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      Psychometric properties of the Arabic version of the confusion assessment method for the intensive care unit (CAM-ICU)

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          Abstract

          Background

          It is recommended that critically ill patients undergo routine delirium monitoring with a valid and reliable tool such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). However, the validity and reliability of the Arabic version of the CAM-ICU has not been investigated. Here, we test the validity and reliability of the Arabic CAM-ICU.

          Methods

          We conducted a psychometric study at ICUs in a tertiary-care hospital in Saudi Arabia. We recruited consecutive adult Arabic-speaking patients, who had stayed in the ICU for at least 24 hours, and had a Richmond Agitation-Sedation Scale (RASS) score ≥ − 2 at examination. Two well-trained examiners (ICU nurse and intensivist) independently assessed delirium in eligible patients with the Arabic CAM-ICU. Evaluations by the two examiners were compared with psychiatrist blind clinical assessment of delirium according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Subgroup analyses were conducted for age, invasive mechanical ventilation, and gender.

          Results

          We included 108 patients (mean age: 62.6 ± 17.6; male: 51.9%), of whom 37% were on invasive mechanical ventilation. Delirium was diagnosed in 63% of enrolled patients as per the psychiatrist clinical assessment. The Arabic CAM-ICU sensitivity was 74% (95% confidence interval [CI] = 0.63–0.84) and 56% (95%CI = 0.44–0.68) for the ICU nurse and intensivist, respectively. Specificity was 98% (95%CI = 0.93–1.0) and 92% (95%CI = 0.84–1.0), respectively. Sensitivity was greater for mechanically-ventilated patients, women, and those aged ≥65 years. Specificity was greater for those aged < 65 years, non-mechanically-ventilated patients and men. The median duration to complete the Arabic CAM-ICU was 2 min (interquartile range, 2–3) and 4.5 min (IQR, 3–5) for the ICU nurse and intensivist, respectively. Inter-rater reliability (kappa) was 0.66.

          Conclusions

          The Arabic CAM-ICU demonstrated acceptable reliability and validity to assess delirium in Arabic-speaking ICU patients.

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          Most cited references 28

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          Incidence, risk factors and consequences of ICU delirium.

          Delirium in the critically ill is reported in 11-80% of patients. We estimated the incidence of delirium using a validated scale in a large cohort of ICU patients and determined the associated risk factors and outcomes. Prospective study in a 16-bed medical-surgical intensive care unit (ICU). 820 consecutive patients admitted to ICU for more than 24 h. Tools used were: the Intensive Care Delirium Screening Checklist for delirium, Richmond Agitation and Sedation Scale for sedation, and Numerical Rating Scale for pain. Risk factors were evaluated with univariate and multivariate analysis, and factors influencing mortality were determined using Cox regression. Delirium occurred in 31.8% of 764 patients. Risk of delirium was independently associated with a history of hypertension (OR 1.88, 95% CI 1.3-2.6), alcoholism (2.03, 1.2-3.2), and severity of illness (1.25, 1.03-1.07 per 5-point increment in APACHE II score) but not with age or corticosteroid use. Sedatives and analgesics increased the risk of delirium when used to induce coma (OR 3.2, 95% CI 1.5-6.8), and not otherwise. Delirium was linked to longer ICU stay (11.5+/-11.5 vs. 4.4+/-3.9 days), longer hospital stay (18.2+/-15.7 vs. 13.2+/-19.4 days), higher ICU mortality (19.7% vs. 10.3%), and higher hospital mortality (26.7% vs. 21.4%). Delirium is associated with a history of hypertension and alcoholism, higher APACHE II score, and with clinical effects of sedative and analgesic drugs.
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            Costs associated with delirium in mechanically ventilated patients.

