Occurrence of delirium is severely underestimated in the ICU during daily care

Abstract

Objective: Delirium is associated with prolonged intensive care unit (ICU) stay and higher mortality. Therefore, the recognition of delirium is important. We investigated whether intensivists and ICU nurses could clinically identify the presence of delirium in ICU patients during daily care. Methods: All ICU patients in a 3-month period who stayed for more than 48 h were screened daily for delirium by attending intensivists and ICU nurses. Patients were screened independently for delirium by a trained group of ICU nurses who were not involved in the daily care of the patients under study. The Confusion Assessment Method for the ICU (CAM-ICU) was used as a validated screening instrument for delirium. Values are expressed as median and interquartile range (IQR; P25-P75). Results: During the study period, 46 patients (30 male, 16 female), median age 73 years (IQR = 64-80), with an ICU stay of 6 days (range 4-11) were evaluated. CAM-ICU scores were obtained during 425 patient days. Considering the CAM-ICU as the reference standard, delirium occurred in 50% of the patients with a duration of 3 days (range 1-9). Days with delirium were poorly recognized by doctors (sensitivity 28.0%; specificity 100%) and ICU nurses (sensitivity 34.8%; specificity 98.3%). Recognition did not differ between hypoactive or active status of the patients involved. Conclusion: Delirium is severely under recognized in the ICU by intensivists and ICU nurses in daily care. More attention should be paid to the implementation of a validated delirium-screening instrument during daily ICU care.

Incidence of cholinesterase inhibitor therapy initiation among hospitalized patients

“…A previous study found that clinicians are unable to diagnose 70% of cases of delirium when a validated delirium screening tool is not used. 18 Therefore, we did not attempt to quantify the incidence of delirium using progress notes or diagnosis codes, as this incidence would be falsely low and unreliable. Our hospital is currently improving the culture of awareness of delirium, and efforts are being made to establish and improve routine screening for delirium in both the acute care and critical care setting.…”

Kunnskapsbasert vurdering av delirium hos intensivpasienten

“…Tilnaermingen var imidlertid usystematisk og preget av subjektive vurderinger. Også dette er et bilde av praksis som stemmer med tidligere forskning; sykepleiere bruker metoder som nevrologisk undersøkelse, observasjon og samtale med pasienten for å vurdere om pasienten har delirium (2,7,35,36). Både våre funn og disse tidligere studiene viser at sykepleiere vektlegger orienteringsevne, avvikende atferd, bevissthet, pupiller, agitasjon og evne til å følge oppfordring.…”

“…Konsekvensene av delirium hos intensivpasienten er betydelige i form av økt døde-lighet, økt liggetid på respirator og i sykehus, og langtidsplager som angst og konsentrasjonsvansker for pasienten (3)(4)(5)(6). Det er derfor et stort problem at delirium ikke blir oppdaget hos denne pasientgruppen (2,(7)(8)(9)(10).…”

“…Forskning har imidlertid vist at sykepleieres observasjoner av deliriums kliniske uttrykk ofte ikke er strukturerte og detaljerte nok til at diagnosen kan stilles. Dette gjelder spesielt for intensivpasienter som har redusert eller manglende evne til å kommunisere verbalt (2,7,9,12).…”

Pharmacological and Nonpharmacological Management of Delirium in Critically Ill Patients

“…Once thought to be an inevitable byproduct of sepsis and severe illness, delirium is now known to be a form of acute brain dysfunction associated with higher mortality [2][3][4], increased length of hospital stay [5], increased costs [6], and long-term cognitive impairment [7][8][9][10]. The development of valid and reliable instruments to assess delirium has resulted in better recognition of delirium [11,12], although it continues to be under-recognized [13]. The focus of delirium research has been extended to include pharmacological and nonpharmacological strategies to prevent and minimize the duration of delirium.…”