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Objectives: The Society of Critical Care Medicine recommends routine delirium monitoring, based on data in critically ill patients without primary neurologic injury. We sought to answer whether there are valid and reliable tools to monitor delirium in neurocritically ill patients and whether delirium is associated with relevant clinical outcomes (e.g., survival, length of stay, functional independence, cognition) in this population., Data Sources: We systematically reviewed Cumulative Index to Nursing and Allied Health Literature, Web of Science, and PubMed., Study Selection and Data Extraction: Inclusion criteria allowed any study design investigating delirium monitoring in neurocritically ill patients (e.g., neurotrauma, ischemic, and/or hemorrhagic stroke) of any age. We extracted data relevant to delirium tool sensitivity, specificity, negative predictive value, positive predictive value, interrater reliability, and associated clinical outcomes., Data Synthesis: Among seven prospective cohort studies and a total of 1,173 patients, delirium was assessed in neurocritically patients using validated delirium tools after considering primary neurologic diagnoses and associated complications, finding a pooled prevalence rate of 12-43%. When able to compare against a common reference standard, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the test characteristics showed a sensitivity of 62-76%, specificity of 74-98%, positive predictive value of 63-91%, negative predictive value of 70-94%, and reliability kappa of 0.64-0.94. Among four studies reporting multivariable analyses, delirium in neurocritically patients was associated with increased hospital length of stay (n = 3) and ICU length of stay (n = 1), as well as worse functional independence (n = 1) and cognition (n = 2), but not survival., Conclusions: These data from studies of neurocritically ill patients demonstrate that patients with primary neurologic diagnoses can meet diagnostic criteria for delirium and that delirious features may predict relevant untoward clinical outcomes. There is a need for ongoing investigations regarding delirium in these complicated neurocritically ill patients.

Background: Delirium predicts higher long-term cognitive morbidity. We previously identified a cohort of patients with spontaneous intracerebral hemorrhage and delirium and found worse outcomes in health-related quality of life (HRQoL) in the domain of cognitive function., Objective: We tested the hypothesis that agitation would have additional prognostic significance on later cognitive function HRQoL., Methods: Prospective identification of 174 patients with acute intracerebral hemorrhage, measuring stroke severity, agitation, and delirium, with a standardized protocol and measures. HRQoL was assessed using the Neuro-QOL at 28 days, 3 months, and 1 year. Functional outcomes were measured with the modified Rankin Scale., Results: Among the 81 patients with HRQoL follow-up data available, patients who had agitation and delirium had worse cognitive function HRQoL scores at 28 days (T scores for delirium with agitation 20.9 ± 7.3, delirium without agitation 30.4 ± 16.5, agitation without delirium 36.6 ± 17.5, and neither agitated nor delirious 40.3 ± 15.9; p = 0.03) and at 1 year (p = 0.006). The effect persisted in mixed models after correction for severity of neurologic injury, age, and time of assessment (p = 0.0006) and was not associated with medication use, seizures, or infection., Conclusions: The presence of agitation with delirium in patients with intracerebral hemorrhage may predict higher risk of unfavorable cognitive outcomes up to 1 year later., (Copyright © 2017 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.)

The evidence linking delirium to poor outcomes after critical illness is compelling, including higher mortality, prolonged mechanical ventilation, longer length of intensive care unit stay, and long-term cognitive impairments. The attitude toward delirium in the neurologic community is shifting away from viewing it as an unmodifiable, inevitable consequence of severe illness to treating it is as a neurologic emergency, akin to seizures or encephalitis. Delirium, like other manifestations of critical illness encephalopathy, is an organ dysfunction syndrome. Given the brain's central role in maintaining homeostasis, brain failure may dysregulate many downstream functions of significant consequence in critically ill patients. The diagnosis of delirium may be confounded in patients with primary brain disorders, but nevertheless delirium symptoms in the neurologic population are also independently associated with worse outcomes. There is scant evidence for directed pharmacological treatment of delirium, but multicomponent care bundles that address the management of pain, agitation, sedation, and delirium are effective at reducing the burden of delirium in the general intensive care unit population. The management of delirium in the neurologic intensive care environment is mostly extrapolated from studies on general medical critical illness and noncritically ill neurologic patients. Further investigation into the unique risks and management needs of critically ill neurologic and neurosurgical patients is needed to reduce the burden of delirium in that population., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Delirium symptoms are associated with later worse functional outcomes and long-term cognitive impairments, but the neuroanatomical basis for delirium symptoms in patients with acute brain injury is currently uncertain. We tested the hypothesis that hematoma location is predictive of delirium symptoms in patients with intracerebral hemorrhage, a model disease where patients are typically not sedated or bacteremic., Methods: We prospectively identified 90 patients with intracerebral hemorrhage who underwent routine twice-daily screening for delirium symptoms with a validated examination. Voxel-based lesion-symptom mapping with acute computed tomography was used to identify hematoma locations associated with delirium symptoms (N = 89)., Results: Acute delirium symptoms were predicted by hematoma of right-hemisphere subcortical white matter (superior longitudinal fasciculus) and parahippocampal gyrus. Hematoma including these locations had an odds ratio for delirium of 13 (95 % CI 3.9-43.3, P < 0.001). Disruption of large-scale brain networks that normally support attention and conscious awareness was thus associated with acute delirium symptoms., Conclusions: Higher odds ratio for delirium was increased due to hematoma location. The location of neurological injury could be of high prognostic value for predicting delirium symptoms.

