Southern African Journal of Anaesthesia and Analgesia

ISSN: 2220-1181 (Print) 2220-1173 (Online) Journal homepage: http://www.tandfonline.com/loi/ojaa20

Assessment of delirium in the intensive care unit

TF Kallenbach & LA Amado

To cite this article: TF Kallenbach & LA Amado (2017) Assessment of delirium in the
intensive care unit, Southern African Journal of Anaesthesia and Analgesia, 23:3, 57-63, DOI:
10.1080/22201181.2017.1332809

To link to this article: https://doi.org/10.1080/22201181.2017.1332809

© 2017 The Author(s). Open Access article

distributed under the terms of the Creative
Commons License [CC BY-NC 3.0]

Published online: 13 Jun 2017.

Submit your article to this journal

Article views: 898

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=ojaa20
Southern African Journal of Anaesthesia and Analgesia 2017; 23(3):57–63
http://dx.doi.org/10.1080/22201181.2017.1332809 South Afr J Anaesth Analg
ISSN 2220-1181   EISSN 2220-1173
Open Access article distributed under the terms of the © 2017 The Author(s)
Creative Commons License [CC BY-NC 3.0]
http://creativecommons.org/licenses/by-nc/3.0 RESEARCH

Assessment of delirium in the intensive care unit

TF Kallenbacha* and LA Amadob

a
 epartment of Anaesthesia, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand,
D
Johannesburg, South Africa
b
Department of Anaesthesia, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
*Corresponding author, email: [email protected] 

Delirium poses a significant burden on our healthcare, with patients in the intensive care unit (ICU) at an increased risk for
developing this disorder. In addition, the ICU environment poses unique challenges in the assessment of delirium. It is paramount
that the healthcare provider has an understanding of delirium in ICU, and monitors for it vigilantly. There have been various
scoring systems developed to assist in this regard. However, the most commonly used and validated tools for the assessment of
delirium are the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening
Checklist (ICDSC). Biomarkers of delirium are emerging as tools to diagnose delirium, stratify severity, monitor progress, and
predict outcomes, potentially changing the way we approach delirium in the future.

Keywords: biomarkers, checklist, critical care, delirium, intensive care units, medical staff, patient care, South Africa

Introduction most of the medical referrals were due to delirium, with HIV
Delirium is a prevalent problem in the intensive care unit (ICU),1–4 being the most common underlying factor.10 The differing
with an associated significant morbidity and mortality.5–8 In the characteristics have led authors to postulate that the spectrum
South African context, data are scarce but it appears that the face of delirium will differ in sub-Saharan Africa as compared with
of delirium differs from our First World counterparts.9,10 Thus developed countries.9,10
vigilant screening and accurate diagnosis of delirium is
paramount for good medical care. This article will take a brief Pathophysiology and risk factors
look at delirium itself, and then discuss the methods and issues The pathophysiology of delirium is poorly understood, but is
for the assessment of delirium in ICU. likely to be multi-factorial as several risk factors are usually
present in one patient, and there is considerable overlap in the
Understanding delirium various mechanisms of action.13,14 The pathogenesis may differ
Delirium is defined by the Diagnostic and Statistical Manual 5th from case to case with different causes being present.1 Some
edition (DSM-5) as a fluctuating change in attention, awareness theories on delirium pathophysiology are presented in Table 2.
and cognition that develops over hours to days.4 The affected
individuals exhibit labile emotions and disordered behaviour Delirium is a significant problem in ICU due to the increased
including absent cooperation with medical staff, removing number of risk factors present in these patients compared with
catheters or lines, and attempts to escape medical care. Their non-ICU patients.1,14 By identifying these features, one may be
symptoms often worsen at night due to limited external stimuli, alerted to the possibility of a patient developing delirium. It is,
and delirious patients exhibit sleep–wake cycle disturbances. however, possible to develop delirium despite no predisposing
Importantly, the condition cannot be explained by an underlying traits.22 Predisposing elements may be thought of as those
neurocognitive disorder, and delirium cannot be diagnosed in a relating to the patient’s medical condition, those relating to the
comatose state as the diagnosis does require a response from a surgery if done, and those relating to the ICU stay. This is outlined
verbal cue.1,4,11 The DSM-5 diagnostic criteria are summarised in in Table 3.
Table 1.
Assessing delirium
The incidence of delirium in the intensive care setting varies from Morbidity and mortality with delirium is significant with elevated
7% to 87%. This marked discrepancy exists as there are differences in-hospital mortality, higher incidence of self-extubation and
in studies done with regard to population characteristics, type of removal of catheters, greater need for re-intubation, worsened
ICU used (medical, surgical, both), study methodology, functional and cognitive decline, and increased costs.4–8 However,
assessment tool used for diagnosis of delirium, staff training, timely diagnosis and management may curtail the duration and
medications used and individual ICU practices.1–3 There are few associated morbidity and mortality of delirium.4,11
data on the prevalence or incidence of delirium in South Africa,
but the studies done have shown a wide variation.9,10,12 In a One must note that the diagnosis of delirium in ICU might go
systemic review of studies done in sub-Saharan Africa, delirium unrecognised due to: inadequate bedside assessment; poor
was found most commonly in the 17–65 years age range, which knowledge of delirium by medical staff; symptoms attributed to
contrasts with the usual predominance in the elderly.9 There was other disorders such as dementia; few direct monitors of the
a high association of delirium with infections, particularly the central nervous system; assessment of delirium impaired by lack
human immunodeficiency virus (HIV). This was further reinforced of verbal contact due to need for ventilation, sedatives or opiates;
by a psychiatry study done in a Johannesburg hospital where presence of the hypoactive form of delirium.4,11,13,14,18,23, 7 Brummel

