Delirium

Factors associated with delirium in critical patients in a health institution in Bucaramanga, Colombia

OBJECTIVE

To determine the incidence and the factors associated with delirium in intensive care unit patients.

METHODS

A cohort study conducted on 134 patients in the intensive care unit at a clinic in Bucaramanga, Colombia., who were recruited in the first 24hours following admission and on whom the Richmond Agitation-Sedation Scale (RASS), PRE-DELIRIC version in Spanish, and Confusion Assessment method for Intensive Care Unit (CAM-ICU) were applied; the outcome was evaluated through daily monitoring with CAM-ICU.

RESULTS

The incidence of delirium was 20.2%, the predominating type was hypoactive at 66.7%, followed by the hyperactive type at 7.4% and mixed at 25.9%. Fifty-two percent of the patients with delirium died. In the bivariate analysis, the use of sedatives (Relative Risk(RR) 2.4, 95% confidence interval (95% CI) = 1.2-4.5), infection (RR = 2. 8, 95% CI=1.3-5.9), metabolic acidosis (RR = 4 3, 95% CI=2.3-8.0), mechanical ventilation (RR = 4 6, 95% CI=2.0-10.6), aged over 60 years (RR = 2 3, 95% CI=1.09-5.3) and APACHE score greater than 14 (RR = 3. 0) (95% CI=1.1-8.2) were identified as risk factors for delirium. The multivariate analysis only found a relationship with infection (RR = 3 8, 95% CI=1.6-9.1) and being aged over 60 years (RR = 3 2, 95% CI 1.2-8.3).

CONCLUSIONS

delirium is frequent in patients in the intensive care unit, especially the hypoactive type. Half of the patients with delirium died. The main risk factors for delirium are infection and being over 60 years age, therefore, delirium prevention activities should focus on these critical patients.

[Spanish version of the CAM-ICU (Confusion Assessment Method for the Intensive Care Unit). Pilot study of validation]

OBJECTIVE

To validate the Spanish version of the CAM-ICU.

DESIGN

Validation study. The inter-rater reliability and validity were evaluated using a blind comparison with the DSM-IVTR criteria (reference standard) in a group of patients hospitalized in an Intensive Care Unit (ICU).

SETTING

Medical-surgical ICU.

PATIENTS

129 adults with RASS >-4 score, within the 24-48 h of ICU admission. Independent application of the CAM-ICU by two intensive care specialists and evaluation by a psychiatrist using the DSM-IVTR criteria for delirium.

RESULTS

Prevalence of delirium in the sample was 26.4%, this being and 48.3% in the 29 patients who received mechanical ventilation. Inter-rater reliability in the whole sample according to the Kappa index was 0.792 (95% CI 0.662-0.922, p<0.001) and in those who received mechanical ventilation was 0.726 (95% CI 0.487-0.965, p<0.001). The sensitivity, specificity, positive predicted value (PPV), negative predicted value (NPV), positive likelihood ratio (+LR), and negative likelihood ratio (-LR) were 79.4% (95% CI 63.2-89.7%); 97.9% (95% CI 92.6-99.4%); 93.1% (95% CI 78.0-98.1%); 93.0% (95% CI 86.3-96.6%); 37.72 (95% CI 9.47-150.20) and 0.21(95% CI 0.11-0.41), respectively, in the whole sample. In mechanically-ventilated patients, sensitivity, specificity, PPV, NPV, +LR and -LR were 92.9% (95% CI 68.5-98.7%); 86.7% (95% CI 62.1-96.3%); 86.7% (95% CI 62.1-96.3%); 92.9% (95% CI 68.5-98.7%); 6.96(95% CI 1.90-25.51) and 0.08 (95% CI 0.01-0.55), respectively.

CONCLUSION

The Spanish version of the CAM-ICU is reliable. Its sensitivity, specificity and predictive values should be considered good.

Delirium: a focused review

Delirium is a common condition, especially in hospitalized patients. It is also associated with increased morbidity and mortality. Several studies have investigated risk factors for the development of delirium during hospitalization. This article reviews the clinical features, etiology, clinical evaluation, and treatment of this syndrome.

Visual hallucinations in consultation-liaison neuropsychiatry

BACKGROUND

In consultation-liaison settings, neuropsychiatrists are commonly asked to assess patients with hallucinatory syndromes and to differentiate 'functional' from 'organic' psychotic presentations.

METHODS

The occurrence and management of visual hallucinations (VH) in healthy individuals, lesion states, neurodegenerative disorders, intoxication/withdrawal states and delirium are reviewed.

RESULTS

The presence of VH has been shown to predict a secondary rather than primary psychotic illness and an understanding of the neurobiology of the visual system - including how and where underlying neurotransmitter systems interact in visual processing and how perturbations can result in VH - allows for appropriate clinical assessment and management.

Prevention, diagnosis and treatment of delirium: staff educational approaches

Delirium is a common disorder especially among older people admitted to medical and surgical units. Research has demonstrated that many cases are underdiagnosed, misdiagnosed or not properly managed. Some of the difficulties encountered in the diagnosis, treatment and prevention may, in part, stem from a historical low emphasis on delirium in medical and nursing education. In recent years, attempts have been made to understand the impact of education on the prevention and management of delirium. In this review, diagnosis, treatment and prevention of delirium are considered in relation to the difficulties encountered in each of these areas. The role of increasing doctors' and nurses' awareness in the understanding of delirium through educational programs is also reviewed. The outcome of many cases of delirium is not changed by current treatment; however, there is increasing evidence that strategies employing appropriate multicomponent and/or educational staff intervention programs may decrease the prevalence of delirium.