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Delirium in the Intensive Care Unit
Abstract
Delirium is a common condition in the intensive care unit (ICU). Between 16-89% of all ICU patients experience an episode of delirium during admission. Several detection tools have been developed for use specifically in the ICU. The Confusion Assessment Method for the intensive care unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) combine high sensitivity with high specificity. Treatment consists of treatment of underlying disorders, nonpharmacological measures and symptomatic drug therapy. The prognosis for ICU patients who experience delirium is worse than for those who do not. Delirious patients are more likely to develop complications, spend longer in hospital and have a higher mortality rate. In view of the high frequency, poor prognosis, high costs and lack of studies into the treatment of ICU delirium, research into the possibilities for prevention, early detection and treatment of the condition is essential.
... The detection of patients who are at increased risk and proper recognition of the clinical picture of delirium is becoming an important component in the care of geriatric surgical patients (7). If delirium is allowed to go on unrecognized and is not adequately treated, it may increase postoperative complications, prolong the duration and cost of hospitalization, and can have long-term consequences on patients' cog-nitive status and aspects of quality of life (8). ...
Introduction/Aim. Postoperative delirium is defined as an acute state of confusion that develops within hours or days after surgical intervention. With the global aging of the world population, the number of geriatric patients who will undergo surgery is on a steady rise, increasing therefore the possibility of postoperative delirium. The primary aim of this study was to determine the effect of age, type of surgical procedure, as well as the type of anesthesia on postoperative delirium. Methods. The investigation was performed in the form of a prospective study. Patients who underwent general and regional anesthesia were included. Benzodiazepines and atropine were used for premedication; from among intravenous anesthetics, propofol was used for hypnosis and from inhalation anesthetics sevoflurane; for analgesia, opioids were used. Bupivacaine was used to administer regional anesthesia. The level of cognitive functioning was tested using two tests: the Mini Mental Examination in the preoperative period and the CAM-ICU in the postoperative period. Results. Using the t-test for independent samples, it was found that there was a statistically significant difference between the two age groups of patients. It was found that there was no statistically significant difference in terms of cognitive functioning between patients who received general anesthesia and those who received regional anesthesia. The results of the analysis showed that there was no statistically significant difference between groups who received different types of surgery. Conclusion. The practical value of this study is that the preparation of patients for these types of abdominal interventions can follow the general guidelines.
... Prevalence deliria v běžné populaci činí kolem 1-2 %, výskyt se zvyšuje u hospitalizovaných pacientů. U pacientů na jednotkách intenzivní péče (JIP) je popisován výskyt deliria v rozmezí 16-90 %, u specifické populace po kardiochirurgických operacích je prevalence 10-73 % [2][3][4][5]. Široký rozptyl výskytu je dán především různou populací nemocných, variabilitou klinického sledování a rozdílnými screeningovými metodami. Delirium se v intenzivní péči (IP) vyskytuje častěji u starších nemocných [6] s maximem výskytu do prvních 48 hod od přijetí [7]. ...
Delirium in intensive care patients occurs with high prevalence and is associated with increased morbidity and mortality, worse long-term clinical outcome and higher economic costs. The article describes the pathophysiology, risk factors and individual types of delirium in patients in the intensive care. The current concepts of access to patients in intensive care are presented with the aim of early detection, treatment and prevention of delirium development.
Background— Postoperative delirium is a common complication associated with the elderly, causing increased morbidity and prolonged hospital stay. However, its risk factors in chronic subdural hematoma patients have not been well studied. Methods— A total of 202 consecutive patients with chronic subdural hematoma at Peking University Third Hospital between January 2018 and January 2023 were enrolled. Various clinical indicators were analyzed to identify independent risk factors for postoperative delirium using univariate and multivariate regression analyses. Delirium risk prediction models were developed as a nomogram and a Markov chain. Results— Out of the 202 patients (age, 71 (IQR, 18); female-to-male ratio, 1:2.7) studied, 63 (31.2%) experienced postoperative delirium. Univariate analysis identified age (p < 0.001), gender (p = 0.014), restraint belt use (p < 0.001), electrolyte imbalance (p < 0.001), visual analog scale score (p < 0.001), hematoma thickness (p < 0.001), midline shift (p < 0.001), hematoma side (p = 0.013), hematoma location (p = 0.018), and urinal catheterization (p = 0.028) as significant factors. Multivariate regression analysis confirmed the significance of restraint belt use (B = 7.657, p < 0.001), electrolyte imbalance (B = -3.993, p = 0.001), visual analog scale score (B = 2.331, p = 0.016), and midline shift (B = 0.335, p = 0.007). Hematoma thickness and age had no significant impact. Conclusion— Increased midline shift and visual analog scale scores, alongside restraint belt use and electrolyte imbalance elevate delirium risk in chronic subdural hematoma surgery. Our prediction models may offer reference value in this context.
