Delusions in intensive care: How can healthcare professionals help?

BBC Radio 4 recently aired the series The History of Delusions. One episode focused on delusions specific to people who had been patients on intensive care units.

An intensive care unit (ICU) is a highly specialised area of secondary care. They provide technology-driven treatment for patients in multi-organ failure. Until recently, little attention was paid to the psychological impact of admission to ICU. Delirium, previously referred to as ICU Syndrome or ICU Psychosis, affects around 60% of ICU patients (Brummel and Girard, 2013). Delirium is thought to be caused by critical illness, sleep deprivation, and sedative drugs such as Benzodiazepines. Delirious patients may appear agitated or withdrawn; or display both states alternately. The syndrome is associated with poor post-discharge outcomes, including anxiety and depression (Salluh et al., 2015) and reduced socio-economic function (Griffiths et al., 2013).

“Delusions are false beliefs stemming from an incorrect perception of reality.”

Delusions are one element of delirium and are false beliefs stemming from an incorrect perception of reality. Delusions can also be experienced by non-delirious patients. Post-discharge, former ICU patients report vivid memories of their delusions, often over-powering actual ‘factual’ memories of intensive care. These ‘false’ memories have been linked to the development of post-traumatic stress disorder (Jones, 2010).

Patients report experiencing feelings of motion and of being moved (Svenningsen et al., 2016), which can perhaps be linked to the use of pressure-relieving air mattresses together with the way patients are frequently moved around the unit to accommodate new admissions. As a former ICU sister, I heard numerous beliefs and stories from my patients. One lady accused staff of stealing her organs, one by one, night after night. Another was convinced her sons had left her in intensive care so we could murder her and they could receive their inheritance. Another patient wrote to staff to tell them about his delusions, the memory of which persisted a year after his discharge. He recalled how ‘Satan and his helpers’ visited each patient. I interpreted this as a reference to the consultants’ ward round.

“One lady accused staff of stealing her organs, one by one, night after night.”

The journalist David Aaronovitch reportedly fought off nurses who he believed were using oxygen to tenderise his flesh prior to eating him. Many patients report believing that they are involved in games or challenges, where they feel compelled to do certain tasks ‘or else’.  Such delusions may explain some of the agitation and hypervigilance seen amongst ICU patients. Not all delusions are persecutory, however: one patient told me that he was on a cruise with the greats of Formula 1 motor racing and asked his bemused relatives to bring in his passport and dinner jacket.

“Not all delusions are persecutory, however: one patient told me that he was on a cruise with the greats of Formula 1 motor racing…”

So how can healthcare professionals help?

We have written about how discharged patients value diaries written by their family and ICU staff. The diaries help patients reclaim ownership of lost time and reconstruct their illness narrative. Such diaries should be used alongside multi-disciplinary follow-up support (Teece and Baker, 2017). The recent POPPI Trial explored the use of nurse-led interventions to provide a calm environment and detect signs of psychological distress in patients, and future phases will trial the effectiveness of other interventions. The bedside nurse has an important role to play in screening for delirium, re-orientating, reassuring, and comforting frightened and vulnerable patients.

Do you have any experience of caring for delirious patients, or supporting discharged patients who have experienced delirium whilst in hospital? Comments and questions are very welcome. You can
contact Angela Teece directly or use the comments form below.

References

BRUMMEL, N. E. & GIRARD, T. D. 2013. Preventing delirium in the intensive care unit. Critical Care Clinics, 29, 51-65.

GRIFFITHS, J., HATCH, R. A., BISHOP, J., MORGAN, K., JENKINSON, C., CUTHBERTSON, B. H. & BRETT, S. J. 2013. An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study. Critical Care, 17, 1-12.

JONES, C. 2010. Post-traumatic stress disorder in ICU survivors. Journal of the Intensive Care Society, 11, 12-14.

SALLUH, J. I. F., WANG, H., SCHNEIDER, E. B., NAGARAJA, N., YENOKYAN, G., DAMLUJI, A., SERAFIM, R. B. & STEVENS, R. D. 2015. Outcome of delirium in critically ill patients: systematic review and meta-analysis. British Medical Journal, 350.

SVENNINGSEN, H., EGEROD, I. & DREYER, P. 2016. Strange and scary memories of the intensive care unit: a qualitative, longitudinal study inspired by Ricoeur’s interpretation theory. Journal of Clinical Nursing, 25, 2807-2815. h

TEECE, A. & BAKER, J. 2017. Thematic Analysis: How do patient diaries affect survivors’ psychological recovery? Intensive and Critical Care Nursing, 41, 50-56.

Artwork credit: original artist unknown, but sourced from the Delirium Care Network @deliriumcare

Swallowing Awareness Day: What Does Eating & Drinking Mean To You?