Rationale: The prognostic significance of delirium symptoms in intensive care unit (ICU) patients with focal neurologic injury is unclear., Objectives: To determine the relationship between delirium symptoms and subsequent functional outcomes and quality of life (QOL) after intracerebral hemorrhage., Methods: We prospectively enrolled 114 patients. Delirium symptoms were routinely assessed twice daily using the Confusion Assessment Method for the ICU by trained nurses. Functional outcomes were recorded with modified Rankin Scale (scored from 0 [no symptoms] to 6 [dead]), and QOL outcomes with Neuro-QOL at 28 days, 3 months, and 12 months., Measurements and Main Results: Thirty-one (27%) patients had delirium symptoms ("ever delirious"), 67 (59%) were never delirious, and the remainder (14%) had persistent coma. Delirium symptoms were nearly always hypoactive, were detected mean 6 days after intracerebral hemorrhage presentation, and were associated with longer ICU length of stay (mean 3.5 d longer in ever vs. never delirious patients; 95% confidence interval, 1.5-8.3; P = 0.004) after correction for age, admit National Institutes of Health (NIH) Stroke Scale, and any benzodiazepine exposure. Delirium symptoms were associated with increased odds of poor outcome at 28 days (odds ratio, 8.7; 95% confidence interval, 1.4-52.5; P = 0.018) after correction for admission NIH Stroke Scale and age, and with worse QOL in the domains of applied cognition-executive function and fatigue after correcting for the NIH Stroke Scale, age, benzodiazepine exposure, and time of follow-up., Conclusions: After focal neurologic injury, delirium symptoms were common despite low rates of infection and sedation exposure, and were predictive of subsequent worse functional outcomes and lower QOL.

Critically ill patients with a primary neurological injury or illness pose unique challenges for pain, agitation, and delirium management in intensive care units (ICUs). Detection and monitoring can be limited by contextual level of consciousness (LOC) alterations, cognition, expression, or language deficits. Recent data suggest that existing pain assessment tools may not be applicable to all neurocritically ill patients, especially in those with LOC alterations and atypical pain-associated behaviors. Targeted sedation goals may be neurologically disease specific; for instance, intracranial pressure (ICP) targets will supersede sedation titration by other criteria. Technology such as bispectral index (BIS) may be beneficial in avoiding excessive medication administration in deeply sedated neurologically injured ICU patients. Given the wide variety of pathology in the neurocritically ill patients, it is unclear if delirium can be diagnosed and unequivocally differentiated from symptoms of the underlying neurological pathology. However, delirium symptoms may herald life-threatening primary insult progression or result from a new secondary neurological injury and should be monitored. Patients with neurological injury or illness are often excluded from ICU studies addressing pain, sedation, and delirium, but this need not be the case. We review what is understood in this area based on current evidence., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objectives: The Society of Critical Care Medicine recommends routine delirium monitoring, based on data in critically ill patients without primary neurologic injury. We sought to answer whether there are valid and reliable tools to monitor delirium in neurocritically ill patients and whether delirium is associated with relevant clinical outcomes (e.g., survival, length of stay, functional independence, cognition) in this population.Data Sources: We systematically reviewed Cumulative Index to Nursing and Allied Health Literature, Web of Science, and PubMed.Study Selection and Data Extraction: Inclusion criteria allowed any study design investigating delirium monitoring in neurocritically ill patients (e.g., neurotrauma, ischemic, and/or hemorrhagic stroke) of any age. We extracted data relevant to delirium tool sensitivity, specificity, negative predictive value, positive predictive value, interrater reliability, and associated clinical outcomes.Data Synthesis: Among seven prospective cohort studies and a total of 1,173 patients, delirium was assessed in neurocritically patients using validated delirium tools after considering primary neurologic diagnoses and associated complications, finding a pooled prevalence rate of 12-43%. When able to compare against a common reference standard, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the test characteristics showed a sensitivity of 62-76%, specificity of 74-98%, positive predictive value of 63-91%, negative predictive value of 70-94%, and reliability kappa of 0.64-0.94. Among four studies reporting multivariable analyses, delirium in neurocritically patients was associated with increased hospital length of stay (n = 3) and ICU length of stay (n = 1), as well as worse functional independence (n = 1) and cognition (n = 2), but not survival.Conclusions: These data from studies of neurocritically ill patients demonstrate that patients with primary neurologic diagnoses can meet diagnostic criteria for delirium and that delirious features may predict relevant untoward clinical outcomes. There is a need for ongoing investigations regarding delirium in these complicated neurocritically ill patients. [ABSTRACT FROM AUTHOR]