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Delirium in the intensive care setting: A reevaluation of the validity of the CAM–ICU and ICDSC versus the DSM–IV–TR in determining a diagnosis of delirium as part of the daily clinical routine

  • Soenke Boettger (a1), David Garcia Nuñez (a1) (a2), Rafael Meyer (a3), André Richter (a1), Susana Franco Fernandez (a4), Alain Rudiger (a4), Maria Schubert (a5) and Josef Jenewein (a1)...

Abstract

Background:

In the intensive care setting, delirium is a common occurrence that comes with subsequent adversities. Therefore, several instruments have been developed to screen for and detect delirium. Their validity and psychometric properties, however, remain controversial.

Method:

In this prospective cohort study, the Confusion Assessment Method for the Intensive Care Unit (CAM–ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) were evaluated versus the DSM–IV–TR in the diagnosis of delirium with respect to their validity and psychometric properties.

Results:

Out of some 289 patients, 210 with matching CAM–ICU, ICDSC, and DSM–IV–TR diagnoses were included. Between the scales, the prevalence of delirium ranged from 23.3% with the CAM–ICU, to 30.5% with the ICDSC, to 43.8% with the DSM–IV–TR criteria. The CAM–ICU showed only moderate concurrent validity (Cohen's κ = 0.44) and sensitivity (50%), but high specificity (95%). The ICDSC also reached moderate agreement (Cohen's κ = 0.60) and sensitivity (63%) while being very specific (95%). Between the CAM–ICU and the ICDSC, the concurrent validity was again only moderate (Cohen's κ = 0.56); however, the ICDSC yielded higher sensitivity and specificity (78 and 83%, respectively).

Significance of Results:

In the daily clinical routine, neither the CAM–ICU nor the ICDSC, common tools used in screening and detecting delirium in the intensive care setting, reached sufficient concurrent validity; nor did they outperform the DSM–IV–TR diagnostic criteria with respect to sensitivity or positive prediction, but they were very specific. Thus, the non-prediction by the CAM–ICU or ICDSC did not refute the presence of delirium. Between the CAM–ICU and ICDSC, the ICDSC proved to be the more accurate instrument.

Copyright

Corresponding author

Address correspondence and reprint requests to: Soenke Boettger, Department of Psychiatry and Psychotherapy, University Hospital of Zurich, University of Zurich, Ramistraase 100, 8091 Zurich, Switzerland. E-mail: soenke.boettger@usz.ch.

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Shared first authorship.

