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Behrens LL, McGhan G, Abbott KM, Fick DM, Kolanowski AM, Liu Y, Buck HG, Roes M, Heid AR, Spector A, Van Haitsma K. Mapping Core Concepts of Person-Centered Care in Long-Term Services and Supports. J Gerontol Nurs 2019; 45:7-13. [PMID: 30690649 DOI: 10.3928/00989134-20190111-02] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Person-centered care (PCC) has a wide range of definitions, most based on expert opinion rather than empirical analysis. The current study used an empirical concept mapping approach to identify core components of PCC used in long-term services and supports (LTSS). The aim is to help providers and researchers develop a unified set of domains that can be used to assess and improve the quality of PCC in real-world settings. Results yielded six domains describing essential elements of PCC in LTSS: Enacting Humanistic Values, Direct Care Worker Values, Engagement Facilitators, Living Environment, Communication, and Supportive Systems; and two underlying dimensions: Intrapersonal Activities and Extrapersonal Services and Social and Physical Environment. Nurses can use the results to enhance clinical knowledge and skills around delivery of PCC. Researchers can use the results to build a comprehensive and unified measure to accelerate adoption of PCC practices shown to benefit older adults, families, and the LTSS workforce. [Journal of Gerontological Nursing, 45(2), 6-13.].
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Fick DM. Caring for Our Earth and Ourselves: Focusing Attention on Climate Change and Older Adults. J Gerontol Nurs 2019; 45:2-3. [PMID: 31651982 DOI: 10.3928/00989134-20191011-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Fong TG, Racine AM, Fick DM, Tabloski P, Gou Y, Schmitt EM, Hshieh TT, Metzger E, Bertrand SE, Marcantonio ER, Jones RN, Inouye SK. The Caregiver Burden of Delirium in Older Adults With Alzheimer Disease and Related Disorders. J Am Geriatr Soc 2019; 67:2587-2592. [PMID: 31605539 DOI: 10.1111/jgs.16199] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 08/27/2019] [Accepted: 09/02/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To measure the burden of delirium in older adults with or without Alzheimer disease or related disorders (ADRDs). DESIGN Prospective, observational cohort. SETTING Inpatient hospital and study participants' homes. PARTICIPANTS A subset (n = 267) of older medical and surgical patients and their caregivers enrolled in the Better Assessment of Illness study. MEASUREMENTS Delirium burden was measured using the DEL-B instrument (range = 0-40, with higher scores indicating greater burden) in caregivers (DEL-B-C) and patients 1 month after hospitalization. Severity of cognitive impairment (Montreal Cognitive Assessment [MoCA]), delirium presence (Confusion Assessment Method [CAM]), and delirium severity (CAM-Severity [CAM-S]) were measured during hospitalization and at 1-month follow-up. ADRD diagnosis was determined by a clinical consensus process. RESULTS For patients with (n = 56) and without (n = 211) ADRD, both DEL-B instruments had good internal consistency. DEL-B-C scores had a median (interquartile range) among caregivers of patients with and without ADRD of 9 (5-15) and 5 (1-11), respectively (P < .05). If the patient developed delirium, caregivers experienced greater burden (β[delirium × ADRD] = -.29; P = .42), regardless of ADRD status. Further, caregiver burden was modestly correlated with patient MoCA scores (Spearman correlation coefficient, ρ = -0.18; P = .01). Patients with ADRD who developed delirium self-reported less burden than those without ADRD (β[delirium × ADRD] = -.67; P = .044). As with caregivers, delirium burden was modestly correlated with patient MoCA score (ρ = -0.18; P = .005) and correlated with the CAM-S in patients without ADRD (ρ = 0.38; P < .001) but not for patients with ADRD (ρ = -0.07; P = .61). CONCLUSIONS Delirium resulted in the same degree of increased caregiver burden regardless of whether a patient had ADRD, signifying delirium is equally stressful to caregivers, even among those with experience caring for someone with a chronic cognitive disorder. Delirium burden is only modestly associated with degree of cognitive impairment, suggesting that other aspects of delirium contribute to burden. J Am Geriatr Soc 67:2587-2592, 2019.
