1
DELIRIUM SCREENING IN CRITICALLY ILL PATIENTS: A
Systematic Review and Meta-Analysis
ONLINE DATA SUPPLEMENT
Ary Serpa Neto, MD, MSc; Antônio P Nassar Júnior, MD; Sérgio O Cardoso, MD; José
A Manetta, MD; Victor GM Pereira, MD; Daniel C Espósito, MD; Maria CT
Damasceno, MD, PhD; and Arjen J Slooter, MD, PhD
2
MATERIALS AND METHODS
Search methods for identification of studies
Sensitivity search strategy using text words (tw) and Medical Subject Heading (mh):
1) Population:
(confusion [MeSH Terms] OR mental disorders [MeSH Terms] OR delirium [Text
Word] OR encephalopathy [Text Word] OR acute confusional state [Text Word])
2) Setting:
(intensive care [MeSH Terms] OR critical care [MeSH Terms] OR intensive care unit
[Text Word] OR ICU [Text Word] OR critically ill [Text Word])
3) Intervention:
(diagnosis [MeSH Terms])
COMBINED:
1 AND 2 AND 3
3
RESULTS
Quality of the studies analyzed
Studies
1
van Eijk, 2009
Y
Toro, 2010
Y
Tobar, 2010
Y
Lin, 2004
Y
Luetz, 2008
Y
Guenther, 2010
Y
Ely, 2001a
Y
Ely, 2001b
Y
van Eijk, 2011
Y
Heo, 2011
Y
Mitasova, 2011
Y
George, 2011
Y
Radtke 2009
Y
Bergeron, 2001
Y
Gusmão-Flores, 2011
Y
Y: Yes; N: No; U: Unclear
2
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
3
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
The QUADAS tool
4
5
6
7
U
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
U
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
U
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
U
Y
Y
Y
8
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
9
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
U
U
U
U
Y
U
Y
Y
Y
U
Y
Y
Y
Y
Y
11
U
U
U
U
Y
U
Y
Y
Y
U
Y
Y
Y
Y
Y
12
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
13
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
1. Was the spectrum of patients representative of the patients who will receive the test in
practice?
2. Were selection criteria clearly described?
3. Is the reference standard likely to correctly classify the target condition?
4. Is the time period between reference standard and index test short enough to be
reasonably sure that the target condition did not change between the two tests?
5. Did the whole sample or a random selection of the sample, receive verification using
a reference standard of diagnosis?
6. Did patients receive the same reference standard regardless of the index test result?
14
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
4
7. Was the reference standard independent of the index test (i.e. the index test did not
form part of the reference standard)?
8. Was the execution of the index test described in sufficient detail to permit replication
of the test?
9. Was the execution of the reference standard described in sufficient detail to permit its
replication?
10. Were the index test results interpreted without knowledge of the results of the
reference standard?
11. Were the reference standard results interpreted without knowledge of the results of
the index test?
12. Were the same clinical data available when test results were interpreted as would be
available when the test is used in practice?
13. Were uninterpretable/ intermediate test results reported?
14. Were withdrawals from the study explained?
5
EXCLUDED ARTICLES
01. McNicoll L, Pisani MA, Ely EW, Gifford D, Inouye SK. Detection of delirium
in the intensive care unit: comparison of confusion assessment method for the
intensive care unit with confusion assessment method ratings. J Am Geriatr Soc
2005;53:495-500.
Compared CAM-ICU with CAM.
02. Larsson C, Axell AG, Ersson A. Confusion assessment method for the intensive
care unit (CAM-ICU): translation, retranslation and validation into Swedish
intensive care settings. Acta Anaesthesiol Scand 2007;51:888-92.
Evaluated delirium with CAM-ICU only. Not comparative.
03. Plaschke K, von Haken R, Scholz M, Engelhardt R, Brobeil A, Martin E,
Weigand MA. Comparison of the confusion assessment method for the intensive
care unit (CAM-ICU) with the Intensive Care Delirium Screening Checklist
(ICDSC) for delirium in critical care patients gives high agreement rate(s).
Intensive Care Med 2008;34:431-6.
Evaluated delirium with CAM-ICU and ICDSC only, without a gold standard.
04. Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency
department patients: recognition, risk factors, and psychomotor subtypes. Ac
Emerg Med 2009;16:193-200.
Evaluated delirium with CAM-ICU only. Not comparative.
6
05. Rompaey BV, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Elseviers
M, Bossaert L. A comparison of the CAM-ICU and the NEECHAM Confusion
Scale in intensive care delirium assessment: an observational study in nonintubated patients. Crit Care 2008;12:R16.
Comparison between CAM-ICU and NEECHAM, without a gold-standard.
06. Pisani MA, Araujo KLB, Van Ness PH, Zhang Y, Ely EW, Inouye SK. A
research algorithm to improve detection of delirium in the intensive care unit. Crit
Care 2006;10:R121.
The CAM-ICU was used as gold-standard.
07. Spronk PE, Riekerk B, Hofhuis J, Rommes JH. Occurrence of delirium is
severely underestimated in the ICU during daily care. Intensive Care Med
2009;35:1276-80.
