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Delirium Transitions in the Medical ICU: Exploring the Role of Sleep Quality and Other Factors*

Kamdar, Biren B. MD, MBA, MHS1,2; Niessen, Timothy MD, MPH3; Colantuoni, Elizabeth PhD1,4; King, Lauren M. RN, MSN1,5; Neufeld, Karin J. MD, MPH1,6; Bienvenu, O. Joseph MD, PhD1,6; Rowden, Annette M. PharmD7; Collop, Nancy A. MD8; Needham, Dale M. MD, PhD1,2,9

doi: 10.1097/CCM.0000000000000610
Clinical Investigations
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Objectives: Disrupted sleep is a common and potentially modifiable risk factor for delirium in the ICU. As part of a quality improvement project to promote sleep in the ICU, we examined the association of perceived sleep quality ratings and other patient and ICU risk factors with daily transition to delirium.

Design: Secondary analysis of prospective observational study.

Setting: Medical ICU over a 201-day period.

Patients: Two hundred twenty-three patients with greater than or equal to one night in the medical ICU in between two consecutive days of delirium assessment.

Interventions: None.

Measurements and Main Results: Daily perceived sleep quality ratings were measured using the Richards-Campbell Sleep Questionnaire. Delirium was measured twice daily using the Confusion Assessment Method for the ICU. Other covariates evaluated included age, sex, race, ICU admission diagnosis, nighttime mechanical ventilation status, prior day’s delirium status, and daily sedation using benzodiazepines and opioids, via both bolus and continuous infusion. Perceived sleep quality was similar in patients who were ever versus never delirious in the ICU (median [interquartile range] ratings, 58 [35–76] vs 57 [33–78], respectively; p = 0.71), and perceived sleep quality was unrelated to delirium transition (adjusted odds ratio, 1.00; 95% CI, 0.99–1.00). In mechanically ventilated patients, receipt of a continuous benzodiazepine and/or opioid infusion was associated with delirium transition (adjusted odds ratio, 4.02; 95% CI, 2.19–7.38; p < 0.001), and patients reporting use of pharmacological sleep aids at home were less likely to transition to delirium (adjusted odds ratio, 0.40; 95% CI, 0.20–0.80; p = 0.01).

Conclusions: We found no association between daily perceived sleep quality ratings and transition to delirium. Infusion of benzodiazepine and/or opioid medications was strongly associated with transition to delirium in the ICU in mechanically ventilated patients and is an important, modifiable risk factor for delirium in critically ill patients.

1Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD.

2Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD.

3Department of Medicine, Johns Hopkins University, Baltimore, MD.

4Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

5Medical Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD.

6Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD.

7Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD.

8Emory Sleep Disorders Center, Wesley Woods Health Center, Emory University, Atlanta, GA.

9Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD.

* See also p. 248.

This work was performed at Johns Hopkins University.

Current address for Dr. Kamdar: Division of Pulmonary and Critical Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA.

Drs. Kamdar and Niessen contributed equally to this research as cofirst authors.

Dr. Kamdar was supported by a Ruth L. Kirschstein National Research Service Award award from the National Institutes of Health (F32 HL104901). His institution received grant support from the NIH (NIH Ruth Kirschstein NRSA Research Award F32 HL104901). Dr. Colantuoni’s institution received grant support from the NIH; received support for article research from the NIH. Dr. Collop served as board member for the American Academy of Sleep Medicine and received royalties from Up To Date. Dr. Needham received support for article research from the NIH. His institution received grant support from the NIH (NRSA award to Biren Kamdar). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: bkamdar@mednet.ucla.edu

© 2015 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins