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Monitoring Delirium in the ICU

  • M. Seeling
  • A. Heymann
  • C. Spies

Abstract

For most of us, critical care used to consist of directly applying physiological and pathophysiological knowledge — which we so proudly and diligently acquired during medical school — in the real world. Pulmonary, cardiac, renal, and later metabolic functions were the concerns of the day and their dysfunction comprised the major determinants of disease. Introducing a new dimension, Pronovost et al. [1] showed us that team efforts make a great contribution towards improving critical care outcomes. Since Bedford observed the postoperative long-term confusional state back in 1955 [2], we have come a long way, to understand that the acute impairment of cognitive functions is not only an annoying side issue which is difficult to deal with on the critical care ward, but that it all too often determines the outcome of patients when all other organ functions should have been under control. Defining this ‘sixth vital sign’ necessitated some evolutionary development in that international terminology had to be agreed on — a process that is still underway. Despite international clarification by means of the International Statistical Classification of Diseases (ICD)-10 and the Diagnostic and Statistical Manual of Mental Disorders (DSM), there is no real gold-standard for diagnosing acute confusional state.

Keywords

Intensive Care Unit Intensive Care Unit Patient Alcohol Withdrawal Syndrome Confusion Assessment Method Patient Data Management System 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Pronovost P, Holzmueller CG, Clattenburg L, et al (2006). Team care: beyond open and closed intensive care units. Curr Opin Crit Care 12: 604–608CrossRefPubMedGoogle Scholar
  2. 2.
    Bedford PD (1955) Adverse cerebral effects of anaesthesia on old people. Lancet 269: 259–263CrossRefPubMedGoogle Scholar
  3. 3.
    Tucker GJ (1999) The diagnosis of delirium and DSM-IV. Dement Geriatr Cogn Disord 10: 359–363CrossRefPubMedGoogle Scholar
  4. 4.
    Skrobik Y (2007) Delirium as destiny: clinical precision and genetic risk. Crit Care Med 35: 304–305CrossRefPubMedGoogle Scholar
  5. 5.
    Morandi A, Pandharipande, P, Trabucchi, et al (2008) Understanding international differences in terminology for delirium and other types of acute brain dysfunction in critically ill patients. Intensive Care Med 34: 1907–1915CrossRefPubMedGoogle Scholar
  6. 6.
    Cheung CZ, Alibhai SM, Robinson M, et al (2008) Recognition and labeling of delirium symptoms by intensivists: Does it matter? Intensive Care Med 34: 437–446CrossRefPubMedGoogle Scholar
  7. 7.
    Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y (2001) Intensive care delirium screening checklist: Evaluation of a new screening tool. Intensive Care Med 27: 859–864CrossRefPubMedGoogle Scholar
  8. 8.
    Ely EW, Inouye SK, Bernard GR, et al (2001) Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 286: 2703–2710CrossRefPubMedGoogle Scholar
  9. 9.
    Ely EW, Shintani A, Truman B, et al (2004) Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 291: 1753–1762CrossRefPubMedGoogle Scholar
  10. 10.
    McNicoll L, Pisani MA, Zhang Y, Ely EW, Siegel MD, Inouye SK (2003) Delirium in the intensive care unit: occurrence and clinical course in older patients. J Am Geriatr Soc 51: 591–598CrossRefPubMedGoogle Scholar
  11. 11.
    Loney PL, Chambers LW, Bennett KJ, Roberts JG, Stratford PW (1998) Critical appraisal of the health research literature: prevalence or incidence of a health problem. Chronic Dis Can 19: 170–176PubMedGoogle Scholar
  12. 12.
    Peterson JF, Pun BT, Dittus RS, et al (2006) Delirium and its motoric subtypes: a study of 614 critically ill patients. J Am Geriatr Soc 54: 479–484CrossRefPubMedGoogle Scholar
  13. 13.