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Massimo L, Xie SX, Rennert L, Fick DM, Halpin A, Placek K, Williams A, Rascovsky K, Irwin DJ, Grossman M, McMillan CT. Occupational attainment influences longitudinal decline in behavioral variant frontotemporal degeneration. Brain Imaging Behav 2019. [PMID: 29542053 DOI: 10.1007/s11682-018-9852-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
To evaluate whether occupational attainment influences the trajectory of longitudinal cognitive decline in behavioral variant frontotemporal degeneration (bvFTD). Single-center, retrospective, longitudinal study. Sixty-three patients meeting consensus criteria for bvFTD underwent evaluation at the University of Pennsylvania Frontotemporal Degeneration Center. All patients were studied longitudinally on letter-guided fluency, category-naming fluency and Boston Naming Test (BNT). Occupational attainment was defined categorically by assigning each individual's occupation to a professional or non-professional category. Linear mixed-effects models evaluated the interaction of neuropsychological performance change with occupational status. Regression analyses were used to relate longitudinal decline in executive function to baseline MRI grey matter atrophy. Higher occupational status was associated with a more severe slope of cognitive decline on letter-guided fluency and category-naming fluency, but not BNT. Faster rates of longitudinal decline on letter-guided and category-naming fluency were associated with more severe baseline grey matter atrophy in right dorsolateral and inferior frontal regions. Our longitudinal findings suggest that bvFTD individuals with higher lifetime cognitive experience demonstrate more rapid decline on measures of executive function. This finding converges with cross-sectional evidence suggesting that lifetime cognitive experiences contribute to heterogeneity in clinical progression in bvFTD.
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Fick DM. Aging and Disabilities: How to Age Well With Down Syndrome and Leave No One Behind. J Gerontol Nurs 2019; 45:2-4. [PMID: 31026325 DOI: 10.3928/00989134-20190410-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Steinman MA, Fick DM. Using Wisely: A Reminder on How to Properly Use the American Geriatrics Society Beers Criteria
®. J Gerontol Nurs 2019; 45:3-6. [DOI: 10.3928/00989134-20190211-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Steinman MA, Fick DM. Using Wisely: A Reminder on the Proper Use of the American Geriatrics Society Beers Criteria®. J Am Geriatr Soc 2019; 67:644-646. [PMID: 30693954 DOI: 10.1111/jgs.15766] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 12/18/2018] [Indexed: 01/21/2023]
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Jena AB, Chou JW, Yoon L, Aubry WM, Berger J, Burton W, Fendrick AM, Fick DM, Franklin D, Killion R, Lakdawalla DN, Neumann PJ, Patel K, Yee J, Sakurada B, Yu-Isenberg K. Understanding and improving value frameworks with real-world patient outcomes. THE AMERICAN JOURNAL OF MANAGED CARE 2018; 24:506-509. [PMID: 30452207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To provide recommendations that will improve approaches to measuring the value of new medical technologies to patients. STUDY DESIGN Informed discussion by experts after literature review. METHODS A working group was formed, and participants discussed how value frameworks should incorporate key features important to patients in evaluating new medical technologies, particularly for chronic diseases. RESULTS The working group suggests that new value frameworks should integrate real-world evidence to complement randomized controlled trials, incorporate the ways in which real-world behavior mediates outcomes, and explicitly discuss how therapies affect real-world equity and disparities in care. CONCLUSIONS Collective stakeholders that include key decision makers within our healthcare system need to recognize the importance of implementing real-world evidence and devote resources to further research into the chronic disease areas in which the impact of human behavior is amplified by the duration of disease and treatment.
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Fick DM. A Constant Learning Process: How Our Work Impacts Editors, Readers, Clinicians, and Scientists. J Gerontol Nurs 2018; 44:3-4. [PMID: 30257017 DOI: 10.3928/00989134-20180918-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Fick DM. The Critical Vital Sign of Cognitive Health and Delirium: Whose Responsibility Is It? J Gerontol Nurs 2018; 44:3-5. [DOI: 10.3928/00989134-20180713-03] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Fick DM, Inouye SK, McDermott C, Zhou W, Ngo L, Gallagher J, McDowell J, Penrod J, Siuta J, Covaleski T, Marcantonio ER. Pilot Study of a Two-Step Delirium Detection Protocol Administered By Certified Nursing Assistants, Physicians, and Registered Nurses. J Gerontol Nurs 2018; 44:18-24. [PMID: 29596707 DOI: 10.3928/00989134-20180302-01] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/26/2018] [Indexed: 01/08/2023]
Abstract
The feasibility and acceptability of a two-step screening protocol for delirium identification was pilot tested. Step 1, a screening tool, comprises two items: "Please tell me the day of the week," and "Please tell me the months of the year backwards starting with December." If either/both items are incorrect, Step 2, a 3-minute diagnostic assessment, follows. Trained researchers enrolled 24 hospitalized older adults and identified 22% to be delirious after a reference standard assessment. Thereafter, physicians and RNs completed the two-step protocol, whereas certified nursing assistants (CNAs) completed the screener only, on the same patients. All three clinical assessments were successfully completed in 100% of enrolled participants and within the target 2-hour time window in 91%. The screener and two-step protocol achieved high sensitivities and specificities in RNs, CNAs, and physicians. Qualitative information on barriers to and facilitators of implementation was also collected. Nurses and other clinicians can feasibly implement this ultra-brief screener and two-step protocol, which holds promise to improve delirium identification. [Journal of Gerontological Nursing, 44(5), 18-24.].
