Assessment of Delirium Using the Confusion Assessment Method in Older Adult Inpatients in Malaysia

Abstract Introduction Paediatric Delirium (PD) is a neuropsychiatric complication that occurs during the management of children in the critical care environment (Paediatric Intensive Care (PICU) and Neonatal Intensive Care (NICU). Delirium can be classified as hypoactive (decreased responsiveness and withdrawal), hyperactive (agitation and restlessness), and mixed (combined) (1). PD can be assessed using a number of assessment tools. PD has been historically underdiagnosed or misdiagnosed, having many overlapping symptoms with other syndrome such as pain and iatrogenic withdrawal syndrome (2). An appreciation of the extent of PD would help clinicians and policy makers drive interventions to improve recognition, prevention and management of PD in clinical practice. Aim To estimate the pooled prevalence of PD using validated assessment tools, and to identify risk factors including patient-related, critical-care related and pharmacological factors. Methods A systematic search of PubMed, EMBASE and CINAHL databases was undertaken. Eligible articles included observational studies or trials that estimated a prevalence of PD in a NICU/PICU population using a validated PD assessment tool. Validated tools are the paediatric Confusion Assessment Method-ICU (pCAM-ICU), the Cornell Assessment of Pediatric Delirium (CAPD), the PreSchool Confusion Assessment Method for the ICU (psCAM-ICU), pCAM-ICU severity scale (sspCAM-ICU), and the Sophia Observation Withdrawal Symptoms scale Paediatric Delirium scale (SOS-PD) (1). Only full text studies were included. No language restrictions were applied. Two reviewers independently screened records. Data was extracted using a pre-piloted form and independently verified by another reviewer. Quality was assessed using tools from the National Institutes of Health. A pooled prevalence was calculated from the studies that estimated PD prevalence using the most commonly applied tool, the CAPD (1). Results Data from 23 observational studies describing prevalence and risk factors for PD in critically ill children were included (Figure 1). Variability in study design and outcome reporting was found. Study quality was generally good. Using the validated tools prevalence ranged from 10–66% of patients. Hypoactive delirium was the most prevalent sub-class identified. Using the 13 studies that used the CAPD tool, a pooled prevalence of 35% (27%-43% 95%CI) was calculated. Younger ages, particularly less than two years old, sicker patients, particularly those undergoing mechanical and respiratory ventilatory support were more at risk for PD. Restraints, the number of sedative medications, including the cumulative use of benzodiazepines and opioids were identified as risk factors for the development of PD. PD was associated with longer durations of mechanical ventilation, longer stays and increased costs. Data on association with increased mortality risk is limited and conflicting. Conclusion PD affects one third of critical care admissions and is resource intense. Routine assessment in clinical practice may facilitate earlier detection and management strategies. Modifiable risk factors such as the class and number of sedative and analgesic medications used may contribute to the development of PD. Early mobility and lessening use of these medications present strategies to prevent PD occurrence. Longitudinal prospective multi-institutional studies to further investigate the presentations of the different delirium subtypes and modifiable risk factors that potentially contribute to the development of PD, are required. References 1. Semple D (2020) A systematic review and pooled prevalence of PD, including identification of the risk factors for the development of delirium in critically ill children. doi: 10.17605/OSF.IO/5KFZ8 2. Ista E, te Beest H, van Rosmalen J, de Hoog M, Tibboel D, van Beusekom B, et al. Sophia Observation withdrawal Symptoms-Paediatric Delirium scale: A tool for early screening of delirium in the PICU. Australian Critical Care. 2018;31(5):266–73

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Delirium in Hospitalized Older Patients: Recognition and Risk Factors

Journal of Geriatric Psychiatry and Neurology ◽

10.1177/089198879801100302 ◽

1998 ◽

Vol 11 (3) ◽

pp. 118-125 ◽

Cited By ~ 142

Author(s):

Sharon K. Inouye

Keyword(s):

