Optimising the recognition of delirium in the intensive care unit

Optimising the recognition of delirium in the intensive care unit

Best Practice & Research Clinical Anaesthesiology 26 (2012) 385–393 Contents lists available at SciVerse ScienceDirect Best Practice & Research Clin...

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Best Practice & Research Clinical Anaesthesiology 26 (2012) 385–393

Contents lists available at SciVerse ScienceDirect

Best Practice & Research Clinical Anaesthesiology journal homepage: www.elsevier.com/locate/bean

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Optimising the recognition of delirium in the intensive care unit John W. Devlin, Pharm.D, FCCM, FCCP, Associate Professor a, *, Nathan E. Brummel, MD, Fellow b, c, Nada S. Al-Qadheeb, Critical Care Pharmacy Fellow, FCCP a, d a

Northeastern University School of Pharmacy, 360 Huntington Ave., R218 TF, Boston, MA 02118, USA Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Medical Center East, 6th Floor, 1215 Medical Center Drive, Suite 6100, Nashville, TN 37232, USA b

Keywords: delirium recognition screening confusion assessment method-intensive care unit intensive care delirium screening checklist intensive care unit critical care quality improvement

Delirium affects up to 80% of critically ill patients and negatively influences patient outcome. Consensus guidelines advocate that a validated screening tool like the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) be used to identify delirium rather than a subjective approach. The CAM-ICU and ICDSC have the most rigorous psychometric data to support their use. The differences between these two instruments are far less important to the outcome of patients than the regular and reliable use of either in routine ICU care. Implementation of a large-scale delirium screening effort is both feasible and sustainable and should be accompanied by both didactic and bedside education. An ICU clinical road map should be used on a daily basis that promotes delirium assessment, establishes a targeted sedation goal and defines the analgesic/sedative regimen that is best suited to maintain patient comfort, prevent delirium and promote wakefulness. Ó 2012 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ1 617 285 8610; Fax: þ1 617 373 7655. E-mail addresses: [email protected] (J.W. Devlin), [email protected] (N.E. Brummel), [email protected] (N.S. Al-Qadheeb). c Tel.: þ1 615 936 4959; Fax: þ1 615 936 1269. d Tel.: þ1 617 636 6243; Fax: þ1 617 373 7655. 1521-6896/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpa.2012.08.002

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Delirium, a syndrome characterised by acute change in mental status, including inattention and disorganised thinking, affects up to 80% of critically ill patients and negatively affects patient outcome.14 Patients who develop delirium will have a longer intensive care unit (ICU) and hospital stay, be more challenging to liberate from mechanical ventilation and are more likely to die in the year after delirium occurs.57 In addition, delirium may transition to dementia, particularly in the elderly, reduce post-hospital functionality and increase health-care costs.810 The availability of valid and reliable ICU delirium screening instruments has facilitated its recognition in the critical care setting and enabled clinicians to better define the patients who will benefit from delirium prevention and treatment strategies.2,11 While practice guidelines recommend that patients in the ICU be routinely screened for delirium using a validated tool, questions remain regarding the screening tool that should be used, how screening efforts should be implemented and sustained and whether routine delirium screening improves patient outcome.1216 The objective of this chapter is to discuss the importance and feasibility of delirium screening in the ICU, to compare the validity and reliability of the most commonly used critical care delirium screening instruments and to provide ICU clinicians with practical strategies to boost their delirium screening efforts. Why screen for delirium in the ICU? In routine clinical practice, critical care clinicians often fail to recognise delirium in their patients.17,18 The ability to accurately assess delirium in the ICU is a key component of any systematic strategy that is focussed on preventing or treating delirium. Realising that bedside screening for delirium is not a replacement for a formal diagnostic evaluation by either a psychiatrist or neurologist, it nevertheless remains an efficient, low-risk assessment that will help ICU clinicians address reversible causes for delirium (when it is suspected), avoid initiating treatments for agitation known to worsen delirium (e.g., benzodiazepines) and promote regular interdisciplinary discussion of the cognitive status of all patients.19,20 While multifactorial intervention programmes have been shown to reduce the duration of delirium, length of hospitalisation and lower mortality when completed in patients outside the ICU, the impact of systematic delirium assessment in the ICU on patient outcome remains poorly delineated.2123 Despite the lack of rigorous evidence to support delirium screening among the critically ill, ICU delirium screening efforts, particularly among patients with hypoactive delirium and those with multiple risk factors for its development, will allow clinicians to detect and treat delirium sooner. Why use a validated screening tool when screening for delirium in the ICU? Given the multifactorial and fluctuating nature of delirium, a cursory ‘one time only’ evaluation of delirium at the ICU bedside, without the use of validated screening tool, is often ineffectual and has been shown to be a poor strategy to identify delirium in the critically ill.18,19,24 Failure to use a validated screening tool had been shown to lead to a false recognition of delirium that might lead clinicians to institute antipsychotic therapy – an intervention associated with important safety concerns.25,26 Delirium is challenging to recognise in the ICU setting: most patients are intubated and cannot verbally communicate, the use of medications that reduce level of consciousness is prevalent, hypoactive delirium is common and patients may be too unstable to participate in lengthy assessments.27,28 Based on the numerous limitations associated with use of a subjective approach, new consensus guidelines from the Society of Critical Care Medicine advocate that critically ill patients should be routinely screened for delirium using a validated screening tool.16 Which screening tool should be used to detect delirium in the ICU? The ideal delirium screening tool combines high sensitivity (i.e., will be positive when delirium is present) and high specificity (i.e., will be negative when delirium is not present). Among the ICU delirium screening tools developed, the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the instruments having the greatest psychometric strength.2,11,12,16,24 Across multiple studies, that have included both ventilated and non-

