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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 9-11

Point prevalence of delirium among critically ill patients in Saudi Arabia: A multicenter study


1 Adult Intensive Care Unit, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
2 King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
3 Department of Critical Care, King Abdullah Medical City, Makkah, Saudi Arabia
4 King Abdulaziz University Hospital, Jeddah, Saudi Arabia
5 Prince Sultan Military Medical City, Riyadh, Saudi Arabia
6 King Fahad University Hospital, Khobar, Saudi Arabia
7 Al Noor Specialist Hospital, Makkah, Saudi Arabia
8 King Fahad Medical City, Riyadh, Saudi Arabia
9 King Abdulaziz Medical City, Jeddah, Saudi Arabia
10 King Khaled University Hospital, Riyadh, Saudi Arabia
11 King Saud Medical City, Riyadh, Saudi Arabia
12 King Abdulaziz Medical City, Riyadh, Saudi Arabia
13 Johns Hopkins Aramco Health Care, Dhahran, Saudi Arabia
14 mam Abdulrahman Al Faisal Hospital, Dammam, Saudi Arabia
15 mam Abdulrahman Al Faisal Hospital, Dammam; Saudi Critical Care Society, Riyadh, Saudi Arabia

Date of Submission27-Jan-2020
Date of Decision06-Feb-2020
Date of Acceptance09-Feb-2020
Date of Web Publication30-Apr-2020

Correspondence Address:
Nada S Al-Qadheeb
Research Center, King Khaled Medical City, Dammam and First Health Cluster in Eastern Province E1, King Fahad Specialist Hospital Dammam, P. O. Box 15215, Dammam 31444
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sccj.sccj_7_20

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  Abstract 


Delirium is commonly recognized among critically ill patients; previous work suggests that delirium prevalence is up to 80% in intensive care unit (ICU) patients and is associated with a variety of adverse outcomes. While several tools have been validated for the detection of ICU delirium, the confusion assessment method -ICU and the intensive care delirium screening checklist are the most widely studied and used. Several risk factors are known to influence delirium occurrence such as benzodiazepines use, drug-induced coma, sleep alterations, metabolic disturbances, and sepsis. In Saudi Arabia, few studies have discussed delirium burden and associated risk factors among critically ill patients. Therefore, the aim of this study is to determine the prevalence of ICU delirium and to study the risk factors associated with the development of delirium in patients in the intensive care setting in Saudi Arabia. This is a 1-day cross-sectional study performed on January 28, 2020, in the medical-surgical ICUs at 14 hospitals in Saudi Arabia. Patients are excluded from the study if they have traumatic brain injury, documented dementia in patient's medical chart, and the inability to conduct valid delirium assessment.

Keywords: Delirium, intensive care delirium screening checklist, intensive care unit, prevalence


How to cite this article:
Al-Qadheeb NS, Hashhoush M, Maghrabi K, Rugaan A, Eltatar F, Algethamy H, Abudayah A, Ismail N, Almubarak, Alkhatib K, Amaani M, Ghabashi A, Almaani M, Amin R, Alharthy AM, Nasim N, ElRakaiby G, Alonazi F, Alnajdi I, Alansari M, Al Ahmed M, Alenazi A, Alruwaili A, Almuslim O. Point prevalence of delirium among critically ill patients in Saudi Arabia: A multicenter study. Saudi Crit Care J 2020;4:9-11

How to cite this URL:
Al-Qadheeb NS, Hashhoush M, Maghrabi K, Rugaan A, Eltatar F, Algethamy H, Abudayah A, Ismail N, Almubarak, Alkhatib K, Amaani M, Ghabashi A, Almaani M, Amin R, Alharthy AM, Nasim N, ElRakaiby G, Alonazi F, Alnajdi I, Alansari M, Al Ahmed M, Alenazi A, Alruwaili A, Almuslim O. Point prevalence of delirium among critically ill patients in Saudi Arabia: A multicenter study. Saudi Crit Care J [serial online] 2020 [cited 2020 Jun 1];4:9-11. Available from: http://www.sccj-sa.org/text.asp?2020/4/1/9/283643




  Introduction Top


Delirium, defined as a disturbance in attention and awareness, develops over a short period of time and accompanied by a fluctuating course of change in cognition.[1] Rates of delirium range from 50% to 80% in mechanically ventilated patients and 20%–50% in patients with lower severity of illness. These results highly depend on the population studied, and the diagnostic tool was used. Underrecognition of delirium is an extensive problem and is estimated to occur in 30%–75% of cases. Common subtypes of delirium include mixed (54%), hypoactive delirium characterized by lethargy, reduced activity (44%), and hyperactive form (1.6%) characterized by restlessness and agitation.[2],[3],[4],[5],[6],[7],[8],[9],[10]