Risk Factors ◽

High Risk ◽

Older Patients ◽

Confusion Assessment Method ◽

Assessment Method ◽

Precipitating Factors ◽

Acute Confusional State ◽

Confusional State ◽

Confusion Assessment ◽

Simplified Algorithm

Delirium, or acute confusional state, represents a common, serious, potentially preventable and increasing problem for older hospitalized patients. This study is intended to improve overall understanding of the problem of delirium and thus to lessen its adverse impact on the older population. The specific aims of this study are (1) to examine the epidemiology of delirium in older patients; (2) to evaluate barriers to recognition; (3) to present the Confusion Assessment Method (CAM) simplified algorithm to improve recognition; (4) to elucidate predisposing and precipitating factors for delirium; and (5) to propose preventive strategies. Delirium occurs in 10-60% of the older hospitalized population and is unrecognized in 32-66% of cases. The CAM algorithm provides a sensitive (94-100%), specific (90-95%), reliable, and easy to use means for identification of delirium. Four predisposing and five precipitating factors were identified and validated to identify patients at high risk for development of delirium. Primary prevention of delirium should address important delirium risk factors and target patients at intermediate to high risk for delirium at admission.

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Sedation in the Intensive Care Setting

10.2310/7ccsp.8262 ◽

2019 ◽

Author(s):

William John Wallisch IV ◽

Ata Murat Kaynar

Keyword(s):

Care Setting ◽

Confusion Assessment Method ◽

Assessment Method ◽

Assessment Tools ◽

Intensive Care Setting ◽

Sedation Scale ◽

Richmond Agitation Sedation Scale ◽

Confusion Assessment ◽

The Past ◽

Sedation Program

The recent clinical trials on sedation and delirium in the ICU shifted the scales dramatically in the past 10 to 20 years and less sedation is now the accepted norm with titration goals. Now the art of sedation is in the hands of the clinicians to achieve a balance between alleviation of pain and anxiety while keeping patients calm, cooperative, and part of daily activities in the ICU. In this chapter we summarize the various assessment tools for optimal sedation in the ICU as well as the medications used to achieve sedation. However, the clinicians should not forget the nonpharmacologic approaches such as prevention of sleep interruption as part of a successful comprehensive sedation program in the ICU. This review contains 3 tables, and 22 references. Key Words: confusion assessment method, delirium, dexmedetomidine, etomidate, fentanyl, GABA, ketamine, propofol, Richmond agitation-sedation scale (RASS), sedation-agitation scale (SAS)

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Agitation

Acute Care Casebook ◽

10.1093/med/9780190865412.003.0036 ◽

2018 ◽

pp. 180-183

Author(s):

Megan Rashid

Keyword(s):

Correct Diagnosis ◽

Altered Mental Status ◽

Confusion Assessment Method ◽

Assessment Method ◽

Early Mobility ◽

Confusion Assessment ◽

Life Threatening ◽

High Risk Populations ◽

Icu Delirium ◽

Abcdef Bundle

The case illustrates a classic example of intensive care unit (ICU) delirium, which often goes unrecognized but can adversely affect both morbidity and mortality. The Confusion Assessment Method for the ICU (CAM-ICU) is a validated tool for diagnosing delirium, but it remains a diagnosis of exclusion, and it is important to rule out potentially life-threatening medical causes of altered mental status. Treatment is difficult even with the correct diagnosis, and prevention is key. The ABCDEF bundle (assessing and managing pain, both SAT and SBT, choice of analgesia/sedation, delirium, early mobility, and family engagement) is a tool that identifies high-risk populations, and can help mitigate the prevalence of ICU delirium.

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Sedation in the Intensive Care Setting

10.2310/em.8262 ◽

2019 ◽

Author(s):

William John Wallisch IV ◽

Ata Murat Kaynar

Keyword(s):

Care Setting ◽

Confusion Assessment Method ◽

Assessment Method ◽

Assessment Tools ◽

Intensive Care Setting ◽

Sedation Scale ◽

Richmond Agitation Sedation Scale ◽

Confusion Assessment ◽

The Past ◽

Sedation Program

The recent clinical trials on sedation and delirium in the ICU shifted the scales dramatically in the past 10 to 20 years and less sedation is now the accepted norm with titration goals. Now the art of sedation is in the hands of the clinicians to achieve a balance between alleviation of pain and anxiety while keeping patients calm, cooperative, and part of daily activities in the ICU. In this chapter we summarize the various assessment tools for optimal sedation in the ICU as well as the medications used to achieve sedation. However, the clinicians should not forget the nonpharmacologic approaches such as prevention of sleep interruption as part of a successful comprehensive sedation program in the ICU. This review contains 3 tables, and 22 references. Key Words: confusion assessment method, delirium, dexmedetomidine, etomidate, fentanyl, GABA, ketamine, propofol, Richmond agitation-sedation scale (RASS), sedation-agitation scale (SAS)

