Different assessment tools for intensive care unit delirium: which score to use?

OBJECTIVE: To compare validity and reliability of three instruments for detection and assessment of delirium in intensive care unit (ICU) patients. Delirium in critically ill patients is associated with higher mortality, prolonged duration of ICU stay, and greater healthcare costs. Currently, there are several assessment tools available for detection of delirium, but only a few of these assessment systems are developed specifically to screen for delirium in ICU patients. DESIGN: Prospective cohort study. SETTING: ICU at a university hospital. PATIENTS: A total of 156 surgical patients aged > or = 60 yrs consecutively admitted to the ICU, with a length of stay of at least 24 hrs. MEASUREMENTS AND MAIN RESULTS: This study was approved by the institutional ethics committee. Trained staff members performed daily and independently the Confusion Assessment Method for the ICU (CAM-ICU), the Nursing Delirium Screening Scale (Nu-DESC), and the Delirium Detection Score (DDS). These evaluations were compared against the reference standard conducted by a delirium expert (blinded to the study), who used delirium criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Of 156 patients, 63 (40%) were identified as delirious by the reference standard during the study. Using the CAM-ICU and the Nu-DESC, we measured comparable sensitivities (CAM-ICU, 81%; Nu-DESC, 83%). The specificity of the CAM-ICU was significantly higher than that of the Nu-DESC (96% vs. 81%, p < .01). In contrast, the DDS showed poor sensitivity (30%), whereas the specificity was significantly higher compared with the Nu-DESC (DDS, 91%; Nu-DESC, 81%, p < .05). The interrater reliability was "almost perfect" for the CAM-ICU (kappa = 0.89) and "substantial" for DDS and Nu-DESC (kappa = 0.79, 0.68). CONCLUSION: The CAM-ICU showed the best validity of the evaluated scales to identify delirium in ICU patients. The Nu-DESC might be an alternative tool for detection of ICU delirium. The DDS should not be used as a screening tool.

Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care--short version.

Targeted monitoring of analgesia, sedation and delirium, as well as their appropriate management in critically ill patients is a standard of care in intensive care medicine. With the undisputed advantages of goal-oriented therapy established, there was a need to develop our own guidelines on analgesia and sedation in intensive care in Germany and these were published as 2(nd) Generation Guidelines in 2005. Through the dissemination of these guidelines in 2006, use of monitoring was shown to have improved from 8 to 51% and the use of protocol-based approaches increased to 46% (from 21%). Between 2006-2009, the existing guidelines from the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) were developed into 3(rd) Generation Guidelines for the securing and optimization of quality of analgesia, sedation and delirium management in the intensive care unit (ICU). In collaboration with another 10 professional societies, the literature has been reviewed using the criteria of the Oxford Center of Evidence Based Medicine. Using data from 671 reference works, text, diagrams and recommendations were drawn up. In the recommendations, Grade "A" (very strong recommendation), Grade "B" (strong recommendation) and Grade "0" (open recommendation) were agreed. As a result of this process we now have an interdisciplinary and consensus-based set of 3(rd) Generation Guidelines that take into account all critically illness patient populations. The use of protocols for analgesia, sedation and treatment of delirium are repeatedly demonstrated. These guidelines offer treatment recommendations for the ICU team. The implementation of scores and protocols into routine ICU practice is necessary for their success.