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Objective: To describe the multiprofessional care for the management of critical patients in delirium in the ICU from the evidences found in the literature., Methods: This integrative review was carried out in the period from February 1 to June 30, 2016 through searches on PubMed, Scopus, Web of Science, and CINAHL, with the following descriptors: delirium, critical care e intensive care units, which brought up 17 original papers., Results: A bundle and a guideline, two systematic reviews, evidence 1a and four clinical trials, evidence 1b and 2b, cohort and observational studies were found. The multiprofessional care was presented to better understand the diagnosis of delirium, sedation pause, early mobilization, pain, agitation and delirium guidelines, psychomotor agitation, cognitive orientation, sleep promotion, environment and family participation., Conclusion: The care for delirium is wide and not specific, which determines its multifactorial aspect.

Background: Agitation is a common, challenging symptom affecting large numbers of people with dementia and impacting on quality of life (QoL). There is an urgent need for evidence-based, cost-effective psychosocial interventions to improve these outcomes, particularly in the absence of safe, effective pharmacological therapies. This study aimed to evaluate the efficacy of a person-centred care and psychosocial intervention incorporating an antipsychotic review, WHELD, on QoL, agitation, and antipsychotic use in people with dementia living in nursing homes, and to determine its cost., Methods and Findings: This was a randomised controlled cluster trial conducted between 1 January 2013 and 30 September 2015 that compared the WHELD intervention with treatment as usual (TAU) in people with dementia living in 69 UK nursing homes, using an intention to treat analysis. All nursing homes allocated to the intervention received staff training in person-centred care and social interaction and education regarding antipsychotic medications (antipsychotic review), followed by ongoing delivery through a care staff champion model. The primary outcome measure was QoL (DEMQOL-Proxy). Secondary outcomes were agitation (Cohen-Mansfield Agitation Inventory [CMAI]), neuropsychiatric symptoms (Neuropsychiatric Inventory-Nursing Home Version [NPI-NH]), antipsychotic use, global deterioration (Clinical Dementia Rating), mood (Cornell Scale for Depression in Dementia), unmet needs (Camberwell Assessment of Need for the Elderly), mortality, quality of interactions (Quality of Interactions Scale [QUIS]), pain (Abbey Pain Scale), and cost. Costs were calculated using cost function figures compared with usual costs. In all, 847 people were randomised to WHELD or TAU, of whom 553 completed the 9-month randomised controlled trial. The intervention conferred a statistically significant improvement in QoL (DEMQOL-Proxy Z score 2.82, p = 0.0042; mean difference 2.54, SEM 0.88; 95% CI 0.81, 4.28; Cohen's D effect size 0.24). There were also statistically significant benefits in agitation (CMAI Z score 2.68, p = 0.0076; mean difference 4.27, SEM 1.59; 95% CI -7.39, -1.15; Cohen's D 0.23) and overall neuropsychiatric symptoms (NPI-NH Z score 3.52, p < 0.001; mean difference 4.55, SEM 1.28; 95% CI -7.07,-2.02; Cohen's D 0.30). Benefits were greatest in people with moderately severe dementia. There was a statistically significant benefit in positive care interactions as measured by QUIS (19.7% increase, SEM 8.94; 95% CI 2.12, 37.16, p = 0.03; Cohen's D 0.55). There were no statistically significant differences between WHELD and TAU for the other outcomes. A sensitivity analysis using a pre-specified imputation model confirmed statistically significant benefits in DEMQOL-Proxy, CMAI, and NPI-NH outcomes with the WHELD intervention. Antipsychotic drug use was at a low stable level in both treatment groups, and the intervention did not reduce use. The WHELD intervention reduced cost compared to TAU, and the benefits achieved were therefore associated with a cost saving. The main limitation was that antipsychotic review was based on augmenting processes within care homes to trigger medical review and did not in this study involve proactive primary care education. An additional limitation was the inherent challenge of assessing QoL in this patient group., Conclusions: These findings suggest that the WHELD intervention confers benefits in terms of QoL, agitation, and neuropsychiatric symptoms, albeit with relatively small effect sizes, as well as cost saving in a model that can readily be implemented in nursing homes. Future work should consider how to facilitate sustainability of the intervention in this setting., Trial Registration: ISRCTN Registry ISRCTN62237498.