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Sedation in the Intensive Care Setting

10.2310/anes.8262 ◽

2019 ◽

Author(s):

William John Wallisch IV ◽

Ata Murat Kaynar

Keyword(s):

Care Setting ◽

Confusion Assessment Method ◽

Assessment Method ◽

Assessment Tools ◽

Intensive Care Setting ◽

Sedation Scale ◽

Richmond Agitation Sedation Scale ◽

Confusion Assessment ◽

The Past ◽

Sedation Program

The recent clinical trials on sedation and delirium in the ICU shifted the scales dramatically in the past 10 to 20 years and less sedation is now the accepted norm with titration goals. Now the art of sedation is in the hands of the clinicians to achieve a balance between alleviation of pain and anxiety while keeping patients calm, cooperative, and part of daily activities in the ICU. In this chapter we summarize the various assessment tools for optimal sedation in the ICU as well as the medications used to achieve sedation. However, the clinicians should not forget the nonpharmacologic approaches such as prevention of sleep interruption as part of a successful comprehensive sedation program in the ICU. This review contains 3 tables, and 22 references. Key Words: confusion assessment method, delirium, dexmedetomidine, etomidate, fentanyl, GABA, ketamine, propofol, Richmond agitation-sedation scale (RASS), sedation-agitation scale (SAS)

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Delirium in Australian Hospitals: A Prospective Study

Current Gerontology and Geriatrics Research ◽

10.1155/2013/284780 ◽

2013 ◽

Vol 2013 ◽

pp. 1-8 ◽

Cited By ~ 16

Author(s):

C. Travers ◽

G. J. Byrne ◽

N. A. Pachana ◽

K. Klein ◽

L. Gray

Keyword(s):

Older Patients ◽

Prospective Observational Study ◽

Confusion Assessment Method ◽

Assessment Method ◽

Adverse Outcomes ◽

Confusion Assessment ◽

Hospital Patients ◽

Research Nurses ◽

High Index Of Suspicion ◽

A Prospective Study

Objectives. Australian data regarding delirium in older hospitalized patients are limited. Hence, this study aimed to determine the prevalence and incidence of delirium among older patients admitted to Australian hospitals and assess associated outcomes.Method. A prospective observational study (n=493) of patients aged ≥70 years admitted to four Australian hospitals was undertaken. Trained research nurses completed comprehensive geriatric assessments using standardized instruments including the Confusion Assessment Method to assess for delirium. Nurses also visited the wards daily to assess for incident delirium and other adverse outcomes. Diagnoses of dementia and delirium were established through case reviews by independent physicians.Results. Overall, 9.7% of patients had delirium at admission and a further 7.6% developed delirium during the hospital stay. Dementia was the most important predictor of delirium at (OR=3.18, 95% CI: 1.65–6.14) and during the admission (OR=4.82; 95% CI: 2.19–10.62). Delirium at and during the admission predicted increased in-hospital mortality (OR=5.19, 95% CI: 1.27–21.24;OR=31.07, 95% CI: 9.30–103.78).Conclusion.These Australian data confirm that delirium is a common and serious condition among older hospital patients. Hospital clinicians should maintain a high index of suspicion for delirium in older patients.

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Sedation in the Intensive Care Setting

10.2310/pm.8262 ◽

2019 ◽

Author(s):

William John Wallisch IV ◽

Ata Murat Kaynar

Keyword(s):

Care Setting ◽

Confusion Assessment Method ◽

Assessment Method ◽

Assessment Tools ◽

Intensive Care Setting ◽

Sedation Scale ◽

Richmond Agitation Sedation Scale ◽

Confusion Assessment ◽

The Past ◽

Sedation Program

The recent clinical trials on sedation and delirium in the ICU shifted the scales dramatically in the past 10 to 20 years and less sedation is now the accepted norm with titration goals. Now the art of sedation is in the hands of the clinicians to achieve a balance between alleviation of pain and anxiety while keeping patients calm, cooperative, and part of daily activities in the ICU. In this chapter we summarize the various assessment tools for optimal sedation in the ICU as well as the medications used to achieve sedation. However, the clinicians should not forget the nonpharmacologic approaches such as prevention of sleep interruption as part of a successful comprehensive sedation program in the ICU. This review contains 3 tables, and 22 references. Key Words: confusion assessment method, delirium, dexmedetomidine, etomidate, fentanyl, GABA, ketamine, propofol, Richmond agitation-sedation scale (RASS), sedation-agitation scale (SAS)