Aims and objectives
This study aimed to investigate the effectiveness of a delirium prevention care protocol on pain, functional status, sleep quality and delirium prevention in patients with hip fractures.
Background
The development of delirium following hip fracture is common among older patients. According to the National Institute for Health and Care Excellence, 30% of delirium cases are preventable. The prevention of delirium, a multifactorial syndrome, can be achieved through a multicomponent care protocol that targets specific risk factors for delirium.
Design
A randomised controlled study was conducted according to the CONSORT 2010 guidelines. The Clinical Trial Registry number is NCT04188795.
Methods
A total of 84 patients were assigned to two groups by block randomisation. The intervention group (n = 41) received nursing care according to a protocol and the control group (n = 43) received standard nursing care. Study data were collected using the demographic information form, the Confusion Assessment Method-Intensive Care Unit (CAM-ICU), the Barthel Index, the Mini Nutritional Assessment–short form and the Richards–Campbell Sleep Questionnaire (RCSQ). The pain of the patients was assessed by using a Visual Analog Scale (VAS).
Results
The mean age of the patients was 80.6 years (standard deviation 8.0; range 65.0– 97.5 years), and the percentage of the male patients were 36.3%. No statistically significant differences were found between the groups in terms of pain and functional status in the preoperative period, on the first postoperative day, or in the predischarge period (p > 0.05 for each). The sleep quality of patients in the intervention group was significantly better than in the control group for all three time measurements (p < 0.05 for each). While 15% of patients in the control group developed delirium, no patient in the intervention group developed delirium (x²=6.486, p = 0.026).
Conclusion
This study demonstrated that a delirium prevention care protocol may reduce the incidence of delirium and improve sleep quality.
Relevance to practice
The study highlighted that nurses can contribute to preventing patients’ delirium using nonpharmacologic and independent nursing interventions.
For the past 2500 years, delirium has been described based on the presence of behavioral symptoms. Each year, as many as 1 in 5 acute care and 80% of critically ill patients develop delirium. The United States spends approximately $164 million annually to combat the associated consequences of delirium. There are no laboratory tools available to assist with diagnosis and ongoing monitoring of delirium; therefore, current national guidelines for psychiatry, geriatrics, and critical care strongly recommend routine bedside screening. Despite the significance, health care teams fail to accurately identify approximately 80% of delirium episodes.
The utility of conventional electroencephalogram (EEG) in the diagnosis and monitoring of delirium has been well established. Neurochemical and the associated neuroelectrical changes occur in response to overwhelming stress before behavioral symptoms; therefore, using EEG will improve early delirium identification. Adding EEG analysis to the current routine clinical assessment significantly increases the accuracy of detection. Using newer EEG technology with a limited number of leads that is capable of processing EEG may provide a viable option by reducing the cost and need for expert interpretation. Because EEG monitoring with automatic processing has become technically feasible, it could increase delirium recognition. Electroencephalogram monitoring may also provide identification before symptom onset when nursing interventions would be more effective, likely reducing the long-term ramifications. Having an objective method that nurses can easily use to detect delirium could change the standard of care and provide earlier identification.
To determine the attributable mortality caused by delirium in critically ill patients.
Prospective cohort study.
32 mixed bed intensive care unit in the Netherlands, January 2011 to July 2013.
1112 consecutive adults admitted to an intensive care unit for a minimum of 24 hours.
Trained observers evaluated delirium daily using a validated protocol. Logistic regression and competing risks survival analyses were used to adjust for baseline variables and a marginal structural model analysis to adjust for confounding by evolution of disease severity before the onset of delirium.
Mortality during admission to an intensive care unit.
Among 1112 evaluated patients, 558 (50.2%) developed at least one episode of delirium, with a median duration of 3 days (interquartile range 2-7 days). Crude mortality was 94/558 (17%) in patients with delirium compared with 40/554 (7%) in patients without delirium (P<0.001). Delirium was significantly associated with mortality in the multivariable logistic regression analysis (odds ratio 1.77, 95% confidence interval 1.15 to 2.72) and survival analysis (subdistribution hazard ratio 2.08, 95% confidence interval 1.40 to 3.09). However, the association disappeared after adjustment for time varying confounders in the marginal structural model (subdistribution hazard ratio 1.19, 95% confidence interval 0.75 to 1.89). Using this approach, only 7.2% (95% confidence interval -7.5% to 19.5%) of deaths in the intensive care unit were attributable to delirium, with an absolute mortality excess in patients with delirium of 0.9% (95% confidence interval -0.9% to 2.3%) by day 30. In post hoc analyses, however, delirium that persisted for two days or more remained associated with a 2.0% (95% confidence interval 1.2% to 2.8%) absolute mortality increase. Furthermore, competing risk analysis showed that delirium of any duration was associated with a significantly reduced rate of discharge from the intensive care unit (cause specific hazard ratio 0.65, 95% confidence interval 0.55 to 0.76).
