Recognition and labeling of delirium symptoms by intensivists: Does it matter?
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
The approach to acute cognitive dysfunction varies among physicians, including intensivists. Physicians may differ in their labeling of cognitive abnormalities in critically ill patients. We aimed to survey: (a) what Canadian intensive care unit (ICU) physicians identify as “delirium”; (b) choices of non-pharmacological and pharmacological management; and (c) consultation patterns among ICU patients with cognitive abnormalities.
A mail-in self-administered survey was sent to Canadian intensivists registered with the Canadian Critical Care Society. The survey contained three clinical scenarios which described cognitively abnormal patients with: (a) hepatic encephalopathy; (b) multiple drug overdose; and (c) post-operative aortic aneurysm repair. Symptoms, which included fluctuating level of consciousness, inattention, disorientation, hallucinations, sleep/wake cycle disturbance, and paranoia, all fulfilled DSM-IV criteria for delirium. We asked for diagnoses in short-answer format for each scenario, and offered multiple selections of non-pharmacological and pharmacological therapies and consultation options.
All intensivists registered with the Canadian Critical Care Society.
Measurements and results
One-hundred thirty surveys were returned, for a response rate of 58.3%. When an etiological cognitive dysfunction diagnosis was obvious, 83–85% responded with the medical diagnosis to explain the cognitive abnormalities; only 43–55% used the term “delirium”. In contrast, where an underlying medical problem was lacking, 74% of respondents diagnosed “delirium” (p = 0.002). Non-pharmacological and pharmacological management varied considerably by physician and scenario but independently from whether the term “delirium” was selected. Commonly selected pharmacological agents were antipsychotics and benzodiazepines, followed by narcotics, non-narcotic analgesics, and other sedatives. Whether and when intensivists chose to consult other services varied.
Canadian intensivists diagnose delirium based upon the presence or absence of an obvious medical etiology. Wide variation exists in approach to management, as well as patterns of consultation.
- Ely W, Margolin R, Francis J, May L, Truman B, Dittus R, Speroff T, Gautman S, Bernard G, Inouye S (2001) Evaluation of delirum in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 29:1370–1379 CrossRef
- Dubois M, Bergeron N, Dumont M, Dial S, Skrobik Y (2001) Delirium in an intensive care unit: a study of risk factors. Intensive Care Med 27:1297–1304 CrossRef
- Lin S, Liu C, Wang C, Lin H, Huang C, Huang P, Fang Y, Shieh M, Kuo H (2004) The impact of delirium on the survival of mechanically ventilated patients. Crit Care Med 32:2254–2259 CrossRef
- McNicoll L, Pisani M, Zhang Y, Ely W, Siegel M, Inouye S (2003) Delirium in the Intensive Care Unit: occurrence and clinical course in older patients. J Am Geriatr Soc 51:591–598 CrossRef
- Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell F, Inouye SK, Bernard GR, Dittus RS (2004) Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. J Am Med Assoc 291:1753–1762 CrossRef
- Ouimet S, Kavanagh B, Gottfried S, Skrobik Y (2007) Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 33:66–73 CrossRef
- Ely EW, Stephens RK, Jackson JC (2007) 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
- Carnes M, Howell T, Rosenberg M, Francis J, Hildebrand C, Knuppel J (2003) Physicians vary in approaches to the clinical management of delirium. J Am Geriatr Soc 51:234–239 CrossRef
- Skrobik Y (2002) Haloperidol should be used sparingly. Crit Care Med 30:2613–2614 CrossRef
- Gardner DM, Ross J, Baldessarini RJ, Waraich P (2005) Modern antipsychotic drugs: a critical overview. Can Med Assoc J 172:1703–1711 CrossRef
- Kress JP, Pohlman AS, O'Connor MF, Hall JB (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342:1471–1477 CrossRef
- Meagher DJ (2001) Delirium: optimizing management. Br Med J 322:144–149 CrossRef
- American Psychiatric Association (1999) Practice Guidelines for the treatment of patients with delirium. Am J Psychiatry 156:S1–S20
- McGuire BE, Basten CJ, Ryan CJ, Gallagher J (2000) Intensive care unit syndrome: a dangerous misnomer. Arch Intern Med 160:906–909 CrossRef
- 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 CrossRef
- Riker RR, Robbins T, Bruce H, Fraser GL, Addor H (2006) ICU delirium assessment tools often disagree. Crit Care Med 34:A7 CrossRef
- Inouye SK, Charpentier PA (1996) Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. J Am Med Assoc 275:852–857 CrossRef
- McCusker J, Cole M, Abrahamowicz M (2001) Environmental risk factors for delirium in hospitalized older people. J Am Geriatr Soc 49:1327–1334 CrossRef
- Rubin BS, Dube AH, Mitchell AK (1993) Asphyxial death due to physical restraint: case series. Arch Fam Med 2:405–408 CrossRef
- Micek ST, Anand NJ, Laible BR, Shannon WD, Kollef MH (2005) Delirium as detected by the CMA-ICU predicts restraint use among mechanically ventilated medical patients. Crit Care Med 33:1260–1265 CrossRef
- Inouye S, Van Dyck C, Alessi C, Balkin S, Siegal A, Horwitz R (1990) Clarifying confusion: the confusion assessment method. A new method for the detection of delirium. Ann Intern Med 113:941–948
- Cummings SM, Savitz LA, Konrad TR (2001) Reported response rates to mailed physician questionnaires. Health Serv Res: 35:1347–1355
- Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M (2000) Comparison of vignettes, standardized patients, and chart abstraction. J Am Med Assoc 283:1715–1722 CrossRef
- Recognition and labeling of delirium symptoms by intensivists: Does it matter?
Intensive Care Medicine
Volume 34, Issue 3 , pp 437-446
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- Intensive Care
- Critical care
- Industry Sectors
- Author Affiliations
- 1. Department of Medicine, University of Toronto, M5G 2C4, Toronto, Ontario, Canada
- 2. Departments of Medicine and Health Policy, Management, and Evaluation, University Health Network, Toronto Rehabilitation Institute, University of Toronto, M5G 2C4, Toronto, Ontario, Canada
- 3. Queen’s University, Kingston, Ontario, Canada
- 4. Department of Public Health Sciences, University Health Network, University of Toronto, M5G 2C4, Toronto, Ontario, Canada
- 5. Departments of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- 6. Hopital Maisonneuve Rosemont, University of Montreal, 5415 boulevard De l’Assomption, H1T 2M4, Montreal, Quebec, Canada