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Deconstructing Poststroke Delirium in a Prospective Cohort of Patients With Intracerebral Hemorrhage

Reznik, Michael E. MD1,2; Drake, Jonathan MD1; Margolis, Seth A. PhD1,3; Moody, Scott BS1; Murray, Kayleigh BS1; Costa, Samantha BS1; Mahta, Ali MD1,2; Wendell, Linda C. MD1,2,4; Thompson, Bradford B. MD1,2; Rao, Shyam S. MD1,2; Barrett, Anna M. MD5; Boukrina, Olga PhD5; Daiello, Lori A. PharmD, ScM1; Asaad, Wael F. MD, PhD2; Furie, Karen L MD, MPH1; Jones, Richard N. ScD1,3

doi: 10.1097/CCM.0000000000004031
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Objectives: Poststroke delirium may be underdiagnosed due to the challenges of disentangling delirium symptoms from underlying neurologic deficits. We aimed to determine the prevalence of individual delirium features and the frequency with which they could not be assessed in patients with intracerebral hemorrhage.

Design: Prospective observational cohort study.

Setting: Neurocritical Care and Stroke Units at a university ­hospital.

Patients: Consecutive patients with intracerebral hemorrhage from February 2018 to May 2018.

Interventions: None.

Measurements and Main Results: An attending neurointensivist performed 257 total daily assessments for delirium on 60 patients (mean age 68.0 [SD 18.4], 62% male, median intracerebral hemorrhage score 1.5 [interquartile range 1–2], delirium prevalence 57% [n = 34]). Each assessment included the Confusion Assessment Method for the ICU, Intensive Care Delirium Screening Checklist, a focused bedside cognitive examination, chart review, and nurse interview. We characterized individual symptom prevalence and established delirium diagnoses using Diagnostic and Statistical Manual of Mental Disorders, fifth edition criteria, then compared performance of the Confusion Assessment Method for the ICU and Intensive Care Delirium Screening Checklist against reference-standard expert diagnosis. Symptom fluctuation (61% of all assessments), psychomotor changes (46%), sleep-wake disturbances (46%), and impaired arousal (37%) had the highest prevalence and were never rated “unable to assess,” while inattention (36%), disorientation (27%), and disorganized thinking (18%) were also common but were often rated "unable to assess" (32%, 43%, and 44% of assessments, respectively), most frequently due to aphasia (32% of patients). Including nonverbal assessments of attention decreased the frequency of "unable to assess" ratings to 11%. Since the Intensive Care Delirium Screening Checklist may be positive without the presence of symptoms that require verbal assessment, it was more accurate (sensitivity = 77%, specificity = 97%, area under the receiver operating characteristic curve, 0.87) than the Confusion Assessment Method for the ICU (sensitivity = 41%, specificity = 88%, area under the receiver operating characteristic curve, 0.64).

Conclusions: Delirium is common after intracerebral hemorrhage, but severe neurologic deficits may confound its assessment and lead to underdiagnosis. The Intensive Care Delirium Screening Checklist’s inclusion of nonverbal features may make it more accurate than the Confusion Assessment Method for the ICU in patients with neurologic deficits, but novel tools designed for such patients may be warranted.

1Department of Neurology, Brown University, Alpert Medical School, Providence, RI.

2Department of Neurosurgery, Brown University, Alpert Medical School, Providence, RI.

3Department of Psychiatry and Human Behavior, Brown University, Alpert Medical School, Providence, RI.

4Section of Medical Education, Brown University, Alpert Medical School, Providence, RI.

5Kessler Foundation and Kessler Institute for Rehabilitation, West Orange, NJ.

Dr. Reznik is supported by the Rhode Island Foundation and departmental funds from Brown University’s Center for Biomedical Informatics. Dr. Margolis is partially supported by grant funding from the American Academy of Clinical Neuropsychology Foundation and a research career development award from the Department of Neurology at Lifespan Health System and The Miriam Hospital. Dr. Wendell received funding from Biogen (investigator meeting for Phase 3 Study to Evaluate the Efficacy and Safety of Intravenous BIIB093 [Glibenclamide] for Severe Cerebral Edema Following Large Hemispheric Infarction [CHARM]). Dr. Barrett received funding from National Institutes of Health (NIH), Wallerstein Foundation for Geriatric Improvement, DART Neuroscience, Bright Cloud International Corp; she received funding from WebMD/emedicine.com (textbook chapter honoraria) and Kessler Foundation (employee); and she received support for article research from the NIH. Dr. Boukrina’s institution received funding from NIH grant 1R21HD095488-01. Drs. Barrett and Boukrina are supported by the American Heart Association (Scientist Development Grant 17SDG33660442) and the Kessler Foundation. Dr. Asaad is supported by NIH grants R01-MH115035 and P20-GM103645. Dr. Jones is primarily supported by NIH grants R01-AG044518, R01-AG051170, and R01-AG029672, VA grant 650D48063, and departmental funds from the Departments of Psychiatry and Neurology at the Alpert Medical School at Brown University. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Michael E. Reznik, MD, Division of Neurocritical Care, Department of Neurology, Rhode Island Hospital, 593 Eddy Street, APC 712, Providence, RI 02903. E-mail: Michael_Reznik@brown.edu

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