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ventilated patients from different ICU settings and countries, the CAM-ICU and ICDSC are the delirium screening tools shown to have the most robust validation data and thus are the ICU screening tools most frequently used in practice.17,29,30 This section briefly reviews the CAM-ICU and the ICDSC, including the domains of delirium each evaluates, how each should be used in clinical practice and the psychometric properties that are most important to the bedside clinician. Confusion assessment method for the intensive care unit The CAM-ICU is derived from the Confusion Assessment Method and accounts for the non-verbal nature of most ICU patients by substituting the Attention Screening Exam for the Mini Mental State Exam.2 This instrument evaluates the four key diagnostic features of delirium: (1) acute change or fluctuation in mental status from baseline, (2) inattention, (3) altered level of consciousness and (4) disorganised thinking (Fig. 1). Feature 1 uses clinical information to assess the patient’s mental status and is positive if the patient exhibits a change in mental status from his or her pre-hospital baseline or demonstrates a fluctuation in mental status over the preceding 24 h. Feature 2 asks the patient to complete a test of attention (e.g., asking the patient to squeeze the examiner’s hand every time the patient hears the letter ‘A’ as the examiner spells out S-A-V-E-A-H-A-A-R-T). Feature 2 is positive if the patient makes more than two errors during exam (e.g., squeezes on letters other than ‘A’ or fails to squeeze on the letter ‘A’). Feature 3 evaluates level of consciousness with the use of a sedation scale [e.g., Richmond Agitation–Sedation Scale (RASS) or Riker Sedation Agitation Scale (SAS)] and is positive if the patient’s level of consciousness is anything but alert and calm. Finally, Feature 4 evaluates for disorganised thinking by asking the patient to perform a multi-step task (e.g., holding up two fingers and then adding a third) and by answering four ‘yes/no’ questions (e.g., Do fish live in the sea?). Feature 4 is positive if the patient is unable to follow the command or misses more than one of the questions. The CAM-ICU is considered positive if Features 1 and 2 and either Features 3 or 4 are present. It is important to note that patients who are deeply sedated (RASS  4 or SAS  2) cannot be evaluated with the CAM-ICU until they are more awake.

Fig. 1. Confusion assessment method for the intensive care unit (CAM-ICU) flowsheet.