Background: Legislation, guidelines and accreditation standards cal for the minimization of physical restraints, yet their use remains common in intensive care units (ICUs) both in Canada and internationally. In Canada, physical restraints are prescribed by physicians. However, assessment of their need, application, and removal are primarily the responsibility of ICU nurses., Objectives: We sought to describe Canadian ICU nurses' decision-making and practices of physical restraint application and discontinuation, as well as alternative measures attempted prior to their use for critically ill adults., Methods: We conducted a prospective, observational study in two medical-surgical ICUs (tertiary academic and large community teaching hospital) of physical restraint use., Results: We collected physical restraint data from the medical records of 141 patients from October 2011 to September 2012. Most restrained patients were mechanically ventilated (n = 118, 84%). Of the 247 reasons for restraint application identified for these 141 patients, agitation (n = 107, 43%), restlessness (n = 42, 17%) and use as a precautionary measure (n = 42, 17%) were the most commonly documented. Of the 167 behaviours observed and documented by nurses as indicative of agitation, pulling at the endotracheal tube or other lines/tubes (n = 111, 66%) was most commonly cited. Nurses documented the use of various strategies as an alternative to physical rest raint prior to their use for 46 (33%) patients. Of the 96 alternative strategies attempted, communication comprising reorientation and reminders was the most frequently documented (n = 26, 27%). Nurses reported having considered removing restraints during their shift for 61 (43%) patients. The criterion most commonly deemed essential for restraint removal was a calm patient (51 of the 104 reasons listed, 49%)., Conclusions: Our study suggests that patient behaviour indicative of agitation was the most common reason for physical restraint application. Use as a precautionary measure and in situations where nurses' ability to be present at the bedside was reduced, as well as the limited use of alternative measures prior to physical restraint suggest restraint minimization may not be optimal.

Pain and distress are widespread for people with dementia. However, effective pain management is limited by the quality of assessment tools. In this study, the development and trial of the Mahoney Pain Scale, which aims to assess pain in advanced dementia and distinguish it from agitation is described. A total of 112 participants with advanced dementia who experienced either pain, agitation, neither or both were assessed via the Mahoney Pain Scale during a pleasant and aversive activity. The Mahoney Pain Scale demonstrated adequate interrater reliability and internal consistency. As predicted, participants experiencing pain and/or agitation obtained higher Mahoney Pain Scale scores during the aversive activity. Participants also differed with respect to their pattern of scores, and consequently, the Mahoney Pain Scale differentiated pain states from non-pain ones. The clinical impressions of nurses who trialed the tool were favorable; they reported that it seemed accurate and easy to use. Thus, the Mahoney Pain Scale may be useful for assessing pain in dementia.

Integrative brain failure is often a comorbidity of critical illness, and although not uncommon, is perhaps the least understood of all the various organ failure phenomena. Factors that contribute to integrative brain failure include inadequate management of pain, stress, anxiety, and the several underlying mechanisms that create agitation in the intensive care unit patient. Delirium, a resultant organic mental syndrome, is reversible when promptly recognized and aggressively managed. The nurse who is astute in clinical assessments and skillful in the management of the environment of care can prevent and control states of anxiety, irritability, restlessness, and sleep disturbances that contribute to the development of delirium.

Goals in the care of the mechanically ventilated patient are sedation, analgesia, anxiolysis, and muscle relaxation. Causes of distress in these patients include: pain, sleep deprivation, anxiety, psychosis, agitation, and delirium. Drugs used to alleviate these stressors are opiates, benzodiazepines, neuromuscular blocking agents, anesthetic induction agents, and inhalational agents. When caring for the agitated patient on the mechanical ventilator, physiologic, mechanical, and emotional causes must all be investigated. Finally, nonpharmacologic therapy is of utmost importance in the care of these patients.