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Intensive and Critical Care Nursing (2004) 20, 206213

ORIGINAL ARTICLE

Screening for delirium in an adult intensive

care unit

Brigit Roberts*

Department of Intensive Care, 4th Floor G Block, Sir Charles Gairdner Hospital, Hospital Avenue,

Nedlands, WA 6009, Australia

Accepted 6 April 2004

KEYWORDS

Delirium;

Intensive care;

Screening;

Implication

Summary Delirium is an acute, reversible disorder of attention and cognition andmay be viewed as cerebral dysfunction similar to the failure of any other organ.The development of delirium is associated with increased morbidity and mortality,extended length-of-stay in the intensive care unit and longer time spent sedated andventilated. Nearly every clinical, pharmacological and environmental factor presentand necessary in the ICU setting has the potential to cause delirium. Since all of thesefactors cannot be removed, it is paramount to increase the awareness amongst healthcare professionals so as to minimise under-recognition and encourage future researchinto factors that may improve the long-term outcome for ICU patients.

There is a need for user-friendly, validated assessment tools for the intubated and

ventilated ICU patient, which can be applied at the time of ICU admission withoutthe need for lengthy psychiatric assessment. Nursing professionals are at the forefrontof those who are able to provide holistic care through meaningful conversation andempathetic touch.

A 6-month Quality Improvement (QI) project screening patients for signs of deliriumprovided a foundation for discussion. All patients admitted to ICU for more than 72 h,with a hospital length-of-stay less than 96 h prior to ICU admission were screened.Patients admitted following neurological insults or with pre-existing altered mentalstate were excluded. The QI project showed the incidence of delirium to be 40% ofthe total sample (n = 73) in a mixed medical/surgical and elective/emergency patientpopulation. 2004 Elsevier Ltd. All rights reserved.

Background

Until recently only little emphasis has been placedon the close monitoring of brain function in in-tensive care unit (ICU) patients. Conversely, mostorgans such as the pulmonary and cardiovascular

*Tel.: +61-8-9346-1010; fax: +61-8-9346-4431.E-mail address: brigit.roberts@health.wa.gov.au

(B. Roberts).

systems are continuously and rigorously observedin the ICU, in order to detect any early changes anddeterioration in the patients condition. The inci-dence and outcome of ICU delirium is now gainingincreasing interest in the literature.

Delirium is an acute, fluctuating, reversible dis-order of attention and cognition or an alteredlevel of consciousness (Roberts, 2001). The devel-opment of delirium in the ICU is associated withan underlying medical condition, such as sepsis,hypoxaemia or metabolic disturbances (Cardy and

0964-3397/$ see front matter 2004 Elsevier Ltd. All rights reserved.doi:10.1016/j.iccn.2004.04.003

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Screening for delirium in an adult intensivecare unit 207

Matta, 1997; Haskell et al., 1997). The causes ofdelirium are multi-factorial and often divided intothree categories (Ely et al., 2001b). Firstly, ad-vanced age, underlying primary cerebral illnesses(e.g. dementia or substance abuse) and chronicillnesses (e.g. cardiovascular, metabolic, respira-

tory and renal) increase the risk for developingdelirium (Dubois et al., 2001). Secondly, pharma-cological agents appear to be a critical element inthe aetiology of delirium and although almost anydrug can precipitate the development of delirium,certain classes of drugs such as opioids, anticholin-ergic agents and benzodiazepines are more com-monly implicated (Adis International Limited, 1997;Easton and MacKenzie, 1988). Thirdly, environ-mental factors may also play a part in the dis-ease process and add to the cerebral dysfunction.Sleep disruption, noise, pain, sensory overload andineffective communication are examples of the

special environment that may predispose patientsto the development of delirium in ICU (Justic,2000).