Southern African Journal of Anaesthesia and Analgesia is co-published by Medpharm Publications, NISC (Pty) Ltd and Informa UK Limited
[trading as the Taylor & Francis Group]
58 Southern African Journal of Anaesthesia and Analgesia 2017; 23(3):57–63

Table 1: Summary of DSM-5 criteria4

Diagnostic criteria:

(a) Disturbance in attention (in terms of ability to direct, focus, sustain, or shift attention) and reduced awareness or orientation
(b) Occurs over a short time period (hours to days), fluctuates during the day, and is an alteration from the patient’s pre-existing functioning
(c) Disturbance in cognition (memory, orientation, language, visual-spatial ability, or perception)
(d) The above is found to be the direct result of a medical condition, substance intoxication or withdrawal, toxin, or a combination of factors
Specified subtypes:

(1) Acute – delirium present for a few hours to days

(2) Persistent – delirium present for weeks to months
(3) Hyperactive – increased level of psychomotor activity evident by labile mood, agitation, or refusal to cooperate
(4) Hypoactive – decreased level of psychomotor activity evident by sluggishness or lethargy
(5) Mixed level of activity – normal level of psychomotor activity but with disturbances in attention and awareness, which may fluctuate

Table 2: Pathophysiology of delirium1,2,5,13–21

Theory Supporting data

Cerebral inflammation • May be a response to infection, a risk factor for delirium
• Inflammatory mediators are able to cross the blood–brain barrier, increase endothelial permeability,
reduce cerebral blood flow by inducing micro-aggregates or vasoconstriction, and interfere with
neurotransmitters
• Inflammatory state will induce production of interleukins, which are implicated in delirium
Imbalance of neurotransmitters
Acetylcholine defi- • Acetylcholine is involved in awareness and attention
ciency • Anticholinergic drugs may be a risk factor for delirium and cholinesterase inhibitors may reduce the duration
of delirium
Serotonin excess • Serotonin is associated with learning and memory
• Selective serotonin reuptake inhibitors are associated with delirium
GABA increase • Inflammation up-regulates GABAA receptors, promoting neural inhibition
• Benzodiazepines promote delirium
Dopamine excess • Increased uptake of substrate amino acids (tryptophan, phenylalanine, tyrosine) could lead to increased
production of dopamine and noradrenaline
• Hypoxia and opioids, which are risk factors for delirium, increase dopamine
Cerebral hypoperfusion • Neuroimaging has found reduced cerebral blood flow in delirious patients
• Microcirculation abnormalities have been documented in delirium
Cerebral hypoxaemia • Reduced oxidative metabolism with cerebral slowing shown on EEG
• Microglial activation due to ischaemic hypoxia leads to a pro-inflammatory response, aggravating the cerebral
inflammatory response and delirium
Genetic • Alterations in apolipoprotein E

Table 3: Risk factors for delirium in ICU1–3,5,13–16,18,23–26

Patient-related Surgery-related ICU-related

• Age greater than 70 years • Emergency surgery • Disruption of sleep cycle
• 
Co-morbidities (visual, hearing, • Surgery type: hip fracture, vascular (AAA, peripheral • Metabolic or electrolyte abnormalities (acidosis, glu-
depression, dementia, epilepsy, vascular), cardiac (CABG, valvular), major abdominal, cose, sodium)
cerebrovascular disease, conges- major ENT, urological, thoracic
• Physical restraints and immobilisation
tive heart failure, respiratory/re- • Longer duration of surgery
• Catheters (NGT, bladder, rectal, CVC)
nal/liver dysfunction, infections
• Intraoperative blood loss, blood transfusions, haema-
such as HIV) • Medications (anticholinergics, sedatives, analgesics)
tocrit drop to less than 30%
• Alcohol and psychoactive drug • Pain
• Fluctuations in partial pressure of oxygen
abuse •  Hypotension
• Intraoperative hypothermia
• Malnutrition and dehydration •  Hypoxia
• Greater severity of illness as indi- •  Infection
cated by an illness severity scor-
•  Prolonged ventilation
ing system (such as APACHE)
• Sepsis

