Anja Heymann

Different assessment tools for intensive care unit delirium: which score to use?

Objective: To compare validity and reliability of three instruments for detection and assessment of delirium in intensive care unit (ICU) patients. Delirium in critically ill patients is associated with higher mortality, prolonged duration of ICU stay, and greater healthcare costs. Currently, there are several assessment tools available for detection of delirium, but only a few of these assessment systems are developed specifically to screen for delirium in ICU patients. Design: Prospective cohort study. Setting: ICU at a university hospital. Patients: A total of 156 surgical patients aged ≥60 yrs consecutively admitted to the ICU, with a length of stay of at least 24 hrs. Measurements and Main Results: This study was approved by the institutional ethics committee. Trained staff members performed daily and independently the Confusion Assessment Method for the ICU (CAM-ICU), the Nursing Delirium Screening Scale (Nu-DESC), and the Delirium Detection Score (DDS). These evaluations were compared against the reference standard conducted by a delirium expert (blinded to the study), who used delirium criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Of 156 patients, 63 (40%) were identified as delirious by the reference standard during the study. Using the CAM-ICU and the Nu-DESC, we measured comparable sensitivities (CAM-ICU, 81%; Nu-DESC, 83%). The specificity of the CAM-ICU was significantly higher than that of the Nu-DESC (96% vs. 81%, p < .01). In contrast, the DDS showed poor sensitivity (30%), whereas the specificity was significantly higher compared with the Nu-DESC (DDS, 91%; Nu-DESC, 81%, p < .05). The interrater reliability was “almost perfect” for the CAM-ICU (&kgr; = 0.89) and “substantial” for DDS and Nu-DESC (&kgr; = 0.79, 0.68). Conclusion: The CAM-ICU showed the best validity of the evaluated scales to identify delirium in ICU patients. The Nu-DESC might be an alternative tool for detection of ICU delirium. The DDS should not be used as a screening tool.

Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care--short version.

Targeted monitoring of analgesia, sedation and delirium, as well as their appropriate management in critically ill patients is a standard of care in intensive care medicine. With the undisputed advantages of goal-oriented therapy established, there was a need to develop our own guidelines on analgesia and sedation in intensive care in Germany and these were published as 2nd Generation Guidelines in 2005. Through the dissemination of these guidelines in 2006, use of monitoring was shown to have improved from 8 to 51% and the use of protocol-based approaches increased to 46% (from 21%). Between 2006–2009, the existing guidelines from the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) were developed into 3rd Generation Guidelines for the securing and optimization of quality of analgesia, sedation and delirium management in the intensive care unit (ICU). In collaboration with another 10 professional societies, the literature has been reviewed using the criteria of the Oxford Center of Evidence Based Medicine. Using data from 671 reference works, text, diagrams and recommendations were drawn up. In the recommendations, Grade “A” (very strong recommendation), Grade “B” (strong recommendation) and Grade “0” (open recommendation) were agreed. As a result of this process we now have an interdisciplinary and consensus-based set of 3rd Generation Guidelines that take into account all critically illness patient populations. The use of protocols for analgesia, sedation and treatment of delirium are repeatedly demonstrated. These guidelines offer treatment recommendations for the ICU team. The implementation of scores and protocols into routine ICU practice is necessary for their success.

Delayed Treatment of Delirium Increases Mortality Rate in Intensive Care Unit Patients

Delirium in the intensive care unit (ICU) is a serious complication associated with a poor outcome in critically ill patients. In this prospective observational study of the effect of a delay in delirium therapy on mortality rate, 418 ICU patients were regularly assessed using the Delirium Detection Score (DDS). The departmental standard required that if delirium was diagnosed (DDS > 7), therapy should be started within 24 h. In total, 204 patients (48.8%) were delirious during their ICU stay. In 184 of the delirious patients (90.2%), therapy was started within 24 h; in 20 patients (9.8%), therapy was delayed. During their ICU stay, patients whose delirium treatment was delayed were more frequently mechanically ventilated, had more nosocomial infections (including pneumonia) and had a higher mortality rate than patients whose treatment was not delayed. Thus, it would appear that a delay in initiating delirium therapy in ICU patients was associated with increased mortality.

[The Intensive Care Delirium Screening Checklist (ICDSC)--translation and validation of intensive care delirium checklist in accordance with guidelines].

BACKGROUND Although Delirium is the most common psychiatric disease in ICU settings, it is recognized late or not at all in up to 84 % of all cases. METHODS Translation of the ICDSC, in accordance with ISPOR guidelines and validation by conducting a screening of 68 ICU patients. RESULTS The translation process was authorized by the original author. The final German translation of the ICDSC showed a sensitivity and specificity of 89 % and 57 % respectively. CONCLUSION The ICDSC is suitable for delirium screening by nurses even on ventilated patients. Besides a high sensitivity another advantage is the possibility to screen for a subsyndromal delirium.

