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Subsyndromal Delirium and Institutionalization Among Patients With Critical Illness
Nathan E Brummel1, Leanne M Boehm2, Timothy D Girard2
1Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center. nathan.brummel@vanderbilt.edu.
Background:
The prognostic importance of subsyndromal delirium is unknown.
Objective:
To test whether duration of subsyndromal delirium is independently associated with institutionalization.
Methods:
The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was used twice daily to assess for subsyndromal delirium in patients with respiratory failure or shock. Delirium was considered present if the assessment was positive. Subsyndromal delirium was considered present if the assessment was negative but the patient exhibited any CAM-ICU features. Multivariable regression was used to determine the association between duration of subsyndromal delirium and institutionalization, adjusting for age, education, baseline cognition and disability, comorbidities, severity of illness, delirium, coma, sepsis, and doses of sedatives and opiates.
Results:
Subsyndromal delirium, lasting a median of 3 days, developed in 702 of 821 patients (86%). After adjusting for covariates, duration of subsyndromal delirium was an independent predictor of increased odds of institutionalization (P = .007). This association was greatest in patients with less delirium (P for interaction = .01). Specifically, of patients who were never delirious, those with 5 days of subsyndromal delirium (upper interquartile range [IQR]) were 4.2 times more likely to be institutionalized than those with 1.5 days of subsyndromal delirium (lower IQR).
Conclusions:
Subsyndromal delirium occurred in most critically ill patients, and its duration was an independent predictor of institutionalization. Routine monitoring of all delirium symptoms may enable detection of full and subsyndromal forms of delirium.
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