    Pisani MA, Murphy TE, Van Ness PH, Araujo KL, Inouye SK (2007) Characteristics associated with delirium in older patients in a medical intensive care unit. Arch Intern Med 167: 1629–1634CrossRefPubMedGoogle Scholar
  14. 14.
    Dubois MJ, Bergeron N, Dumont M, Dial S, Skrobik Y (2001) Delirium in an intensive care unit: a study of risk factors. Intensive Care Med 27: 1297–1304CrossRefPubMedGoogle Scholar
  15. 15.
    Lin SM, Huang CD, Liu CY, et al (2008) Risk factors for the development of early-onset delirium and the subsequent clinical outcome in mechanically ventilated patients. J Crit Care 23: 372–379CrossRefPubMedGoogle Scholar
  16. 16.
    Ely EW, Gautam S, Margolin R, et al (2001) The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 27: 1892–1900CrossRefPubMedGoogle Scholar
  17. 17.
    Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y (2007) Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 33: 66–73CrossRefPubMedGoogle Scholar
  18. 18.
    Milbrandt EB, Deppen S, Harrison PL, et al (2004) Costs associated with delirium in mechanically ventilated patients. Crit Care Med 32: 955–62CrossRefPubMedGoogle Scholar
  19. 19.
    Jackson JC, Gordon SM, Hart RP, Hopkins RO, Ely EW (2004) The association between delirium and cognitive decline: a review of the empirical literature. Neuropsychol Rev 14: 87–98CrossRefPubMedGoogle Scholar
  20. 20.
    Inouye SK, Schlesinger MJ, Lydon TJ (1999) Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med 106: 565–573CrossRefPubMedGoogle Scholar
  21. 21.
    Bellelli G, Bianchetti A, Trabucchi M (2008) Delirium and costs of informal home care. Arch Intern Med 168:1717CrossRefPubMedGoogle Scholar
  22. 22.
    Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK (2008) One-year health care costs associated with delirium in the elderly population. Arch Intern Med 168: 27–32CrossRefPubMedGoogle Scholar
  23. 23.
    Leslie DL, Zhang Y, Bogardus ST, Holford TR, Leo-Summers LS, Inouye SK (2005) Consequences of preventing delirium in hospitalized older adults on nursing home costs. J Am Geriatr Soc 53: 405–409CrossRefPubMedGoogle Scholar
  24. 24.
    Rizzo JA, Bogardus STJr, Leo-Summers L, Williams CS, Acampora D, Inouye SK (2001) Multicomponent targeted intervention to prevent delirium in hospitalized older patients: what is the economic value? Med Care 39: 740–752CrossRefPubMedGoogle Scholar
  25. 25.
    Inouye SK, Bogardus STJr, Charpentier PA, et al (1999) A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 340: 669–676CrossRefPubMedGoogle Scholar
  26. 26.
    Rockwood K, Brown M, Merry H, Sketris I, Fisk J (2002) Societal costs of vascular cognitive impairment in older adults. Stroke 33: 1605–1609CrossRefPubMedGoogle Scholar
  27. 27.
    Pitkala KH, Laurila JV, Strandberg TE, Kautiainen H, Sintonen H, Tilvis RS (2008) Multicomponent geriatric intervention for elderly inpatients with delirium: effects on costs and health-related quality of life. J Gerontol A Biol Sci Med Sci 63: 56–61PubMedGoogle Scholar
  28. 28.
    Ely EW, Stephens RK, Jackson, et al (2004) Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: a survey of 912 healthcare professionals. Crit Care Med 32: 106–112CrossRefPubMedGoogle Scholar
  29. 29.
    Verstraete L, Joosten, E, Milisen, K (2008) [Opinions of physicians and nurses regarding the prevention, diagnosis and management of delirium]. Tijdschr Gerontol Geriatr 39: 26–34PubMedCrossRefGoogle Scholar
  30. 30.
    Jacobi J, Fraser, GL, Coursin et al. (2002) Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 30: 119–141CrossRefPubMedGoogle Scholar
  31. 31.
    Martin J, Bäsell K, Bürkle H, et al (2005) Analgesie und Sedierung in der Intensivmedizin-S2-Leitlinien der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin. Anästh Intensivmed 46 (Suppl 1/2005): 1–20Google Scholar
  32. 32.
    Mattia C, Savoia G, Paoletti F, et al (2006) SIAARTI Recommendations for analgo-sedation in intensive care unit. Minerva Anestesiol 72: 769–805PubMedGoogle Scholar
