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Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients

Pratik Pandharipande| Bryan A. Cotton| Ayumi Shintani| Jennifer Thompson| Sean Costabile| Brenda Truman Pun| Robert Dittus| E. Wesley Ely
Original
Volume 33, Issue 10 / October , 2007

Pages 1726 - 1731

Abstract

Objective

Acute brain dysfunction or delirium occurs in the majority of mechanically ventilated (MV) medical intensive care unit (ICU) patients and is associated with increased mortality. Unfortunately delirium often goes undiagnosed as health care providers fail to recognize in particular the hypoactive form that is characterized by depressed consciousness without the positive symptoms such as agitation. Recently, clinical tools have been developed that help to diagnose delirium and determine the subtypes. Their use, however, has not been reported in surgical and trauma patients. The objective of this study was to identify the prevalence of the motoric subtypes of delirium in surgical and trauma ICU patients.

Methods

Adult surgical and trauma ICU patients requiring MV longer than 24 h were prospectively evaluated for arousal and delirium using well validated instruments. Sedation and delirium were assessed using the Richmond Agitation Sedation Scale (RASS) and the Confusion Assessment Method in the ICU (CAM-ICU), respectively. Patients were monitored for delirium for a maximum of 10 days or until ICU discharge.

Patients

A total of 100 ICU patients (46 surgical and 54 trauma) were enrolled in this study. Three patients were excluded from the final analysis because they stayed persistently comatose prior to their death.

Measurements and results

Prevalence of delirium was 70% for the entire study population with 73% surgical and 67% trauma ICU patients having delirium. Evaluation of the subtypes of delirium revealed that in surgical and trauma patients, hypoactive delirium (64% and 60%, respectively) was significantly more prevalent than the mixed (9% and 6%) and the pure hyperactive delirium (0% and 1%).

Conclusions

The prevalence of the hypoactive or “quiet” subtype of delirium in surgical and trauma ICU patients appears similar to that of previously published data in medical ICU patients. In the absence of active monitoring with a validated clinical instrument (CAM-ICU), however, this subtype of delirium goes undiagnosed and the prevalence of delirium in surgical and trauma ICU patients remains greatly underestimated.

