However, the present study has some limitations. Firstly, more than half of the patients were excluded due to preexisting psychosis or neurologic disease. We do not have exact detailed clinical information of these patients even though we screened all patients who are admitted to ICU. Whether there are valid and reliable instruments to monitor delirium in neuro-critically ill patients and whether delirium is related to relevant clinical outcomes in this population are still unknown. These questions should be clarified in future research. Secondly, Ely et al, who originally studied the CAM-ICU, interviewed the patients’ family members to estimate their baseline mental status. However, we just presumed the patients’ baseline mental status from the previous medical records because the nurses in our study could not accomplish such family interviews. Thirdly, we used DSM-IV but not DSM-V criteria as the reference standard evaluation in this study. Although studies[21–22] indicated that DSM-IV and DSM-V have no significant difference in diagnosing delirium, DSM-V was supposed to be more restrictive in defining in terms of its cognitive features. Further study could be required to explore the diagnostic relevance of different application of these criteria.
In conclusion, this study provides evidence to support that the Tibetan version of CAM-ICU monitoring is valid, reliable, and feasible in Tibetan ICU patients. We hope that the availability of such worksheet will facilitate the implementation of delirium screening in Tibetan-speaking ICU inpatients and eventually improve the outcome of patients.
The work was supported by a grant from the National Natural Science Foundation of China (No. 81601657).
1. Kotfis K, Marra A, Ely EW. ICU delirium
– a diagnostic and therapeutic challenge in the intensive care unit. Anaesthesiol Intensive Ther
2018; 50:128–140. doi: 10.5603/AIT.a2018.0011.
2. Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, et al. Evaluation of delirium
in critically ill patients: validation
of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU
). Crit Care Med
2001; 29:1370–1379. doi: 10.1097/00003246-200107000-00012.
3. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE, et al. Delirium
as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA
2004; 291:1753–1762. doi: 10.1001/jama.291.14.1753.
4. Krewulak KD, Stelfox HT, Leigh JP, Ely EW, Fiest KM. Incidence and prevalence of delirium
subtypes in an adult ICU: a systematic review and meta-analysis. Crit Care Med
2018; 46:2029–2035. doi: 10.1097/CCM.0000000000003402.
5. Lin SM, Liu CY, Wang CH, Lin HC, Huang CD, Huang PY, et al. The impact of delirium
on the survival of mechanically ventilated patients. Crit Care Med
2004; 32:2254–2259. doi: 10.1097/01.ccm.0000145587.16421.bb.
6. Salluh JI, Soares M, Teles JM, Ceraso D, Raimondi N, Nava VS, et al. Delirium
epidemiology in critical care (DECCA): an international study. Crit Care
2010; 14:R210doi: 10.1186/cc9333.
7. Girard TD, Jackson JC, Pandharipande PP, Pun BT, Thompson JL, Shintani AK, et al. Delirium
as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med
2010; 38:1513–1520. doi: 10.1097/CCM.0b013e3181e47be1.
8. Ely EW, Gautam S, Margolin R, Francis J, May L, Speroff T, et al. The impact of delirium
in the intensive care unit on hospital length of stay. Intensive Care Med
2001; 27:1892–1900. doi: 10.1007/s00134-001-1132-2.
9. Lima DP, Ochiai ME, Lima AB, Curiati JA, Farfel JM, Filho WJ. Delirium
in hospitalized elderly patients and post-discharge mortality. Clinics
2010; 65:251–255. doi: 10.1590/S1807-59322010000300003.
10. Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med
2002; 30:119–141. doi: 10.1097/00003246-200201000-00020.
11. Luetz A, Heymann A, Radtke FM, Chenitir C, Neuhaus U, Nachtigall I, et al. Different assessment tools for intensive care unit delirium
: which score to use? Crit Care Med
2010; 38:409–418. doi: 10.1097/CCM.0b013e3181cabb42.
12. Salluh JI, Dal-Pizzol F, Mello PVC, Friedman G, Silva E, Teles JMM, et al. Delirium
recognition and sedation practices in critically ill patients: a survey on the attitudes of 1015 Brazilian critical care physicians. J Crit Care
2009; 24:556–562. doi: 10.1016/j.jcrc.2009.04.004.
13. Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, et al. Delirium
in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU
2001; 286:2703–2710. doi: 10.1001/jama.286.21.2703.
14. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine
2000; 25:3186–3191. doi: 10.1097/00007632-200012150-00014.
15. Wild D, Grove A, Martin M, Eremenco S, McElroy S, Verjee-Lorenz A, et al. Principles of good practice for the translation and cultural adaptation process for Patient-Reported Outcomes (PRO) measures: report of the ISPOR Task Force for translation and cultural adaptation. Value Health
2005; 8:94–104. doi: 10.1111/j.1524-4733.2005.04054.x.
16. Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium
in adult patients in the intensive care unit. Crit Care Med
2013; 41:278–280. doi: 10.1097/CCM.0b013e3182783b72.
17. Guenther U, Popp J, Koecher L, Muders T, Wrigge H, Ely EW, et al. Validity and reliability of the CAM-ICU
flowsheet to diagnose delirium
in surgical ICU patients. J Crit Care
2010; 25:144–151. doi: 10.1016/j.jcrc.2009.08.005.
18. Heo EY, Lee BJ, Hahm BJ, Song EH, Lee HA, Yoo CG, et al. Translation and validation
of the Korean Confusion Assessment Method for the intensive care unit. BMC Psychiatry
2011; 11:94–97. doi: 10.1186/1471-244X-11-94.
19. Toro AC, Escobar LM, Franco JG, Diaz-Gomez JL, Munoz JF, Molina F, et al. Spanish version of the CAM-ICU
(Confusion Assessment Method for the intensive care unit). Pilot study of validation
. Med Intensive
2010; 34:14–21. doi: 10.1016/j.medin.2009.07.002.
20. Gusmao-Flores D, Salluh JI, Dal-Pizzol F, Ritter C, Tomasi CD, Lima MA, et al. The validity and reliability of the Portugese versions of three tools used to diagnose delirium
in critically ill patients. Clinics
2011; 66:1917–1922. doi: 10.1590/S1807-59322011001100011.
21. Adamis D, Rooney S, Meagher D, Mulligan O, McCarthy G. A comparison of delirium
diagnosis in elderly medical inpatients using the CAM, DRS-R98, DSM-IV and DSM-5 criteria. Int Psychogeriatr
2015; 27:883–889. doi: 10.1017/S1041610214002853.
22. Meagher DJ, Morandi A, Inouye SK, Ely W, Adamis D, Maclullich AJ, et al. Concordance between DSM-IV and DSM-5 criteria for delirium
diagnosis in a pooled database of 768 prospectively evaluated patients using the delirium
rating scale-revised-98. BMC Med
2014; 12:164–173. doi: 10.1186/s12916-014-0164-8.