Key: HIV = human immunodeficiency virus; APACHE = Acute Physiology and Chronic Health Evaluation; AAA = abdominal aortic aneurysm;
CABG = coronary artery bypass grafting; ENT = ear, nose and throat; NGT = nasogastric tube; CVC = central venous catheter.
Assessment of delirium in the intensive care unit 59

et al. argue that due to this important association of delirium fluctuation in mental status, inattention, altered level of
with increased morbidity and mortality, delirium monitoring consciousness, and disorganised thinking (See Figure 1).40,41,43
should be as routine as measuring the patient’s blood pressure
or heart rate.28 An acute change or fluctuation in mental status is assessed from
baseline or any change within the past 24 h. This criterion has a
Scoring systems simple yes or no answer. Inattention is assessed by asking the
The gold standard assessment of delirium is by a geriatrician, patient to squeeze the investigator’s hand when the letter ‘A’ is
neurologist or psychiatrist.29 However, in the ICU setting such read in a 10-letter sequence, allowing for a maximum of two
evaluations need to be done at the bedside by the attending errors. Any discrepancies can be confirmed with a visual test.
healthcare staff. Several studies have shown that both intensivists Altered level of consciousness is assessed by using that patient’s
and ICU nurses perform poorly when using clinical judgement current RASS or SAS score. Lastly, disorganised thinking is assessed
alone, resulting in many missed cases of delirium.28,30,31 Thus by the patient’s ability to answer four ‘yes/no’-type questions as
delirium assessments are usually aided by a scoring system, well as obey a command.28,43 If the first two steps already indicate
modified for the ICU environment due to the unique challenges the absence of delirium, the scoring system does not have to be
in this setting as elucidated above. Assessments done in ICU done to completion, thus shortening the time required.28
need to be non-verbal, easy to use, short, and able to be done
without psychiatric training.2 Delirium is diagnosed when altered mental state and inattention
are present, as well as disorganised thinking or altered level of
In order to assess delirium, the patient must have an adequate consciousness.40 CAM-ICU may be conducted by any trained
level of arousal or responsiveness.28 Thus level of consciousness health professional and each assessment takes less than 5 min to
must be measured using scales such as Richmond Agitation– complete.28,34,37,41 CAM-ICU has a sensitivity of 93% and specificity
Sedation Scale or Riker Sedation–Agitation Scale.28,32 of 89%, as well as high inter-rater reliability demonstrated by
data from several studies.41,44 Reliability and validity has been
The Richmond Agitation and Sedation Scale (RASS) has a assessed extensively against the DSM criteria for delirium.28 The
10-point scale with four levels denoting agitation (+1 to +4), one CAM-ICU scoring system has been found to be easy to understand
level denoting a calm and alert state (0), and five to assess and use.38
sedation (–1 to –5).33 For the assessment of delirium to be
possible, the patient must at least be rousable to voice, usually However, the CAM-ICU tool does not allow for the assessment of
by stating the patient’s name, without the need for physical the delirium subtype.43 Also it represents only a point in time.
stimulation (RASS of at least –3).34 Thus, to avoid missing delirium, clinicians should perform a
CAM-ICU assessment several times daily.28,43,45 Another factor to
The Sedation–Agitation Scale (SAS) developed by Riker uses consider is that patient cooperation is required to use this scoring
seven categories for differing severity of sedation or agitation. tool.28,38
The categories used are: dangerous agitation, very agitated,
agitated, calm and cooperative, sedated, very sedated, and Intensive Care Delirium Screening Checklist (ICDSC)
unable to rouse. Although less commonly used, this scale has The ICDSC is an 8-item checklist based on the DSM IV delirium
been validated for use in ICU.35,36 For assessment of delirium, the criteria, evaluated over a period of 8 to 24 h.43,47 These include:
SAS should be 3 or more.28 level of consciousness (which may be given a RASS or SAS score),
inattention (difficulty following commands, or easily distracted
Several scoring systems have been developed for delirium by external stimuli, or difficulty in shifting focus), disorientation
assessment and tested in ICU. These include, but are not limited (for place, time or person), hallucinations/delusions/psychosis,
to, the Confusion Assessment Method for the Intensive Care Unit psychomotor agitation or retardation, inappropriate speech or
(CAM-ICU), the Intensive Care Delirium Screening Checklist mood, sleep/wake cycle disturbances, and symptom fluctuation
(ICDSC), the Neelon and Champagne (NEECHAM) Confusion over 24 h. One point is given for each symptom present in the
Scale, the Nursing Delirium Screening Scale (Nu-DESC), the specified time period, with a score greater than 3 signifying
Cognitive Test for Delirium (CTD), and the Delirium Detection delirium (See Figure 2).28,43,46
Score (DDS).28,37–39
The ICDSC may be conducted by non-specialist staff and each
The CAM-ICU and ICDSC are most widely used, as well as being assessment takes approximately 7 to 10 min to complete.34
validated for use in intubated (and therefore non-verbal) Unlike CAM-ICU where the patient’s involvement is required, the
patients.28,32 Both scores have high sensitivity, specificity, and patient’s involvement in the evaluation with the ICDSC is
inter-rater reliability, and are recommended by the 2013 Society passive.44 The ICDSC is also easy to incorporate into daily practice,
of Critical Care Medicine ‘Clinical Practice Guidelines for the as it utilises data used during daily patient care.45,47 This scoring
Management of Pain, Agitation, and Delirium in Adult Patients in system also has the advantage of being able to diagnose
the Intensive Care Unit’.32 Thus there will be only a brief subsyndromal delirium, as indicated by a score of 1–3.43,46,48
explanation of the other scoring systems already mentioned in
Table 4. The ICDSC has greater sensitivity than CAM-ICU (99%) but lower
specificity (64%).5 The lower specificity may be due to the fact
Confusion Assessment Method for the Intensive that the original validation study did not exclude patients in
Care Unit (CAM-ICU) comas or with conditions which may mimic delirium.43,47 Level of
The CAM-ICU scoring system has been developed from the consciousness is considered the point on the checklist most
standard Confusion Assessment Method (CAM) scoring system, likely to be incorrectly scored by inexperienced observers, and
which was developed and validated in general medical wards Bergeron et al. wrote that this weakens the scale to an extent.47
and based on DSM-IIIR criteria.28,40–42 CAM-ICU utilises four The symptom definitions have been found to require further
features of delirium for diagnosis, namely: an acute alteration or clarification and validation.28,43,47
60 Southern African Journal of Anaesthesia and Analgesia 2017; 23(3):57–63