Used only CAM-ICU without comparison with a gold standard.
08. Sharma PT, Sieber FE, Zakriya KJ, Pauldine RW, Gerold KB, Hang J, Smith
TH. Recovery room delirium predicts postoperative delirium after hip-fracture
repair. Anesth Analg 2005;101:1215-20.
Used only CAM-ICU without comparison with a gold standard.
09. Neufeld KJ, Hayat MJ, Coughlin JM, Huberman AL, Leistikow NA, Krumm
SK, Needham DM. Evaluation of two intensive care delirium screening tools for
non-critically ill hospitalized patients. Psychosomatics 2011;52:133-40.
Evaluated non-critically ill patients.
7
10. Smith HA, Boyd J, Fuchs DC, Melvin K, Berry P, Shintani A, Eden SK, Terrell
MK, Boswell T, Wolfram K, Sopfe J, Barr FE, Pandharipande PP, Ely EW.
Diagnosing delirium in critically ill children: Validity and reliability of the
Pediatric Confusion Assessment Method for the Intensive Care Unit. Crit Care
Med 2011;39:150-7.
Pediatric population.
11. Devlin JW, Fong JJ, Fraser GL, Riker RR. Delirium assessment in the
critically ill. Intensive Care Med 2007;33:929-40.
Review article.
12. Radtke FM, Franck M, Schneider M, Luetz A, Seeling M, Heinz A, et al.
Comparison of three scores to screen for delirium in the recovery room. Br J
Anaesth 2008;101:338-43.
Evaluated CAM and not CAM-ICU.
13. Wei LA, Fearing MA, Sternberg EJ, Inouye SK. The Confusion Assessment
Method: a systematic review of current usage. J Am Geriatr Soc 2008;56:823-30.
Systematic review.
14. Plaschke K, Fichtenkamm P, Schramm C, Hauth S, Martin E, Verch M, Karck
M, Kopitz J. Early postoperative delirium after open-heart cardiac surgery is
associated with decreased bispectral EEG and increased cortisol and interleukin-6.
Intensive Care Med 2010;36:2081-9.
Used only CAM-ICU without comparison with a gold standard.
8
15. Katznelson R, Djaiani GN, Borger MA, Friedman Z, Abbey SE, Fedorko L,
Karski J, Mitsakakis N, Carroll J, Beattie WS. Preoperative use of statins is
associated with reduced early delirium rates after cardiac surgery. Anesthesiology
2009;110:67-73.
Used only CAM-ICU without comparison with a gold standard.
16. Riekerk B, Pen EJ, Hofhuis JG, Rommes JH, Schultz MJ, Spronk PE.
Limitations and practicalities of CAM-ICU implementation, a delirium scoring
system, in a Dutch intensive care unit. Intensive Crit Care Nurs 2009;25:242-9.
A descriptive study about delirium understanding in a Dutch intensive care.
17. Devlin JW, Fong JJ, Schumaker G, O'Connor H, Ruthazer R, Garpestad E.
Use of a validated delirium assessment tool improves the ability of physicians to
identify delirium in medical intensive care unit patients. Crit Care Med
2007;35:2721-4.
Evaluated only ICDSC without comparison with a gold standard.
18. Otter H, Martin J, Bäsell K, von Heymann C, Hein OV, Böllert P, Jänsch P,
Behnisch I, Wernecke KD, Konertz W, Loening S, Blohmer JU, Spies C. Validity
and reliability of the DDS for severity of delirium in the ICU. Neurocrit Care.
2005;2(2):150-8.
Evaluated only DDS without comparison with a glod standard.
19. Hudetz JA, Iqbal Z, Gandhi SD, Patterson KM, Byrne AJ, Pagel PS.
Postoperative Delirium and Short-term Cognitive Dysfunction Occur More
Frequently in Patients Undergoing Valve Surgery With or Without Coronary
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Artery Bypass Graft Surgery Compared With Coronary Artery Bypass Graft
Surgery Alone: Results of a Pilot Study. J Cardiothorac Vasc Anesth 2011;25:8116.
Evaluated only ICDSC without comparison with a gold standard.
20. Skrobik Y, Devlin JW. The intensive care delirium screening checklist has
many potential benefits over the nursing delirium screening scale. Crit Care Med
2010;38:1610-1.
A letter about ICDSC
21. Devlin JW, Fong JJ, Howard EP, Skrobik Y, McCoy N, Yasuda C, Marshall J.
Assessment of delirium in the intensive care unit: nursing practices and
perceptions. Am J Crit Care 2008;17:555-65.
An interview with nurses about delirium
22. Roberts B, Rickard CM, Rajbhandari D, Turner G, Clarke J, Hill D, Tauschke
C, Chaboyer W, Parsons R. Multicentre study of delirium in ICU patients using a
simple screening tool. Aust Crit Care 2005;18:6,8-9,11-4 passim.
Evaluated only ICDSC without comparison with a gold standard.
23. Hart RP, Levenson JL, Sessler CN, Best AM, Schwartz SM, Rutherford LE.
Validation of a cognitive test for delirium in medical ICU patients. Psychosomatics
1996;37:533-46.