Overall, delirium prolongs admission in the intensive care unit but does not cause death in critically ill patients. Future studies should focus on episodes of persistent delirium and its long term sequelae rather than on acute mortality.Trial registration Clinicaltrials.gov NCT01905033.
© Klein Klouwenberg et al 2014.
This article serves to (1) review the relationship of the terms "delirium" and "encephalopathy," (2) describe delirium as defined in current diagnostic systems, (3) summarize the epidemiology and theories of pathogenesis, (4) review clinical diagnostic approaches, and (5) highlight the history using EEG in the study of delirium in the psychiatric literature. Delirium is an important medical syndrome with significant implications; there is continued need for better physiologic measures of the underlying brain dysfunction.
Delirium is a significant psychiatric disorder in intensive care units that has negative impact on morbidity and mortality of intensive care patients. Subjective clinical assessment of patients by non-psychiatric health professionals in intensive care units is not sufficient for detection and measurement of delirium. Therefore, different scoring scales for delirium assessment have been developed. This paper reviews the characteristics of commonly used scoring scales for assessment of delirium in intensive care units: the Confusion Assessment Method-Intensive Care Unit (CAM-ICU), the Intensive Care Delirium Screening Checklist (ICD-SC), the Nursing Delirium Screening Scale (Nu-DESC) and the Detecting Delirium Scale (DDS). Routine implementation of objective scoring scales is not widespread. Evidence suggests that objective assessment of delirium contributes to its early detection in intensive care and initiation of appropriate treatment. It is therefore advisable to make additional educational effort to provide an objective scoring scale for the assessment of delirium, such as CAM-ICU, to be routinely used in intensive care units.
Delirium is a common, difficult-to-diagnose clinical condition in critical care units. The lack of recognition of delirium often results in increased morbidity and mortality. The study aimed to determine the validity and reliability of the Intensive Care Delirium Screening Checklist (ICDSC) in a resource-poor medical intensive care setting in South India.
Fifty-three patients admitted into the medical intensive care unit of a teaching hospital who were neither mute nor intubated were recruited for the study. Trained residents administered the ICDSC to screen for delirium. A consultant psychiatrist used the International Classification of Diseases, 10th Revision diagnostic criteria for research to determine the presence of delirium.
The optimal threshold for screening, as ICDSC total score of 3 or more, was obtained by using a receiver operating characteristic curve. Although a sensitivity and specificity of 75% and 74%, respectively, were obtained at the original cutoff of 4, a sensitivity of 90% and specificity of 61.54% were achieved with a cutoff of 3. In a subsample of 21 patients, interrater reliability was evaluated and found to be 0.947 (95% confidence interval, 0.870-0.979). The ICDSC had good internal consistency, with Cronbach α of .754 and Guttman split-half coefficient of 0.71. Factor analysis revealed a 2-factor structure, namely, altered sensorium/psychopathology and sleep-wake cycle problems.
Our findings indicate that in nonintubated intensive care unit patients, the ICDSC can be used to screen for delirium but should not be used as a diagnostic instrument in this patient population and that residents can be trained in the use of the instrument in resource-poor critical care settings. Using a different threshold for positivity of 3 rather than 4 appeared to offer improved screening characteristics in this resource-poor critical care setting.
To implement delirium monitoring, test reliability, and monitor compliance of performing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in trauma patients.
Prospective, observational study in a level 1 trauma unit of a tertiary care, university-based medical center.
Acutely injured patients admitted to the trauma unit between 1 February 2006 and 16 April 2006.
Following web-based teaching modules and group in-services, bedside nurses evaluated patients daily for depth of sedation with the Richmond Agitation-Sedation Scale (RASS) and for the presence of delirium with the CAM-ICU. On randomly assigned days over a 10-week period, evaluations by nursing staff were followed by evaluations by an expert evaluator of the RASS and the CAM-ICU to assess compliance and reliability of the CAM-ICU in trauma patients. Following the audit period the nurses completed a postimplementation survey. The expert evaluator performed 1,011 random CAM-ICU assessments within 1h of the bedside nurse's assessments. Nurses completed the CAM-ICU assessments in 84% of evaluations. Overall agreement (kappa) between nurses and expert evaluator was 0.77 (0.721-0.822; p < 0.0001), in TBI patients 0.75 (0.667-0.829; p < 0.0001) and in mechanically ventilated patients 0.62 (0.534-0.704; p < 0.0001). The survey revealed that nurses were confident in performing the CAM-ICU, realized the importance of delirium, and were satisfied with the training that they received. It also acknowledged obstacles to implementation including nursing time and failure of physicians/surgeons to address treatment approaches for delirium.
