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Original article
DOI: 10.1016/j.sedeng.2019.04.004
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Available online 21 September 2019
Delirium in patients of the Intensive Care Unit of a health institution in Monteria, Colombia
Delirium en pacientes de la Unidad de Cuidados Intensivos de una institución de salud en Montería, Colombia
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Jorge Luis Herrera Herreraa,
Corresponding author
jlherrera2201@gmail.com

Corresponding author.
, Edinson Oyola Lopezb,c, Yolima Judith Llorente Péreza
a Universidad del Sinú Elías Bechara Zainúm, Montería, Córdoba, Colombia
b Unidad Renal Davita, Montería, Córdoba, Colombia
c Universidad de Cartagena, Cartagena de Indias, Colombia
Received 21 March 2019. Accepted 05 April 2019
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Tables (3)
Table 1. General characteristics (data card and APACHE II).
Table 2. Rate of delirium and classification by type (CAM-ICU).
Table 3. Multivariate analysis between rate of delirium and patient characteristics.
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Abstract
Introduction

Delirium, in addition to causing suffering to patients, relatives and caregivers, is associated with increases in morbidity, mortality and hospital complications, which leads to high costs for the health system.

Objective

To determine the incidence of delirium and related factors in patients admitted to an intensive care unit of a health institution in the city of Monteria, Colombia.

Methods

A descriptive, longitudinal study with a quantitative approach that includes the correlation of variables of interest with the incidence of delirium. For the collection of information and subsequent analysis, the CAM-ICU scale –which allowed the identification of the presence of delirium– and the APACHE II severity scale were used. Likewise, a data card was prepared based on clinical and epidemiological variables of interest.

Results

The patients were mostly men (50.5%) with an average age of 60 years. The incidence of delirium was 22% with hyperactive presentation in 62% of cases. There was no relationship between the presence of delirium and the variables of age, sex and APACHE II, although correlation was observed with the use of mechanical ventilation and with the days of stay in the health centre.

Conclusions

Patients who developed delirium, the hyperactive form being the most common, were characterised either by having spent several days in the ICU or having undergone mechanical ventilation.

Keywords:
Delirium
Incidence
Critical care
Resumen
Introducción

El delirium, además de causar sufrimiento a pacientes, familiares y cuidadores, está asociado a incrementos en la morbilidad, mortalidad y complicaciones hospitalarias, lo que deriva en altos costos para el sistema de salud.

Objetivo

Determinar la incidencia de delirium y los factores relacionados en los pacientes ingresados en una unidad de cuidados intensivos de una institución de salud en la ciudad de Montería, Colombia.

Método

Estudio de tipo descriptivo, longitudinal con enfoque cuantitativo, que incluye la correlación de variables de interés con la incidencia de delirium. Para la recolección de información y posterior análisis, se utilizó la escala CAM-ICU –que permitió identificar la presencia de delirium– y la escala de severidad APACHE II. Así mismo, se elaboró una cédula de datos a partir de variables clínicas y epidemiológicas de interés.

Resultados

Los pacientes en su mayoría fueron hombres (50,5%) con edad promedio de 60 años. La incidencia de delirium fue de 22% con presentación hiperactiva en el 62% de los casos. No se documentó relación entre la presencia de delirium y las variables de edad, sexo y APACHE II, aunque sí se observó correlación con el uso de ventilación mecánica y con los días de estancia en el centro de salud.

Conclusiones

Los pacientes que presentaron delirium, siendo la forma hiperactiva la más común, se caracterizaron ya sea por haber estado varios días de estancia en la Unidad de Cuidados Intensivos o por haber estado sometidos a ventilación mecánica.

