High Burden of Delirium and Pain in the ICU
Delirium and pain are ubiquitous challenges in the management of critically ill patients, frequently associated with adverse clinical outcomes, including prolonged mechanical ventilation, increased length of stay, long-term cognitive impairment, and higher mortality. Despite the evolution of intensive care practices, these conditions often remain under-recognized or inadequately managed. The publication of the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium (PAD) marked a pivotal shift toward evidence-based strategies, emphasizing the importance of routine monitoring and the ‘analgesia-first’ approach.
Recent evidence, however, suggests a need to re-evaluate the current landscape. A significant secondary analysis of a large-scale systematic review and meta-analysis led by Leong et al. (2025) provides a contemporary look at the prevalence and incidence of these conditions, offering a critical benchmark for critical care providers worldwide.
Methodological Framework of the Study
This study represents a secondary analysis of a prior systematic review (PROSPERO ID: CRD42022367715). The researchers conducted a rigorous search across MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials, covering literature from inception through May 15, 2023.
Study Selection and Data Synthesis
From an initial pool of 517 full-text articles, the authors included 213 original studies spanning 226 publications, representing a massive cohort of 183,285 patients. The eligibility criteria focused on randomized or observational studies of critically ill adults that reported the incidence or prevalence of delirium or pain. To ensure statistical robustness, proportion data were transformed using the Freeman-Tukey double arcsine method before being pooled in a random effects meta-analysis model. The risk of bias was meticulously assessed using the Joanna Briggs Institute prevalence checklist.
Key Findings: Prevalence, Subtypes, and Temporal Trends
The meta-analysis yielded high-level evidence regarding the current state of delirium and pain in intensive care units globally.
Delirium Prevalence and Incidence
Based on 173 studies, the pooled prevalence of delirium was 35.7% (95% CI 32.4–39.0%). When examining incidence (new cases occurring during the ICU stay), the pooled rate was 28.8% (95% CI 23.2–34.8%) across 41 studies. This indicates that more than one in three patients admitted to the ICU will experience delirium during their stay.
The Challenge of Hypoactive Delirium
One of the most significant findings was the distribution of delirium subtypes. Hypoactive delirium was identified as the most common subtype, with a prevalence of 16.5% (95% CI 12.1–21.4%). This is clinically significant because hypoactive delirium is often ‘silent’ and frequently missed during routine clinical rounds compared to the more disruptive hyperactive subtype.
Pain Prevalence
Pain remains a major concern, with a pooled prevalence of 43.5% (95% CI 28.6–58.9%) across 11 studies. This high figure underscores the ongoing necessity for systematic pain assessment tools, particularly for patients who cannot self-report due to mechanical ventilation or sedation.
The Impact of 2013 PAD Guidelines
A critical component of this study was the temporal analysis comparing data before and after the publication of the 2013 PAD guidelines. The results suggest that standardized guidelines are indeed changing clinical practice.
Reduction in Delirium
Delirium prevalence significantly decreased from 39.9% (pre-2013) to 32.3% (post-2013), with a p-value of 0.02. Interestingly, delirium incidence did not show a statistically significant decrease, suggesting that while fewer patients may have delirium at any given point, the rate of new onset cases remains a persistent hurdle.
Significant Decline in Pain
Perhaps the most striking finding was the reduction in pain prevalence. Before the 2013 guidelines, pain prevalence was estimated at 64.6%. Post-2013, this figure dropped to 35.8% (p = 0.046). This nearly 30% reduction highlights the success of ‘analgesia-first’ protocols and the more widespread adoption of validated pain scales like the Critical-Care Pain Observation Tool (CPOT).
Clinical Commentary and Mechanistic Insights
The findings by Leong et al. provide both encouragement and a call to action. The decline in delirium and pain prevalence is likely a direct result of the ‘ABCDEF’ bundle implementation (Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia and Sedation; Delirium Monitoring and Management; Early Mobility; and Family Engagement).
The Persistence of Hypoactive Delirium
Despite these improvements, the high rate of hypoactive delirium remains a diagnostic blind spot. Unlike the agitated patient who requires immediate intervention, the hypoactive patient may appear ‘calm’ or ‘sleepy,’ while suffering from significant neurocognitive dysfunction. This study reinforces the need for mandatory, twice-daily screening using validated tools like the CAM-ICU or the Intensive Care Delirium Screening Checklist (ICDSC).
Limitations and Generalizability
While the study is comprehensive, the authors acknowledge the heterogeneity of the included studies. Variability in ICU types (medical vs. surgical), patient acuity, and the specific assessment tools used across different centers may influence the pooled results. However, the sheer volume of the data (over 180,000 patients) lends substantial weight to the conclusions.
Conclusion
The meta-analysis confirms that while we have made significant strides in reducing the burden of delirium and pain in the ICU since 2013, these conditions still affect nearly half of all patients. The persistent prevalence of hypoactive delirium suggests that our monitoring efforts must become even more rigorous. For the clinician, these data serve as a reminder that the implementation of standardized bundles is not merely a bureaucratic requirement but a proven intervention that significantly reduces patient morbidity.
Reference
Leong AY, Edginton S, Lee LA, Jaworska N, Burry L, Fiest KM, Doig CJ, Niven DJ. Prevalence and incidence of ICU delirium and pain: a systematic review and meta-analysis. Intensive Care Med. 2025 Nov;51(11):2093-2103. doi: 10.1007/s00134-025-08167-7 IF: 21.2 Q1 . Epub 2025 Oct 21. PMID: 41117943 IF: 21.2 Q1