There are three manifestations of delirium, thehyperactive or agitated patients, who may expe-rience visual hallucinations and whose behaviourmay be agitated or even bizarre and out of char-acter. This may be frightening and disturbing forboth patients and their relatives (Roberts, 2001).Patients may think that they are going crazyand worry that they will be labelled psychi-atrically unstable, whilst relatives may be be-

wildered at seeing their loved ones acting in abizarre and at times obnoxious manner (Blacher,1997). In contrast, patients may display hypoac-tivity or lethargy, which often will go unnoticedbecause the patients appear not to pose difficul-ties in their clinical management (Laitinen, 1996).The third manifestation is a combination of hyper-and hypoactivity. In all three variants, patientssymptoms will usually fluctuate between lucid anddisturbed periods over the course of a day. Whetherpatients display delirious manifestations or notthey may nevertheless experience vivid dreams orsuffer from delusions and hallucinations that areoften persecutory in nature (Rundshagen et al.,2002).

The reported incidences of ICU delirium varygreatly from 16% up to 85% of patients observed tobe affected (Bergeron et al., 2001; Jacobson andSchreibman, 1997; Truman and Ely, 2003). Tradi-tional psychiatric evaluation of the sedated andventilated ICU patient is difficult (Bergeron et al.,2002). A number of assessment tools have beenevaluated in the non-ICU population. These toolsrely on verbal interaction and/or lengthy profes-sional consultation with the patients and are there-

fore not suitable for the ICU population (Breibartet al., 1997; Trzepacz et al., 1988). Some tests onlyprovide a snapshot of the patients real con-dition because of fluctuating symptoms, whereastesting is performed at a specific time (Robertsson,1999). Hence, the results depend on the period of

assessment. Different screening tools emphasisevarious aspect of delirium (Skrobik, 2003). The In-tensive Care Delirium Screening Checklist (ICDSC)focuses on thought content whereas the ConfusionAssessment Method-ICU (CAM-ICU) concentrateson arousal and thus may be influenced by factorssuch as variation in administration of sedation,which may cause fluctuation in levels of conscious-ness. Bergeron et al. (2001, 2002) were using theICDSC and reported the incidence of delirium be-tween 16 and 19% in a mixed medical/surgical ICUpopulation with mean APACHE II scores of 14 and15. In contrast, when Ely et al. (2001a,c) used

the CAM-ICU they reported the incidence of delir-ium at 87 and 83%, respectively, in a medical ICUpatient population with a mean APACHE II scoreof 19.

These figures are likely to rise even further withthe current trend for older patients with more com-plex co-morbidity to be admitted to ICUs and of-fered increasingly sophisticated treatment modal-ities (McNicoll et al., 2003; St Pierre, 1996). Thelength of ICU stay may also influence delirium inci-dence with patients staying less than 24 h reportingfewer hallucination events (8%) than patients re-

maining in excess of 24 h (38%) (Rundshagen et al.,2002). Psychiatrists are rarely involved in ICU care,yet research has shown that ICU patients who wouldbe diagnosed as delirious by a psychiatrist remainundiagnosed by the ICU nursing and medical staffin up to 70% of cases (Eden and Foreman, 1996;Truman and Ely, 2003).

Although previously thought to be benign, it isnow recognised that the development of delirium inICU is associated with a 1560% increase in morbid-ity and mortality (McCusker et al., 2002; McGuireet al., 2000). ICU and hospital length-of-stay (LOS)are prolonged and there is a higher requirementfor nursing care together with a greater likelihoodof the delirious patient being institutionalised afterdischarge (Geary, 1994; Inaba-Roland and Maricle,1992). The agitated patient is at risk of removinglife-preserving devices such as endotracheal tubesand indwelling catheters, whereas the lethargic pa-tient is prone to the development of decubitus ul-cers and nosocomial pneumonia (Ely et al., 2001b).While most ICU health care professionals can iden-tify when a patient becomes agitated, confused andirrational, diagnosing the lethargic patient as deliri-ous is difficult. Failure by health professionals to

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recognise the developing signs of delirium may havean adverse effect on long-term outcomes and there-fore a comprehensive nursing assessment should bestarted at admission (Justic, 2000).

Definitions

Hallucination

Trying to catch a non-existing object; seeing anon-existing object (Bergeron et al., 2001).

Delusion

Refusing medication or treatment due to fear ofbeing harmed; believing he/she is being mistreatedby secret enemies.

