Abstract WP413: Deconstructing Post-Stroke Delirium in a Prospective Cohort of Patients With Intracerebral Hemorrhage

Abstract

Introduction: Post-stroke delirium is associated with worse outcomes, yet is likely underdiagnosed due to the challenges of disentangling delirium symptoms from underlying neurological deficits. We aimed to determine the prevalence of individual delirium features and the frequency with which they could not be assessed in a cohort of patients with intracerebral hemorrhage (ICH). Methods: Consecutive patients admitted with ICH received daily assessments for delirium by an expert clinician, all of which included the Confusion Assessment Method for the ICU (CAM-ICU), Intensive Care Delirium Screening Checklist (ICDSC), a focused bedside cognitive exam, chart review, and nurse interview. We characterized individual symptom prevalence and established delirium diagnoses using DSM-5 criteria, then compared performance of the CAM-ICU and ICDSC with reference-standard diagnosis. Results: We performed 257 assessments on 60 patients (mean age 68.0 [SD 18.4], 62% male, median ICH score 1.5 [IQR 1-2]), of whom 55% had delirium. Symptom fluctuation (61% of all assessments), impaired arousal (37%), psychomotor changes (46%), and sleep-wake disturbances (46%) had a high prevalence and were never rated “unable to assess” (UTA), while inattention (36%), disorganized thinking (18%), and disorientation (27%) were also common but were often UTA (32%, 44%, and 43% of assessments, respectively), most frequently due to aphasia (present in 32% of patients). As the ICDSC may be positive without the presence of symptoms that require verbal assessment, it was more accurate ( Sensitivity= 77%, Specificity= 97%) than the CAM-ICU ( Sensitivity= 41%, Specificity= 88%) relative to the DSM-5-based reference standard. Allowing non-verbal assessments of attention using visual and auditory stimuli decreased the frequency of UTA assessments to 11%. Conclusion: Delirium is common after ICH, but reliance on verbal interaction with patients may confound its assessment and lead to underdiagnosis. The ICDSC’s inclusion of non-verbal features makes it more accurate than the CAM-ICU, but novel tools specifically designed for patients with neurological deficits may be warranted.