Table 4: Other delirium scoring instruments28,32,34,37,38,44,50–52

Scoring system Abbreviated title Items utilised Scoring of delirium Disadvantages

Neelon and Champagne Confu- NEECHAM Information processing: Scores range from 0 (minimal Little validation against DSM
sion Scale attention, following commands, responsiveness) to 30 (normal criteria for delirium
orientation function)
Behaviour: appearance, motor, Delirium diagnosed with score Not developed for critical care
verbal below 20 patients
Physiological parameters: vital Unable to use in intubated
signs, oxygen saturation, urinary patients
incontinence
Nursing Delirium Screening Scale Nu-DESC Disorientation Each item rated a score of 0 to 2 Developed for general medical
patients, little validation for
ICU use
Inappropriate behaviour Maximum score of 10 Sedation not accounted for
Inappropriate communication Delirium diagnosed with a score Higher incidence of false-pos-
of 2 or more itive results due to diagnosing
prodromal symptoms as delirium
Hallucination
Psychomotor retardation
Cognitive Test for Delirium CTD Orientation Each item scored from 0 to 6 Designed for research assistants
Attention Maximum score of 30 Takes 10–15 min to complete
Memory Delirium diagnosed with a score Assesses cognitive symptoms of
below 19 delirium only
Comprehension
Vigilance
Delirium Detection Score DDS Agitation Varying points assigned to each Low validation against DSM
item criteria for delirium
Anxiety Maximum score of 56 Symptoms monitored during the
course of a shift, increasing the
time for scoring
Hallucinations Delirium diagnosed with a score High false-negative rate
greater than 7
Orientation
Seizures
Tremor
Paroxysmal sweating
Altered sleep–wake rhythm

CAM-ICU has been demonstrated by Van Eijk et al. to have better (NHLS). Private costs for both NSE and S100B by Ampath
diagnostic accuracy than ICDSC,46 whereas another study by laboratories are ZAR317.50 each (personal correspondence).
Plaschke shows high agreement between the two.45 Sensitivity Costs of running these tests need to be weighed against the cost
of CAM-ICU has been shown to be lower with bedside nurses of interventions avoided as a result of their use. There has been
compared with research nurses, highlighting the importance of particular interest in looking at inflammatory markers as well as
training when scoring systems are implemented in clinical the neuroprotein NSE and S100B protein, and these will be
practice.28,43,49 It has been noted that emphasis should be placed briefly discussed further.
on the consistent, regular and reliable use of either CAM-ICU or
ICDSC, rather than the differences between them.43 Inflammatory biomarkers
Studies on inflammatory biomarkers have looked at various
Biomarkers cytokines and chemokines.56 A study by Van Boogaard et al. divided
Biomarkers may provide an important step not only in improving patients into two groups, namely ‘inflamed’ (possessing a positive
our diagnosis of delirium, but also in monitoring progression, culture in a specimen of any origin, requiring antibiotics, or with
assessing severity, predicting long-term outcomes, and better more than two criteria of the systemic inflammatory response
understanding the pathophysiology of delirium.53,54 The ideal syndrome) and ‘non-inflamed’ (absence of the above). Of the
biomarker would be specific for the brain, cheap, easy to inflammatory markers measured, in the inflamed group a raised
measure, resistant to metabolism, unaffected by renal clearance, level of interleukin-8 was associated with delirium. In the non-
and have high sensitivity and specificity for diagnosis and inflamed group raised interleukin-10 as well as amyloid-β levels
outcome.55 For all biomarkers, the timing of testing may be were associated with delirium. The latter, amyloid-β, was associated
challenging given the fluctuating course inherent to delirium.56 with long-term cognitive failure, highlighting a role in differentiating
Another important consideration is cost. At the time of writing, between the two groups.53 Ritter et al. in a prospective cohort study
neither neuron-specific enolase (NSE) nor S100B protein tests are also managed to demonstrate that biomarkers involved in sepsis
processed by the South Africa National Health Laboratory Service independently predicted the presence of delirium.57
Assessment of delirium in the intensive care unit 61