Quality Improvement project

To increase the awareness of delirium in the ICU set-ting amongst health care professionals the authorconducted a prospective Quality Improvement (QI)project. The objective of a QI project is to establishthe performance of quality care in an institution byidentification of issues or problems; collection andassessment of information about important aspectsof care and service provided; implementation ofactions to improve standards of care; and mea-surement of outcomes (Western Australian Con-solidated Legislation, Western Australian HealthServices Act, 1994).

The QI project was chosen as a pilot study witha view to establish the incidence and outcome ofdelirium in an 18-bed tertiary Australian ICU. Thisunit admits in excess of 1300 general medical andsurgical adult patients per year.

Framework of quality improvementassessment

The researcher screened all ICU patients admittedfor more than 72 h over a 6-month period. The72-h time frame was chosen to exclude routinepost-operative patients (Granberg et al., 1998).Individuals who had a hospital LOS greater than96 h prior to ICU admission were excluded in or-der to ensure that the observed behaviour wasa result of the ICU admission and not causedby prolonged prior hospital admission. Likewise,those admitted following neurological insultsor pre-existing altered mental state were alsoexcluded.

Patient delirium assessment

At the time of this project (January 2001July 2001)no ICU-specific delirium assessment tools existed,and as previously stated, the existing generic delir-ium tools were unable to be applied to ICU patients.

Therefore, based on subjective measurements theresearcher performed daily direct patient observa-tions and review of the nursing and medical notes,using a framework grounded in the literature. Theresearcher noted signs of agitation (e.g. pluck-ing in the air or catching non-existing objects),patients ability to concentrate and follow com-mands, and general behaviour such as restlessnessand sleep/wake disturbances. Similarly assessmentof patients with psychomotor slowing/retardation(e.g. staring into the room and lack of response tostimuli in the absence of sedatives) were recorded.Patients displaying either agitation or psychomo-

tor slowing were classified as delirious and patientswith none of the above symptoms were ranked asnon-delirious.

Other data

Demographic data including gender, age, admis-sion category (emergency/elective), and the AcutePhysiology and Chronic Health Evaluation II (APACHEII) score (Knaus et al., 1985) were collected on ad-mission. ICU and hospital LOS and outcome werealso recorded.

Patient characteristics

The total number of ICU admissions for the 6-monthperiod was 632 patients. Fig. 1 describes the track-ing of patients included in the sample, the fre-quency of delirium and reasons for exclusion in thefinal sample. The major reason for exclusion wasshort-term (

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Screening for delirium in an adult intensivecare unit 209

Patient showing

signs of Delirium29(40%)

Patients without

signs of delirium44(60%)

ICU LOS 92hours prior to ICU

admission30

Patients excludeddue to brain insult

44

Number of patients insurvey

73

Patients excluded Patients included

Total number of all ICU admissions632

Figure 1 Track of patients included in QI project.

Table 1 Demographic data.

Characteristics Delirious (n = 29) (40%) Non-delirious (n = 44) (60%)

Age, mean (range) 58 (1783) 62 (1684)Gender, n = male/female 22/7 26/18ICU death, n (%) 0 (0) 8 (18)Hospital death, n (%) 2 (7) 6 (14)

APACHE II, mean (range) 16 (234) 16 (238)Medical/emergency surgical/elective

surgical admissions (n)14/5/10 24/1/19

ICU LOS days, mean (range) 9 (236) 8 (233)Hospital LOS days, mean (range) 25 (456) 23 (380)

groups and notably fewer patients displaying signsof delirium died in ICU.

Discussion

The reports in the professional literature of ahigh incidence of delirium in ICU, the frequencyof under-recognition and the associated poor out-come demand that much more effort go into gain-ing further knowledge and understanding of thephenomenon. We must be able to provide the bestcare for patients both physically, psychologicallyand emotionally, show empathy to the relativesand offer support and treatment options for ourcolleagues.