Eating, drinking and swallowing difficulties (dysphagia) are experienced by at least a third of adults with mental health conditions, dementia and acquired neurological diagnoses. Dysphagia often goes unrecognised until severe, however, and fatal choking incidents or aspiration pneumonia are leading causes of premature death in people with mental health conditions. The impact of any level of dysphagia can be considerable, affecting not just physical health but also quality of life issues such as socialising and relationships. My PhD research brings together communication and swallowing difficulty – the two roles of Speech and Language Therapy. As a Specialist Speech and Language Therapist the extent of my role is often misunderstood; so my work has involved raising awareness of the impact of dysphagia in this population (Guthrie et al., 2015; Guthrie & Stansfield, 2017).

“What would it be like if you couldn’t share a meal or a drink with family or friends?”

This year’s Dysphagia Awareness Day (#swallowaware2019) takes place on Wednesday 13th March as part of Nutrition and Hydration week. Speech and Language Therapists, Healthy Living Practitioners, Dietitians and other clinicians across the Leeds and York Partnership Foundation Trust are offering staff and service users with mental health conditions the chance to try some different smoothies and to think about how they swallow and cope with different consistencies.

As you eat, drink and swallow on Wednesday, take a moment to think about how important food and drink is in your everyday life. How would you feel if every swallow was painful or you were at risk of choking or aspirating (when food or drink ‘goes down the wrong way’)? What would it be like if you couldn’t share a meal or a drink with family or friends?

Susan Guthrie is a Highly Specialist Speech and Language Therapist and CArDINAL Clinical Academic Research Fellow. You can follow Susan on Twitter @SusanGuthrieSLT and on Researchgate. To find out more about the events taking place across the Leeds and York Partnership Foundation Trust please contact Susan via our contact page or directly (hcsg@leeds.ac.uk). If you have any concerns about swallowing please seek a referral to Speech and Language Therapy for assessment and advice.

References

Guthrie, S., Lecko, C. and Roddam, H. (2015) Care staff perceptions of choking incidents: what details are reported? Journal of Applied Research in Intellectual Disabilities, 28(2), pp.121-132.

Guthrie, S. and Stansfield, J. (2017) Teatime Threats. Choking Incidents at the Evening Meal. Journal of Applied Research in Intellectual Disabilities: JARID, 30(1), pp.47-60.

February Update

February may be a short month, but we have been no less busy…

John has been out and about. He attended a meeting of NHS England’s Expert Reference Group: Restrictive Practices where he presented evidence for the current use of rapid tranquilisation in inpatient settings. The talk was based on work conducted jointly with Peter Pratt, NHS England & NHS Improvement Head of MH & LD Medicines Strategy (follow Peter @jppharm). John also attended a conference promoting nursing research in Greater Manchester Mental Health NHS Foundation Trust where he had been invited to talk about the need to develop research into safe, effective and therapeutic staffing in inpatient units.

Nicola and John joined fellow academic mental health nurses to discuss various matters at their meeting at the University of Birmingham. An overview of the meeting can be found on the MHNAUK website.

Forthcoming Events

7 March

We are delighted to announce that Richard Gray, Professor of Clinical Nursing Practice will be delivering a School of Healthcare Education and Debate lecture on 7th March. Professor Gray, who is visiting from La Trobe University, Melbourne, Australia, will speak about ‘How to Enhance the Physical Activity of People with Severe Mental Illness?’ For further details and to register please visit Eventbrite.

14 March

Nicola blogged earlier this month about her Carers World Café event on 14th March where she hopes to find out more about the research priorities of carers of people with mental illness. Spaces are still available and if you would like to attend please contact us or Nicola for further information and to reserve a place.

5 June

We continue to make progress with our NIHR-funded studies and we are preparing a range of reports and resources in different formats. Some of these will be made available via this website, so watch this space. We are also pleased that half of the available places have already been reserved for our @BCTcompare free dissemination event in June. We are very keen to ensure that service users and carers attend and contribute to the discussion and can cover travel expenses. If you would like to attend or to enquire about travel expenses, please contact us or reserve a ticket via Eventbrite.

New Project Starting Soon

Liz and her team are about to embark on a new study in April examining NHS staff views about collecting sexual orientation data. More information to follow!

World Café: What do carers want from mental health research?

Nicola, Kathryn and John are excited to be working in partnership with Doug MacInnes at Canterbury and Christchurch University and Cheryl Watkinson at Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) to understand the best ways to involve and recruit informal carers in mental health research.

We’re doing this because we know that, in the UK, there are around 1.5 million carers (mostly family members) providing unpaid mental health care. Last year, RDaSH supported us to interview carers about their experiences of transitions between mental health services. The carers we spoke to told us that they don’t always feel listened to or supported, but despite feeling stressed, they said that providing care can be rewarding. By listening to carers in these interviews, we realised that carers provide essential care and have important caring skills that we know little about. We plan to do more research with carers but…

“Carers are rarely asked for their priorities for research.”