The CAM-ICU can be successfully implemented in a university-based trauma unit with high compliance and reliability. Quality improvement projects seeking to implement delirium monitoring would be wise to address potential pitfalls including time complaints and the negative impact of physician indifference regarding this form of organ dysfunction.
Research on haloperidol's pharmacokinetics, side effects, indications, and efficacy is reviewed. Issues related to high-dose therapy, rapid neuroleptization, intravenous administration, use in geriatric patients, and coadministration with lithium in mania are discussed. Overall, 25 years of experience have indicated that haloperidol can be used safely and effectively to manage a variety of psychiatric illnesses, so long as dosage and method of administration are adjusted to individual patients' needs. Research continues on the use of this drug, not only in psychiatry but in several other areas of medical practice.
In 3 patients, 2 women aged 21 and 65 and a man aged 60, admitted for the treatment of B-cell lymphoma, trauma caused by a traffic accident and Kahler's disease respectively, hypoactive delirium, apathy of unknown origin and depressive disorder or adjustment disorder with depressive mood ('demoralisation') were seen and caused somatic recovery to be compromised. The consulting psychiatrist prescribed methylphenidate with good results. They formed part of a group of 34 patients who were given methylphenidate on these indications over a period of 12 months. These indications are not among the accepted indications for this drug. In the literature, the beneficial use of psychostimulants in somatic illness has been described almost exclusively in palliative care and case reports of other somatically-ill patients with a poor prognosis. No reports were found on the effects of methylphenidate used for treatment of patients with hypoactive delirium nor were guidelines for its use in somatically-ill patients with a good prognosis. A randomised clinical trial to substantiate these reported findings is warranted.
The authors reviewed MEDLINE and references of major articles in the published literature over the last 30 years regarding the complications of alcohol abuse and discuss the critical care aspects of alcohol abuse. This article discusses the severe medical conditions associated with alcohol abuse that lead to admission to the medical intensive care unit. The clinical manifestations, pathophysiology, diagnostic studies, and management of these conditions are discussed in detail.
To standardize treatment of alcohol withdrawal syndrome (AWS) in internal medicine patients using an adult AWS practice guideline with a symptom-triggered management approach.
Prospective interventional (pilot group) and retrospective (control group).
University teaching hospital.
Thirty-two internal medicine patients identified as being at risk for AWS and treated according to the AWS practice guideline who were compared with 49 internal medicine patients managed with nonstandardized approaches.
Patients in the pilot group were assessed using the AWS type indicator. They received lorazepam, clonidine, or haloperidol, based on AWS type indicator assessment and adult AWS practice guideline criteria.
Data collected and analyzed were drugs administered to control AWS symptoms, use of sitters and physical restraints, length of hospital stay, and discharge from hospital receiving tapered drug therapy. Pilot patients received 46.6% less benzodiazepine (p=0.001), 20% more clonidine (p=0.01), and 18.2% more haloperidol (p=0.002) than control patients. No drug therapy was required in 19% of pilot patients compared with 2% of controls (p=0.01). Significantly more control (71.4%) than pilot patients (18.8%) were discharged with tapered benzodiazepine therapy (p<or=0.01). No significant differences were found between groups for sitters, restraints, or hospital length of stay.
This pilot project suggests that internal medicine patients at risk for AWS can be managed with a standardized, symptom-triggered approach using decreased amounts of benzodiazepine in combination with adjunctive agents to treat adrenergic hyperactivity and delirium. Further data are necessary to determine the impact of the practice guideline on patient outcome measurements.
Agitation is a psychomotor disturbance characterized by a marked increase in motor and psychological activity in a patient. It occurs very frequently in the intensive care setting. It may be isolated, or accompanied by other mental disorders, such as severe anxiety and delirium. Frequently, agitation is a sign of brain dysfunction and, as such, may have adverse consequences, for at least two reasons. First, agitation can interfere with the patient's care and second, there is evidence demonstrating that the prognosis of agitated (and delirious) patients is worse than that of non-agitated (non-delirious) patients. These conditions are often under-diagnosed in the intensive care unit (ICU). Consequently, a systematic evaluation of this problem in ICU patients should be conducted. Excellent tools are presently available for this purpose. Treatment, including prevention, must be undertaken without delay, and the ICU physician should follow logical, strict and systematic rules when applying therapy.