The agitated and restless patient can be diffi-cult to care for and many healthcare professionals

approach the patient with trepidation. The pa-tient may be termed cantankerous and healthprofessionals may become angry and frustratedwith the patient. On the other hand, the patient,Russell (1999) suggests, who lies still in bed anddoes not attempt any eye contact or movement,is easily overlooked whilst more acute treatmentpre-occupies carers. Health professionals may beunable to identify delirium in such patients dueto a lack of understanding of the complexity ofdelirium. Tanios et al. (2004) comment that the in-adequacy of delirium monitoring in ICU may reflectthe absence of proven preventative or therapymodalities except in severe cases. They concludethat there is a strong case for delirium monitoringonce effective interventions are in place.

It must be ascertained as part of a holistic assess-ment whether the patient is suffering from delir-

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210 B. Roberts

ium with hallucinatory and delusional thoughts orwhether there are other reasons for the patientsbehaviour such as pain; frustration due to an inabil-ity to communicate effectively; fear of unfamiliarsurroundings and procedures; or lack of externalstimuli.

Incidence

The great variation in the reported rates of delir-ium incidence in the literature may relate to dif-fering patient case-mix and acuity between ICUs.Emergency ICU admissions usually require multi-ple pharmacological agents and invasive therapysuch as renal replacement therapy and prolongedmechanical ventilation. In contrast, units whichpredominantly admit elective surgical patients mayhave a lower rate of delirium. This QI project foundthe incidence of delirium in the sample to be 40%

(n = 29), two thirds of whom were emergency ad-missions with an average APACHE II score of 16. Thisfalls within previously reported levels (1085%) andcharacteristics reported in the literature. Bergeronet al. (2001) described a 16% incidence of deliriumin a group of patients (n = 93) with a mean APACHEII score 14 and of whom 53% were medical admis-sions. Aldemir et al. (2001) showed delirium to oc-cur in 11% in a sample of solely surgical admissions,in particular male emergency admission, but he didnot define the sample acuity. Dubois et al. (2001)found delirium in 19% of patients (n = 198), 16% of

whom were medical, and 23% surgical admissions,with an average APACHE II score of 15. In contrast,two studies by Ely et al. (2001a,c) (n = 96 and38, respectively) found the incidence of deliriumto be in the mid-eighties percentile. Both studieswere conducted in only medical admissions and themean APACHE II score was 23 in the first study and17 in the second. Granberg et al. (2002) found in astudy of 19 patients with a mean TISS score of 34that 74% (n = 19) developed delirium of whom 43%(n = 6) suffered severe delirium. The findings fromthese studies have been summarised in Table 2. Itseems that patients with higher acuity and suffer-

Table 2 Summary of publications on incidence of delirium in ICU.

Authors Incidence of delirium (%) Number of participants (n) APACHE II

The researcher 40 73 16Bergeron et al. (2001) 16 93 14Aldemir et al. (2001) 11 818 Not recordedDubois et al. (2001) 19 198 15Granberg et al. (2002) 74 19 TISS 34Ely et al. (2001a) 83 96 23Ely et al. (2001c) 87 38 17

ing a medical condition appear to have a higherrisk of developing delirium than less sick surgicalpatients. Medical ICU patients are known to beamongst the sickest in the hospital system, withcomplex co-morbidities and poly-pharmacologicaltreatments (Ely et al., 2001b).

Under-recognition

Delirium in the ICU remains an under-recognisedsyndrome and early recognition of signs and symp-toms could reduce the associated morbidity andmortality (Justic, 2000; Rabinowitz, 2002). In astudy of non-ICU patients (n = 797), Inouye et al.(2001) reported that nurses failed to recognisedelirium in 69% (n = 91) of the cases (n = 131)noted by the researcher. They identified four riskfactors for under-recognition of delirium as (1) pa-tients displaying the hypoactive variant of delirium,

(2) advanced age, (3) vision impairment and (4)dementia. Eden and Foreman (1996) echoed thesefindings in a case study where only 50% of criticalcare nurses interviewed were able to recognisethe changes in mental state associated with thedevelopment of delirium. Furthermore the nursesreported frustration and difficulties with medicalstaff being reluctant to act on the reported symp-toms. Armstrong et al. (1997) cited 69% of delir-ium misdiagnosis in the ICU setting versus 41% ingeneral wards. They concluded that agitated be-haviour in ICU was so common that health profes-

sionals perceived it to be normal ICU behaviour.In a recent study by Ely et al. (2004) most health-care professionals considered ICU delirium a veryserious problem, yet 78% of study participants ac-knowledged that delirium was an under-diagnosedsyndrome.

