Delirium at the intensive care unit and long-term survival: a retrospective study

Abstract

Background: Delirium is a common complication in patients at the intensive care unit (ICU) and is associated with prolonged ICU-stay and hospitalization and with increased morbidity. The impact of ICU-delirium on long-term survival is not clearly understood.

Methods: This retrospective single center observational study was conducted at the Institute of Intensive Care Medicine at the University Hospital Zurich, Switzerland. All adult ICU-survivors over a four-year period were screened for eligibility. ICU-delirium was defined based on the Intensive Care Delirium Screening Checklist (ICDSC), together with the coded diagnosis F05 in the International Classification of Diseases (ICD-2019). ICU-survivors who developed delirium during their ICU stay (group D) were compared with ICU-survivors who did not (group ND). Survival was evaluated according to data from hospital electronic health records up to four years from ICU-discharge. The survival analysis was reported using Kaplan-Meier curves and absolute risk differences (ARD). A multivariable logistic regression model was fitted with long-term survival at four years after ICU-discharge as outcome of interest, including several clinical conditions and interventions associated with long-term survival for ICU patients. For subgroup analysis, ICU-survivors were grouped based on age at the time of admission (45-54, 55-64, ≥ 65 years), and on relevant clinical conditions.

Results: A total of 9'604 patients fulfilled the inclusion criteria, of them 22.6% (n = 2'171) developed ICU-delirium. Overall, patients in the group D had a significantly lower probability of survival than patients in the group ND (p < 0.0001, ARD = 11.8%). In the multivariable analysis, ICU-delirium was confirmed as independently associated with long-term survival. After grouping for age categories, patients between 55 and 64 years of age in the group D were less likely to survive than patients in the group ND at every time point analyzed, up to four years after ICU discharge (p < 0.001, ARD = 7.3%). This difference was even more significant in the comparison between patients over 65 years (p < 0.0001, ARD 11.1%). No significant difference was observed in the other age groups.

Conclusions: In the study population, ICU-delirium was independently associated with a reduced long-term survival. Patients who developed ICU-delirium had a reduced survival up to four years after ICU discharge and this association was particularly evident in patients above 55 years of age.

Keywords: Delirium; Encephalopathy; ICU; Long-term survival.

Fig. 1

Flow chart. Inclusion and exclusion criteria. study population flow chart. ICU: intensive care unit, ICDSC: Intensive Care Delirium Screening Checklis,; SAPS II: Simplified Acute Physiology Score II, ICD: International Classification of Diseases

Fig. 2

Diagnostic Categories of ICU Admission. Pie chart illustrating the distribution of the study population according to the main diagnosis for ICU admission as coded with the ICD-10

Fig. 3

Forrest plot with OR and 95% CI for different factors associated with long term survival at 4 years after ICU-discharge. Y/N: yes/no, M/F: male/female, ICU-LOS: intensive care unit - length of stay, COPD: chronic obstructive pulmonary disease, OR: odds ratio, CI: confidence interval

Fig. 4

Survival analysis of patients in the ND and D group illustrated by Kaplan-Meier plots. A. Survival analysis for the study population. B.Ppatients between 45 and 54 years. C. Patients between 55 and 64 years. D. Patients aged ≥ 65 years. E. Mechanically ventilated patients. F Patients with malignancies. G Patients with acute respiratory failure. H. Patients with COPD. I. Patients with pre-existing dementia. J. Patients undergoing renal replacement therapy. ND: non-delirium group, D: delirium group, CI: confidence interval, COPD: chronic obstructive pulmonary disease