Several studies suggest that delirium is an independent predictor of a longer time in the intensive care unit (ICU) and on mechanical ventilation, greater cost, and higher mortality. Furthermore, delirium is linked to worsening cognitive performance that persists for months to years after ICU discharge.[11],[12],[13],[14] While numerous delirium risk factors have been reported in the literature, benzodiazepines use, drug-induced coma, sleep alterations, metabolic disturbances, and sepsis are modifiable risk factors that should be addressed in clinical practice.[2],[3],[4],[5],[6],[7],[8]

Given the negative sequelae of delirium, the society of critical care medicine pain agitation and delirium guideline recommends routine delirium screening in the ICU with the validated confusion assessment method-ICU (CAM-ICU) or the intensive care delirium screening checklist (ICDSC).[2],[3],[15],[16] Plaschke et al. compared the CAM-ICU and the ICDSC, a good agreement between both tools was found (kappa coefficient of 0.80; confidence interval [CI] 95%: 0.78–0.84; P < 0.001).[17]

While the CAM-ICU evaluates four features (acute fluctuation in mental status, inattention, altered level of consciousness, and disorganized thinking) in a focused patient assessment approach, taking <2 min to complete, the 8-domain ICDSC assesses four symptoms of delirium (altered level of consciousness, inattention, disorientation, and psychosis) in a focused patient assessment method and four domains (changes in psychomotor activity, inappropriate speech/mood, sleep disturbances, and fluctuations of symptoms) over the prior and current nursing shift. An ICDSC score ≥4 has been shown to highly correlate with a formal psychiatric diagnosis of delirium. Both tools are validated in several languages including Arabic and English.[2],[15],[18],[19] The Arabic CAM-ICU and ICDSC demonstrated a good reliability and validity to assess delirium in Arabic-speaking critically ill patients.

In Saudi Arabia, little is known about ICU delirium, its burden and associated risk factors among critically ill patients. In 2014, a survey related to delirium was conducted in one center in Saudi Arabia, 54% scored their performance related to delirium assessment and management in the ICU as fair to poor. Aljuaid et al. tested the validity and reliability of the Arabic CAM-ICU in a tertiary care hospital in Saudi Arabia, delirium was diagnosed in 63% of enrolled patients as per the psychiatrist clinical assessment. In 2019, the Arabic version of ICDSC was successfully developed by Al-Qadheeb et al. demonstrating an acceptable reliability and validity in detecting delirium among critically ill Arabic-speaking population. Incidence of delirium was 21% as per the psychiatrist evaluation and 17% using the Arabic version of ICDSC.[18],[19] In addition, Rasheed et al. reported an incidence of 17.3% in ICU patients from one center in Saudi Arabia using the CAM-ICU. Moreover, the authors investigated risk factors associated with delirium and found a strong association with sedation, mechanical ventilation, and a baseline Glasgow Coma Scale score of <15.[20] Epidemiological data from a large number of ICUs may provide a more precise estimate of prevalence and may help design future observational studies.

In this study, we sought to determine, in a multicenter fashion, the point prevalence of ICU delirium and to study the risk factors associated with the development of delirium among critically ill patients in Saudi Arabia.


  Materials and Methods Top


The study is a 1-day cross-sectional study performed on January 28, 2020, in the medical-surgical ICUs at 14 hospitals in Saudi Arabia. We submitted for approval from all the institutional review boards from all participating centers. All 14 ICUs are closed units integrating well-established pain and sedation protocols.

Critically ill patients expected to stay in the ICU for at least 24 h with a Richmond Agitation and Sedation Scale (RASS) score of ≥−3 are included in the study. Patients are excluded from the study if they have traumatic brain injury, documented dementia in patient's medical chart, and inability to conduct valid delirium assessment. Delirium is diagnosed by trained ICU physicians and/or critical care clinical pharmacists using the ICDSC [Figure 1]. Assessments are performed once to twice daily.
Figure 1: Intensive care delirium screening checklist scoring tool

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A multi-faceted approach is utilized to train clinicians. Each investigator is instructed and trained on how to use the ICDSC through online materials to educate about delirium. An independent delirium expert will be available for questions. All data entries are performed using Research Electronic Data Capture tools. Each investigator is provided an access to the tool where a comprehensive manual describing the process of data entry and data collection is available. A training manual for the RASS and ICDSC in Arabic and English is provided for the investigators. A conference call explaining the application and pitfalls of the ICDSC is scheduled with all investigators. Standard descriptive statistics are used. Prevalence is calculated with 95% CI, α =0.05, and 5% level of significance. Logistic regression is used for dependent correlation.