            To determine the costs associated with delirium in mechanically ventilated medical intensive care unit patients. Prospective cohort study. A tertiary care academic hospital. Patients were 275 consecutive mechanically ventilated medical intensive care unit patients. We prospectively examined patients for delirium using the Confusion Assessment Method for the Intensive Care Unit. Delirium was categorized as "ever vs. never" and by a cumulative delirium severity index. Costs were determined from individual ledger-level patient charges using cost-center-specific cost-to-charge ratios and were reported in year 2001 U.S. dollars. Fifty-one of 275 patients (18.5%) had persistent coma and died in the hospital and were excluded from further analysis. Of the remaining 224 patients, delirium developed in 183 (81.7%) and lasted a median of 2.1 (interquartile range, 1-3) days. Baseline demographics were similar between those with and without delirium. Intensive care unit costs (median, interquartile range) were significantly higher for those with at least one episode of delirium ($22,346, $15,083-$35,521) vs. those with no delirium ($13,332, $8,837-$21,471, p <.001). Total hospital costs were also higher in those who developed delirium ($41,836, $22,782-$68,134 vs. $27,106, $13,875-$37,419, p =.002). Higher severity and duration of delirium were associated with incrementally greater costs (all p <.001). After adjustment for age, comorbidity, severity of illness, degree of organ dysfunction, nosocomial infection, hospital mortality, and other potential confounders, delirium was associated with 39% higher intensive care unit (95% confidence interval, 12-72%) and 31% higher hospital (95% confidence interval, 1-70%) costs. Delirium is a common clinical event in mechanically ventilated medical intensive care unit patients and is associated with significantly higher intensive care unit and hospital costs. Future efforts to prevent or treat intensive care unit delirium have the potential to improve patient outcomes and reduce costs of care.
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              Delirium predicts 12-month mortality.

              Delirium has not been found to be a significant predictor of postdischarge mortality, but previous research has methodologic limitations including small sample sizes and inadequate control of confounding. This study aimed to determine the independent effects of presence of delirium, type of delirium (incident vs prevalent), and severity of delirium symptoms on 12-month mortality among older medical inpatients. A prospective, observational study of 2 cohorts of medical inpatients was conducted with patients 65 years or older: 243 patients had prevalent or incident delirium, and 118 controls had no delirium. Baseline measures included presence of delirium and/or dementia, severity of delirium symptoms, physical function, comorbidity, and physiological and clinical severity of illness. Mortality during the 12 months after enrollment was analyzed with the Cox proportional hazards model with adjustment for covariates. The unadjusted hazard ratio of delirium with mortality was 3.44 (95% confidence interval, 2.05-5.75); the adjusted hazard ratio was 2.11 (95% confidence interval, 1.18-3.77). The effect of delirium was sustained over the entire 12-month period after adjustment for covariates and was stronger among patients without dementia. Among patients with dementia, there was a weak, nonsignificant effect of delirium on survival. After adjustment for covariates, mortality did not differ between patients with incident and prevalent delirium, but among patients with delirium without dementia, greater severity of delirium symptoms was associated with higher mortality. Delirium is an independent marker for increased mortality among older medical inpatients during the 12 months after hospital admission. It is a particularly important prognostic marker among patients without dementia.
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                Author and article information

                Contributors
                mahawij@gmail.com
                rn_a_deeb@hotmail.com
                dbsawym@yahoo.com
                sayeghd.daniah@gmail.com
                moteb_alotaibi@hotmail.com
                arabi@ngha.med.sa
                Journal
                BMC Psychiatry
                BMC Psychiatry
                BMC Psychiatry
                BioMed Central (London )
                1471-244X
                6 April 2018
                6 April 2018
                2018
                : 18
                Affiliations
                [1 ]ISNI 0000 0004 0608 0662, GRID grid.412149.b, King Abdullah International Medical Research Center, Nursing Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, , King Saud bin Abdulaziz University for Health Sciences, ; Riyadh, Saudi Arabia
                [2 ]ISNI 0000 0004 0608 0662, GRID grid.412149.b, King Abdullah International Medical Research Center, Research Office, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, , King Saud bin Abdulaziz University for Health Sciences, ; Riyadh, Saudi Arabia
                [3 ]ISNI 0000 0004 0608 0662, GRID grid.412149.b, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, , King Saud bin Abdulaziz University for Health Sciences, ; Riyadh, Saudi Arabia
                [4 ]ISNI 0000 0004 0608 0662, GRID grid.412149.b, King Abdullah International Medical Research Center, Mental Health Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, , King Saud bin Abdulaziz University for Health Sciences, ; Riyadh, Saudi Arabia
                [5 ]ISNI 0000 0004 0608 0662, GRID grid.412149.b, King Abdullah International Medical Research Center, College of Medicine, , King Saud Bin Abdulaziz University for Health Sciences, ; Riyadh, Saudi Arabia
                [6 ]ISNI 0000 0004 1790 7311, GRID grid.415254.3, Intensive Care Department, King Abdulaziz Medical City, National Guard Health Affairs, ; Riyadh, Saudi Arabia
                Article
                1676
                10.1186/s12888-018-1676-0
                5889594
                29625595
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Funding
                Funded by: King Abdullah International Medical Research Center
                Award ID: RC15/091/R
                Award Recipient :
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2018

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