Figure 1: CAM-ICU scoring system.40

transporters, exposing the brain to potentially toxic metabolites.57

Also, inflammatory markers may arise due to complex
relationships with neurotransmitters implicated in delirium.58

Neuron-specific enolase biomarker

Neuron-specific enolase (NSE) is an intra-cytoplasmic enzyme
found predominantly in neurons and neuroendocrine tissue.56 It
catalyses the conversion of 2-phospho-D-glycerate to
phosphoenolpyruvate in the glycolytic pathway. Thus levels of
NSE will be elevated when cells in the aforementioned tissues
rupture. The enzyme, which has molecular weight of 78 kDa, has
a half-life of 24 h (in comparison with the shorter half-life of the
S100B protein).56 However, several issues have resulted in
conflicting results as to whether NSE may predict poor
neurological outcomes, as contamination from non-neural
sources of the enzyme, hypothermia, and individual differences
Figure 2: ICDSC scoring system.47
caused by genetic polymorphisms may alter findings.55
Additionally, major injury to the central nervous system such as
However, there have been inconsistencies between studies in ischaemic stroke, traumatic brain injury, temporal lobe epilepsy,
terms of which inflammatory markers to use.53,57,58 One must keep and neurosurgery may cause the release of NSE independent of
in mind that there may not be a direct effect of cytokines on brain delirium.55,58 Studies specifically pertaining to NSE and delirium
function, but rather that inflammation alters the permeability of have inconsistent results, and it has been suggested that
the blood–brain barrier and inhibits certain specific drug efflux neuronal injury markers such as NSE have more value in
62 Southern African Journal of Anaesthesia and Analgesia 2017; 23(3):57–63