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Intensive care delirium screening checklist The ICDSC is an eight-item instrument based on Diagnostic and Statistical Manual, fourth edition (DSM-IV) criteria and other features of delirium that evaluate: (1) altered level of consciousness, (2) inattention, (3) disorientation, (4) hallucinations or delusions, (5) psychomotor agitation or retardation, (6) inappropriate speech or mood, (7) sleep/wake cycle disturbances and (8) symptom fluctuation (Table 1).11 The ICDSC was developed to provide ICU providers with an easy-to-use screening tool at the bedside that circumvents the communication limitations of ICU patients, incorporates data that is gathered during routine patient care and can be completed quickly by the patients’ nurse, physician or

Table 1 The intensive care delirium screening checklist. 1. Altered level of consciousness Choose ONE from A–E. Note: May need to reassess patient if current or recent administration of sedation therapy A. Exaggerated response to normal stimulation Riker/SAS ¼ 5, 6, or 7 Score 1 point B. Normal wakefulness Riker/SAS ¼ 4 Score 0 point C. Response to mild or moderate Riker/SAS ¼ 3 Score 1 point stimulation (follows commands) *Score 0 if LOC related to recent sedation/analgesia D. Response only to intense and Riker/SAS ¼ 2 *Stop assessment repeated stimulation (e.g. loud voice and pain) E. No response Riker/SAS ¼ 1 *Stop assessment 2. Inattention Score 1 point for any of the following abnormalities: A. Difficulty in following commands OR B. Easily distracted by external stimuli OR C. Difficulty in shifting focus Does the patient follow you with their eyes? 3. Disorientation Score 1 point for any one obvious abnormality: A. Mistake in either time, place or person Does the patient recognize ICU caregivers who have cared for him/her and not recognize those that have not? What kind of place are you in? (list examples) 4. Hallucinations or Delusions Score 1 point for either: A. Equivocal evidence of hallucinations or a behaviour due to hallucinations (Hallucination ¼ perception of something that is not there with NO stimulus) OR B. Delusions or gross impairment of reality testing (Delusion ¼ false belief that is fixed/unchanging) Any hallucinations now or over past 24 h? Are you afraid of the people or things around you? [fear that is inappropriate to the clinical situation] 5. Psychomotor Agitation or Retardation Score 1 point for either: A. Hyperactivity requiring the use of additional sedative drugs or restraints in order to control potential danger (e.g. pulling IV lines out or hitting staff) OR B. Hypoactive or clinically noticeable psychomotor slowing or retardation Based on documentation and observation over shift by primary caregiver 6. Inappropriate Speech or Mood Score 1 point for either: A. Inappropriate, disorganized or incoherent speech OR B. Inappropriate mood related to events or situation Is the patient apathetic to current clinical situation (ie. lack of emotion)? Any gross abnormalities in speech or mood? Is patient inappropriatelydemanding? 7. Sleep/Wake Cycle Disturbance Score 1 point for: A. Sleeping less than 4 h at night OR B. Waking frequently at night (do not include wakefulness initiated by medical staff or loud environment) OR C. Sleep  4 h during day Based on primary caregiver assessment 8. Symptom Fluctuation Score 1 point for: fluctuation of any of the above items (ie. 1–7) over 24 h (e.g. from one shift to another)Based on primary caregiver assessment TOTAL ICSDC SCORE (Add 1–8) SAS ¼ Sedation Agitation Scale; ICDSC ¼ Intensive Care Delirium Screening Checklist.

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pharmacist. Patients who are not heavily sedated (i.e., RASS  4 or SAS  2) are evaluated for the presence of each feature over the nursing shift with some of the values (e.g., sleep–wake cycle and symptom fluctuation) being obtained from assessments completed over the past 24 h. During the evaluation period, 1 point is given towards each domain that is present, with a score of 4 or higher denoting the presence of delirium.

