Increasing the awareness of delirium in critically ill patients

EDITORIAL

^IInstituto D'Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brazil

^IIPostgraduate Program, Instituto Nacional de Câncer - INCA - Rio de Janeiro (RJ), Brazil

^IIIDivision of Neurosciences Critical Care, The Johns Hopkins University School of Medicine -Baltimore, USA

Corresponding author

Delirium is a syndrome of acute brain dysfunction that occurs frequently in critically ill patients and encompasses a wide array of clinical manifestations.^(1,2) Although there has been a significant increase in the number of studies regarding the pathophysiology, epidemiology, outcomes and even clinical trials involving patients with delirium, surveys demonstrate that this condition remains underdiagnosed worldwide.^(3,4) Considering that delirium is identified in more than 80% of mechanically ventilated patients⁽²⁾ and is associated with increased mortality and long-term cognitive impairment,⁽⁵⁾ how do we account for the failure to diagnose this important syndrome? Several factors must be considered.

1 - Physicians do not know enough about delirium

Several surveys have evaluated the knowledge of healthcare professionals about delirium; the results have demonstrated that, although the overall knowledge about the diagnosis and management of delirium has increased over the past decade,^(4,6) it is still insufficient considering the elevated frequency and the health and social burdens represented by this condition. For example, recent surveys demonstrate that up to 90% of respondents believe that hyperactivity and hallucinations are necessary features for the diagnosis of delirium

2 - Validated delirium-screening tools are not implemented in most intensive care units

Reliance on a clinical impression may cause healthcare professionals to overlook up to two-thirds of cases of delirium, most likely due to emphasis on its hyperactive presentation. By contrast, improved rates of delirium identification may be achieved using a validated scale. Although several scales are available, the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the most frequently employed, and both have been validated in Portuguese.⁽⁷⁾ These scales are reproducible and accurately identify delirium.⁽⁸⁾ Portuguese versions are easily available on a free-access, educational website (www.icudelirium.org), including a validated short version of the CAM-ICU (named "flowsheet"). Nonetheless, there remains a significant gap between the available evidence and clinical practice; moreover, studies demonstrate that routine implementation of validated delirium scales occurs in less than half of intensive care unit patients.⁽³⁾

3 - Clinicians do not know what to do when delirium is diagnosed

A relevant issue is that physicians frequently state that they "do not know what to do" when a patient is diagnosed with delirium, and this is especially true with the hypoactive subgroup. This perception generates skepticism with respect to the utility of delirium screening. Whereas pharmacologic intervention is not typically required for patients with hypoactive delirium, the timely recognition of delirium can prompt a range of other measures such as a comprehensive search for etiologic/precipitating factors and the institution of nonpharmacologic interventions such as early rehabilitation therapy and environmental optimization. Promising interventions include cognitively stimulating tasks,⁽⁹⁾ bringing the family to the bedside, early mobility⁽¹⁰⁾ and restoring sensorial control (using glasses and hearing aids when appropriate). In summary, much can be done when delirium is recognized.

In this edition of the journal, Carvalho et al. present results of a descriptive systematic review of delirium-rating scales in critically ill patients. They identify six scales that have been validated for delirium identification in critically ill patients, two of which have been validated in Portuguese-speaking populations. The researchers conclude that, although all the studied scales accurately identify delirium, the Intensive Care Delirium Screening Checklist⁽¹¹⁾ might be best suited for routine implementation in the Brazilian setting. Faria and Moreno, in a broad narrative review, present different aspects of this disease, including its risk factors, clinical symptoms and an updated therapeutic and preventive approach.⁽¹²⁾ The studies published in this issue of the Revista Brasileira de Terapia Intensiva represent a gain in knowledge that is valuable to critical care providers. The articles provide an opportunity to increase the awareness of delirium in Brazilian ICUs. Educational efforts and training of healthcare professionals in the systematic implementation of screening tools are fundamental steps in this process.

REFERENCES

• 1. Salluh JI, Soares M, Teles JM, Ceraso D, Raimondi N, Nava VS, Blasquez P, Ugarte S, Ibanez-Guzman C, Centeno JV, Laca M, Grecco G, Jimenez E, Árias-Rivera S, Duenas C, Rocha MG; Delirium Epidemiology in Critical Care Study Group. Delirium epidemiology in critical care (DECCA): an international study. Crit Care. 2010;14(6):R210.
• 2. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291(14):1753-62.
• 3. Salluh JI, Dal-Pizzol F, Mello PV, Friedman G, Silva E, Teles JM, Lobo SM, Bozza FA, Soares M; Brazilian Research in Intensive Care Network. Delirium recognition and sedation practices in critically ill patients: a survey on the attitudes of 1015 Brazilian critical care physicians. J Crit Care. 2009;24(4):556-62.
• 4. Patel RP, Gambrell M, Speroff T, Scott TA, Pun BT, Okahashi J, et al. Delirium and sedation in the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals. Crit Care Med. 2009;37(3):825-32.
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• 6. Ely EW, Stephens RK, Jackson JC, Thomason JW, Truman B, Gordon S, et al. Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: a survey of 912 healthcare professionals. Crit Care Med. 2004;32(1):106-12.
• 7. Gusmao-Flores D, Salluh JI, Dal-Pizzol F, Ritter C, Tomasi CD, Lima MA, et al. The validity and reliability of the Portuguese versions of three tools used to diagnose delirium in critically ill patients. Clinics (Sao Paulo). 2011;66(11):1917-22.
• 8. Gusmao-Flores D, Figueira Salluh JI, Chalhub RA, Quarantini LC. The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies. Crit Care. 2012;16(4):R115.
• 9. Brummel NE, Jackson JC, Girard TD, Pandharipande PP, Schiro E, Work B, et al. A combined early cognitive and physical rehabilitation program for people who are critically ill: the activity and cognitive therapy in the intensive care unit (ACT-ICU) trial. Phys Ther. 2012;92(12):1580-92.
• 10. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):1874-82.
• 11. Carvalho JP, Almeida AR, Gusmao-Flores D. Escalas de avaliação de delirium em pacientes graves: revisão sistemática da literatura. Rev Bras Ter Intensiva. 2013;25(2):148-154.
• 12. Faria RS, Moreno RP. Delirium na unidade de cuidados intensivos: uma realidade sub-diagnosticada. Rev Bras Ter Intensiva. 2013;25(2):137-147.

Increasing the awareness of delirium in critically ill patients

Jorge Ibrain de Figueira Salluh^I,II; Robert David Stevens^III

Publication Dates

• Publication in this collection
  01 Aug 2013
• Date of issue
  June 2013