Information about the pre-morbid mental stateof the ICU patient is often scant and health pro-fessionals must frequently rely on relatives forassessment of precipitating factors for the devel-opment of delirium (Roberts, 2001). Formal assess-ment skills and lectures about delirium should notonly be part of the post-graduate ICU courses but

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Screening for delirium in an adult intensivecare unit 211

taught at under-graduate level to both nursing andmedical students.

Diagnosis of delirium

There are many different terms for delirium. Some

professionals refer to delirium as Acute Confu-sional State (Lipowski, 1987), ICU syndrome(Granberg et al., 1998) and some use the termICU Psychosis (Easton and MacKenzie, 1988;Justic, 2000). There is a need for standardisedterminology and most researchers today use theterm delirium as defined in the Diagnostic andStatistical Manual of Mental Disorders, Fourth Edi-

tion (American Psychiatric Association, 1994) toavoid confusion, minimise under-recognition andenhance further research.

ICU-specific delirium assessment tools are neces-sary. Conventional tools rely on verbal interaction

between the patient and the assessor, and in addi-tion, the assessment is often very time consuming.Most patients in ICU are intubated and ventilatedand their movement often restricted by cathetersand tubes. The physical care of patients seldom al-lows time for lengthy psychological assessment inthe daily routine, nor are ICU health professionalsgenerally given formal mental assessment training.Ely et al. (2001c) comment that our knowledge re-garding the clinical significance of delirium in theICU is limited by the fact that few investigationshave included mechanically ventilated patients in

their delirium studies. Ely et al. (2001b) continuethat oxygenation, blood pressure and a myriad ofother physiological factors are aggressively moni-tored, yet the scales to monitor the developmentof delirium remain crude and poorly validated.

Two objective tools have been developed to de-tect delirium specifically in the ventilated and se-dated patient, the Confusion Assessment Methodfor the Intensive Care Unit (CAM-ICU) (Ely et al.,2001a,c) and the Intensive Care Delirium Screen-ing Checklist (Bergeron et al., 2001). The CAM-ICUis a modification of the Confusion AssessmentMethod (Inouye et al., 1990) adapted to the ICUsetting so that it does not require patient verbali-sation. Both tools are based on the DSM IV (1994)criteria for delirium, and can quickly and easily beapplied by ICU health professionals without for-mal psychiatric training to screen ICU patients,even when patient communication is compromised.In two studies with 38 and 116 participants theCAM-ICU was shown to be reliable and valid fordiagnosing delirium in ICU patients (Ely et al.,2001a,c). The Intensive Care Delirium ScreeningChecklist ICDSC is a checklist of eight items andlikewise was found to be easily applied to the ICU

setting and also validated in two studies (n = 93)and (n = 216) (Bergeron et al., 2001; Dubois et al.,2001).

Ely et al. (2004) reported on a survey of 912 par-ticipants (ICU medical staff (n = 753) and ICU alliedhealth professionals (n = 159)) only 40% (n = 365)

routinely screened for delirium. Only 16% (n = 58 of365) reported use of a formal assessment tool, andof these only 7% (n = 4 of 58) used an ICU-specificscreening tool. It must nevertheless be noted thatthe survey period fell at the same time as the abovementioned ICU-specific screening tools were firstpublished. This would have been a strong factor inthe infrequent use of such a tool.

The QI project was limited in that no formal as-sessment tools were available for use as neither ofthe subsequent studies validating ICU-specific toolshad been published at the time of conducting thedelirium assessment project. Although formal tools

were not used, validity and reliability were pro-moted through the use of a single rater for all pa-tients, who was an experienced ICU nurse and hadthoroughly reviewed the literature pertaining to ICUdelirium and delirium diagnostic criteria, includingexisting generic screening tools. The project is nowbeing repeated as a study in a multi-centre ICU pop-ulation using an ICU validated tool.