Psychometric properties of the CAM-ICU and the ICDSC A comprehensive discussion of the psychometric properties of the CAM-ICU and ICDSC is beyond the scope of this review. Nevertheless, two recent meta-analyses highlight the robust data that supports either the use of the CAM-ICU or the ICDSC in clinical practice (Table 2).12,13 The results of these analyses indicate that while the CAM-ICU and the ICDSC each have good sensitivity (i.e., delirium is detected when it is present), their sensitivity may be lower when these instruments are administered by bedside clinicians rather than research nurses.31 These findings highlight the important role of education when either of these instruments are implemented in clinical practice. The lower specificity (i.e., delirium is detected when it is not present) of the ICDSC (when compared to CAM-ICU) is primarily attributable to the fact that the original ICDSC validation study did not exclude patients with coma, dementia or other psychiatric or neurologic conditions that might mimic delirium.11 Regardless of these differences, when the same ICU cohort is concomitantly evaluated with both instruments, agreement between CAM-ICU and the ICDSC for the presence of delirium has been strong.32

Clinical differences between the CAM-ICU and the ICDSC While guidelines advocate use of either the CAM-ICU or ICDSC in clinical practice, several differences between these two instruments are worthy of mention. The ICDSC takes into account symptom fluctuation over the course of the prior 24 h whereas the CAM-ICU provides an assessment for delirium at the time the assessment is completed. Clinicians should consider boosting the frequency of CAM-ICU assessments to two to three times daily in patients with mental status changes to prevent delirium from being missed. While the ICSDC evaluates more symptoms of delirium than the CAM-ICU, the symptoms that each share in common (i.e., inattention, disorientation and agitation) are the delirium symptoms that are most frequently detected during ICDSC use and that have the best ability to discriminate between patients who are delirious and those who are not.33 Unlike the CAM-ICU, the ICDSC identifies patients with subsyndromal delirium (ICDSC score of 1–3).34 Compared to delirium, subsyndromal delirium may be more preventable, and the risk factors associated with its development are different.22 Patients with subsyndromal delirium (compared to patients who developed neither delirium nor subsyndromal delirium) are more likely to stay in the ICU longer and to require a higher level of care after ICU discharge.34

Table 2 Pooled sensitivity and specificity of the CAM-ICU and ICDSC. CAM-ICU

Neto et al.a Gusmão-Flores et al.b

ICDSC

Nc

Sensitivityd

Specificityd

N

Sensitivity

Specificity

1180 969

75.5 (71.3–79.4) 80.0 (77.1–82.6)

95.8 (94.0–97.1) 95.9 (94.8–96.8)

457 361

80.1 (73.3–85.8) 74.0 (65.3–81.5)

74.6 (69.1 79.5) 81.9 (76.7–86.4)

CAM-ICU ¼ Confusion Assessment Method for the Intensive Care Unit. ICDSC ¼ Intensive Care Delirium Screening Checklist. a Included studies of the CAM-ICU (n ¼ 12) and ICDSC (n ¼ 5) vs. reference rater in critically ill patients, those on surgical wards and those in emergency rooms. b Included studies of the CAM-ICU (n ¼ 9) and the ICDSC (n ¼ 4) exclusively in critically ill patients vs. reference rater. c Number of patients included in pooled analysis. d Data are presented as percent (95% confidence interval).

