Annemiek E. Wolters

Long-term outcome of delirium during intensive care unit stay in survivors of critical illness: a prospective cohort study

IntroductionDelirium is associated with impaired outcome, but it is unclear whether this relationship is limited to in-hospital outcomes and whether this relationship is independent of the severity of underlying conditions. The aim of this study was to investigate the association between delirium in the intensive care unit (ICU) and long-term mortality, self-reported health-related quality of life (HRQoL), and self-reported problems with cognitive functioning in survivors of critical illness, taking severity of illness at baseline and throughout ICU stay into account.MethodsA prospective cohort study was conducted. We included patients who survived an ICU stay of at least a day; exclusions were neurocritical care patients and patients who sustained deep sedation during the entire ICU stay. Delirium was assessed twice daily with the Confusion Assessment Method for the ICU (CAM-ICU) and additionally, patients who received haloperidol were considered delirious. Twelve months after ICU admission, data on mortality were obtained and HRQoL and cognitive functioning were measured with the European Quality of Life – Six dimensions self-classifier (EQ-6D). Regression analyses were used to assess the associations between delirium and the outcome measures adjusted for gender, type of admission, the Acute Physiology And Chronic Health Evaluation IV (APACHE IV) score, and the cumulative Sequential Organ Failure Assessment (SOFA) score throughout ICU stay.ResultsOf 1101 survivors of critical illness, 412 persons (37%) had been delirious during ICU stay, and 198 (18%) died within twelve months. When correcting for confounders, no significant association between delirium and long-term mortality was found (hazard ratio: 1.26; 95% confidence interval (CI) 0.93 to 1.71). In multivariable analysis, delirium was not associated with HRQoL either (regression coefficient: -0.04; 95% CI -0.10 to 0.01). Yet, delirium remained associated with mild and severe problems with cognitive functioning in multivariable analysis (odds ratios: 2.41; 95% CI 1.57 to 3.69 and 3.10; 95% CI 1.10 to 8.74, respectively).ConclusionsIn this group of survivors of critical illness, delirium during ICU stay was not associated with long-term mortality or HRQoL after adjusting for confounding, including severity of illness throughout ICU stay. In contrast, delirium appears to be an independent risk factor for long-term self-reported problems with cognitive functioning.

Anticholinergic Medication Use and Transition to Delirium in Critically Ill Patients: A Prospective Cohort Study.

Objective:Although cholinergic deficiency is presumed to increase delirium risk and use of medication with anticholinergic properties in the ICU is frequent, the relationship between anticholinergic medication use and delirium in this setting remains unclear. We investigated whether exposure to medication with anticholinergic properties increases the probability of transitioning to delirium in critically ill adults and whether this relationship is affected by age or the presence of acute systemic inflammation. Design:Prospective cohort study. Setting:A 32-bed medical-surgical ICU at an academic medical center. Patients:Critically ill adults admitted to the ICU for more than 24 hours without an acute neurological disorder or another condition that would hamper delirium assessment. Interventions:None. Measurements and Main Results:Daily anticholinergic burden was calculated for each patient based on the sum of the Anticholinergic Drug Scale score for each medication administered. Daily mental status was classified as “coma,” “delirium,” or an “awake without delirium” state. The primary outcome, the daily transition from an “awake without delirium” state to “delirium,” was analyzed using a first-order Markov model that adjusted for eight covariables. A total of 1,112 patients were evaluated over 9,867 ICU days. The daily median summed Anticholinergic Drug Scale score was 2 (interquartile range, 1–3). The transition from being in an “awake without delirium” state to “delirium” occurred on 562 of ICU days (6%). After correcting for confounding, a one-unit increase in the Anticholinergic Drug Scale score resulted in a nonsignificant increase in the probability of delirium occurring the next day (odds ratio, 1.05; 95% CI, 0.99–1.10). Neither age nor the presence of acute systemic inflammation modified this relationship. Conclusions:Exposure to medication with anticholinergic properties, as defined by the Anticholinergic Drug Scale, does not increase the probability of delirium onset in patients who are awake and not delirious in the ICU.