Nursing implications

The frequent occurrence of delirium in ICU and

increasing knowledge of its consequences shouldmake the use of a validated screening tool com-pulsory in daily patient assessment. This may helpearly detection of ICU delirium and as a resultfacilitate appropriate intervention to reduce thisphenomenon.

Nursing staff are often the first to recognise sub-tle changes in the patients mental state in theirdaily round-the-clock care of the patients (Roberts,2001). They need to understand and recognisethe symptoms, assess patients, and alleviate thestress that patients may suffer from this experi-ence in order to minimise adverse events. This mayavoid a prolonged ICU or hospital stay, possibledetrimental psychological sequelae or even a fataloutcome. Validated ICU-specific delirium screeningtools should become mandatory in the routine careand ongoing assessment of the ICU patient and ICUhealth professionals need to monitor for patientswho require ongoing psychological counselling.Further research and exploration into optimal ICUscreening tools are warranted (Ely et al., 2004) aswell as promoting their uses in the clinical setting.

The causes of delirium are multi-factorial andmuch emphasis has been placed on the ICU environ-

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ment. Whilst it may not elude the development ofdelirium it is important as far as possible to maintaina daynight cycle, re-orientate the patient to timeand place, allow the patient time to rest and reduceexcessive noise and light especially at night time(Geary, 1994). More important may be consideration

of empathetic communication and touch (Russell,1999), maintenance of patients dignity both per-sonally and spiritually (Halm and Alpen, 1993;Todres et al., 2000), and adequate pain control(Szokol and Vender, 2001). Patients interviews af-ter ICU discharge in Russells (1999) study revealeda high degree of anxiety and psychological problemseven after 6 months. This was particularly relatedto poor communication between staff and patients.The professional literature is now focusing on thelong-term sequelae of the ICU admission, withdelirium sometimes linked to post-traumatic stressdisorder (Jones et al., 2001; Rotondi et al., 2002;

Rundshagen et al., 2002; Schelling et al., 1998).Through teaching and staff orientation we mustchange the attitude of ICU health professionalsaway from a preoccupation with the physical as-pects of the ICU patient, however, important thesemay be (Tanios et al., 2004). We must learn to thinkof the patient in a holistic manner and to providedignity during daily care such as bed baths andheed the need for privacy when possible. We mustoffer communication of relevance to the patientother than explanation of procedures but rathertalk about their loved ones and hold the patients

hand with empathy and care not merely to avoidthem pulling out tubes.

The uncharacteristic behaviour these patientsdisplay may also have a profound impact on therelatives, when their beloved one acts aggressivelyor anxiously, is abusive, or lies lethargically in thebed (Blacher, 1997; Geary, 1994; Roberts, 2001).Nurses will often be the first to broach and dis-cuss this phenomenon with the relatives and it isimportant that the relatives understand that thecondition is reversible and that we, as health pro-fessionals, understand that this is not the patientsnormal behaviour.

Nursing care should focus on managing the stres-sors that can be alleviated such as sleep deprivationand level of noise whilst simultaneously assistingthe patients to cope with the factors that cannotbe eliminated such as anxiety and immobilisation.

Conclusion

The incidence and circumstances of the develop-ment of delirium are becoming increasingly impor-tant in the management of ICU patients, and are

gaining more awareness in both the nursing andmedical communities. At the same time all stepsmust be taken to minimise the associated rise inmorbidity and mortality. ICU patients are gener-ally difficult to assess for delirium due to the ad-ministration of psychoactive drugs and an inability

to speak due to endotracheal tubes and other re-straining treatment modalities. The high incidenceof delirium in ICU warrants further exploration ofthe development of user-friendly and validatedassessment tools.

This QI project found the incidence of deliriumwithin the limits of that reported in the literaturedespite the small sample size and the absence ofa formally validated ICU delirium assessment tool.This project provides a foundation for the furtherevaluation of patients subjective experiences oftheir ICU stay in order for ICU health professionalsto provide holistic, quality care for patients.

