Translation and Validation of the Tibetan Confusion Assessment Method for the Intensive Care Unit
Delirium is a significant clinical condition characterized by acute confusion, inattention, disorganized thinking, and altered levels of consciousness. It is a common complication among patients in intensive care units (ICUs), with incidence rates ranging from 16% to 87%, and even higher in elderly and mechanically ventilated patients. Delirium not only prolongs ICU and hospital stays but also increases healthcare costs and the risk of long-term cognitive impairment. Moreover, patients with delirium have a higher mortality rate compared to those without. Given these serious implications, the Society of Critical Care Medicine (SCCM) guidelines recommend routine screening and assessment for delirium in ICU patients.
Among the various tools developed for delirium assessment, the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is one of the most widely used. CAM-ICU, developed by Ely et al., is a simple, reliable, and valid tool for assessing ICU delirium. It is particularly useful for patients with speech impairments due to endotracheal intubation or tracheotomy. The tool has high specificity (98%–100%) and sensitivity (93%–100%) and can be administered by non-psychiatrists with minimal training, taking only a few minutes to complete. Due to its effectiveness, CAM-ICU has been translated into over 40 languages. However, a Tibetan version of the CAM-ICU was not available, limiting its use in Tibet, where approximately 3.31 million people speak Tibetan. This study aimed to translate and validate the CAM-ICU for practical use in Tibetan ICU settings.
The study was conducted between July 2018 and November 2018 at the Tibet Autonomous Region People’s Hospital, an 800-bed university-affiliated teaching hospital with 18 adult ICU beds. The study population included adult ICU patients who were hospitalized for more than 24 hours and could understand the Tibetan language. Patients with preexisting psychosis or neurologic disease, those who were comatose or moribund, those diagnosed with delirium before assessment and prescribed antipsychotics, those with a history of vision or hearing impairment, and those who refused informed consent were excluded from the study.
The CAM-ICU was translated into Tibetan by native Tibetan speakers proficient in English, following the guidelines recommended by the Translation and Cultural Adaptation group. The translation process involved independent translations by the authors, followed by discussions to finalize the Tibetan version. The final version was back-translated into English by a professional translator and sent to the original author, E. Wesley Ely, for approval. The Tibetan version of the CAM-ICU (Tibetan CAM-ICU) was made available on the international website for medical professionals.
To validate the Tibetan CAM-ICU, two study nurses independently assessed delirium in the enrolled patients using the Tibetan CAM-ICU. A neurologist with more than 10 years of experience independently assessed delirium using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria as the reference standard. All assessments were conducted between 10:00 AM and 1:00 PM to avoid bias due to changes in patients’ conditions.
A total of 268 consecutive patients were admitted to the ICU during the study period. After applying the exclusion criteria, 96 patients were included in the study. According to the DSM-IV criteria, 42 out of 96 (43.8%) patients developed delirium. The sensitivities of the Tibetan CAM-ICU were 90.5% for nurse 1 and 92.9% for nurse 2, while their specificities were 85.2% and 90.7%, respectively. The positive predictive values (PPV) were 82.6% for nurse 1 and 88.6% for nurse 2, and the negative predictive values (NPV) were 92.0% and 94.2%, respectively. The Tibetan CAM-ICU demonstrated good interrater reliability between nurse 1 and nurse 2, with a kappa coefficient of 0.91.
The study results showed that the Tibetan CAM-ICU had high sensitivity and specificity against the DSM-IV reference raters, making it a valid and reliable tool for delirium assessment in Tibetan ICU patients. The tool’s high interrater reliability further supports its use in clinical practice. However, the study had some limitations. More than half of the patients were excluded due to preexisting psychosis or neurologic disease, and the study did not have detailed clinical information on these patients. Additionally, the study used DSM-IV instead of DSM-V criteria as the reference standard, and future research could explore the diagnostic relevance of different criteria.
The translation and validation of the Tibetan CAM-ICU is a significant achievement for the national aid medical team in Tibet. With the help of professors from Peking Union Medical College Hospital (PUMCH), the local medical team at Tibet Autonomous Region People’s Hospital (TARPH) translated the CAM-ICU into Tibetan and made it available on the international website for the first time. This development sets an example for the professional advancement of critical care medicine in the Tibet autonomous region.
In conclusion, the Tibetan version of the CAM-ICU is a valid, reliable, and feasible tool for delirium assessment in Tibetan ICU patients. Its availability will facilitate the implementation of delirium screening in Tibetan-speaking ICU inpatients and potentially improve patient outcomes. The study underscores the importance of culturally adapted tools in healthcare and highlights the collaborative efforts in advancing medical practices in underserved regions.
doi.org/10.1097/CM9.0000000000000168
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