Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review*

Patel, Mayur B.; Bednařík, Josef; Lee, Patricia; Shehabi, Yahya; Salluh, Jorge I.; Slooter, Arjen J. C.; Klein, Kate; Skrobik, Yoanna; Morandi, Alessandro; Spronk, Peter E.; Naidech, Andrew M.; Pun, Brenda T.; Bozza, Fernando A.; Marra, Annachiara; John, Sayona; Pandharipande, Pratik P.; Ely, E. Wesley

doi:10.1097/ccm.0000000000003349

Cited by 75 publications

(83 citation statements)

References 67 publications

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“…In this prospective observational study, the delirium incidence of 18.7%, according to the diagnostic reference, was in accordance with the past reports with mostly neurovascular or trauma patients [8,15,21]. A similar delirium incidence in our more heterogeneous cohort may indicate that delirium occurs at largely similar frequencies in other neurological disorders with treatment on a neurocritical care unit.…”

Section: Discussionsupporting

confidence: 91%

“…In our cohort, we found low sensitivity (66.9%) and acceptable specificity (93.3%) for screening with CAM-ICU. Values were below those reported in a selected cohort of stroke patients by Mitasova and co-workers [16], but above those reported in other studies with neurological/neurosurgical patients [15,17,18,20]. The sensitivity (69.3%) and specificity (93.9%) of the ICDSC were comparable to those of CAM-ICU and similar to the findings in the study by Larsen and co-workers [20].…”

Section: Discussionsupporting

confidence: 77%

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Delirium Screening in Neurocritical Care and Stroke Unit Patients: A Pilot Study on the Influence of Neurological Deficits on CAM-ICU and ICDSC Outcome

et al. 2020

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Background/Objective: Delirium is a common complication in critically ill patients with a negative impact on hospital length of stay, morbidity, and mortality. Little is known on how neurological deficits affect the outcome of commonly used delirium screening tools such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) in neurocritical care patients. Methods: Over a period of 1 month, all patients admitted to a neurocritical care and stroke unit at a single academic center were prospectively screened for delirium using both CAM-ICU and ICDSC. Tool-based delirium screening was compared with delirium evaluation by the treating clinical team. Additionally, ICD-10 delirium criteria were assessed. Results: One hundred twenty-three patients with a total of 644 daily screenings were included. Twenty-three patients (18.7%) were diagnosed with delirium according to the clinical evaluation. Delirium incidence amounted to 23.6% (CAM-ICU) and 26.8% (ICDSC). Sensitivity and specificity of both screening tools were 66.9% and 93.3% for CAM-ICU and 69.9% and 93.9% for ICDSC, respectively. Patients identified with delirium by either CAM-ICU or ICDSC presented a higher proportion of neurological deficits such as impaired consciousness, expressive aphasia, impaired language comprehension, and hemineglect. Subsequently, generalized estimating equations identified a significant association between impaired consciousness (as indexed by Richmond Agitation and Sedation Scale) and a positive delirium assessment with both CAM-ICU and ICDSC, while impaired language comprehension and hemineglect were only associated with a positive CAM-ICU result. Conclusions: A positive delirium screening with both CAM-ICU and ICDSC in neurocritical care and stroke unit patients was found to be significantly associated with the presence of neurological deficits. These findings underline the need for a more specific delirium screening tool in neurocritical care patients.