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References

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American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders, 3rd rev. ed. Washington, DC: American Psychiatric Association.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, 4th ed., Text Revision. Washington, DC: American Psychiatric Association.
Balas, M.C., Happ, M.B., Yang, W., et al. (2009). Outcomes associated with delirium in older patients in surgical ICUs. Chest, 135(1), 1825. Epub ahead of print Nov 18, 2008. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2963095/.
Bergeron, N., Dubois, M.J., Dumont, M., et al. (2001). Intensive Care Delirium Screening Checklist: Evaluation of a new screening tool. Intensive Care Medicine, 27(5), 859864.
Bickel, H., Gradinger, R., Kochs, E., et al. (2008). High risk of cognitive and functional decline after postoperative delirium: A three-year prospective study. Dementia and Geriatric Cognitive Disorders, 26(1), 2631. Epub ahead of print Jun 24.
Bucht, G., Gustafson, Y. & Sandberg, O. (1999). Epidemiology of delirium. Dementia and Geriatric Cognitive Disorders, 10(5), 315318.
DeVellis, R.F. (2012). Scale development: Theory and applications. Los Angeles: Sage Publications, esp. pp. 109110.
Devlin, J. W., Fong, J.J., Schumaker, G., et al. (2007). Use of a validated delirium assessment tool improves the ability of physicians to identify delirium in medical intensive care unit patients. Critical Care Medicine, 35(12), 27212724; quiz 2725.
Ely, E.W., Inouye, S.K., Bernard, G.R., et al. (2001 a). Delirium in mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit (CAM–ICU). The Journal of the American Medical Association, 286(21), 27032710. Available from http://jamanetwork.com/journals/jama/fullarticle/194422.
Ely, E.W., Margolin, R., Francis, J., et al. (2001 b). Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM–ICU). Critical Care Medicine, 29(7), 13701379.
Ely, E.W., Shintani, A., Truman, B., et al. (2004). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. The Journal of the American Medical Association, 291(14), 17531762. Available from http://jamanetwork.com/journals/jama/fullarticle/198503.
George, C., Nair, J.S., Ebenezer, J.A., et al. (2011). Validation of the Intensive Care Delirium Screening Checklist in nonintubated intensive care unit patients in a resource-poor medical intensive care setting in South India. Journal of Critical Care, 26(2), 138143. Epub ahead of print Jan 26.
Gottesman, R.F., Grega, M.A., Bailey, M.M., et al. (2010). Delirium after coronary artery bypass graft surgery and late mortality. Annals of Neurology, 67(e), 338344. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3723404/.
Gusmao-Flores, D., Salluh, J. I., Dal Pizzol, F., et al. (2011). The validity and reliability of the Portuguese versions of three tools used to diagnose delirium in critically ill patients. Clinics (São Paulo), 66(11), 19171922. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3203964/.
Gusmao-Flores, D., Salluh, J.I., Chalhub, R.A., et al. (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. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3580690/.
Heymann, A., Radtke, F., Schiemann, A., et al. (2010). Delayed treatment of delirium increases mortality rate in intensive care unit patients. The Journal of International Medical Research, 38(5), 15841595.
Inouye, S.K., van Dyck, C.H., Alessi, C.A., et al. (1990). Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine, 113(12), 941948.
Inouye, S.K., Westendorp, R.G. & Saczynski, J.S. (2014). Delirium in elderly people. Lancet, 383(9920), 911922. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4120864/.
Koster, S., Hensens, A.G. & van der, P.J. (2009). The long-term cognitive and functional outcomes of postoperative delirium after cardiac surgery. The Annals of Thoracic Surgery, 87(5), 14691474.
Laurila, J.V., Pitkala, K.H., Strandberg, T.E., et al. (2003). The impact of different diagnostic criteria on prevalence rates for delirium. Dementia and Geriatric Cognitive Disorders, 16(3), 156162.
Lin, S. M., Liu, C.Y., Wang, C.H., et al. (2004). The impact of delirium on the survival of mechanically ventilated patients. Critical Care Medicine, 32(22), 22542259.
Luetz, A., Heymann, A., Radtke, F.M., et al. (2010). Different assessment tools for intensive care unit delirium: Which score to use? Critical Care Medicine, 38(2), 409418.
McNicoll, L., Pisani, M.A., Ely, E.W., et al. (2005). Detection of delirium in the intensive care unit: Comparison of confusion assessment method for the intensive care unit with confusion assessment method ratings. Journal of the American Geriatrics Society, 53(3), 495500.
Meagher, D., O'Regan, N., Ryan, D., et al. (2014). Frequency of delirium and subsyndromal delirium in an adult acute hospital population. The British Journal of Psychiatry, 205, 478485. Epub ahead of print Oct 30. Available from http://bjp.rcpsych.org/content/205/6/478.long.
Mitasova, A., Kostalova, M., Bednarik, J., et al. (2012). Post-stroke delirium incidence and outcomes: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM–ICU). Critical Care Medicine, 40(2), 484490.
Neufeld, K.J., Hayat, M.J., Coughlin, J.M., et al. (2011). Evaluation of two intensive care delirium screening tools for non-critically ill hospitalized patients. Psychosomatics, 52(2), 133140.
Neufeld, K.J., Leoutsakos, J.S., Sieber, F.E., et al. (2013). Evaluation of two delirium screening tools for detecting post-operative delirium in the elderly. British Journal of Anaesthesia, 111(4), 612618. Epub ahead of print May 8. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3770063/.
Norkiene, I., Ringaitiene, D., Misiuriene, I., et al. (2007). Incidence and precipitating factors of delirium after coronary artery bypass grafting. Scandinavian Cardiovascular Journal, 41(3), 180185.
Ouimet, S., Kavanagh, B.P., Gottfried, S.B., et al. (2007). Incidence, risk factors and consequences of ICU delirium. Intensive Care Medicine, 33(1), 6673. Epub ahead of print Nov 11, 2006.
Pun, B.T. & Ely, E.W. (2007). The importance of diagnosing and managing ICU delirium. Chest, 132(2), 624636.
Rosen, S.F., Clagett, G.P., Valentine, R.J., et al. (2002). Transient advanced mental impairment: An underappreciated morbidity after aortic surgery. Journal of Vascular Surgery, 35(2), 376381. Available from http://www.jvascsurg.org/article/S0741-5214(02)57363-8/pdf.
Santos, F.S., Velasco, I.T. & Fraguas, R. Jr. (2004). Risk factors for delirium in the elderly after coronary artery bypass graft surgery. International Psychogeriatrics, 16(2), 175193.
Trzepacz, P.T., Breitbart, W., Franklin, J., et al. (1999). Practice guideline for the treatment of patients with delirium. American Psychiatric Association. The American Journal of Psychiatry, 156(Suppl. 5), 120. Available from http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/delirium.pdf.
van Eijk, M.M., van Marum, R.J., Klijn, I.A., et al. (2009). Comparison of delirium assessment tools in a mixed intensive care unit. Critical Care Medicine, 37(6), 18811885.
van Eijk, M.M., van den, B.M., van Marum, R.J., et al. (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), 340344. Epub ahead of print May 11.
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