predicting later dementia in a patient who has suffered an 11. Mistraletti G, Pelosi P, Mantovani ES, et al. Delirium: clinical approach
episode of delirium.54 and prevention. Best Pract Res Clin Anaes. 2012;26(3):311–26.
doi:10.1016/j.bpa.2012.07.001.
12. Stuart-Clark H, Vorajee N, Zuma S, et al. Twelve-month outcomes of
S100B biomarker
patients admitted to the acute general medical service at Groote Schuur
S100 proteins are cytosolic calcium-binding proteins. The Hospital. S Afr Med J 2012;102(6):549–53. doi:10.7196/samj.5615.
subtype of this family of proteins, S100B, is found predominantly 13. Girard TD, Pandharipande PP, Ely EW. Delirium in the intensive care
in astroglial and Swann cells but does exhibit extra-neural unit. Crit Care. 2008;12(Suppl 3):S3. doi:10.1186/cc6149.
sources.59 S100B has a half-life of 25 min, but the timing of the 14. van Eijk MMJ, Slooter AJC. Delirium in intensive care unit
peak levels depends on the source of the biomarker.60 The precise patients. Semin Cardiothorac Vasc Anesth. 2010;14(2):141–7.
functions of these proteins are unknown, but they are thought to doi:10.1177/1089253210371495.
be involved in glial and neuronal proliferation and activation.55 15. Pandharipande P, Jackson J, Ely EW. Delirium: acute cognitive
Astrocytes are activated following brain injury and the dysfunction in the critically ill. Curr Opin Crit Care. 2005;11:360–8.
subsequent proliferation results in elevations of S100B proteins, 16. Calvo-Ayala E, Khan B. Delirium management in critically ill patients. J
Symptoms Signs. 2013;2(1):23–32.
which are secreted into the cerebrospinal fluid.55,61 The majority
17. Gunther ML, Morandi A, Ely EW. Pathophysiology of delirium in the
that are secreted during and immediately after surgery are due intensive care unit. Crit Care Clin. 2008;24(1):45–65. doi:10.1016/j.
to contamination from extra-neural sources.55 Thus elevations of ccc.2007.10.002.
this protein more than 24 h after surgery are more indicative of a 18. Field RR, Wall MH. Delirium. Semin Cardiothorac Vasc Anesth.
neural cause, and daily serial measurements are recommended.61 2013;17(3):170–9. doi:10.1177/1089253213476957.
S100B protein elevation has shown promise as a biomarker in a 19. Trabold B, Metterlein T. Postoperative delirium: risk factors, prevention,
variety of neurological disorders, but has shown an inconclusive and treatment. J Cardiothorac Vasc Anesth. 2014;28(5):1352–60.
correlation with delirium in small studies.53,62–65 doi:10.1053/j.jvca.2014.03.017.
20. Schiemann A, Hadzidiakos D, Spies C. Managing ICU delirium. Curr Opin
Crit Care. 2011;17(2):131–40. doi:10.1097/mcc.0b013e32834400b5.
Conclusion
21. Vijayakumar B, Elango P, Ganessan R. Post-operative delirium in elderly
The awareness and assessment of delirium should be an patients. Indian J Anaesth. 2014;58(3):251–6. doi:10.4103/0019-
important feature in ICU care. The use of an ICU scoring system is 5049.135026.
advocated for this purpose. The CAM-ICU and ICDSC systems are 22. Saporito A, Sturini E. Incidence of postoperative delirium is high even
both well validated, but the choice between the two is guided by in a population without known risk factors. J Anesth. 2013;28(2):198–
clinician preference with emphasis on correct and consistent use 201. doi:10.1007/s00540-013-1706-5.
as part of the daily routine. Regular neural biomarker use is 23. Jones SF, Pisani MA. ICU delirium. Curr Opin Crit Care. 2012;18(2):146–
undermined by limited supporting literature and cost constraints. 51. doi:10.1097/mcc.0b013e32835132b9.
However, as we continue to study ways to diagnose, monitor and 24. Choi JG. Delirium in the intensive care unit. Korean J Anesthesiol.
essentially understand delirium, so the care of our patients will 2013;65(3):195–202. doi:10.4097/kjae.2013.65.3.195.
25. Krzych ŁJ, Wybraniec MT, Krupka-Matuszczyk I, et al. Complex
advance.
assessment of the incidence and risk factors of delirium in a large
cohort of cardiac surgery patients: a single-center 6-year experience.