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Miller GE, Sarpong EM, Davidoff AJ, Yang EY, Brandt NJ, Fick DM. Determinants of Potentially Inappropriate Medication Use among Community-Dwelling Older Adults. Health Serv Res 2017; 52:1534-1549. [PMID: 27686781 PMCID: PMC5517671 DOI: 10.1111/1475-6773.12562] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine the determinants of potentially inappropriate medication (PIM) use. DATA SOURCES/STUDY SETTING U.S. nationally representative data on (n = 16,588) noninstitutionalized older adults (age ≥65) with drug use from the 2006-2010 Medical Expenditure Panel Survey. STUDY DESIGN We operationalized the 2012 Beers Criteria to identify PIM use during the year, and we examined associations with individual-level characteristics hypothesized to be quality enabling or related to need complexity. PRINCIPAL FINDINGS Almost one-third (30.9 percent) of older adults used a PIM. Multivariate results suggest that poor health status and high-PIM-risk conditions were associated with increased PIM use, while increasing age and educational attainment were associated with lower PIM use. Contrary to expectations, lack of a usual care source of care or supplemental insurance was associated with lower PIM use. Medication intensity appears to be in the pathway between both quality-enabling and need-complexity characteristics and PIM use. CONCLUSION Our results suggest that physicians attempt to avoid PIM use in the oldest old but have inadequate focus on the high-PIM-risk conditions. Educational programs targeted to physician practice regarding high-PIM-risk conditions and patient literacy regarding medication use are potential responses.
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Yevchak A, Fick DM, Kolanowski AM, McDowell J, Monroe T, LeViere A, Mion L. Implementing Nurse-Facilitated Person-Centered Care Approaches for Patients With Delirium Superimposed on Dementia in the Acute Care Setting. J Gerontol Nurs 2017; 43:21-28. [PMID: 28661543 DOI: 10.3928/00989134-20170623-01] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 05/23/2017] [Indexed: 11/20/2022]
Abstract
Little is understood about the use of person-centered care (PCC) for individuals with delirium superimposed on dementia (DSD), especially in the acute care setting. As part of a larger clinical trial, the purpose of the current exploratory study was to describe examples and qualitatively derived themes of nurse-facilitated PCC for hospitalized older adults with dementia and delirium. A total of 750 delirium rounds were analyzed across three diverse acute care sites. Qualitative derived themes of PCC included: (a) Knowing the Patient's Baseline; (b) Knowing the Patient's Interests and Values; (c) Enhancing Sensory Abilities to Communicate; (d) Individualizing Cognitive Stimulation; and (e) Enhancing Behavioral Approaches to Comfort and Sleep. Barriers included failure to see the patient as an individual and lack of time. Principles of PCC were effectively used, demonstrating the potential for PCC to ease the burden of DSD for all members of the health care team. [Journal of Gerontological Nursing, 43(12), 21-28.].