  33. 33.
    Devlin JW, Fong JJ, Fraser GL, Riker RR (2007) Delirium assessment in the critically ill. Intensive Care Med 33: 929–940CrossRefPubMedGoogle Scholar
  34. 34.
    Pandharipande P, Jackson J, Ely EW (2005) Delirium: Acute cognitive dysfunction in the critically ill. Curr Opin Crit Care 11: 360–368PubMedGoogle Scholar
  35. 35.
    Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI (1990) Clarifying confusion: the confusion assessment method. a new method for detection of delirium. Ann Intern Med 113: 941–948PubMedGoogle Scholar
  36. 36.
    Wei LA, Fearing MA, Sternberg EJ, Inouye SK (2008) The confusion assessment method: a systematic review of current usage. J Am Geriatr Soc 56: 823–830CrossRefPubMedGoogle Scholar
  37. 37.
    Wilson JMG, Jungner G (1968) Principles and Practice of Screening for Disease. WHO, GenevaGoogle Scholar
  38. 38.
    Cadman D, Chambers L, Feldman W, Sackett D (1984) Assessing the effectiveness of community screening programs. JAMA 251: 1580–1585CrossRefPubMedGoogle Scholar
  39. 39.
    Eaton WW, Martins SS, Nestadt G, Bienvenu OJ, Clarke D, Alexandre P (2008) The burden of mental disorders. Epidemiol Rev 30: 1–14CrossRefPubMedGoogle Scholar
  40. 40.
    Sharma PT, Sieber FE, Zakriya KJ, et al (2005) Recovery room delirium predicts postoperative delirium after hip-fracture repair. Anesth Analg 101: 1215–1220CrossRefPubMedGoogle Scholar
  41. 41.
    Devlin JW, Marquis F, Riker RR, et al (2008) Combined didactic and scenario-based education improves the ability of intensive care unit staff to recognize delirium at the bedside. Crit Care 12:R19CrossRefPubMedGoogle Scholar
  42. 42.
    Carnes M, Howell T, Rosenberg M, Francis J, Hildebrand C, Knuppel J (2003) Physicians vary in approaches to the clinical management of delirium. J Am Geriatr Soc 51: 234–239CrossRefPubMedGoogle Scholar
  43. 43.
    Gardner DM, Baldessarini RJ, Waraich P (2005) Modern antipsychotic drugs: a critical overview. CMAJ 172: 1703–1711PubMedGoogle Scholar
  44. 44.
    Siddiqi N, Stockdale R, Britton AM, Holmes J (2007) Interventions for preventing delirium in hospitalised patients. Cochrane Database Syst Rev: CD005563Google Scholar
  45. 45.
    Bourne RS, Tahir TA, Borthwick M, Sampson EL (2008) Drug treatment of delirium: past, present and future. J Psychosom Res 65: 273–282CrossRefPubMedGoogle Scholar
  46. 46.
    Lonergan E, Britton AM, Luxenberg J, Wyller T (2007) Antipsychotics for delirium. Cochrane Database Syst Rev: CD005594Google Scholar
  47. 47.
    Spies CD, Dubisz N, Funk W, et al. (1995) Prophylaxis of alcohol withdrawal syndrome in alcohol-dependent patients admitted to the intensive care unit after tumour resection. Br J Anaesth 75: 734–739PubMedGoogle Scholar
  48. 48.
    Spies CD, Dubisz N, Neumann T, et al (1996) Therapy of alcohol withdrawal syndrome in intensive care unit patients following trauma: results of a prospective, randomized trial. Crit Care Med 24: 414–422CrossRefPubMedGoogle Scholar
  49. 49.
    Spies CD, Otter HE, Huske B, et al (2003) Alcohol withdrawal severity is decreased by symptom-orientated adjusted bolus therapy in the ICU. Intensive Care Med 29: 2230–2238CrossRefPubMedGoogle Scholar
  50. 50.
    Cole MG, McCusker J, Bellavance F, et al (2002) Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. CMAJ 167: 753–759PubMedGoogle Scholar
  51. 51.
    Pun BT, Gordon SM, Peterson JF, et al (2005) Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers. Crit Care Med 33: 1199–1205CrossRefPubMedGoogle Scholar
  52. 52.
    Liptzin B (1999) What criteria should be used for the diagnosis of delirium? Dement Geriatr Cogn Disord 10: 364–367CrossRefPubMedGoogle Scholar
  53. 53.
    Simon SE, Bergmann MA, Jones RN, Murphy KM, Orav EJ, Marcantonio ER (2006) Reliability of a structured assessment for nonclinicians to detect delirium among new admissions to postacute care. J Am Med Dir Assoc 7: 412–415CrossRefPubMedGoogle Scholar