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Which screening tool should be used? The presence of delirium in the ICU will frequently be missed unless a validated delirium screening tool is formally implemented into practice and used on a regular basis. Current guidelines advocate that either the CAM-ICU or the ICDSC should be used to identify delirium in the ICU.14,16 More information about each tool may be found at www.icudelirium.org. It should be emphasised that the regular and reliable multidisciplinary use of either of these validated delirium screening instruments should be the primary goal of any delirium screening implementation effort rather than a focus on whether CAMICU or the ICDSC is the delirium instrument that is best suited to use. Routine delirium screening plays an integral role in the ‘ABCDE’ approach to managing sedation, delirium, early mobilisation and mechanical ventilation.29 Is delirium screening feasible? A number of studies, that have included more than 2000 patients, have shown that large-score implementation of a delirium screening tool in the ICU is both feasible and sustainable.4,17,3538 These efforts report that the compliance of the bedside nurse to screening efforts is high, that reliability between bedside ICU clinicians and a trained delirium expert for the presence of delirium is strong and that delirium screening is sustainable in routine clinical practice for up to a 3-year period. It is important to emphasise that these published ICU delirium screening implementation efforts did not occur without extensive education, frequent reminders to clinicians to screen their patients on a regular basis, regular evaluations of the quality of the delirium assessments being completed and a multidisciplinary ICU team that valued the role of delirium assessments in daily care decisions. Education regarding delirium assessment should be provided both didactically (i.e., classroom or web) and at the bedside (where the correct use of the screening tool is demonstrated) to all members of the ICU team and on a regular basis.35,39,40 The results of delirium screening efforts should be presented during both morning report and/or bedside rounds. Spot-checking, that involves the bedside clinician and a trained rater (e.g., clinical nurse educator) each conducting a delirium assessment and then comparing findings, is another important strategy that can be used to both improve and sustain the quality of ICU delirium monitoring programmes.35,37 Qualitative feedback from individual ICU clinicians will help overcome barriers to delirium assessment given the unique cultural and environmental factors that often exist in individual units. Evaluation of delirium screening efforts should occur soon after an instrument is implemented using one-on-one clinician interviews or a focus group. The CAM-ICU and ICDSC should always be considered by ICU clinicians as a screening tool rather than a definitive diagnosis. A psychiatric consultation may still be warranted in situations where the patient’s symptoms are atypical or the medical history is unknown. When a delirium screening programme is implemented, ICU clinicians should be made to feel comfortable that they may not also always be able to evaluate all domains of the CAM-ICU or ICDSC. In these instances, these ‘partial’ assessments should be documented in the patient record and considered during future assessments. How should delirium screening results be used in ICU clinical practice? The results of delirium assessments should be documented in the patient record and discussed during multidisciplinary ICU rounds. Clinicians should employ a road map on daily rounds that incorporates not only delirium assessment but also the targeted sedation goal and the analgesic and/ or sedation regimen that is best suited to maintain comfort in each patient. For patients found to have delirium, clinicians should conduct a thorough evaluation for potential delirium causes, particularly those that are reversible.41,42 In some instances, further diagnostic strategies may be required and consultation with a neurologist or psychiatrist beneficial. Pharmacologic intervention (e.g., antipsychotic therapy) remains controversial, particularly in ICU patients with delirium who are not agitated.

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Summary Delirium affects up to 80% of critically ill patients and negatively affects patient outcome. Delirium is often missed when evaluated subjectively, therefore, a validated ICU screening tool like the CAM-ICU or the ICDSC should be used. While other ICU screening tools are available, the CAM-ICU and ICDSC have the most rigorous psychometric data to support their use and are the screening tools most frequently used in ICU practice. While differences between the CAM-ICU and ICDSC exist, the decision surrounding which of these instruments to use is far less important than implementation of an ICU delirium screening protocol that promotes regular assessment of all patients. Multiple, large studies have shown that a large-scale implementation of a delirium screening tool in the ICU is both feasible and sustainable. Education surrounding delirium screening should be provided both didactically and at the bedside to all members of the ICU team and the results of delirium assessment efforts should be incorporated in ICU checklists and discussed during rounds. The quality of delirium screening efforts should be regularly checked and qualitative feedback from ICU clinicians should be encouraged. An ICU clinical road map should be used on a daily basis that promotes delirium assessment, establishes a sedation goal and defines the analgesic and/or sedation regimen that is best suited to maintain comfort, prevent delirium and promote wakefulness. When delirium is identified, clinicians should conduct a thorough patient evaluation to identify the underlying causes that can be potentially reversed.

Practice points 1. All patients admitted to the ICU should be regularly evaluated for delirium. 2. A validated screening tool like the CAM-ICU or ICDSC should be used to identify delirium rather than subjective clinical assessment methods. 3. Sedation assessment with a validated instrument (e.g., RASS) should be implemented prior to implementing a delirium screening programme. 4. Delirium screening should be completed by all clinicians involved in the daily care of patients (e.g., nurses, physicians and pharmacists). 5. Both didactic (e.g., classroom or web-based) and bedside educational strategies should be used to educate clinicians surrounding the proper use of either the CAM-ICU or the ICDSC. 6. Differences between the CAM-ICU and the ICDSC should be far less important to ICU clinicians than the regular and reliable use of either of these screening tools in daily practice, the documentation of all assessments and the systematic use of screening results in daily care decisions.