This present study represents the first attempt to report the prevalence of ICU delirium in Saudi Arabia in a multicenter fashion. The availability of such data enforces the routine use of validated tools to screen for delirium in critical care units in Saudi Arabia, an algorithm can then be developed to determine the cause and a management strategy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington DC: American Psychiatric Association; 2013.  Back to cited text no. 1
    
2.
Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive care delirium screening checklist: Evaluation of a new screening tool. Intensive Care Med 2001;27:859-64.  Back to cited text no. 2
    
3.
Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, et al. Delirium in mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001;286:2703-10.  Back to cited text no. 3
    
4.
Chanques G, Payen JF, Mercier G, de Lattre S, Viel E, Jung B, et al. Assessing pain in non-intubated critically ill patients unable to self report: An adaptation of the behavioral pain scale. Intensive Care Med 2009;35:2060-7.  Back to cited text no. 4
    
5.
Sharma A, Malhotra S, Grover S, Jindal SK. Incidence, prevalence, risk factor and outcome of delirium in intensive care unit: A study from India. Gen Hosp Psychiatry 2012;34:639-46.  Back to cited text no. 5
    
6.
Shehabi Y, Botha JA, Boyle MS, Ernest D, Freebairn RC, Jenkins IR, et al. Sedation and delirium in the intensive care unit: An Australian and New Zealand perspective. Anaesth Intensive Care 2008;36:570-8.  Back to cited text no. 6
    
7.
Thomason JW, Shintani A, Peterson JF, Pun BT, Jackson JC, Ely EW. Intensive care unit delirium is an independent predictor of longer hospital stay: A prospective analysis of 261 non-ventilated patients. Crit Care 2005;9:R375-81.  Back to cited text no. 7
    
8.
Ouimet S, Riker R, Bergeron N, Cossette M, Kavanagh B, Skrobik Y. Subsyndromal delirium in the ICU: Evidence for a disease spectrum. Intensive Care Med 2007;33:1007-13.  Back to cited text no. 8
    
9.
Robinson TN, Raeburn CD, Tran ZV, Brenner LA, Moss M. Motor subtypes of postoperative delirium in older adults. Arch Surg 2011;146:295-300.  Back to cited text no. 9
    
10.
Ryan DJ, O'Regan NA, Caoimh RÓ, Clare J, O'Connor M, Leonard M, et al. Delirium in an adult acute hospital population: Predictors, prevalence and detection. BMJ Open 2013;3:e001772.  Back to cited text no. 10
    
11.
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;291:1753-62.  Back to cited text no. 11
    
12.
Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, et al. Long-term cognitive impairment after critical illness. N Engl J Med 2013;369:1306-16.  Back to cited text no. 12
    
13.
Norman BC, Jackson JC, Graves JA, Girard TD, Pandharipande PP, Brummel NE, et al. Employment outcomes after critical illness: An analysis of the bringing to light the risk factors and incidence of neuropsychological dysfunction in ICU survivors cohort. Crit Care Med 2016;44:2003-9.  Back to cited text no. 13
    
14.
Jackson JC, Pandharipande PP, Girard TD, Brummel NE, Thompson JL, Hughes CG, et al. Depression, post-traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: A longitudinal cohort study. Lancet Respir Med 2014;2:369-79.  Back to cited text no. 14
    
15.
Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, et al. Evaluation of delirium in critically ill patients: Validation of the confusion assessment method for the intensive care unit (CAM-ICU). Crit Care Med 2001;29:1370-9.  Back to cited text no. 15
    
16.
Devlin JW, Skrobik Y, Gélinas C, Needham D, Sloooter A, Pandharipande P, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility and sleep disruption in adult patients in the ICU. Crit Care Med 2018;46:e825-73.  Back to cited text no. 16
    
17.
Plaschke K, von Haken R, Scholz M, Engelhardt R, Brobeil A, Martin E, et al. Comparison of the confusion assessment method for the intensive care unit (CAM-ICU) with the intensive care delirium screening checklist (ICDSC) for delirium in critical care patients gives high agreement rate(s). Intensive Care Med 2008;34:431-6.  Back to cited text no. 17
    
18.
Aljuaid MH, Deeb AM, Dbsawy M, Alsayegh D, Alotaibi M, Arabi YM. Psychometric properties of the Arabic version of the confusion assessment method for the intensive care unit (CAM-ICU). BMC Psychiatry 2018;18:91.  Back to cited text no. 18
    
19.
Al-Qadheeb NS, Nazer LH, Aisa TM, Osman HO, Rugaan AS, Alzahrani AS, et al. Arabic intensive care delirium screening checklist's validity and reliability: A multicenter study. J Crit Care 2019;54:170-4.  Back to cited text no. 19
    
20.
Rasheed AM, Amirah M, Abdallah M, Awajeh AM, Parameaswari PJ, Al Harthy A. Delirium Incidence and risk factors in adult critically Ill patients in Saudi Arabia. J Emerg Trauma Shock 2019;12:30-4.  Back to cited text no. 20
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