Delirium and Associated Length of Stay and Costs in Critically Ill Patients

Dziegielewski, Claudia; Skead, Charlenn; Canturk, Toros; Webber, Colleen; Fernando, Shannon M.; Thompson, Laura H.; Foster, Madison; Ristovic, Vanja; Lawlor, Peter G.; Chaudhuri, Dipayan; Dave, Chintan; Herritt, Brent; Bush, Shirley H.; Kanji, Salmaan; Tanuseputro, Peter; Thavorn, Kednapa; Rosenberg, Erin; Kyeremanteng, Kwadwo

doi:10.1155/2021/6612187

Cited by 30 publications

(21 citation statements)

References 81 publications

(97 reference statements)

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“…Patients with delirium needed more time to reach a physical and cognitive state which enabled discharge from acute care. In accordance with other published study results [ 85 , 86 ], our study confirmed that delirium is associated with increased in-hospital mortality [ 90 ].…”

Section: Discussionsupporting

confidence: 93%

Liver diseases as a novel risk factor for delirium in the ICU–Delirium and hepatic encephalopathy are two distinct entities

et al. 2022

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Background Delirium prevalence is high in critical care settings. We examined the incidence, risk factors, and outcome of delirium in a medical intensive care unit (MICU) with a particular focus on liver diseases. We analyzed this patient population in terms of delirium risk prediction and differentiation between delirium and hepatic encephalopathy. Methods We conducted an observational study and included 164 consecutive patients admitted to an MICU of a university hospital. Patients were assessed for delirium using the Confusion Assessment Method for ICUs and the Richmond Agitation-Sedation Scale (RASS). On admission and at the onset of delirium Sequential Organ Failure Assessment (SOFA) score was determined. A population of patients with liver disease was compared to a population with gastrointestinal diseases. In the population with liver diseases, hepatic encephalopathy was graded according to the West Haven classification. We analyzed the incidence, subtype, predisposing, precipitating, and health-care setting-related factors, treatment, outcome of delirium and the association between delirium and hepatic encephalopathy in patients with liver diseases. Results The incidence of delirium was 32.5% (n = 53). Univariable binary regression analyses adjusted by the Holm-Bonferroni method showed that the development of delirium was significantly determined by 10 risk factors: Alcohol abuse (p = 0.016), severity of disease (Simplified Acute Physiology Score (SAPS) II, p = 0.016), liver diseases (p = 0.030) and sepsis (p = 0.016) compared to the control group (gastrointestinal (GI) diseases and others), increased sodium (p = 0.016), creatinine (p = 0.030), urea (p = 0.032) or bilirubin (p = 0.042), decreased hemoglobin (p = 0.016), and mechanical ventilation (p = 0.016). Of note, we identified liver diseases as a novel and relevant risk factor for delirium. Hepatic encephalopathy was not a risk factor for delirium. Delirium and hepatic encephalopathy are both life-threatening but clearly distinct conditions. The median SOFA score for patients with delirium at delirium onset was significantly higher than the SOFA score of all patients at admission (p = 0.008). Patients with delirium had five times longer ICU stays (p = 0.004) and three times higher in-hospital mortality (p = 0.036). Patients with delirium were five times more likely to be transferred to an intensive medical rehabilitation unit for post-intensive care (p = 0.020). Treatment costs per case were more than five times higher in patients with delirium than in patients without delirium (p = 0.004). Conclusions The 10 risk factors identified in this study should be assessed upon admission to ICU for effective detection, prevention, and treatment of delirium. Liver diseases are a novel risk factor for delirium with a level of significance comparable to sepsis as an established risk factor. Of note, in patients with liver diseases delirium and hepatic encephalopathy should be recognized as distinct entities to initiate appropriate treatment. Therefore, we propose a new algorithm for efficient diagnosis, characterization, and treatment of altered mental status in the ICU. This algorithm integrates the 10 risk factor prediction-model for delirium and prompts grading of the severity of hepatic encephalopathy using the West Haven classification if liver disease is present or newly diagnosed.