Conflict of interest – The authors have no conflict of interest. BioMed Res Int. 2013;2013:1–9. doi:10.1155/2013/835850.
26. Zaal IJ, Devlin JW, Peelen LM, et al. A systematic review of risk factors
References for delirium in the ICU*. Crit Care Med. 2015;43(1):40–7. doi:10.1097/
1. Girard TD, Ely EW. Delirium in the critically ill patient. In: Young GB, ccm.0000000000000625.
Wijdicks EFM, editors. Handbook of Clinical Neurology. 3rd ed. 27. Andrejaitiene J, Sirvinskas E. Early post-cardiac surgery delirium risk
Elsevier; 2008. p. 39–56. doi:10.1016/s0072-9752(07)01703-4 factors. Perfusion. 2011;27(2):105–12. doi:10.1177/0267659111425621.
2. Devlin JW, Fong JJ, Fraser GL, et al. Delirium assessment in the 28. Brummel NE, Vasilevskis EE, Han JH, et al. Implementing delirium
critically ill. Intensive Care Med. 2007;33(6):929–40. doi:10.1007/ screening in the ICU. Crit Care Med 2013;41(9):2196–208. doi:10.1097/
s00134-007-0603-5 ccm.0b013e31829a6f1e.
3. Vasilevskis EE, Han JH, Hughes CG, et al. Epidemiology and risk 29. van den Boogaard M, Schoonhoven L, van der Hoeven JG, et al.
factors for delirium across hospital settings. Best Pract Res Clin Anaes. Incidence and short-term consequences of delirium in critically ill
2012;26(3):277–87. doi:10.1016/j.bpa.2012.07.003. patients: a prospective observational cohort study. Int J Nurs Stud.
4. American Psychiatric Association. Diagnostic and statistical manual 2012;49(7):775–83. doi:10.1016/j.ijnurstu.2011.11.016.
of mental disorders, fifth edition (dsm-5). Washington, DC: American 30. Mistarz R, Eliott S, Whitfield A, et al. Bedside nurse–patient
Psychiatric Publishing; 2013. interactions do not reliably detect delirium: An observational study.
5. Shim JJ, Leung JM. An update on delirium in the postoperative Aust Crit Care. 2011;24(2):126–32. doi:10.1016/j.aucc.2011.01.002.
setting: Prevention, diagnosis and management. Best Pract Res Clin 31. Spronk P, Riekerk B, Elias S, et al. The occurrence of delirium is
Anaes. 2012;26(3):327–43. doi:10.1016/j.bpa.2012.08.003. severely underestimated by intensivists and intensive care unit
6. van den Boogaard M, Peters SAE, van der Hoeven JG, et al. The impact nurses during daily ICU care. Crit Care 2007;11(Suppl 2):P420.
of delirium on the prediction of in-hospital mortality in intensive care doi:10.1186/cc5580.
patients. Crit Care. 2010;14(4):R146. doi:10.1186/cc9214. 32. Barr J, Fraser G, Puntillo K, et al. Clinical practice guidelines for the
7. Salluh JI, Soares M, Teles JM, et al. Delirium epidemiology in critical management of pain, agitation, and delirium in adult patients in the
care (DECCA): an international study. Crit Care. 2010;14(6):R210. intensive care unit. Crit Care Med. 2013;41:263–306. doi:10.1097/
doi:10.1186/cc9333. ccm.0b013e3182783b72.
8. Rudolph JL, Marcantonio ER. Postoperative delirium. Anesth Analg. 33. Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over
2011;112(5):1202–11. doi:10.1213/ane.0b013e3182147f6d. time in ICU patients. JAMA. 2003;289(22):2983–91. doi:10.1001/
9. Paddick SM, Kalaria RN, Mukaetova-Ladinska ER. The prevalence and jama.289.22.2983.
clinical manifestations of delirium in sub-Saharan Africa: A systematic 34. Grover S, Kate N. Assessment scales for delirium: a review. World J
review with inferences. J Neurol Sci. 2015;348:6–17. doi:10.1016/j. Psychiatry. 2012;2(4):58–70. doi:10.5498/wjp.v2.i4.58.
jns.2014.10.034. 35. Khan BA, Guzman O, Campbell NL, et al. Comparison and
10. 
Tema N, Janse van Rensburg A. Psychiatric consultations and agreement between the richmond agitation-sedation scale and
the management of associated comorbid medical conditions the riker sedation-agitation scale in evaluating patients' eligibility
in a regional referral hospital. S Afr J Psychiat. 2015;21(2):67–72. for delirium assessment in the ICU. Chest. 2012;142(1):48–54.
doi:10.7196/sajp.551. https://doi.org/10.1378/chest.11-2100
Assessment of delirium in the intensive care unit 63

