Confusion assessment method for the intensive care unit, Delirium, Incidence, Intensive care unit, Risk factors
Citation Information :
Junior MM, Kumar A, Kumar P, Gupta P. Assessment of Delirium as an Independent Predictor of Outcome among Critically Ill Patients in Intensive Care Unit: A Prospective Study. Indian J Crit Care Med 2022; 26 (6):676-681.
Background: Delirium is frequently observed among critically ill patients in the intensive care unit. Although a preventable and reversible process, it is associated with greater morbidity and mortality. Early recognition and interpreting the predisposing and precipitating risk factors for delirium can improve outcomes among these patients.
Objective: A prospective observational study was conducted with the primary objective to evaluate the incidence of delirium in a mixed adult intensive care unit. The secondary objectives were the evaluation of risk factors and outcomes of delirium.
Methods: All patients who were more than 18 years of age and with an ICU stay of more than 24 hours were included in the study. Patients with prior history of neurological disorders, psychosis, and who were deaf were excluded. Eligible patients were evaluated by the residents to detect delirium using confusion assessment method for the intensive care unit (CAM-ICU) as a tool.
Results: A total of 110 patients were included, and delirium was detected in 41 patients (37.3%). Among the predisposing risk factors, only hypertension was significantly associated with delirium. Among precipitating factors, mechanical ventilation, use of physical restraints and presence of window/natural light exposure, high Acute Physiology and Chronic Health Evaluation II scores, use of opioids, and benzodiazepines were associated with delirium. In multivariate risk regression analysis, presence of window/natural light exposure [odds ratio (OR), 55.52; 95% CI (8.887–346.904)]; (p <0.001) and duration of stay in ICU OR (1.145); 95% CI (1.058–1.238) (p = 0.001) were independent risk factors of delirium. Also, high mortality (53.7%) was observed among the delirious group of patients.
Conclusion: Delirium is a common problem in the ICU and is associated with poor outcomes. Various risk factors are linked to ICU environment.
Ouimet S, Kavanagh BP, Gottfried SB, Skobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 2007;33(1): 66–73. DOI: 10.1007/s00134-006-0399-8.
Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harell FE, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. J Am Med Assoc 2004;291(14): 1753–1762. DOI: 10.1001/jama.291.14.1753.
Devlin JW, Fong JJ, Fraser GL, Riker RR. Delirium assessment in the critically ill. Intensive Care Med 2007;33(6):929–940. DOI: 10.1007/s00134-007-0603-5.
Ely EW, Stephens RK, Jackson JC, Thomason JW, Truman B, Gordon S, et al. Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: a survey of 912 healthcare professionals. Crit Care Med 2004;32(1):106–112. DOI: 10.1097/01.CCM.0000098033.94737.84.
Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). J Am Med Assoc 2001;286(21):2703–2710. DOI: 10.1001/jama.286.21.2703.
Grover S, Subodh BN, Avasthi A, Chakrabarti S, Kumar S, Sharan P, et al. Prevalence and clinical profile of delirium: a study from a tertiary-care hospital in north India. Gen Hosp Psychiatry 2009;31(1):25–29. DOI: 10.1016/j.genhosppsych.2008.06.001.
Krewulak KD, Stelfox HT, Leigh JP, Ely EW, Fiest KM. Incidence and prevalence of delirium subtypes in an adult ICU: a systematic review and meta-analysis. Crit Care Med 2018;46(12):2029–2035. DOI: 10.1097/CCM.0000000000003402.
Rompaey BV, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Elseviers M, Bossaert L. A comparison of the CAM-ICU and the NEECHAM Confusion Scale in intensive care delirium assessment: an observational study in non-intubated patients. Crit Care 2008;12(1):R16. DOI: 10.1186/cc6790.
Thomason JW, Shintani A, Peterson JF, Pun BT, Jackson JC, Ely EW. Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients. Crit Care 2005;9(4):R375–R381. DOI: 10.1186/cc3729.
George C, Nair JS, Ebenezer JA, Gangadharan A, Christudas A, Gnanaseelan LK, et al. Validation of the intensive care delirium screening checklist in nonintubated intensive care unit patients in a resource-poor medical intensive care setting in South India. J Crit Care 2011;26(2):138–143. DOI: 10.1016/j.jcrc.2010.11.002.
Bamalwa M, Mahmood SN, Praharaj SK. Delirium in cardiac ICU patients. Ann Clin Psychiatry 2016;28(1):51–55. PMID: 26855986.
Dubois MJ, Bergeron N, Dumont M, Dial S, Skrobik Y. Delirium in an intensive care unit: a study of risk factors. Intensive Care Med 2001;27(8):1297–1304. DOI: 10.1007/s001340101017.
Waldstein SR, Manuck SB, Ryan CM, Muldoon MF. Neuropsychological correlates of hypertension: Review and methodologic considerations. Psychol Bull 1991;110(3):451–468. DOI: 10.1037/0033-2909.110.3.451.
Van Rompaey B, Elseviers MM, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Bossaert L. Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care 2009;13(3):R77. DOI: 10.1186/cc7892.
Sharma A, Malhotra S, Grover S, Jindal SK. Incidence, prevalence, Risk factor and outcome of delirium in intensive care unit: a study from India. Gen Hosp Psych 2012;34(6):639–646. DOI: 10.1016/j.genhosppsych.2012.06.009.
Lahariaya S, Grover S, Bagga S, Sharma A. Delirium in patients admitted to a cardiac Intensive care unit with cardiac emergencies in a developing country: incidence, prevalence, risk factor and outcome. Gen Hosp Psych 2014;36(2):156–164. DOI: 10.1016/j.genhosppsych.2013.10.010.
Ebersoldt M, Sharshar T, Annane D. Sepsis-associated delirium. Intensive Care Med 2007;33(6):941–950. DOI: 10.1007/s00134-007-0622-2.
Smonig R, Magalhaes E, Bouadma L, Andremont O, Montmollin E, Essardy F, et al. Impact of natural light exposure on delirium burden in adult patients receiving invasive mechanical ventilation in the ICU: a prospective study. Ann Intensive Care 2019;9(1):120. DOI: 10.1186/s13613-019-0592-x.
Pan Y, Jiang Z, Yuan C, Wang L, Zhou J, Tao M, et al. Influence of physical restraints on delirium of adult patients in ICU. A nested case-control study. J Clin Nurs 2018;27(9–10):1950–1957. DOI: 10.1111/jocn.14334.
Lat I, McMillian W, Taylor S, Janzen JM, Papadopoulos S, Korth L, et al. The impact of delirium on clinical outcomes in mechanically ventilated surgical and trauma patients. Crit Care Med 2009;37(6):1898–1905. DOI: 10.1097/CCM.0b013e31819ffe38.
Aldemir M, Ozen S, Kara IH, Sir A, Bac B. Predisposing factors for delirium in the surgical intensive care unit. Crit Care 2001;5(5): 265–270. DOI: 10.1186/cc1044.
Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): a randomised controlled trial. Lancet 2008;371(9607):126–134. DOI: 10.1016/S0140-6736(08)60105-1.
Ely EW, Gautam S, Margolin R, Francis J, May L, Speroff T, et al. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 2001;27(12):1892–1900. DOI: 10.1007/s00134-001-1132-2.