Recognition and labeling of delirium symptoms by intensivists: Does it matter?

Catherine Z. Cheung, Shabbir M. H. Alibhai, Michael Robinson, George Tomlinson, Dean Chittock, John Drover, Yoanna Skrobik

The approach to acute cognitive dysfunction varies among physicians, including intensivists. Physicians may differ in their labeling of cognitive abnormalities in critically ill patients. We aimed to survey: (a) what Canadian intensive care unit (ICU) physicians identify as "delirium"; (b) choices of non-pharmacological and pharmacological management; and (c) consultation patterns among ICU patients with cognitive abnormalities. A mail-in self-administered survey was sent to Canadian intensivists registered with the Canadian Critical Care Society. The survey contained three clinical scenarios which described cognitively abnormal patients with: (a) hepatic encephalopathy; (b) multiple drug overdose; and (c) post-operative aortic aneurysm repair. Symptoms, which included fluctuating level of consciousness, inattention, disorientation, hallucinations, sleep/wake cycle disturbance, and paranoia, all fulfilled DSM-IV criteria for delirium. We asked for diagnoses in short-answer format for each scenario, and offered multiple selections of non-pharmacological and pharmacological therapies and consultation options. All intensivists registered with the Canadian Critical Care Society. One-hundred thirty surveys were returned, for a response rate of 58.3%. When an etiological cognitive dysfunction diagnosis was obvious, 83-85% responded with the medical diagnosis to explain the cognitive abnormalities; only 43-55% used the term "delirium". In contrast, where an underlying medical problem was lacking, 74% of respondents diagnosed "delirium" (p=0.002). Non-pharmacological and pharmacological management varied considerably by physician and scenario but independently from whether the term "delirium" was selected. Commonly selected pharmacological agents were antipsychotics and benzodiazepines, followed by narcotics, non-narcotic analgesics, and other sedatives. Whether and when intensivists chose to consult other services varied. Canadian intensivists diagnose delirium based upon the presence or absence of an obvious medical etiology. Wide variation exists in approach to management, as well as patterns of consultation.