36. Riker R, Fraser G, Simmons L, et al. Validating the sedation-agitation 51. Carvalho J, Almeida A, Gusmao-Flores D. Delirium rating scales
scale with the bispectral index and visual analog scale in adult ICU in critically ill patients: a systematic literature review. Revista
patients after cardiac surgery. Intensive Care Med. 2001;27(5):853–8. Brasileira de Terapia Intensiva 2013;25(2):148–54. doi:10.5935/0103-
doi:10.1007/s001340100912. 507x.20130026.
37. Van Rompaey B, Schuurmans MJ, Shortridge-Baggett LM, et al. A 52. Otter H, Martin J, Bäsell K, et al. Validity and reliability of the DDS
comparison of the CAM-ICU and the NEECHAM Confusion Scale in for severity of delirium in the ICU. Neurocrit Care. 2005;2(2):150–8.
intensive care delirium assessment: an observational study in non- doi:10.1385/ncc:2:2:150.
intubated patients. Crit Care. 2008;12(1):R16. doi:10.1186/cc6790. 53. van den Boogaard M, Kox M, Quinn KL, et al. Biomarkers associated
38. Luetz A, Heymann A, Radtke FM, et al. Different assessment tools with delirium in critically ill patients and their relation with long-term
for intensive care unit delirium: which score to use? Crit Care Med. subjective cognitive dysfunction; indications for different pathways
2010;38(2):409–18. doi:10.1097/ccm.0b013e3181cabb42. governing delirium in inflamed and noninflamed patients. Crit Care
39. Hart RP, Levenson JL, Sessler CN, et al. Validation of a cognitive test for 2011;15(6):R297. doi:10.1186/cc10598.
delirium in medical ICU patients. Psychosomatics. 1996;37(6):533–46. 54. Marcantonio ER, Rudolph JL, Culley D, et al. Review article: serum
doi:10.1016/s0033-3182(96)71517-7. biomarkers for delirium. J Gerontol Series A: Biol Sci Med Sci.
40. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically 2006;61(12):1281–86. doi:10.1093/gerona/61.12.1281.
ventilated patients. JAMA. 2001;286(21):2703–10. doi:10.1001/ 55. Cata JP, Abdelmalak B, Farag E. Neurological biomarkers in the
jama.286.21.2703. perioperative period. Br J Anaesthesia 2011;107(6):844–58.
41. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically doi:10.1093/bja/aer338.
ill patients: validation of the confusion assessment method for the 56. Chu C, Liang C, Lin Y, et al. Biomarkers of delirium: well evidenced
intensive care unit (CAM-ICU). Crit Care Med 2001;29(7):1370–9. or not? J Clin Gerontol Geriatr 2011;2(4):100–4. doi:10.1016/j.
doi:10.1097/00003246-200107000-00012. jcgg.2011.11.005.
42. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality 57. Ritter C, Tomasi C, Dal-Pizzol F, et al. Inflammation biomarkers
in mechanically ventilated patients in the intensive care unit. JAMA. and delirium in critically ill patients. Crit Care. 2014;18(3):R106.
2004;291(14):1753–62. doi:10.1001/jama.291.14.1753. doi:10.1186/cc13887.
43. Devlin JW, Brummel NE, Al-Qadheeb NS. Optimising the recognition 58. Khan B, Zawahiri M, Campbell N, et al. Biomarkers for delirium-a
of delirium in the intensive care unit. Best Pract Res Clin Anaesthesiol. review. J Am Geriatr Soc. 2011;59(2):S256–61. doi:10.1111/j.1532-
2012;26(3):385–93. doi:10.1016/j.bpa.2012.08.002. 5415.2011.03702.x.
44. Tomasi CD, Grandi C, Salluh J, et al. Comparison of CAM-ICU and 59. Kunihara T, Shiiya N, Bin L, et al. Arterio-jugular differences in serum
ICDSC for the detection of delirium in critically ill patients focusing S-100β proteins in patients receiving selective cerebral perfusion.
on relevant clinical outcomes. J Crit Care. 2012;27(2):212–7. Surg Today. 2005;36(1):6–11. doi:10.1007/s00595-005-3105-5.
doi:10.1016/j.jcrc.2011.05.015. 60. Snyder-Ramos SA, Gruhlke T, Bauer H, et al. Cerebral and extracerebral
45. Plaschke K, von Haken R, Scholz M, et al. Comparison of the confusion release of protein S100B in cardiac surgical patients. Anaesthesia.
assessment method for the intensive care unit (CAM-ICU) with the 2004;59(4):344–9. doi:10.1111/j.1365-2044.2004.03663.x.
Intensive Care Delirium Screening Checklist (ICDSC) for delirium in 61. Bloomfield SM, McKinney J, Smith L, et al. Reliability of S100B in
critical care patients gives high agreement rate(s). Intensive Care predicting severity of central nervous system injury. Neurocrit Care.
Med. 2008;34(3):431–6. doi:10.1007/s00134-007-0920-8. 2007;6(2):121–38. doi:10.1007/s12028-007-0008-x.
46. van Eijk MM, van Marum RJ, Klijn IA, et al. Comparison of delirium 62. Yardan T, Erenler AK, Baydin A, et al. Usefulness of s100b protein in
assessment tools in a mixed intensive care unit*. Crit Care Med. neurological disorders. J Pak Med Assoc. 2011;61(3):276–81.
2009;37(6):1881–5. doi:10.1097/ccm.0b013e3181a00118. 63. Herrmann M, Ebert AD, Galazky I, et al. Neurobehavioral outcome
47. Bergeron N, Dubois MJ, Dumont M, et al. Intensive care delirium prediction after cardiac surgery: role of neurobiochemical markers of
screening checklist: evaluation of a new screening tool. Intensive damage to neuronal and Glial brain tissue. Stroke. 2000;31:645–50.
Care Med. 2001;27(5):859–64. doi:10.1007/s001340100909. doi:10.1161/01.str.31.3.645.
48. Ouimet S, Riker R, Bergeon N, et al. Subsyndromal delirium in 64. Gerriets T, Schwarz N, Bachmann G, et al. Evaluation of methods to
the ICU: evidence for a  disease spectrum. Intensive Care Med. predict early long-term neurobehavioral outcome after coronary
2007;33(6):1007–13. doi:10.1007/s00134-007-0618-y. artery bypass grafting. Am J Cardiol. 2010;105(8):1095–101.
49. Maarten M, van Eijk MM, van den Boogaard M, et al. Routine use doi:10.1016/j.amjcard.2009.12.009.
of the confusion assessment method for the intensive care unit: 65. Bokesch PM, Izykenova GA, Justice JB, et al. NMDA receptor
a multicenter study. Am J Respir Crit Care Med. 2011;184(3):340–4. antibodies predict adverse neurological outcome after cardiac
doi:10.1164/rccm.201101-0065oc. surgery in high-risk patients. Stroke. 2006;37:1432–6. doi:10.1161/01.
50. Immers HEM, Schuurmans MJ, van de Bijl JJ. Recognition of delirium str.0000221295.14547.c8.
in ICU patients: a diagnostic study of the NEECHAM confusion scale
in ICU patients. BMC Nurs. 2005;4:41. doi:10.1186/1472-6955-4-7. Received: 17-10-2016 Accepted: 17-05-2017