Acknowledgements

The author wishes to thank Claire Rickard, MonashUniversity School of Rural Health and Latrobe Re-gional Hospital, Traralgon, Australia for her revisionof and input into this article.

References

Adis International Limited. Drug-induced delirium: diagno-

sis, management, and prevention. Drugs Ther Perspect1997;10(3):59.Aldemir M, Ozen S, Kara IH, Sir A, Bac B. Predisposing factors

for delirium in the surgical intensive care unit. Crit Care2001;5:26570.

American Psychiatric Association. Diagnostic and statisticalmanual of mental disorders: fourth edition (DSM IV). Wash-ington DC: American Psychiatric Association; 1994.

Armstrong SC, Cozza KL, Watanabe KS. The misdiagnosis ofdelirium. Psychosomatics 1997;38:4339.

Bergeron N, Dubois M-J, Dumont M, Dial S, Skrobik Y. Inten-sive care delirium screening checklist: evaluation of a newscreening tool. Intensive Care Med 2001;27:85964.

Bergeron N, Skrobik Y, Dubois MJ. Delirium in critically ill pa-tients. Crit Care 2002;6(3):1812.

Blacher RS. The psychological and psychiatric consequences ofthe ICU stay. Eur J Anaesthesiol 1997;14(Suppl 15):457.

Breibart W, Rosenfeld B, Roth A, Smith MJ, Cohen K, Passik S.The Memorial Delirium Assessment Scale. J Pain SymptomsManage 1997;13:12837.

Cardy J, Matta B. Brain failure. Curr Opin Crit Care 1997;3:2738.

Dubois M, Bergeron N, Dumont M, Dial S, Skrobik Y. Deliriumin an intensive care unit: a study of risk factors. IntensiveCare Med 2001;27:1297304.

Easton C, MacKenzie F. Delirium in the ICU. Heart Lung1988;17:22937.

Eden BM, Foreman MD. Problems associated with underrecog-nition of delirium in critical care: a case study. Heart Lung1996;25(5):388400.

7/29/2019 557 Roberts

8/8

Screening for delirium in an adult intensivecare unit 213

Ely EW, Inouye SK, Bernard GR, Francis J, May L, Truman B,et al. Delirium in mechanically ventilated patients. JAMA2001a;286(21):270310.

Ely EW, Siegel MD, Inouye SK. Delirium in the intensivecare unit: an under-recognized syndrome of organ dys-function. Semin Respir Crit Care Med 2001b;22(2):11526.

Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, et

al. Evaluation of delirium in critically ill patients: validationof the Confusion Assessment Method for the Intensive CareUnit (CAM-ICU). Crit Care Med 2001c;29(7):13709.

Ely EW, Stephens RK, Jackson JC, Thomason JWW, Truman B,Gordon S, et al. Current opinions regarding the importance,diagnosis, and management of delirium in the intensive careunit: a survey of 912 healthcare professionals. Crit Care Med2004;32(1):10612.

Geary SM. Intensive care unit psychosis revisited: Understandingand managing delirium in the critically care setting. CritCare Nurse Q 1994;17(1):5163.

Granberg A, Bergbom Engberg I, Lundberg D. Patients expe-rience of being critically ill or severely injured and caredfor in an intensive care unit in relation to the ICU syn-drome. Part I. Intensive Crit Care Nursing 1998;14:294307.

Granberg AIR, Malmros CW, Bergbom IL, Lundberg DBA. Inten-sive care unit syndrome/delirium is associated with anemia,drug therapy and duration of ventilatory treatment. ActaAnaesthesiol Scand 2002;46:72631.

Halm MA, Alpen MA. The impact of technology on patients andfamilies. Nurs Clin N Am 1993;28(2):44357.

Haskell RM, Frankel HL, Rotondi MF. Agitation. AACN Clin Issues1997;8(3):33550.

Inaba-Roland KE, Maricle RA. Assessing delirium in the acutecare setting. Heart Lung 1992;21(1):4855.