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Section: Discussionsupporting

confidence: 91%

Section: Discussionsupporting

confidence: 77%

Delirium Screening in Neurocritical Care and Stroke Unit Patients: A Pilot Study on the Influence of Neurological Deficits on CAM-ICU and ICDSC Outcome

et al. 2020

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“…SDH patients tend to represent a very heterogeneous group, with considerable differences existing between acute and chronic hematomas in terms of their management, clinical manifestations, and outcomes; this supports the idea that RASS fluctuation may be more generalizable for patients with different types of brain injury. Finally, in order to have a comparison for RASS fluctuation, we used the CAM-ICU as a gold-standard delirium screen; this is a commonly used screen in neurologically ill patients, but has not been fully validated [7], and utilizes RASS scores for some of its criteria. A definitive study would need to compare RASS fluctuation to DSM-V criteria as the gold standard.…”

Section: Discussionmentioning

confidence: 99%

“…The study of delirium in neurologically critically ill patients has been limited in part because some studies have suggested a high rate of false positives in this population, particularly from new neurological injuries being misclassified as delirium [7]. This is unsurprising as many of the features of delirium can be seen with neurological injury; for example, prominent inattentiveness has been described with both thalamic injury [8] and frontal lobe injury [9], and non-convulsive seizures have been reported to present with delirium [10].…”

Section: Introductionmentioning

confidence: 99%

Dispersion in Scores on the Richmond Agitation and Sedation Scale as a Measure of Delirium in Patients with Subdural Hematomas

et al. 2018

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Background: Delirium is a frequent complication of critical illness, but its diagnosis is more difficult in brain-injured patients due to language impairment and disorders of consciousness. We conducted a prospective cohort study to determine whether Richmond Agitation and Sedation Scale (RASS) scores could be used to reliably diagnose delirium in the setting of brain injury. We also examined clinical factors associated with delirium in patients with subdural hematomas (SDH) and assessed its impact on functional outcome at discharge. Methods: We prospectively enrolled 55 patients with the primary diagnosis of SDH admitted to the neurological intensive care unit (ICU) and screened them for delirium with the Confusion Assessment Method-ICU (CAM-ICU). As our primary outcome, we examined whether the standard deviation of RASS scores (RASS dispersion) could be used to diagnose delirium. We also looked at trends in RASS scores as a way to distinguish different causes of delirium. Then, using logistic regression, we identified factors associated with delirium in patients with SDH and quantified the impact of delirium on the modified Rankin Scale at discharge. Results: Delirium as defined by the CAM-ICU was present in 35% (N = 19) of patients. RASS dispersion correlated well with the CAM-ICU (AUC of the ROC was 0.84). Analyzing the temporal trend of changes in the RASS was helpful in identifying new brain injuries as the underlying etiology of CAM-ICU positivity. Age, APACHE II scores on admission, baseline functional impairment, midline shift on initial imaging, and infections were associated with an increased risk of delirium. Delirium was associated with a worse functional outcome. Conclusions: RASS dispersion correlates highly with CAM-ICU positivity, and monitoring trends in RASS scores can identify delirium caused by new brain injuries. Delirium as defined by the CAM-ICU is common in patients with SDH and portends worse outcomes.

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“…24 Notably, delirium can and often does coexist with underlying neurological disease such as dementia, traumatic brain injury, and stroke and so is not precluded from developing in these patients. 25,26 The incidence of delirium varies among individual studies but is a frequent diagnosis in all inpatient care settings. Vasilevskis and colleagues estimated that approximately one-third of patients who were hospitalized ultimately developed delirium.…”

Section: Manifestations and Outcomes Of Icu Delirium Manifestationsmentioning

confidence: 99%

Prevention and Management of Delirium in the Intensive Care Unit

Mart

Roberson

Salas

et al. 2020

Semin Respir Crit Care Med

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Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.

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Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review*

Cited by 75 publications

References 67 publications

Delirium Screening in Neurocritical Care and Stroke Unit Patients: A Pilot Study on the Influence of Neurological Deficits on CAM-ICU and ICDSC Outcome

Delirium Screening in Neurocritical Care and Stroke Unit Patients: A Pilot Study on the Influence of Neurological Deficits on CAM-ICU and ICDSC Outcome

Dispersion in Scores on the Richmond Agitation and Sedation Scale as a Measure of Delirium in Patients with Subdural Hematomas

Prevention and Management of Delirium in the Intensive Care Unit

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