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Section: Discussionsupporting

confidence: 93%

Liver diseases as a novel risk factor for delirium in the ICU–Delirium and hepatic encephalopathy are two distinct entities

et al. 2022

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“…In other outcome parameters, delirium is associated with an extended length of stay in SU and hospital. This is comparable and in line with recent reviews and meta-analyses, in patients with stroke and other populations [ 12 , 43 , 44 ]. What is new and subject of concern is the fact that those patients with more severe stroke and delirium had nearly no improvement in rehabilitation during their stay on SU, compared to similar affected patients, but without delirium.…”

Section: Discussionsupporting

confidence: 93%

Delirium on stroke units: a prospective, multicentric quality-improvement project

et al. 2022

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Background Post-stroke delirium (POD) in patients on stroke units (SU) is associated with an increased risk for complications and poorer clinical outcome. The objective was to reduce the severity of POD by implementing an interprofessional delirium-management. Methods Multicentric quality-improvement project on five SU implementing a delirium-management with pre/post-comparison. Primary outcome was severity of POD, assessed with the Nursing Delirium Screening Scale (Nu-DESC). Secondary outcome parameters were POD incidence, duration, modified Rankin Scale (mRS), length of stay in SU and hospital, mortality, and others. Results Out of a total of 799 patients, 59.4% (n = 475) could be included with 9.5% (n = 45) being delirious. Implementation of a delirium-management led to reduced POD severity; Nu-DESC median: pre: 3.5 (interquartile range 2.6–4.7) vs. post 3.0 (2.2–4.0), albeit not significant (p = 0.154). Other outcome parameters were not meaningful different. In the post-period, delirium-management could be delivered to 75% (n = 18) of delirious patients, and only 24 (53.3%) of delirious patients required pharmacological treatments. Patients with a more severe stroke and POD remained on their disability levels, compared to similar affected, non-delirious patients who improved. Conclusions Implementation of delirium-management on SU is feasible and can be delivered to most patients, but with limited effects. Nursing interventions as first choice could be delivered to the majority of patients, and only the half required pharmacological treatments. Delirium-management may lead to reduced severity of POD but had only partial effects on duration of POD or length of stay. POD hampers rehabilitation, especially in patients with more severe stroke. Registry DRKS, DRKS00021436. Registered 04/17/2020, www.drks.de/DRKS00021436.

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“…Delirium, a neuropsychiatric disturbance characterized by a global impairment in cognitive capacity, including awareness and attention, deficient psychomotor activity, and a disrupted sleep-wake cycle ( 1 ), is associated with high mortality ( 2 ), cognitive decline ( 3 ), destruction of autonomy ( 4 ), an elevated hospitalization length and cost burden ( 5 ). Postoperative delirium (POD) is prevalent following cardiac surgery ( 6 ); the occurrence of post-cardiac surgery delirium ranges from 13 to 52% ( 7 ), and age, cognitive decline, weakness, complicated comorbidities, emergency operation, pain, and psychoactive medication administration are pivotal precipitating aspects ( 8 ).…”

Section: Introductionmentioning

confidence: 99%

Melatonin and Its Analogs for Prevention of Post-cardiac Surgery Delirium: A Systematic Review and Meta-Analysis

Han

Tian

et al. 2022

Front. Cardiovasc. Med.

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BackgroundThe effectiveness of melatonin and its analogs in preventing postoperative delirium (POD) following cardiac surgery is controversial. The purpose of this systematic review and meta-analysis was to confirm the benefits of melatonin and its analogs on delirium prevention in adults who underwent cardiac surgery.MethodsWe systematically searched the PubMed, Cochrane Library, Web of Science, Embase, and EBSCOhost databases, the last search was performed in October 2021 and repeated before publication. The controlled studies were included if investigated the impact of melatonin and its analogs on POD in adults who underwent cardiac surgery. The primary outcome was the incidence of delirium. The Stata statistical software 17.0 was used to perform this study.ResultsThis meta-analysis included eight randomized controlled trials (RCTs) and two cohort studies with a total of 1,714 patients. The results showed that melatonin and ramelteon administration were associated with a significantly lower incidence of POD in adults who underwent cardiac surgery (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.29–0.74; P = 0.001). The subgroup analyses confirmed that melatonin 3 mg (OR, 0.37; 95% CI, 0.18–0.76; P = 0.007) and 5 mg (OR, 0.34; 95% CI, 0.21–0.56; P < 0.001) significantly reduced the incidence of POD.ConclusionMelatonin at dosages of 5 and 3 mg considerably decreased the risk of delirium in adults who underwent cardiac surgery, according to our results. Cautious interpretation of our results is important owing to the modest number of studies included in this meta-analysis and the heterogeneity among them.Systematic Review RegistrationPROSPERO registration number: CRD42021246984.

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Delirium and Associated Length of Stay and Costs in Critically Ill Patients

Cited by 30 publications

References 81 publications

Liver diseases as a novel risk factor for delirium in the ICU–Delirium and hepatic encephalopathy are two distinct entities

Liver diseases as a novel risk factor for delirium in the ICU–Delirium and hepatic encephalopathy are two distinct entities

Delirium on stroke units: a prospective, multicentric quality-improvement project

Melatonin and Its Analogs for Prevention of Post-cardiac Surgery Delirium: A Systematic Review and Meta-Analysis

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