Research agenda 1. The impact of regular delirium screening on patient outcome needs to be rigorously evaluated. 2. The validity and reliability of the CAM-ICU and the ICDSC need to be further evaluated in studies where bedside clinicians rather than research personnel conduct the assessments. 3. The relationship between drug-induced sedation and delirium screen positivity needs to be further evaluated. 4. Strategies to overcome current barriers to delirium screening need to be identified and evaluated. 5. Future studies should evaluate the role that electroencephalography (EEG) assessment, magnetic resonance imaging and serum biomarkers can play in helping to predict or identify delirium in the critically ill.

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Conflict of interest None of the authors have a conflict of interest that is relevant to this paper.

References 1. Dubois MJ, Bergeron N, Dumont M et al. Delirium in an intensive care unit: a study of risk factors. Intensive Care Med 2001; 27(8): 1297–1304. *2. Ely EW, Inouye SK, Bernard GR 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(21): 2703–2710. 3. Pisani MA, Murphy TE, Van Ness PH et al. Characteristics associated with delirium in older patients in a medical intensive care unit. Arch Intern Med 2007; 167(15): 1629–1634. *4. Vasilevskis EE, Morandi A, Boehm L et al. Delirium and sedation recognition using validated instruments: reliability of bedside intensive care unit nursing assessments from 2007 to 2010. J Am Geriatr Soc 2011; 59: S249–S255. 5. Pisani MA, Kong SY, Kasl SV et al. Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 2009; 180(11): 1092–1097. 6. Ely EW, Shintani A, Truman B et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291(14): 1753–1762. 7. Shehabi Y, Riker RR, Bokesch PM et al. Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients. Crit Care Med 2010; 38(12): 2311–2318. 8. Girard TD, Jackson JC, Pandharipande PP et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med 2010; 38(7): 1513–1520. 9. van den Boogaard M, Schoonhoven L, Evers AW et al. Delirium in critically ill patients: impact on long-term health-related quality of life and cognitive functioning. Crit Care Med 2012; 40(1): 112–118. 10. Milbrandt EB, Deppen S, Harrison PL et al. Costs associated with delirium in mechanically ventilated patients. Crit Care Med 2004; 32(4): 955–962. *11. Bergeron N, Dubois MJ, Dumont M et al. Intensive care delirium screening checklist: evaluation of a new screening tool. Intensive Care Med 2001; 27(5): 859–864. *12. Neto AS, Nassar Jr. AP, Cardoso SO et al. Delirium screening in critically ill patients: a systematic review and meta-analysis. Crit Care Med 2012; 40(6): 1946–1951. *13. Gusmao-Flores D, Salluh JI, Chalhub RA et al. 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. Crit Care 2012; 16(4): R115. 14. Martin J, Heymann A, Basell K et al. Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care–short version. Ger Med Sci 2010 Feb 2; 8: Doc02. 15. Patel SB & Kress JP. Accurate identification of delirium in the ICU: problems with translating the evidence in the real-life setting. Am J Respir Crit Care Med 2011; 184(3): 287–288. *16. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation and delirium in adult ICU patients. Crit Care Med, in press. 17. Devlin JW, Fong JJ, Howard EP et al. Assessment of delirium in the intensive care unit: nursing practices and perceptions. Am J Crit Care 2008; 17(6): 555–565. quiz 566. *18. Spronk PE, Riekerk B, Hofhuis J et al. Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med 2009; 35(7): 1276–1280. 19. Devlin JW, Fong JJ, Schumaker G et al. Use of a validated delirium assessment tool improves the ability of physicians to identify delirium in medical intensive care unit patients. Crit Care Med 2007; 35(12): 2721–2724. quiz 2725. 20. Pandharipande P, Shintani A, Peterson J et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology 2006; 104(1): 21–26. 21. Lundstrom M, Edlund A, Karlsson S et al. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc 2005; 53(4): 622–628. 22. Skrobik Y, Ahern S, Leblanc M et al. Protocolized intensive care unit management of analgesia, sedation, and delirium improves analgesia and subsyndromal delirium rates. Anesth Analg 2010; 111(2): 451–463. 23. Awissi DK, Begin C, Moisan J et al. I-SAVE study: impact of sedation, analgesia, and delirium protocols evaluated in the intensive care unit: an economic evaluation. Ann Pharmacother 2012; 46(1): 21–28. *24. van Eijk MM, van Marum RJ, Klijn IA et al. Comparison of delirium assessment tools in a mixed intensive care unit. Crit Care Med 2009; 37(6): 1881–1885. 25. Guenther U, Weykam J, Andorfer U et al. Implications of objective vs subjective delirium assessment in surgical intensive care patients. Am J Crit Care 2012; 21(1): e12–20. 26. Devlin JW & Skrobik Y. Antipsychotics for the prevention and treatment of delirium in the intensive care unit: what is their role? Harv Rev Psychiatry 2011; 19(2): 59–67. *27. Devlin JW, Fong JJ, Fraser GL et al. Delirium assessment in the critically ill. Intensive Care Med 2007; 33(6): 929–940. 28. Peterson JF, Pun BT, Dittus RS et al. Delirium and its motoric subtypes: a study of 614 critically ill patients. J Am Geriatr Soc 2006; 54(3): 479–484. 29. Morandi A, Pandharipande P, Trabucchi M et al. Understanding international differences in terminology for delirium and other types of acute brain dysfunction in critically ill patients. Intensive Care Med 2008; 34(10): 1907–1915. 30. Patel RP, Gambrell M, Speroff T et al. Delirium and sedation in the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals. Crit Care Med 2009; 37(3): 825–832. *31. van Eijk MM, van den Boogaard M, van Marum RJ et al. Routine use of the confusion assessment method for the intensive care unit: a multicenter study. Am J Respir Crit Care Med 2011; 184(3): 340–344.