We want to ask carers in mental health about research they want to see, what topics are important to them, how researchers should involve them as partners and recruit them as research participants. Carers are not often asked what mental health research they would like to see carried out and are rarely involved as co-producers or partners in research projects. We plan to share what we find with other researchers and carers to make sure that carers’ voices are louder in mental health research in the future.

“What research do carers want to see?

What topics are important are important to carers?

How can researchers involve carers as partners in research?

How can researcher recruit carers to participate in research?”

What is World Café?

…it’s a way to meet with a large group of different people to answer questions that are important to the guests – in this case, about carer involvement in research. The event will look and feel like a café and cake and hot drinks will be served.

Guests move from table to table to join in conversations about participation in research, supported by a table host. The table hosts will be carers, NHS staff or researchers. We will provide coloured pens and invite guests to write or draw their ideas on the paper tablecloths. We will take the tablecloths away and use these to help us understand carers’ views.

Example of World Café Tablecloth

The School of Healthcare at University of Leeds has provided funding for this event so that we can ask these questions by holding a World Café on the 14th March 2019 at The Doncaster DomeIf you would like to attend this World Café, you can book using the information in the link above or by contacting us or Nicola Clibbens directly.

Follow Nicola on Twitter @UniLeedsMH

Have you attended a World Café before? Do you have questions we should ask at the World Café? We would be delighted to receive comments or ideas.

Tickets Available – Reducing Restrictive Practices: Understanding Key Intervention Components

As we move into the final stages of COMPARE: Establishing components of programmes to reduce restrictive practices: an evidence synthesis, we are pleased to announce that we will share our findings at a dedicated event:

Reducing Restrictive Practices: Understanding Key Intervention Components

12.30-15.30 5 June 2019
Horizon Conference Centre, Leeds

We have identified and mapped over 100 interventions that have been implemented in various adult mental health settings across the world. A free, interactive directory will be made available following this event. Using a specially designed taxonomy, we were able to discern between the active components of a substantial proportion of these interventions. Consequently, for the first time, we will be able to indicate which intervention components have the most (or least) potential to reduce restrictive practices.

We will also introduce a new study that builds on and extends this work: CONTRAST: Establishing components of interventions to reduce restrictive practices with children and young people: an evidence synthesis. Here, we will seek to identify interventions to reduce restrictive practices with children in a range of residential settings.

“We particularly encourage service users and carers to come along and join in the discussion.”

A draft programme for the event can be found below. Please join us for a complimentary lunch from 12.30 onwards. We hope that we will be joined by a wide range of stakeholders with an interest in the reduction of restrictive practices for plenty of networking and discussion. We particularly encourage service users and carers to come along and join in the discussion and we can cover travel expenses for those who wish to do so. Please contact us to make arrangements.

If you have any questions about the event, please do not hesitate to contact us. For travel and parking information visit Horizon, Leeds

Tickets are available via Eventbrite.

January 2019 – Welcome!

In the month that we launch our new website we’ve been busy. The start of the month saw Liz Hughes publish a joint position paper with other members of Mental Health Nurse Academics UK and people with lived experience: “Seeing Red” raises the issue of period dignity in inpatient mental health settings. Liz engaged in a streamed video chat about this issue with UNITE Mental Health.

In addition, Liz is a co-investigator on a new study Identifying and evaluating mental health early intervention services and self-care support for lesbian, gay, bisexual and transgender young people: a mixed methods study led by Lancaster University and funded by the Health Services and Delivery Research stream of the NIHR. The study will examine and evaluate access to mental health support for young people who identify as lesbian, gay bisexual, or transsexual (LGBT). LGBT young people report significantly higher rates of depression, self-harm, suicidality and poor mental health than heterosexual youth. We are pleased to welcome Dr Emily Pattinson, who will be working with Liz on this three year study, to the Mental Health Research Group. 

John Baker and Kathryn Berzins have been busy blogging for the National Elf Service (@mentalelf on Twitter). Kathryn’s blog examined a review which focused on the role of carers under the Mental Health Act, and John’s discussed a recently published systematic review on Community Treatment Orders.

A journal accepted our first paper to explore some of the work led by Joy Duxbury’s team to reduce the use of restrictive interventions in acute mental health settings informed by the 6 Core Strategies approach (more on this in a future blog).

Nicola Clibbens‘ upcoming World Café will focus on carers’ views about their participation in mental health research featured on the radio (Hallam FM). The World Café event will be held in Doncaster at The Dome in Doncaster on 14th March 1-3.30pm as a partnership between Rotherham, Doncaster and South Humber NHS Trust and The University of Leeds.