Changes in Mental Status

Consults are frequently initiated regarding patients' mental status changes. Fluctuations in level of consciousness and orientation, affective dysregulation, and other cognitive and perceptual disturbances have been collectively coined "ICU psychosis" or "ICU syndrome" and were once thought to be caused by environmental factors specific to critical care settings (e.g., Kleck 1984). Critical care patients' increased vulnerability to mental status changes is now recognized as likely due to a confluence of factors related to the patients' underlying illness and drugs and other treatments rather than due to an exclusively environmental etiology. Environmental factors specific to the ICU that threaten patients' mental status, in interaction with other biological factors, include prolonged social isolation, unfamiliar surroundings, sleep deprivation and diurnal rhythm disruptions, and patient immobilization (Martini 2005). Such mental status changes are conceptualized within the framework of delirium, a serious neu-ropsychiatric disorder that has only recently been examined in pediatric populations (Martini 2005; Schieveld et al. 2007, 2008; Turkel et al. 2006). Delirium has been associated with high rates of morbidity and mortality, which may in fact surpass those of all other psychiatric diagnoses (Schieveld et al. 2008; Shaw and DeMaso 2006; Wise and Trzepacz 1996). Mental status changes associated with delirium may lead to profound levels of distress in patients, family members, and medical caregivers alike (Martini 2005; Schieveld and Leentjens 2005), further underscoring the importance of prompt diagnosis and proper management.

The mental health consultant is not commonly called to evaluate for delirium per se but is frequently approached with concerns regarding mental status changes, including sleep disturbances (e.g., altered sleep-wake cycles), perceptual disturbances (e.g., il lusions, hallucinations), other disturbances in consciousness (e.g., reduced ability to sustain attention), disorientation, language disturbances, agitation, irritability, or personality changes. According to Martini (2005), only the most severe cases of pediatric delirium are accurately identified, and other cases are typically ignored or mismanaged. The consultant can offer prompt assessment and psychoeducation as well as advocate for prevention, early detection, and management of delirium through environmental and psychopharmacological interventions.

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