Skip to main content
Top
Published in: Intensive Care Medicine 3/2008

01-03-2008 | Original

Recognition and labeling of delirium symptoms by intensivists: Does it matter?

Authors: Catherine Z. Cheung, Shabbir M. H. Alibhai, Michael Robinson, George Tomlinson, Dean Chittock, John Drover, Yoanna Skrobik

Published in: Intensive Care Medicine | Issue 3/2008

Login to get access

Abstract

Objective

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.

Design

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.

Participants

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.

Conclusions

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.
Literature
1.
go back to reference 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 29:1370–1379PubMedCrossRef 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 29:1370–1379PubMedCrossRef
2.
go back to reference 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 27:1297–1304PubMedCrossRef 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 27:1297–1304PubMedCrossRef
3.
go back to reference 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 32:2254–2259PubMedCrossRef 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 32:2254–2259PubMedCrossRef
4.
go back to reference 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 51:591–598PubMedCrossRef 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 51:591–598PubMedCrossRef
5.
go back to reference 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 291:1753–1762CrossRef 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 291:1753–1762CrossRef
6.
go back to reference Ouimet S, Kavanagh B, Gottfried S, Skrobik Y (2007) Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 33:66–73PubMedCrossRef Ouimet S, Kavanagh B, Gottfried S, Skrobik Y (2007) Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 33:66–73PubMedCrossRef
7.
go back to reference 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 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
8.
go back to reference 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 51:234–239PubMedCrossRef 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 51:234–239PubMedCrossRef
10.
go back to reference Gardner DM, Ross J, Baldessarini RJ, Waraich P (2005) Modern antipsychotic drugs: a critical overview. Can Med Assoc J 172:1703–1711CrossRef Gardner DM, Ross J, Baldessarini RJ, Waraich P (2005) Modern antipsychotic drugs: a critical overview. Can Med Assoc J 172:1703–1711CrossRef
11.
go back to reference 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 342:1471–1477PubMedCrossRef 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 342:1471–1477PubMedCrossRef
12.
go back to reference Meagher DJ (2001) Delirium: optimizing management. Br Med J 322:144–149CrossRef Meagher DJ (2001) Delirium: optimizing management. Br Med J 322:144–149CrossRef
13.
go back to reference American Psychiatric Association (1999) Practice Guidelines for the treatment of patients with delirium. Am J Psychiatry 156:S1–S20 American Psychiatric Association (1999) Practice Guidelines for the treatment of patients with delirium. Am J Psychiatry 156:S1–S20
14.
go back to reference McGuire BE, Basten CJ, Ryan CJ, Gallagher J (2000) Intensive care unit syndrome: a dangerous misnomer. Arch Intern Med 160:906–909PubMedCrossRef McGuire BE, Basten CJ, Ryan CJ, Gallagher J (2000) Intensive care unit syndrome: a dangerous misnomer. Arch Intern Med 160:906–909PubMedCrossRef
15.
go back to reference 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 27:859–864PubMedCrossRef 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 27:859–864PubMedCrossRef
16.
go back to reference Riker RR, Robbins T, Bruce H, Fraser GL, Addor H (2006) ICU delirium assessment tools often disagree. Crit Care Med 34:A7CrossRef Riker RR, Robbins T, Bruce H, Fraser GL, Addor H (2006) ICU delirium assessment tools often disagree. Crit Care Med 34:A7CrossRef
17.
go back to reference Inouye SK, Charpentier PA (1996) Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. J Am Med Assoc 275:852–857CrossRef Inouye SK, Charpentier PA (1996) Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. J Am Med Assoc 275:852–857CrossRef
18.
go back to reference McCusker J, Cole M, Abrahamowicz M (2001) Environmental risk factors for delirium in hospitalized older people. J Am Geriatr Soc 49:1327–1334PubMedCrossRef McCusker J, Cole M, Abrahamowicz M (2001) Environmental risk factors for delirium in hospitalized older people. J Am Geriatr Soc 49:1327–1334PubMedCrossRef
19.
go back to reference Rubin BS, Dube AH, Mitchell AK (1993) Asphyxial death due to physical restraint: case series. Arch Fam Med 2:405–408PubMedCrossRef Rubin BS, Dube AH, Mitchell AK (1993) Asphyxial death due to physical restraint: case series. Arch Fam Med 2:405–408PubMedCrossRef
20.
go back to reference 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 33:1260–1265PubMedCrossRef 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 33:1260–1265PubMedCrossRef
21.
go back to reference 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 113:941–948PubMed 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 113:941–948PubMed
22.
go back to reference Cummings SM, Savitz LA, Konrad TR (2001) Reported response rates to mailed physician questionnaires. Health Serv Res: 35:1347–1355PubMed Cummings SM, Savitz LA, Konrad TR (2001) Reported response rates to mailed physician questionnaires. Health Serv Res: 35:1347–1355PubMed
23.
go back to reference Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M (2000) Comparison of vignettes, standardized patients, and chart abstraction. J Am Med Assoc 283:1715–1722CrossRef Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M (2000) Comparison of vignettes, standardized patients, and chart abstraction. J Am Med Assoc 283:1715–1722CrossRef
Metadata
Title
Recognition and labeling of delirium symptoms by intensivists: Does it matter?
Authors
Catherine Z. Cheung
Shabbir M. H. Alibhai
Michael Robinson
George Tomlinson
Dean Chittock
John Drover
Yoanna Skrobik
Publication date
01-03-2008
Publisher
Springer-Verlag
Published in
Intensive Care Medicine / Issue 3/2008
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI
https://doi.org/10.1007/s00134-007-0947-x

Other articles of this Issue 3/2008

Intensive Care Medicine 3/2008 Go to the issue