village to do that.  Another patient that I had that was also very delirious, very agitated, trying to pull everything. In this case, I would take advantage when the mother came to visit.  I would bring dominoes, cards, and all that, and we would try to keep her engaged when she was out of bed, and also have the mother closely watching her hands.  So basically, as far as resources, I want to share with you that the ICUdelirium.org is one of the best resources we can have, as well as the Society of Critical Care Medicine  website with the ICU liberation and the ABCDEF bundles, particularly the E element, and the 2018 PEDIS guidelines are great resources for all of us trying to work with patients  with delirium. So basically, how can a physical activity impact patient outcomes by preventing delirium in daily practice?  Are there simple initiatives that can be used and sustained to prevent delirium? Every day, for every patient in every ICU, I truly believe that there is something we  can do about it. For out-of-bed activities, I think that every patient should be out of bed every day, except the ones who should not be out of bed.  In that case, it would be somebody who has neuromuscular blockers or unstable fractures and things like that.  As far as exercises, we should encourage our patients to do at least 100 leg lifts and arm lifts every day, obviously for the patients that are awake and able to participate, but  we should not be waiting for the physical therapy. Those interventions should be done for every patient in ICU.  Now the take-home message that I have for all of you now, we have interventions provided by physical therapies in ICU can decrease the incidence of delirium.  Physical therapy in ICU and physical activity in ICU are not the same. So again, it's very important that we do have patients also being mobilized when physical  therapy is not there, just because we do have limited resources and we are not able to be there at all the times.  And physical activity in the management of delirium is everybody's job in the ICU. Thank you very much for, again, this opportunity to share my clinical experience with you.

Video Summary

In this video, Christiane Perme, a physical therapist at Houston Methodist Hospital, discusses the role of physical therapy in preventing and treating delirium in ICU patients. Perme emphasizes the importance of interdisciplinary communication and teamwork in providing safe care for delirious patients. She explains that delirium is associated with long-term cognitive and functional deficits, and early, goal-directed, multi-component, and multidisciplinary interventions are crucial for improved outcomes. Physical therapy is identified as a key non-pharmacological strategy for preventing and treating delirium, but the ability of delirious patients to participate in physical therapy is influenced by factors such as sleep quality and sedation status. Perme discusses the relationship between physical activity and delirium and highlights the interventions and safety considerations for mobilizing patients with delirium. She also emphasizes the importance of educating patients, families, and healthcare professionals and advocates for a multidisciplinary approach to managing delirium in the ICU.

Asset Subtitle

Neuroscience, Patient and Family Support, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Describe environmental and alternative therapies for delirium
Assess neurocognitive therapies for delirium
Determine physical therapy interventions for delirium

Physical Therapy and Its Impact on Delirium
Christiane S. Perme

Meta Tag

Content Type Presentation

Knowledge Area Neuroscience

Knowledge Area Patient and Family Support

Knowledge Level Advanced

Membership Level Select

Tag Delirium

Tag Rehabilitation Medicine

Year 2021

Keywords

physical therapy

delirium

ICU patients

interdisciplinary communication

teamwork

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