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*32. Plaschke K, von Haken R, Scholz M 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(3): 431–436. 33. Marquis F, Ouimet S, Riker R et al. Individual delirium symptoms: do they matter? Crit Care Med 2007; 35(11): 2533–2537. 34. Ouimet S, Riker R, Bergeron N et al. Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intensive Care Med 2007; 33(6): 1007–1013. *35. Pun BT, Gordon SM, Peterson JF et al. Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers. Crit Care Med 2005; 33(6): 1199–1205. 36. Guenther U, Popp J, Koecher L et al. Validity and reliability of the CAM-ICU flowsheet to diagnose delirium in surgical ICU patients. J Crit Care 2010; 25(1): 144–151. 37. Soja SL, Pandharipande PP, Fleming SB et al. Implementation, reliability testing, and compliance monitoring of the confusion assessment method for the intensive care unit in trauma patients. Intensive Care Med 2008; 34(7): 1263–1268. 38. Riekerk B, Pen EJ, Hofhuis JG et al. Limitations and practicalities of CAM-ICU implementation, a delirium scoring system, in a Dutch intensive care unit. Intensive Crit Care Nurs 2009; 25(5): 242–249. *39. Devlin JW, Marquis F, Riker RR et al. Combined didactic and scenario-based education improves the ability of intensive care unit staff to recognize delirium at the bedside. Crit Care 2008; 12(1): R19. 40. Gesin G, Russell BB, Lin AP et al. Impact of a delirium screening tool and multifaceted education on nurses’ knowledge of delirium and ability to evaluate it correctly. Am J Crit Care 2012; 21(1): e1–11. 41. Pun BT & Ely EW. The importance of diagnosing and managing ICU delirium. Chest 2007; 132(2): 624–636. 42. Skrobik Y. Delirium prevention and treatment. Anesthesiology Clin 2011; 29(4): 721–727.