Delirium in ICU: 40-87% Incidence, Hyper/Hypoactive Forms - Research Paper

Introduction

Delirium among ICU patients has a reported incidence of between 40-87%. The highest incidence occurrence is usually among those who receive mechanical ventilation and older adults. In reality, delirium is categorized as hyperactive, hypoactive, and mixed. If delirium is considered as hypoactive, it may be featureless bodily movement and lethargy. In the context of mixed, it entails vacillating between hyper-active and hypo-active forms. Hyper-active is associated with combativeness and agitation. Delirium is marred with adverse effects such as medical complications, prolonged neurocognitive deficits, physical restraint use, and prolonged stay at the hospital. Thus, assessing delirium using a clinically reliable and valid tool gives neurocognitive data needed for an appropriate treatment plan development.

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The Confusion Assessment Method for the ICU (CAM-ICU) is the most preferred instrument for diagnosing delirium by non-psychiatric clinicians and internists (Manual, 2002). The Confusion Assessment Method for ICU is one of the assessment tools used by the Society of Critical Care Medicine's Clinical Practice Guidelines for delirium, agitation, and pain in adults' patient in ICU. Despite being validated in non-mechanically and mechanically ventilated for critically conditions patients, CAM-ICU is yet to be invalidated in the non-ICU setting. However, there are delirium instruments that are validated outside of the ICU, such as the Nursing Delirium Screening Scale, Memorial Delirium Assessment Scale, Delirium Rating Scale, and the original CAM.

Description and Critique of Psychometric Properties

Delirium assessment is one way of testing the overall consciousness assessment. In reality, consciousness can be categorized into two arousal levels and content. Over the years, CAM-ICU has been proven as valid and expresses high inter-rater reliability of about (kappa=0.79 to 0.96) (Ely et al., 2001). If the result is compared with a reference standard diagnosis of delirium. In most instances, nurses who use CAM-ICU have specificities of about 89-100% and sensitivities of 93-100% (Ely et al., 2001). The CAM-ICU can be applied with different patients of ICU, even those with neurobiological, surgical, and medical conditions. In the Emergency Department, a version for screening delirium can be applied. In this context, the alternative is the Intensive Care Delirium Screening Checklist. The approach is the best alternative recommended by the Society of Critical Care Medicine. However, some instruments have been validated for delirium screening in the outside setting of the ICU, which entails the Nursing Delirium Screening Scale, the Memorial Delirium Assessment Scale, the Delirium Rate Scale, and the original CAM.

Description and Critique of Scoring and the Interpretation of Scoring

In the 10 point RASS, the scores range from a (combative) high of 4 to (deeply unresponsive and comatose) of a low-5. While applying the RASS system, spontaneous patients who are not agitated, calm, and alert registered a score of 0, which is termed as a neutral zone. On the contrary, the patients who are agitated and anxious registered a range of scores, which was determined by their anxiety levels. Patients who were anxious registered 1 whereas those who were agitated (fighting ventilator) registered a 2. For those people who were removing or pulling catheter and agitated registered a 3. A score of 4 was among combative patients, especially those who showed danger and violence to the patient. The patients who had varying degrees of sedation because of the ability to maintain eye-contact were assigned to scores of -1 to -5. For instance, those who maintain their eye contact for more than 10 seconds were assigned to -1 score. Patients who had less than 10 seconds were assigned to -2. The patients who opened their eyes but never showed any eye-contact were assigned a -3. Patients who registered a score of -4 when physical stimulation was required were those who had a painful stimulation, physical movement, and eye-opening. A score -5 was for those with painful stimulation or no physical response. In this context, RASS had intra-class reliability and interrater correlation coefficient (r) of 0.97 and 0.95, respectively. The interpretation of the score is clear and can be easily explained to the patients.

Description and Critique of Strengths and Limitations of the Assessment Tool

In most instances, the CAM-ICU is rapid, which implies that it is greater than one minute. One of the strengths of the tool is that it can be easily used to administer with less training needed and can be translated to about 26 different languages. The CAM-ICU is used for visual disturbances and hearing and also easily reproducible (van Eijk et al., 2011). While conducting staff training, the approach should assure assessment reliability and maintain the performance at the first training. The limitation of the approach is that it needs to use special pictures, especially for training manual and hearing-impaired patients.

Description and Appropriate Critique Use in Clinical Practice and Research

The Confusion Assessment Method for the ICU (CAM-ICU) is applied to all the adults admitted at intensive care units (ICU) in the hospital to prevent adverse effects and identify delirium promptly. Since delirium may frequently occur during critical illness, the patients in ICU need to be assessed at every shift of delirium symptoms (Gusmao-Flores et al., 2012). Patients need to be fully aware of their environment to interact appropriately. Society of Critical Care Medicine has often incorporated CAM-ICU in their emergency departments.

References

Ely, E. W., Inouye, S. K., Bernard, G. R., Gordon, S., Francis, J., May, L., ... & Hart, R. P. (2001). Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). Jama, 286(21), 2703-2710. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/194422

Gusmao-Flores, D., Salluh, J. I. F., Chalhub, R. A., & Quarantini, L. C. (2012). 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. Critical care, 16(4), R115. Retrieved from https://link.springer.com/content/pdf/10.1186/cc11407.pdf

Manual, T. (2002). The Confusion Assessment Method for the ICU. Retrieved from https://uploads-ssl.webflow.com/5a56d43d5808f700012d4345/5bb3fd6a95f7f61f0426b321_CAM-ICU-training-manual-2005.pdf

van Eijk, M. M., van den Boogaard, M., van Marum, R. J., Benner, P., Eikelenboom, P., Honing, M. L., ... & Karakus, A. (2011). Routine use of the confusion assessment method for the intensive care unit: a multicenter study. American journal of respiratory and critical care medicine, 184(3), 340-344. Retrieved from https://www.atsjournals.org/doi/pdf/10.1164/rccm.201101-0065OC