The attributable mortality of delirium in critically ill patients: prospective cohort study

Abstract

Objective To determine the attributable mortality caused by delirium in critically ill patients.Design Prospective cohort study.Setting 32 mixed bed intensive care unit in the Netherlands, January 2011 to July 2013.Participants 1112 consecutive adults admitted to an intensive care unit for a minimum of 24 hours.Exposures 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.Main outcome measure Mortality during admission to an intensive care unit.Results 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).Conclusions 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.

Antipsychotic Drug Use and Screening for Delirium in Mechanically Ventilated Patients in Canadian Intensive Care Units: An Observational Study

“…The following variables for entry into the model were selected a priori, on the basis of published studies and clinical importance 6,8,[19][20][21] : age, APACHE II score, use of antipsychotic before ICU admission (a potential marker of delirium before transfer to the ICU), duration of mechanical ventilation, exposure to benzodiazepines (expressed in midazolam equivalents), agitation (defined as a score > 4 on the Riker Sedation-Agitation Scale [SAS]), 22 use of daily sedation interruption, use of a delirium screening tool, and application of physical restraints. Patients with a documented history of schizophrenia who were treated with antipsychotics were excluded from the multivariable analysis.…”

“…[1][2][3][4][5][6] Professional society guidelines 7,8 recommend the routine use of screening tools specifically designed for detecting delirium in critically ill patients (e.g., the Confusion Assessment Method for the Intensive Care Unit [CAM-ICU] 9 and the Intensive Care Delirium Screening Checklist [ICDSC] 10 ). However, international surveys and observational studies have indicated that delirium screening tools are not widely incorporated into critical care practice, [11][12][13][14][15][16] which represents a missed opportunity to detect the syndrome.…”

Ghosts in the health machine

“…Hippocrates associated it firmly with oncoming death (Adamis et al 2007); delirium remains closely associated with mortality (see for example Klouwenberg et al 2014). The two figures I describe -friendly and unfriendly -are one frame through which to understand this world.…”

Assessing and Managing Delirium in Surgical and Internal Medicine: an Overview

“…Mortalite/Morbidite: Deliryum gelişimi, yoğun bakımda yatan ağır hastalarda mortalite oranlarını en az %10 artırır (13). Hastanede yatış sırasında deliryum gelişen yaşlı hastaların taburcu olduktan sonra izlendiği bir çalışmada 12 ay içinde mortalite oranı %63,3 olarak bulunmuştur.…”