Die Nursing Delirium Screening Scale (Nu–DESC) – Richtlinienkonforme Übersetzung für den deutschsprachigen Raum

BACKGROUND Both in the recovery room as well as in the intensive care unit post-operative delirium is the most common psychiatric disease. The post-operative delirium is stated in literature to occur in 15 % to 50 % of patients, whereby up to 80 % of patients requiring intensive care with artificial respiration develop a delirium. The delirium correlates with the length of hospital stay and leads to a tripple rate of the six-month-mortality. Nu-DESC, developed by Gaudreau et al. is a measuring instrument for the clinical diagnostics of deliriums which is quickly operable, care-based and which can thus be easily integrated in everyday routine. The aim of this study was the translation of Nu-DESC from English as basis for the use in clinical research and routine. MATERIALS AND METHODS The translation process was conducted in accordance with the internationally acknowledged guidelines of Translation and Cultural Adaptation of Patient Reported Outcomes Measures - Principles of Good Practice (PGP). An interim German version was developed from 3 independently devised translations, a back-translation of which was then conducted by a registered state-approved translator. The back-translation was then presented to the author of the original for evaluation. RESULTS The back-translation of the German translation was authorised by the author of the original. On the basis of the cognitive debriefing results which were consistently very good to good, the translation process could be finalised and the final German version of Nu-DESC could be passed by the expert team. An evaluation of the German Nu-DESC regarding its practicability showed significant differences between doctors and nursing staff. CONCLUSION The German version of Nu-DESC provides an instrument for evaluating the delirium in the area of clinical routine and research.

Prävention und Therapie

To date, there are few studies available focusing on prevention and therapy of delirium in ICU patients. Monitoring during routine care is important because without using validated tools only one third of the delirious patients will be detected. A lot of non-pharmacological interventions like re-orientation and helping the patient to get back his autonomy, but also goal-orientated sedation support prevention and therapy of delirium. Furthermore, there are hints that pharmacological intervention can reduce incidence and severity of delirium. For delirium prevention there are drugs available acting on different receptor systems (acetylcholine, dopamine, opioid, glutamate). For the use of this drugs, a strict risk-benefit-consideration is necessary due to the low level of evidence of the existing studies. Therapeutically causative and symptom-orientated approaches should be preferred.

Remifentanil Reduces the Incidence of Post-Operative Delirium

A secondary exploratory analysis of data from an observational study was used to study the influence of the opioid used for intraoperative anaesthesia on the incidence of post-operative delirium. Patients who had been admitted to the recovery room following elective general anaesthesia were divided into those who had received fentanyl or remifentanil. For unbiased patient analysis, matched pairs were built with respect to gender, age, physical status, anaesthetic type and surgery duration. In 752 patients, the overall incidence of delirium was 9.9% in the recovery room and 3.8% on the first post-operative day. Compared with the remifentanil group, the fentanyl group had a significantly higher incidence of delirium in the recovery room (12.2% versus 7.7%) and on the first post-operative day (5.8% versus 1.9%). Delirium in the recovery room and on the first post-operative day were both associated with a significantly prolonged post-operative hospital stay. The choice of intraoperative opioid influences the incidence of post-operative delirium. Remifentanil was associated with a lower incidence of post-operative delirium in the early post-operative period.

If delirium is not monitored it will often be not detected

The reported incidence of delirium in critically ill patients ranges widely - from 11% to 87%. Both in the recovery room as well as in the intensive care unit postoperative delirium is the most common psychiatric disease. Patients with ICU delirium have a significant higher 6-month mortality rate. Recent studies could show that the use of a validated delirium assessment tool significantly improves the ability of physicians and nurses to detect delirium in ICU patients. The following article gives a review about different assessment tools of ICU delirium and focuses on the differences between validated delirium scores.

Hyperactive Delirium and Blood Glucose Control in Critically Ill Patients

Delirium is a common complication of critically ill patients and is often associated with metabolic disorders. One of the most frequent metabolic disorders in intensive care unit (ICU) patients is hyperglycaemia. The aim of this retrospective study of 196 adult ICU patients was to determine if there is an association between hyperactive delirium and blood glucose levels in ICU patients. Hyperactive delirium was diagnosed using the delirium detection score. Blood glucose levels were monitored by blood gas analysis every 4 h. Hyperactive delirium was detected in 55 (28%) patients. Delirious patients showed significantly higher blood glucose levels than non-delirious patients Higher overall complication rates, length of ventilation, ICU stay and mortality rates were seen in the delirium group. In a multivariate analysis, glucose level, alcohol abuse, APACHE II score, complication by hospital-acquired pneumonia and a diagnosis of polytrauma on-admission all significantly influenced the appearance of delirium.