Inouye SK, Foreman MD, Mion LC, Katz KH, Cooney Jr LM.Nurses recognition of delirium and its symptoms: com-parison of nurse and researcher ratings. Arch Intern Med2001;161(20):246773.

Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, HorwitzRI. Clarifying confusion: the Confusion Assessment Method.A new method for detection of delirium. Ann Intern Med1990;113:9418.

Jacobson S, Schreibman B. Behavioral and pharmacologic treat-ment of delirium. Am Fam Physician 1997;56(8):200512.

Jones C, Griffith RD, Humphries G, Skirrow PM. Memory, delu-sions, and the development of acute posttraumatic stressdisorder-related symptoms after intensive care. Crit CareMed 2001;29(3):57380.

Justic M. Does ICU psychosis really exist? Crit Care Nurse2000;20(3):2837.

Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II:

a severity of disease classification system. Crit Care Med1985;13:81829.

Laitinen H. Patients experience of confusion in the intensivecare unit following cardiac surgery, Intensive. Intensive CritCare Nurs 1996;12(2):7983.

Lipowski ZJ. Delirium (acute confusional states). JAMA1987;258:178992.

McCusker J, Cole M, Abrahamowicz M, Primeau F, BelzileE. Delirium predicts 12-month mortality. Arch Intern Med2002;162(4):45763.

McGuire BE, Basten CJ, Ryan CJ, Gallagher J. Intensive careunit syndrome. A dangerous misnomer. Arch Intern Med2000;160:9069.

McNicoll L, Pisani MA, Zhang Y, Ely EW, Siegel MD, Inouye SK.Delirium in the intensive care unit: occurrence and clinicalcourse in older patients. J Am Geriatr Soc 2003;51(5):5918.

Rabinowitz T. Delirium: an important (but often unrecognized)clinical syndrome. Curr Psychiatry Rep 2002;4(3):2028.

Roberts BL. Managing delirium in adult intensive care patients.Crit Care Nurse 2001;21(1):4855.

Robertsson B. Assessment scales in delirium. Dement GeriatrCogn Disord 1999;10:36879.

Rotondi AJ, Chelluri L, Sirio C, Mendelsohn A, Schulz R, Belle S,et al. Patients recollections of stressful experiences whilereceiving prolonged mechanical ventilation in an intensivecare unit. Crit Care Med 2002;30(4):74652.

Rundshagen I, Schnabel K, Wegner C, Schulte am Esch J.Incidence of recall, nightmares, and hallucinations dur-ing analgosedation in intensive care. Intensive Care Med2002;28:3843.

Russell S. An exploratory study of patients perceptions, mem-ories and experiences of an intensive care unit. J Adv Nurs1999;29(4):78391.

Schelling G, Stoll C, Haller M, Briegel J, Manert W, HummelT, et al. Health-raleated quality of life and posttraumaticstress disorder in survivors of the acute respiratory distresssyndrome. Crit Care Med 1998;26(4):6519.

Skrobik Y. An overview of delirium in the critical care setting,Geriatrics. Geriatr Aging 2003;6(10):305.

St Pierre J. Delirium in hospitatlized elderly patients: off track.Crit Care Clin N Am 1996;8(1):5360.

Szokol JW, Vender JS. Anxiety, delirium, and pain in the inten-sive care unit. Crit Care Clin 2001;17(4):82142.

Tanios MA, Epstein SK, Teres D. Are we ready to monitorfor delirium in the intensive care unit? Crit Care Med2004;32(1):2956.

Todres L, Fullbrook P, Albarran J. On the receiving end: ahermeneutic-phenomenological analysis of a patients strug-gle to cope while going through intensive care. Nurs CritCare 2000;5(6):27787.

Truman B, Ely EW. Monitoring delirium in critically ill patients.Crit Care Nurse 2003;23(2):2538.

Trzepacz PT, Baker RW, Greenhouse J. A symptom rating scalefor delirium. Psychiatr Res 1988;23:8997.

Western Australian Health Services (Quality Improvement) Act1994. Western Australian Consolidated Legislation.