Palabras clave:
Delirium
Incidencia
Cuidados intensivos
Full Text
Introduction

Delirium is defined as a syndrome of complex and multifactorial aetiology which culminates in a similar pattern of signs and symptoms referring to the patient’s level of consciousness and impairment of cognitive functions. It is characterised by sudden onset, although its evolution is brief and fluctuating.1 Similarly, when the available literature was consulted, several authors agree that this is a neuro-conductive, under-diagnosed, scarcely treated syndrome, but one which is potentially reversible and preventable, confused on occasion with neuropsychiatric conditions such as temporary, spatial disorientation.2

Apart from causing suffering to patients, family members and caregivers, delirium is associated with several consequences, including an increase in morbidity, mortality, hospital complications and costs to the healthcare system, together with poorer functional and cognitive results, a lower quality of life, an increase in hospital stay and a higher need for specialized care.1 In order to mitigate these effects, its presence involves treatment challenges, which should start with the application of prevention and management protocols to guarantee comprehensive and multidimensional treatment in the hands of an interdisciplinary team.

Healthcare authorities worldwide are greatly concerned about this condition and in response to it have conducted international studies which indicate that between 10% and 30% of older people who attend emergency services present with delirium.3 However, what is more alarming is that only one out of every 6 cases is diagnosed.4 Moreover, it has been proven that in hospital environments, this condition is highly frequent in older adults, with variable prevalence and which largely depend on the type of service or unit, as is the case of surgical units where delirium presents in 15%–53% of patients. Equally, in general medical services or geriatric units, there is a delirium rate of between 29% and 64% in institutionalized elderly patients, 18%–35% of whom already presented with delirium in the emergency services. In the intensive care units (ICU) the rate is higher, with figures of up to 80% being reported, data which coincide with those of terminal patients, who develop delirium prior to death.5,6

Studies which have reviewed and analysed the previously cited figures6–8 have determined an increase in hospital stay when this condition is present, which indicates higher demands for ICU care, greater functional impairment and the need for rehabilitation and chronic care units. Similarly, the studies report a higher rate of readmission for the same reason, for care or consultation and higher associated healthcare costs. It has also been demonstrated that delirium is a risk factor which may evolve into dementia and impairment progression may increase for those already suffering from it.6–8

In this context, on a worldwide level investigations including that of Martínez9 in Spain report a rate of delirium in services such as resuscitation units of 18%, along with a statistically significant association between delirium, age and the Acute Physiology and Chronic Health Evaluation (APACHE II) score.10 The panorama in Latin America is similar, as shown by studies conducted in Brazil, which reveal a postoperative rate of delirium of 18.8%.11 The independent determining features of delirium which were identified during this study were age, emergency surgery and the administration of blood components during surgery such as frozen fresh plasma. The follow-up of these patients led to the identification of higher rates of mortality, posterior complications and longer stay in the ICU.9

Dealing with this problem in Colombia reveals figures in keeping with those reported worldwide and in Latin America, such as those found by Rojas and Valencia12 in a study conducted in critical care units in the city of Bogotá, where the rate of delirium in the sample studied was 11.76%, and average duration 2.8 days. Furthermore, in a research study carried out in the city of Pereira, after analysing clinical records, Sánchez et al.13 reported a 90.1% rate of delirium. Out of this figure only 29.5% of patients had been diagnosed as patients with delirium, which led them to conclude that delirium is under-reported by the healthcare team.12

Taking in to account all of the above, another diagnosis-related issue arises that is worth exploring. In the most recent Ibero-American survey on delirium in intensive care patients,14 conducted with intensive care specialists in countries such as Argentina, Mexico, Chile and Colombia, it was found that 56.55% of them always assessed the diagnosis of delirium, 88.3% of them agreed or totally agreed that delirium was an expected event in the ICU, 90.1% agreed that delirium was under diagnosed and 97% responded that it was a preventable problem which required intervention.

After describing the international and national situation of delirium in ICU patients and the factors which could impact the its development and following a review of the scientific literature, it was determined that the department of Cordoba in Colombia possessed no research studies on this theme. The following research questions thus arose: what is the rate of delirium and the factors related to patients staying in an ICU in a IV level institution in Monteria, Colombia?

The determination of the rate of this condition could aid decision-making towards improved patient quality of life, since suffering from delirium leads to long hospital stays, health impairment, requires comprehensive care and above all the application of good guidelines or protocols for its early identification, and opportune, appropriate management. The identification of how delirium evolves could serve as a tool for the different control bodies, not least because interventions impact on cost to the health system and on quality markers. Furthermore, the need for strict follow-up of an event which is highly frequent in hospitals, and especially in ICU becomes apparent.

