Abstract
BackgroundDelirium screening instruments (DSIs) should be used to detect delirium, but they only show moderate sensitivity in patients with neurocritical illness. We explored whether, for these patients, DSI validity is impacted by patient-specific covariates.MethodsData were prospectively collected in a single-center quality improvement project. Patients were screened for delirium once daily using the Intensive Care Delirium Screening Checklist (ICDSC) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Reference was the daily assessment using criteria from the Diagnostic and Statistical Manual, 4th Edition, Text Revision (DSM-IV-TR). In a two-step receiver operating characteristics regression analysis adjusting for repeated measurements, the impact of acute diagnosis of stroke or transient ischemic attack (TIA), neurosurgical intervention, Richmond Agitation Sedation Scale, and ventilation status on test validity was determined.ResultsOf 181 patients screened, 101 went into final analysis. Delirium incidence according to DSM-IV-TR was 29.7%. For the first complete assessment series (CAM-ICU, ICDSC, and DSM-IV-TR), sensitivity for the CAM-ICU and the ICDSC was 73.3% and 66.7%, and specificity was 91.8% and 94.1%, respectively. Consideration of daily repeated measurements increased sensitivity for the CAM-ICU and ICDSC to 75.7% and 73.4%, and specificity to 97.3% and 98.9%, respectively. Receiver operating characteristics regression revealed that lower Richmond Agitation Sedation Scale levels significantly impaired validity of the ICDSC (p = 0.029) and the CAM-ICU in its severity scale version (p = 0.004). Neither acute diagnosis of stroke or TIA nor neurosurgical intervention or mechanical ventilation significantly influenced DSI validity.ConclusionsThe CAM-ICU and ICDSC perform well in patients requiring neurocritical care, regardless of the presence of acute stroke, TIA, or neurosurgical interventions. Yet, even very light or moderate sedation can significantly impair DSI performance.
Highlights
Delirium is the most typical manifestation of a per-definition secondary encephalopathy in the critical care context [1]
Characteristics of the Project Cohort Out of n = 181 patients screened to participate in the quality improvement (QI) project, n = 80 (44.2%) were excluded, leaving n = 101 (55.8%) patients for analysis (Fig. 2)
Patients in the delirium group showed a higher severity of illness [APACHE Simplified Acute Physiology Score II (II) on admission 20 (16–26) vs. 13 (7–19), p < 0.001; Simplified Acute Physiology Score II (SAPS II) on admission 39.5 (31–49) vs. 25.5 (15–38), p < 0.001]
Summary
Delirium is the most typical manifestation of a per-definition secondary encephalopathy in the critical care context [1]. There are only a few studies pertaining to delirium in patients with neurocritical illness. These patients show a pooled delirium prevalence rate of 11.8% to 45.9% in prospective cohort studies [9]. Just like in other patient populations, delirium in this cohort is associated with increased intensive care unit (ICU) and hospital length of stay, cost of care, and occurrence of postintensive care syndrome, long-term cognitive impairments [9]. Delirium screening instruments (DSIs) should be used to detect delirium, but they only show moderate sensitivity in patients with neurocritical illness. For these patients, DSI validity is impacted by patient-specific covariates
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