Intracerebral Hemorrhage and Delirium Symptoms. Length of Stay, Function, and Quality of Life in a 114-Patient Cohort

Abstract

Rationale: The prognostic significance of delirium symptoms in intensive care unit (ICU) patients with focal neurologic injury is unclear. Objectives: To determine the relationship between delirium symptoms and subsequent functional outcomes and quality of life (QOL) after intracerebral hemorrhage. Methods: We prospectively enrolled 114 patients. Delirium symptoms were routinely assessed twice daily using the Confusion Assessment Method for the ICU by trained nurses. Functional outcomes were recorded with modified Rankin Scale (scored from 0 [no symptoms] to 6 [dead]), and QOL outcomes with Neuro-QOL at 28 days, 3 months, and 12 months. Measurements and Main Results: Thirty-one (27%) patients had delirium symptoms ("ever delirious"), 67 (59%) were never delirious, and the remainder (14%) had persistent coma. Delirium symptoms were nearly always hypoactive, were detected mean 6 days after intracerebral hemorrhage presentation, and were associated with longer ICU length of stay (mean 3.5 d longer in ever vs. never delirious patients; 95% confidence interval, 1.5-8.3; P ¼ 0.004) after correction for age, admit National Institutes of Health (NIH) Stroke Scale, and any benzodiazepine exposure. Delirium symptoms were associated with increased odds of poor outcome at 28 days (odds ratio, 8.7; 95% confidence interval, 1.4-52.5; P ¼ 0.018) after correction for admission NIH Stroke Scale and age, and with worse QOL in the domains of applied cognition-executive function and fatigue after correcting for the NIH Stroke Scale, age, benzodiazepine exposure, and time of follow-up. Conclusions: After focal neurologic injury, delirium symptoms were common despite low rates of infection and sedation exposure, and were predictive of subsequent worse functional outcomes and lower QOL. Keywords: delirium; outcomes; quality of lifeThe symptoms of delirium, a potential consequence of multiple clinical disease states and physiologic aberrations, include a shift in baseline mental status, inattention, and disorganized thinking or altered level of consciousness. Although nonspecific, this syndrome is an independent predictor of higher mortality (1), longer length of stay (LOS), higher cost of care, and worse long-term cognitive outcomes in medical, surgical, burn, and trauma intensive care unit (ICU) patients (2). There are few such data, however, in ICU patients with focal neurologic injury without systemic illness.Risk factors for delirium symptoms are typically global (infection [3] and intravenous sedation, particularly benzodiazepines [BZDs]) (4, 5) as opposed to focal lesions (e.g., hematoma). Most mechanically ventilated patients are delirious during hospitalization (1), potentially because of the sedation regimen (e.g., BZD infusion), but sedation is typically minimized in neurologically injured patients to permit repeated neurologic assessment that may lead to an acute intervention (6).Screening tests for delirium have been recently validated in neurologically ill patients (7-9), including ischemic stroke (7, 10) and intracerebra...

Web-Based Assessment of Outcomes After Subarachnoid and Intracerebral Hemorrhage: A New Patient Centered Option for Outcomes Assessment

“…We focused on physical scores in this study, but have previously noted that Neuro-QOL assessments highlight other domains of HRQoL that are unlikely to be adequately assessed by the mRS, such as applied cognition (now referred to as ''cognitive function'' within Neuro-QOL) [17]. How well the mRS captures these other domains of HRQoL is an important topic for future research, but beyond the scope of this report.…”

Agitation, Delirium, and Cognitive Outcomes in Intracerebral Hemorrhage

“…We prospectively recorded baseline demographic, past medical history, clinical data, and follow-up data. (16) Electroencephalographic (EEG) monitoring was routinely performed in unresponsive patients and interpreted by a board-certified epileptologist to evaluate for the presence of subclinical seizures. We assessed patients with the National Institutes of Health (NIH) Stroke Scale (NIHSS), a validated neurologic examination ranging from 0 (no deficit) to 42 (worst possible score), with a score of 8 or more indicating a moderately severe deficit.…”

“…These methods have been previously described. (16) We consider patients to have delirium with agitation if there was a positive CAM-ICU and RASS of 2 or more at any pointduring the hospital stay. Delirium without agitation indicates a positive CAM-ICU at any time with all RASS scores of less than 2 during the hospital stay.…”

“…Using these validated measures on a cohort of patients with intracerebral hemorrhage (ICH, spontaneous bleeding into brain tissue), we previously reported that patients with delirium had poorer functional outcomes at 28 days, and worse Cognitive Function Health Related Quality of Life (HRQoL) at 28 days, three months and one year than similar patients without delirium. (16) We then hypothesized that motor agitation with delirium (hyperactive delirium) would have additional prognostic significance.…”

Altered mental status in the neurocritical care unit

“…Delirium is more common in patients with higher Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and significantly affects patients' long-term well-being and the associated health care costs [18]. In patients with focal neurologic injury, delirium is predictive of subsequent worse functional outcomes and lower quality of life [19].…”