There is justification in approaching this disorder from the discipline of nursing because, according to those consulted, delirium is under-diagnosed and therefore not properly treated, which results in it being omitted from nursing care. Also, the rates of incidence found in the literature are significantly varying and this type of investigation needs to be continued to cover the epidemiological behaviour of this condition. Equally, existing studies have been mostly conducted by medical staff, and there is little nursing bibliography to this effect.

The research itself highlights the need to treat patients who suffer from this disorder with an interdisciplinary team and in an appropriate way. Assessment is to be multi-dimensional and lead to an improvement in the patient’s quality of life through continuous monitoring programmes so that the signs and symptoms of the condition may be identified in their initial stages. Suffering from delirium is a complex condition and has an impact on the curing process, rehabilitation or death of the patient.

In this investigation the general aim sought was therefore to determine the rate of delirium and the factors relating to the patients in the ICU in Monteria, Colombia. The specific aims sought were to provide population characteristics according to several variables of interest (age, gender, the need for mechanical ventilation and length of hospital stay) using APACHE II, identifying the presence of delirium and its subtypes in the sample studied and describing the relationship between delirium and the variables of interest.

The study was conducted in a fourth level Institution providing health services in the city of Monteria (Córdoba). Updated statistics were used and a tool to measure the level of delirium in ICU patients. The method employed for the evaluation of confusion in the ICU (CAM-ICU) facilitates information collection on episodes of delirium and determines the relationship between the delirium found (CAM-ICU) and the rate of severity of the disease (APACHE II). This test is based on the premise that the percentage of a patient’s mortality may be measured by physiological parameters, classifying the patients at risk of death according to laboratory reports, age and status prior to their admission in the ICU.15

MethodsType of study

This study was descriptive and longitudinal with a quantitative approach. The correlation of variables of interest and the rate of delirium were included in its design. Assessment and follow-up of the presence of delirium in patients admitted to an ICU in 2017 was conducted using the CAM-ICU tool, validated within the Colombian context and in Latin American countries with good psychometric properties.16 The classification scale of prognostic severity of the disease was also used, APACHE II,15 which was used and assessed in the Colombian context with optimum predictive capacity.17,18 Data were analysed using Microsoft Office Excel, using descriptive statistics and the SPSS programme for correlations.

Unit of analysis

The unit of analysis confirmed the rate of delirium and the factors studied relating to this: age, gender, APACHE II score and days on mechanical ventilation.

Sample and sampling

The sample was calculated from the population of patients who were admitted to the unit in 2017, using an international purposive sample, which included patients over 18 who had met with ICU admission criteria. A sample of 596 patients was thus obtained. The ethical criteria determined by Resolution 8430 of 199319 and the declaration of Helsinki20 were respected.

Results

During the research period 714 patients were admitted to the unit, of whom 48 died or were referred on before 24h had passed. Seven were under 18 years of age and 63 were excluded due to their health status. In total 596 patients were analysed, from whom the information contained in Table 1 was obtained.

Table 1.

General characteristics (data card and APACHE II).

Variable  Result 
Average age  60 years 
Males  50.5% 
Females  49.5% 
APACHE II  14.3% 
Average stay in the unit in days  5.85 days 
Percentage of patients on mechanical ventilation  40.3% 

Regarding the socio-demographic and clinical variables of interest, most patients (50.5%) were male, compared with 49.5% females, with a general average age of 60. The average APACHE II was 14.3% and days of general stay in the unit were 5.85 days, with 40.3% of patients on mechanical ventilation.

As shown in Table 2, the rate of delirium in the unit selected for study during 2017 was 22%, with the hyperactive form being the most frequent in 62% of cases. To a lesser extent, hypoactive and mixed forms were presented in 35% and 3%, respectively.

Table 2.

Rate of delirium and classification by type (CAM-ICU).

Delirium    Hyperactive  Hypoactive  Mixed 
Present  22%  62%  35%  3% 
Absent  78%

Compared with the multivariate analysis (Table 3), statistical significance was analysed between patients who presented with any form of delirium compared with those who did not. With regard to age, the most frequent age average was 58 years and male (39.8%). Patients who presented with delirium had an average score on the APACHE II scale of 14.3. Patients who required mechanical ventilation presented with a higher rate of delirium, and equally with a higher average of length of stay.