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AVALIAÇÃO DA PREVALÊNCIA DE DELIRIUM EM UMA UNIDADE DE TERAPIA INTENSIVA PÚBLICA

Enfermagem em Foco ◽

10.21675/2357-707x.2019.v10.n3.1759 ◽

2019 ◽

Vol 10 (3) ◽

Author(s):

Juliana Bessa Martins ◽

Adriana Alves Dos Santos ◽

Luís Joeci Jaques De Macedo Júnior ◽

Carolina Chitolina Eberle

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Signs And Symptoms ◽

Confusion Assessment Method ◽

Assessment Method ◽

Porto Alegre ◽

Cross Sectional ◽

Care Clinic ◽

Confusion Assessment ◽

Terapia Intensiva

Objetivo: Conhecer a prevalência do delirium em uma Unidade de Terapia Intensiva Clínica e Cirúrgica pública. Métodos: Abordagem quantitativa descritiva de corte transversal, com pacientes de 18 anos ou mais internados em um hospital público de Porto Alegre-RS, com utilização da escala Confusion Assessment Method in a Intensive Care Unit (CAM-ICU). Resultados: A prevalência do delirium foi 36%. Apresentaram relação com o delirium, com significância estatística: média de idade dos pacientes, a mediana de dias de internação hospitalar e em UTI, tipo de UTI, motivo de internação, doença neurológica anterior, uso de sedação, ventilação mecânica e utilização de haloperidol. Conclusões: Este estudo conclui que o delirium apresentou prevalência de 36%, demonstrando que esta síndrome apresenta prevalência significante em Unidade de Terapia Intensiva, portanto, o reconhecimento de seus sinais e sintomas é fundamental para a sua prevenção, aliada a aplicação de escalas de rastreio.Descritores: Delirium, Unidades de Terapia Intensiva, Enfermagem. EVALUATION OF THE PREVALENCE OF DELIRIUM IN AN PUBLIC INTENSIVE CARE UNITObjective: To know the prevalence of delirium in a Public Intensive Care Clinic and Surgical Unit. Methodology: Descriptive quantitative cross-sectional approach with patients aged 18 years or more admitted to a public hospital in Porto Alegre, Brazil, using the Confusion Assessment Method in the Intensive Care Unit (CAM-ICU). Results: The prevalence of delirium was 36%, in a sample of 335 patients interviewed. The mean age of the patients, median days of hospital stay and ICU, type of ICU, reason for hospitalization, previous neurological disease, use of sedation, mechanical ventilation and use of haloperidol were statistically significant. Conclusions: This study concludes that delirium presented a prevalence of 36%, demonstrating that this syndrome presents a significant prevalence in the Intensive Care Unit, therefore, the recognition of its signs and symptoms is fundamental for its prevention, allied to the application of screening scales.Descriptors: Delirium; Intensive Care Units; Nursing. EVALUACIÓN DE LA PREVALENCIA DE DELIRIUM EN UNA UNIDAD DE TERAPIA INTENSIVA PÚBLICAObjetivo: Conocer la prevalencia del delirium en una Unidad de Terapia Intensiva Clínica y Quirúrgica pública. Metodologia: En el presente trabajo se analizaron los resultados obtenidos en el análisis de los resultados obtenidos en el estudio. Resultados: La prevalencia del delirium fue del 36%, en una muestra de 335 pacientes entrevistados. En la mayoría de los casos, se observó un aumento en la incidencia de la enfermedad de Chagas en el momento de la intervención, Conclusiones: Este estudio concluye que el delirium presentó prevalencia del 36%, demostrando que este síndrome presenta prevalencia significante en Unidad de Terapia Intensiva, por lo tanto, el reconocimiento de sus signos y síntomas es fundamental para su prevención, aliada a la aplicación de escalas de rastreo.Descriptores: Delirium; Unidades de Terapia Intensiva; Enfermería.

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