Advantages of score-based delirium detection compared to a clinical delirium assessment—a retrospective, monocentric cohort study

Purpose Delirium is an underdiagnosed complication on intensive care units (ICU). We hypothesized that a score-based delirium detection using the Nudesc score identifies more patients compared to a traditional diagnosis of delirium by ICU physicians. Methods In this retrospective study, all patients treated on a general medical ICU with 30 beds in a university hospital in 2019 were analyzed. Primary outcome was a documented physician diagnosis of delirium, or a delirium score ≥2 using the Nudesc. Results In 205/943 included patients (21.7%), delirium was diagnosed by ICU physicians compared to 438/943 (46.4%; ratio 2.1) by Nudesc≥2. Both assessments were independent predictors of ICU stay (p<0.01). The physician diagnosis however was no independent predictor of mortality (OR 0.98 (0.57–1.72); p = 0.989), in contrast to the score-based diagnosis (OR 2.31 (1.30–4.10); p = 0.004). Subgroup analysis showed that physicians underdiagnosed delirium in case of hypoactive delirium and delirium in patients with female gender and in patients with an age below 60 years. Conclusion Delirium in patients with hypoactive delirium, female patients and those below 60 years was underdiagnosed by physicians. The score-based delirium diagnosis detected delirium more frequently and correlated with ICU mortality and stay.

Factors Influencing CAM-ICU Documentation and Inappropriate “Unable to Assess” Responses

Background Detecting delirium with standardized assessment tools such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is important, but such detection is frequently hampered by poor documentation and inappropriate “unable to assess” responses (in noncomatose patients). Objective To identify patient, clinical, and workplace factors that may impede or facilitate appropriate delirium assessment through use of the CAM-ICU, specifically documentation and inappropriate “unable to assess” responses. Methods An electronic health record–based data set was used to quantify CAM-ICU documentation and inappropriate “unable to assess” responses during 24 months. Associated patient (eg, age), clinical (eg, diagnosis), and workplace (eg, geographic location within the ICU, shift) factors were evaluated with multivariable regression. Results Of 28 586 CAM-ICU documentation opportunities, 66% were documented; 16% of documentations in alert or lightly sedated patients had inappropriate “unable to assess” responses. Night shift was associated with lower CAM-ICU documentation rates (P = .001), whereas physical restraints and location on side B (rather than side A) of the ICU were associated with higher documentation rates (P &lt; .05 for both). Age older than 80 years, non-White race, intubation, and physical restraints were associated with more inappropriate “unable to assess” responses (all P &lt; .05), as was infusion of propofol, midazolam, dexmedetomidine, or fentanyl (all P &lt; .05). Conclusion Data from electronic health records can identify patient, clinical, and workplace factors associated with CAM-ICU documentation and inappropriate “unable to assess” responses, which can help target quality improvement efforts related to delirium assessment.

A delirium prevalence audit and a pre and post evaluation of an interprofessional education intervention to increase staff knowledge about delirium in older adults

Background Delirium is more prevalent in older people and estimated to occur in up to 50% of the hospital population. Delirium comprises a spectrum of behaviours, including cognitive and attention deficits, and fluctuating levels of consciousness, often associated with an underlying physiological disturbance. Delirium has been increasingly associated with adverse outcomes. Although often preventable or can at least be mitigated, delirium may not be a standard part of assessment and thus may not be recognized in the early stages when it is most likely to be treated successfully. The aim of this study was to evaluate the level of knowledge of delirium amongst clinicians caring for patients at high risk of developing delirium and to determine whether education can improve clinical assessment of delirium. Methods Two hundred and forty-six case notes were audited before and 149 were reviewed after the education intervention and implementation of a delirium screening tool. Clinicians at the hospital were invited to complete a questionnaire on knowledge of delirium. The questionnaire was based on a validated tool which contained 39 questions about delirium. The questionnaire also contained 28 questions on delirium knowledge. Additional questions were included to gather demographic information specific to the hospital. Descriptive statistics, chi square and independent t-tests were conducted to test for differences in knowledge between the pre and post periods. The Squire Checklist Reporting Guidelines for Quality Improvement Studies informed the preparation of the manuscript. Results The audit demonstrated that the use of a cognitive assessment tool overall increased from 8.5% in pre education to 43% in the post education period. One hundred and fifty-nine staff completed the questionnaire in total, 118 the pre and 41 post. The knowledge subscale score was high pre and post education and no statistically significant difference was observed. The greatest increase in knowledge was related to knowledge of the risk factors subscale. The increase in knowledge (6.8%) was statistically significant. Conclusion An interprofessional approach to delirium education was effective in not only increasing awareness of the factors associated with this syndrome but also increased the use of a delirium assessment tool.