  54. 54.
    Pisani MA, Araujo KL, Van Ness PH, Zhang Y, Ely EW, Inouye SK (2006) A research algorithm to improve detection of delirium in the intensive care unit. Crit Care 10: R121CrossRefPubMedGoogle Scholar
  55. 55.
    Tobin MJ (2006) Remembrance of weaning past: the seminal papers. Intensive Care Med 32: 1485–1493CrossRefPubMedGoogle Scholar
  56. 56.
    Justic M (2000) Does “ICU psychosis” really exist? Crit Care Nurse 20: 28–37PubMedGoogle Scholar
  57. 57.
    Inouye SK, Foreman MD, Mion LC, Katz KH, Cooney LMJr (2001) Nurses’ recognition of delirium and its symptoms: comparison of nurse and researcher ratings. Arch Intern Med 161: 2467–2473CrossRefPubMedGoogle Scholar
  58. 58.
    Mathison S (1988) Why triangulate? Educational Researcher 17: 13–17Google Scholar
  59. 59.
    Marcantonio ER, Rudolph JL, Culley D, Crosby G, Alsop D, Inouye SK (2006) Serum biomarkers for delirium. J Gerontol A Biol Sci Med Sci 61: 1281–1286PubMedGoogle Scholar
  60. 60.
    Bossuyt PM, Reitsma JB, Bruns DE, et al (2003) The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration. Ann Intern Med 138:W1–12PubMedGoogle Scholar
  61. 61.
    Tobin MJ, Jubran A (2008) Meta-analysis under the spotlight: focused on a meta-analysis of ventilator weaning. Crit Care Med 36: 1–7CrossRefPubMedGoogle Scholar
  62. 62.
    Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG (1986) Standards for patient monitoring during anesthesia at harvard medical school. JAMA 256: 1017–1020CrossRefPubMedGoogle Scholar
  63. 63.
    Bijker JB, van Klei WA, Kappen TH, van Wolfswinkel L, Moons KG, Kalkman CJ (2007) Incidence of intraoperative hypotension as a function of the chosen definition: literature definitions applied to a retrospective cohort using automated data collection. Anesthesiology 107: 213–220CrossRefPubMedGoogle Scholar
  64. 64.
    Bowton DL (2004) Delirium—the cost of inattention. Crit Care Med 32: 1080–1081CrossRefPubMedGoogle Scholar
  65. 65.
    Pun BT, Ely EW (2007) The importance of diagnosing and managing ICU delirium. Chest 132: 624–636CrossRefPubMedGoogle Scholar
  66. 66.
    American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Association, WashingtonGoogle Scholar
  67. 67.
    Hart RP, Levenson JL, Sessler CN, Best AM, Schwartz SM, Rutherford LE (1996) Validation of a cognitive test for delirium in medical ICU patients. Psychosomatics 37: 533–546PubMedGoogle Scholar
  68. 68.
    Hart RP, Best AM, Sessler CN, Levenson JL (1997) Abbreviated cognitive test for delirium. J Psychosom Res 43: 417–423CrossRefPubMedGoogle Scholar
  69. 69.
    Ely EW, Margolin R, Francis J, et al (2001) Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 29: 1370–1379CrossRefPubMedGoogle Scholar
  70. 70.
    Lin SM, Liu CY, Wang CH, et al (2004) The impact of delirium on the survival of mechanically ventilated patients. Crit Care Med 32: 2254–2259CrossRefPubMedGoogle Scholar
  71. 71.
    Csokasy J (1999) Assessment of acute confusion: use of the NEECHAM Confusion Scale. Appl Nurs Res 12: 51–55CrossRefPubMedGoogle Scholar
  72. 72.
    Immers HE, Schuurmans MJ, van de Bijl JJ (2005) Recognition of delirium in ICU patients: a diagnostic study of the NEECHAM confusion scale in ICU patients. BMC Nurs 4:7CrossRefPubMedGoogle Scholar
  73. 73.
    Otter H, Martin J, Basell K, et al (2005) Validity and reliability of the DDS for severity of delirium in the ICU. Neurocrit Care 2: 150–158CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2009

Authors and Affiliations

  • M. Seeling
    • 1
  • A. Heymann
    • 1
  • C. Spies
    • 1
  1. 1.Department of Anesthesiology and Intensive Care Campus Charité Mitte und Campus Virchow-KlinikumCharité-Universitätsmedizin BerlinBerlinGermany

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