Systemic Corticosteroids and Transition to Delirium in Critically Ill Patients

Objective:Corticosteroids are frequently used in critically ill patients. We investigated whether systemic corticosteroid use increases the probability of transitioning to delirium in a large population of mixed medical-surgical ICU patients. Design:Prospective cohort study. Setting:A 32-bed medical-surgical ICU at an academic medical center. Patients:Critically ill adults (n = 1,112), admitted to the ICU for more than 24 hours without a condition that could hamper delirium assessment. Interventions:None. Measurements and Main Results:Systemic corticosteroid exposure was measured daily and converted to prednisone equivalents (milligrams). Daily mental status was classified as coma, delirium, or an awake without delirium state. Transitions between states were analyzed using a first-order Markov multinomial logistic regression model with 11 different covariables, with the transition from an awake without delirium state to delirium as a primary interest. Among the 1,112 patients, corticosteroids were administered on 35% (3,483/9,867) of the ICU days at a median dose of 50 mg (interquartile range, 25–75 mg) prednisone equivalent. Administration of a corticosteroid, and any increase in the dose of the corticosteroid given on exposure days, was not significantly associated with the transition to delirium (adjusted odds ratio, 1.08; 95% CI, 0.89–1.32 and adjusted odds ratio, 1.00; 95% CI, 0.99–1.01, per 10 mg increase in prednisone equivalent). Conclusions:In a large population of mixed medical-surgical ICU patients, systemic corticosteroid use was not associated with an increased probability of transitioning to delirium.

Long-Term Mental Health Problems After Delirium in the ICU.

Objectives:To determine whether delirium during ICU stay is associated with long-term mental health problems defined as symptoms of anxiety, depression, and posttraumatic stress disorder. Design:Prospective cohort study. Setting:Survey study, 1 year after discharge from a medical-surgical ICU in the Netherlands. Patients:One-year ICU survivors of an ICU admission lasting more than 48 hours, without a neurologic disorder or other condition that would impede delirium assessment during ICU stay. Interventions:None. Measurements and Main Results:One year after discharge, ICU survivors received a survey containing the Hospital Anxiety and Depression Scale with a subscale for symptoms of depression and a subscale for symptoms of anxiety, and the Impact of Event Scale 15 item measuring symptoms of posttraumatic stress disorder. Participants were classified as having experienced no delirium (n = 270; 48%), a single day of delirium (n = 86; 15%), or multiple days of delirium (n = 211; 37%) during ICU stay. Log-binomial regression was used to assess the association between delirium and symptoms of anxiety, depression, and posttraumatic stress disorder. The study population consisted of 567 subjects; of whom 246 subjects (43%) reported symptoms of anxiety (Hospital Anxiety and Depression Scale with a subscale for anxiety, ≥ 8), and 254 (45%) symptoms of depression (Hospital Anxiety and Depression Scale with a subscale for depression, ≥ 8). In 220 patients (39%), the Impact of Event Scale 15 item was greater than or equal to 35, indicating a high probability of posttraumatic stress disorder. There was substantial overlap between these mental health problems—63% of the subjects who scored positive for the presence of any three of the mental health problems, scored positive for all three. No association was observed between either a single day or multiple days of delirium and symptoms of anxiety, depression, or posttraumatic stress disorder. Conclusions:Although symptoms of anxiety, depression, and posttraumatic stress disorder were found to be common 1 year after critical illness, the occurrence of delirium during ICU stay did not increase the risk of these long-term mental health problems.

Systemic Corticosteroids And Transition To Delirium in Critically Ill Patients

Delirium is frequent in the critically ill and is associated with long-term morbidity [1]. Currently, the key approach for delirium in the ICU is avoidance of risk factors. Systemic corticosteroids are often used in the ICU, and regularly administered in high dosages, as increasing evidence suggests potential benefits of these medications in critically ill patients [2, 3]. However, corticosteroids are proposed to be a risk factor delirium in patients with acute lung injury [4].

Long-Term Self-Reported Cognitive Problems After Delirium in the Intensive Care Unit and the Effect of Systemic Inflammation

To describe the association between intensive care unit (ICU) delirium and self‐reported cognitive problems in 1‐year ICU survivors, and investigate whether this association was altered by exposure to systemic inflammation during ICU stay.

The postintensive care syndrome of survivors of critical illness and their families.

• This study gives insight into the social aspects of life after critical illness, with regard to hampered social activities due to physical or psychological problems for former intensive care unit (ICU) patients and their families. Furthermore, it increases the awareness of incapacity of work resumption as a social aspect in the life of the former ICU patients. • Results emphasize the importance of multidisciplinary structured follow-up and support for former ICU patients and their families. Aim