Keywords

References

  1. Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, Truman B, Speroff T, Gautam S, Margolin R, Hart RP, Dittus R (2001) Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 286:2703–2710
    • View reference on PubMed
    • View reference on publisher's website
  2. Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, Speroff T, Gautam S, Bernard GR, Inouye SK (2001) Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 29:1370–1379
    • View reference on PubMed
    • View reference on publisher's website
  3. Thomason JW, Shintani A, Peterson JF, Pun BT, Jackson JC, Ely EW (2005) Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients. Crit Care 9:R375–R381
    • View reference on PubMed
    • View reference on publisher's website
  4. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, Inouye SK, Bernard GR, Dittus RS (2004) Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 291:1753–1762
    • View reference on PubMed
    • View reference on publisher's website
  5. Milbrandt EB, Deppen S, Harrison PL, Shintani AK, Speroff T, Stiles RA, Truman B, Bernard GR, Dittus RS, Ely EW (2004) Costs associated with delirium in mechanically ventilated patients. Crit Care Med 32:955–962
    • View reference on PubMed
    • View reference on publisher's website
  6. 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 14:87–98
    • View reference on PubMed
    • View reference on publisher's website
  7. Granberg A, Engberg B, Lundberg D (1996) Intensive care syndrome: a literature review. Intensive Crit Care Nurs 12:173–182
    • View reference on PubMed
    • View reference on publisher's website
  8. Webb JM, Carlton EF, Geeham DM (2000) Delirium in the intensive care unit: are we helping the patient? Crit Care Nurs Q 22:47–60
    • View reference on PubMed
  9. Ely EW, Siegel MD, Inouye SK (2001) Delirium in the intensive care unit: an under-recognized syndrome of organ dysfunction. Semin Respir Crit Care Med 22:115–126
    • View reference on PubMed
    • View reference on publisher's website
  10. Milisen K, Foreman MD, Godderis J, Abraham IL, Brooten D (1998) Delirium in the hospitalized elderly: nursing assessment and management. Nurs Clin North Am 33:417–436
    • View reference on PubMed
  11. 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 27:859–864
  12. 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 113:941–948
    • View reference on PubMed
  13. Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, Chalfin DB, Masica MF, Bjerke HS, Coplin WM, Crippen DW, Fuchs BD, Kelleher RM, Marik PE, Nasraway SA Jr, Murray MJ, Peruzzi WT, Lumb PD (2002) Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 30:119–141
    • View reference on PubMed
    • View reference on publisher's website
  14. Ely EW, Stephens RK, Jackson JC, Thomason JW, Truman B, Gordon S, Dittus RS, Bernard GR (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 32:106–112
    • View reference on PubMed
    • View reference on publisher's website
  15. Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S, Francis J, Speroff T, Gautam S, Margolin R, Sessler CN, Dittus RS, Bernard GR (2003) Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 289:2983–2991
    • View reference on PubMed
    • View reference on publisher's website
  16. Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA, Tesoro EP, Elswick RK (2002) The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 166:1338–1344
    • View reference on PubMed
    • View reference on publisher's website
  17. Pun BT, Gordon SM, Peterson JF, Shintani AK, Jackson JC, Foss J, Harding SD, Bernard GR, Dittus RS, Ely EW (2005) Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers. Crit Care Med 33:1199–1205
    • View reference on PubMed
    • View reference on publisher's website
  18. Peterson JF, Pun BT, Dittus RS, Thomason JW, Jackson JC, Shintani AK, Ely EW (2006) Delirium and its motoric subtypes: a study of 614 critically ill patients. J Am Geriatr Soc 54:479–484
    • View reference on PubMed
    • View reference on publisher's website
  19. O'Keeffe ST, Lavan JN (1999) Clinical significance of delirium subtypes in older people. Age Ageing 28:115–119
    • View reference on PubMed
    • View reference on publisher's website
  20. Meagher DJ, Hanlon DO, Mahony EO, Casey PR, Trzepacz PT (2000) Relationship between symptoms and motoric subtype of delirium. J Neuropsychiatry Clin Neurosci 12:51–56
    • View reference on PubMed
  21. Meagher DJ, Trzepacz PT (2000) Motoric subtypes of delirium. Semin Clin Neuropsychiatry 5:75–85
    • View reference on PubMed
  22. Justic M (2000) Does “ICU psychosis” really exist? Crit Care Nurs 20:28–37
  23. Marcantonio ER, Goldman L, Mangione CM, Ludwig LE, Muraca B, Haslauer CM, Donaldson MC, Whittemore AD, Sugarbaker DJ, Poss R, (1994) A clinical prediction rule for delirium after elective noncardiac surgery. JAMA 271:134–139
    • View reference on PubMed
    • View reference on publisher's website
  24. Inouye SK (1994) The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 97:278–288
    • View reference on PubMed
    • View reference on publisher's website
  25. Sanders AB (2002) Missed delirium in older emergency department patients: a quality-of-care problem. Ann Emerg Med 39:338–341
    • View reference on PubMed
    • View reference on publisher's website
  26. Hustey FM, Meldon SW (2002) The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med 39:248–253
    • View reference on PubMed
    • View reference on publisher's website
  27. McCusker J, Cole M, Dendukuri N, Belzile E, Primeau F (2001) Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study. Can Med Assoc J 165:575–583
  28. McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E (2002) Delirium predicts 12-month mortality. Arch Intern Med 162:457–463
    • View reference on PubMed
    • View reference on publisher's website
  29. McClusker J, Cole MG, Dendukuri N, Belzile E (2003) Does delirium increase hospital stay? J Am Geriatr Soc 51:1539–1546
    • View reference on publisher's website
  30. Lin SM, Liu CY, Wang CH, Lin HC, Huang CD, Huang PY, Fang YF, Shieh MH, Kuo HP (2004) The impact of delirium on the survival of mechanically ventilated patients. Crit Care Med 32:2254–2259
    • View reference on PubMed
    • View reference on publisher's website
  31. Ely EW, Gautam S, Margolin R, Francis J, May L, Speroff T, Truman B, Dittus R, Bernard R, Inouye SK (2001) The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 27:1892–1900
  32. Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383
    • View reference on PubMed
    • View reference on publisher's website
  33. Deyo RA, Cherkin DC, Ciol MA (1992) Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 45:613–619
    • View reference on PubMed
    • View reference on publisher's website
  34. Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829
    • View reference on PubMed
    • View reference on publisher's website
  35. Vincent JL, Moreno R, Takala J, Willatts S, de Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med 22:707–710
    • View reference on PubMed
  36. Vincent JL, Mendonca AD, Cantraine F, Moreno R, Takala J, Suter P, Sprung CL, Colardyn F, Blecher S, on behalf of the working group on “sepsis-related problems” of the European Society of Intensive Care Medicine (1998) Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Crit Care Med 26:1793–1800
    • View reference on PubMed
  37. Baker SP, O'Neill B, Haddon W Jr, Long WB (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14:187–196
    • View reference on PubMed
  38. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME (1989) A revision of the Trauma Score. J Trauma 29:623–629
    • View reference on PubMed
  39. Boyd CR, Tolson MA, Copes WS (1987) Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. J Trauma 27:370–378
    • View reference on PubMed

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