Table 3.

Multivariate analysis between rate of delirium and patient characteristics.

Variable  DeliriumP value 
  Present  Absent   
Average age  58.2years  44.1 years  .22 
Male  39.8%  60.2%  .2 
Female  23.6%  76.4%  .25 
APACHE II  14.3  10.9  .21 
Average stay in the unit in days  25.3 days  5.2 days  <.001 
Percentage of patients on mechanical ventilation  26.30%  73.7%  <.01 

Regarding statistical significance, no relationship was found between the variables of age, sex, and APACHE II with the presence of delirium. However, a relationship between the appearance of delirium in patients and requirement for ventilation support or length of stay was apparent.

Discussion

Delirium is a complex neuropsychiatric syndrome with a high probability of presentation in patients in all hospital environments. In this respect, the literature reports more cases in older adults, people with previous cognitive impairment or receiving critical care. Clinical symptoms are characterised by a change in level of consciousness and attention, the symptoms of which are fluctuating and associated with other cognitive conditions and disorders of the sleep-wake cycle.21 Furthermore, this condition is considered a medical emergency although the altered mental state may be due to a different cause. When in doubt, it must always be assumed that the patient is suffering from delirium.4

It has therefore been demonstrated that prevalence ranges approximately between 1% and 2%, and is higher in those over 85, where this situation is present in up to 14% of hospitalized patients. Figures regarding this disorder were also reported as between 10% and 56% in old people in special situations, such as postoperative or hospital admissions in units of critical care.2 These figures coincide with the average age found in this study, which was 58 years of age in people who presented with delirium, considered as the older adult population.

The relationship between gender and delirium has been widely reported by authors who have focused on the approach to this phenomenon, finding little statistically significant relationship between these variables. In the study by Rojas and Valencia12 a higher proportion represented by 13.1% is shown in the male sex, with regards to the appearance of delirium. For this research, this syndrome was more common in men, in 39.8% of cases.

For its part, the rate of delirium in intensive care patients is high and would vary from 10% to 80%. This variation is justified, partly by the type of diagnostic tool.22 Ely et al.23 reported an 80% rate in their study; Ayllón et al.21 reported a rate of 41.3% in theirs and Rojas and Valencia12 a rate of 11.76% (not as high). In our study, despite the rate not being as high as that reported in the available literature, we did find a rate of 22%, mostly in the hyperactive form.

With regard to related factors, a statistically significant correspondence was found between delirium in patients with mechanical ventilation and the increase in length of stay. The latter variable was also related to the presentation of delirium, coinciding with that expressed by the authors consulted, who described the relationship between use of mechanical ventilation, length of stay and mortality.13

In contrast to that described, no relationship was found between the age or gender variables, which was in keeping with authors who expressed little or no significance between these variables and the rate of delirium. Regarding the APACHE II score, this variable is controversial in its association with delirium, since it is defined in some research studies as a predisposing factor but in others it is not considered to be correlational.8,13

Conclusions

The rate of delirium during 2017 in the ICU chosen for this study was 22%, with the hyperactive form of delirium being more common. The patients who presented with this syndrome had a longer stay in the unit, and there was a higher rate of delirium for those on mechanical ventilation. Although significant, the rate of delirium in this unit is not very high when we consider that reported in the studies reviewed.

Assessment of delirium is a challenge for nurses, not only because it is difficult to identify, but also because of the impact it has on caring for the person suffering from it. Specialised care is required to treat it. The literature consulted unfolded a range of evidence-based nursing activities to highlight the prevention of this syndrome.

Conflict of interests

The authors have no conflict of interests to declare.

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Please cite this article as Herrera Herrera JL, Oyola Lopez E, Llorente Pérez YJ. Delirium in patients of the Intensive Care Unit of a health institution in Monteria, Colombia. Rev Cient Soc Esp Enferm Neurol. 2019. https://doi.org/10.1016/j.sedene.2019.04.003

Copyright © 2019. Sociedad Española de Enfermería Neurológica
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