A description of CTD without comparison with a gold standard.
24. Hernández-Palazón J, Doménech-Asensi P, Pérez-Espejo MA, LópezHernández F, Burguillos-López S, Martínez-Lage JF. Postoperative delirium in
10
patient neurosurgical: evaluation by means of the Abbreviated Mental Test.
Neurocirugia (Astur) 2006;17:119-24.
Evaluated AMT without comparison with a gold standard
25. Hart RP, Best AM, Sessler CN, Levenson JL. Abbreviated cognitive test for
delirium. J Psychosom Res 1997;43:417-23.
Include only patients with delirium, dementia, depression or schizophrenia.
26. Van Rompaey B, Elseviers MM, Schuurmans MJ, Shortridge-Baggett LM,
Truijen S, Bossaert L. Risk factors for delirium in intensive care patients: a
prospective cohort study. Crit Care 2009;13:R77.
Evaluated NEECHAM without comparison with a gold standard.
27. Gemert van LA, Schuurmans MJ. The Neecham Confusion Scale and the
Delirium Observation Screening Scale: capacity to discriminate and ease of use in
clinical practice. BMC Nurs 2007;29;6:3.
Evaluated non-critically ill patients.
28. Matsushita T, Matsushima E, Maruyama M. Early detection of postoperative
delirium and confusion in a surgical ward using the NEECHAM confusion scale.
Gen Hosp Psychiatry 2004;26:158-63.
Evaluated NEECHAM without comparison with a gold standard.
29. Tomasi CD, Grandi C, Salluh J, Soares M, Giombelli VR, Cascaes S, Macedo
RC, de Souza Constantino L, Biff D, Ritter C, Dal Pizzol F. Comparison of CAMICU and ICDSC for the detection of delirium in critically ill patients focusing on
relevant clinical outcomes. J Crit Care 2011 Jul 5. [Epub ahead of print]
11
Comparison of CAM-ICU and ICDSC.
30. Svenningsen H, Tønnesen E. Delirium incidents in three Danish intensive care
units. Nurs Crit Care 2011;16:186-92.
Evaluated CAM-ICU without comparison with a gold standard.
31. Han JH, Eden S, Shintani A, Morandi A, Schnelle J, Dittus RS, Storrow AB,
Ely EW. Delirium in older emergency department patients is an independent
predictor of hospital length of stay. Acad Emerg Med 2011;18:451-7.
Evaluated CAM-ICU without comparison with a gold standard.
32. Tsuruta R, Nakahara T, Miyauchi T, Kutsuna S, Ogino Y, Yamamoto T,
Kaneko T, Kawamura Y, Kasaoka S, Maekawa T. Prevalence and associated
factors for delirium in critically ill patients at a Japanese intensive care unit. Gen
Hosp Psychiatry 2010;32:607-11.
Evaluated only CAM-ICU without comparison with a gold standard.
33. Branco BC, Inaba K, Bukur M, Talving P, Oliver M, David JS, Lam L,
Demetriades D. Risk factors for delirium in trauma patients: the impact of ethanol
use and lack of insurance. Am Surg 2011;77:621-6.
A study about risk factors.
34. Clarke SP, McRae ME, Del Signore S, Schubert M, Styra R. Delirium in older
cardiac surgery patients: directions for practice. J Gerontol Nurs 2010;36:34-45.
A review article.
12
35. Han JH, Shintani A, Eden S, Morandi A, Solberg LM, Schnelle J, Dittus RS,
Storrow AB, Ely EW. Delirium in the emergency department: an independent
predictor of death within 6 months. Ann Emerg Med 2010;56:244-252.
Evaluated only CAM-ICU without comparison with a gold standard.
36. Lütz A, Heymann A, Radtke FM, Spies CD. If delirium is not monitored it will
often be not detected. Anasthesiol Intensivmed Notfallmed Schmerzther
2010;45:106-11.
A review article.
37. Xie GH, Fang XM. Importance of recognizing and managing delirium in
intensive care unit. Chin J Traumatol 2009;12:370-4.
A review article.
38. Ceriana P, Fanfulla F, Mazzacane F, Santoro C, Nava S. Delirium in patients
admitted to a step-down unit: analysis of incidence and risk factors. J Crit Care
2010;25:136-43.
Evaluated only ICDSC without comparison with a gold standard.
39. Van Rompaey B, Schuurmans MJ, Shortridge-Baggett LM, Truijen S,
Elseviers M, Bossaert L. Long term outcome after delirium in the intensive care
unit. J Clin Nurs 2009;18:3349-57.
Evaluated only CAM-ICU and NEECHAM without comparison with gold standard.
40. Stevens RD, Nyquist PA. Coma, delirium, and cognitive dysfunction in critical
illness. Crit Care Clin 2006;22:787-804.
13
A review article
41. Ranhoff AH, Rozzini R, Sabatini T, Cassinadri A, Boffelli S, Trabucchi M.
Delirium in a sub-intensive care unit for the elderly: occurrence and risk factors.
Aging Clin Exp Res 2006;18:440-5.
Evaluated only CAM-ICU without comparison with a gold standard.