Electroencephalography in Delirium Assessment. A Scoping Review

BackgroundDelirium is a common disorder affecting up to 82% of patients in the intensive care unit (ICU). Delirium assessment scores such as the Confusion Assessment Method (CAM) are time-consuming, they cannot differentiate between different types of delirium and their etiologies, and they may have low sensitivities in the clinical setting. While today, electroencephalography (EEG) is increasingly being applied to delirious patients in the ICU, a lack of clear cut EEG signs, leads to inconsistent assessments. MethodsWe therefore conducted a scoping review on EEG findings in delirium. 1236 articles identified through database search on PubMed and Embase were reviewed. Finally, 33 original articles were included in the synthesis. ResultsEEG seems to offer manifold possibilities in diagnosing delirium. All 33 studies showed a certain degree of qualitative or quantitative EEG alterations in delirium. Thus, normal routine (rEEG) and continuous EEG (cEEG) make presence of delirium very unlikely. All 33 studies used different research protocols to at least some extent. These include differences in time points, duration, conditions, and recording methods of EEG, as well as different patient populations, and diagnostic methods for delirium. Thus, a quantitative synthesis and common recommendations are so far elusive. ConclusionFuture studies should compare the different methods of EEG recording and evaluation to identify robust parameters for everyday use. Evidence for quantitative bi-electrode delirium detection based on increased relative delta power and decreased beta power is growing and should be further pursued. Additionally, EEG studies on the evolution of a delirium including patient outcomes are needed.

Delirium Assessment and Management in Geriatric Psychiatry under Prevailing Indian Laws (MHCA 2017)

The Indian Mental Health Care Act of 2017 (the Act) focuses on the human rights of persons with mental illness. It is based on the individual’s dignity, autonomy, and independence with a client-centered approach. Delirium is frequently seen in the hospitalized geriatric population, more commonly in medical and surgical wards, and much less frequently in psychiatry wards. Delirium is covered under the Act as a “substantial disturbance of thinking, mood, perception, orientation or memory that grossly impairs judgment, behavior, (and) capacity to recognize reality or ability to meet the ordinary demands of life.” The Act provides provisions for capacity assessment, emergency treatment, supported admission, advance directive, and the role of nominated representative in such cases.

EP.TU.380Compliance with delirium guidelines in older surgical patients and susceptibility to improvement

Aim Delirium in older hospitalised adults is both common and serious, particularly following surgery. It is associated with increased mortality, prolonged admission and greater care needs. All patients ≥ 65 years should have a delirium assessment within 24 hours of admission, and again post-operatively. Where delirium is identified, a thorough assessment of reversible causes should be undertaken using validated tools. Despite clear guidelines, delirium remains under-recognised and inconsistently managed. A study was undertaken to determine compliance with delirium assessment and management guidelines for older surgical patients in one acute hospital, and their susceptibility to improvement. Methods A QI project was undertaken using the PDSA cycle. 50 patient records were reviewed retrospectively. Multidisciplinary educational sessions were delivered. A further 50 patient records were audited after 1 month. Primary outcome: delirium assessment (4AT) within 24 hours of admission. Secondary outcome: TIME bundle completed where delirium identified. Results Conclusion Delirium assessment and identification is improved through the use of a standard tool (4AT) and targeted educational sessions. As a common post-operative complication, delirium assessment is an important aspect of routine post-operative care. Further work is needed to improve compliance with use of the TIME bundle when delirium is present.