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Fick DM, Auerbach AD, Avidan MS, Busby-Whitehead J, Ely EW, Jones RN, Marcantonio ER, Needham DM, Pandharipande P, Robinson TN, Schmitt EM, Travison TG, Inouye SK. Network for Investigation of Delirium across the U.S.: Advancing the Field of Delirium with a New Interdisciplinary Research Network. J Am Geriatr Soc 2017. [PMID: 28631268 DOI: 10.1111/jgs.14942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fick DM, Auerbach AD, Avidan MS, Busby-Whitehead J, Ely EW, Jones RN, Marcantonio ER, Needham DM, Pandharipande P, Robinson TN, Schmitt EM, Travison TG, Inouye SK. Network for Investigation of Delirium Across the U.S. (NIDUS): Advancing the Field of Delirium with a New Interdisciplinary Research Network. J Gerontol Nurs 2017; 43:4-6. [PMID: 28448673 DOI: 10.3928/00989134-20170411-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Fick DM. Promoting Cognitive Health: Some Good News and a Brief Summary of the Institute of Medicine Report Cognitive Aging: Progress in Understanding and Opportunities for Action. J Gerontol Nurs 2016; 42:4-6. [PMID: 27337180 DOI: 10.3928/00989134-20160620-01] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Fick DM. The Power of Words: What Can We Learn From the Disabilities Movement? J Gerontol Nurs 2016. [DOI: 10.3928/00989134-20160522-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Semla TP, Fick DM. Reply to Lertxundi U et al. J Am Geriatr Soc 2016; 64:921-2. [DOI: 10.1111/jgs.14039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fick DM, Marcantonio ER. In response to "Preliminary development of an ultrabrief two-item bedside test for delirium". J Hosp Med 2016; 11:155. [PMID: 26669808 DOI: 10.1002/jhm.2524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 11/02/2015] [Indexed: 11/10/2022]
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Detroyer E, Dobbels F, Debonnaire D, Irving K, Teodorczuk A, Fick DM, Joosten E, Milisen K. The effect of an interactive delirium e-learning tool on healthcare workers' delirium recognition, knowledge and strain in caring for delirious patients: a pilot pre-test/post-test study. BMC MEDICAL EDUCATION 2016; 16:17. [PMID: 26768589 PMCID: PMC4714469 DOI: 10.1186/s12909-016-0537-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 01/05/2016] [Indexed: 05/30/2023]
Abstract
BACKGROUND Studies investigating the effectiveness of delirium e-learning tools in clinical practice are scarce. The aim of this study is to determine the effect of a delirium e-learning tool on healthcare workers' delirium recognition, delirium knowledge and care strain in delirium. METHODS A pilot pre-posttest study in a convenience sample of 59 healthcare workers recruited from medical, surgical, geronto-psychiatric and rehabilitation units of a university hospital. The intervention consisted of a live information session on how to use the e-learning tool and, a 2-month self-active learning program. The tool included 11 e-modules integrating knowledge and skill development in prevention, detection and management of delirium. Case vignettes, the Delirium Knowledge Questionnaire, and the Strain of Care for Delirium Index were used to measure delirium recognition, delirium knowledge and experienced care strain in delirium respectively. Subgroup analyses were performed for healthcare workers completing 0 to 6 versus 7 to 11 modules. RESULTS The delirium recognition score improved significantly (mean 3.1 ± SD 0.9 versus 2.7 ± 1.1; P = 0.04), and more healthcare workers identified hypoactive (P = 0.04) and hyperactive (P = 0.007) delirium in the posttest compared to the pretest phase. A significant difference in the change of recognition levels over time between the 0 to 6 and 7 to 11 module groups was demonstrated (P = 0.03), with an improved recognition level in the posttest phase within the 7 to 11 module group (P = 0.007). After adjustment for potential confounders, this difference in the change over time was not significant (P = 0.07) and no change in recognition levels within the 7 to 11 module group was noted (P = 0.19). The knowledge score significantly improved in the posttest compared to the pretest phase (mean 31.7 ± SD2.6 versus 28.3 ± 4.5; P < 0.001), with a significant increased level within the 7 to 11 module group (unadjusted P < 0.001/adjusted P = 0.02). Overall, no difference between posttest and pretest phases was documented for care strain (P = 0.46). CONCLUSION The e-learning tool improved healthcare workers' delirium recognition and knowledge. The effect of the tool is related to its level of completion, but was less explicit after controlling for potential confounders and warrants further investigation. The level of strain did not improve.
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Kolanowski A, Mogle J, Fick DM, Campbell N, Hill N, Mulhall P, Behrens L, Colancecco E, Boustani M, Clare L. Anticholinergic Exposure During Rehabilitation: Cognitive and Physical Function Outcomes in Patients with Delirium Superimposed on Dementia. Am J Geriatr Psychiatry 2015; 23:1250-1258. [PMID: 26419732 PMCID: PMC4691545 DOI: 10.1016/j.jagp.2015.07.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/09/2015] [Accepted: 07/09/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES We examined the association between anticholinergic medication exposure and subsequent cognitive and physical function in patients with delirium superimposed on dementia during rehabilitation. We also examined length of stay and discharge disposition by anticholinergic medication exposure. DESIGN In this secondary analysis we used control group data from an ongoing randomized clinical trial. SETTING/PARTICIPANTS Participants with delirium and dementia were enrolled at admission to post-acute care. These 99 participants had a mean age of 86.11 (±6.83) years; 67.6% were women; 98% were Caucasian; and 33% were positive for at least one APOE e4 allele. MEASURES We obtained daily measures of cognitive and physical function using: Digit Span; memory, orientation and attention items from the Montreal Cognitive Assessment; CLOX; the Confusion Assessment Method; and the Barthel Index. Anticholinergic medication exposure was measured weekly using the Anticholinergic Cognitive Burden Scale. RESULTS Using multilevel models for time we found that greater use of clinically relevant anticholinergic medications in the previous week reduced cognitive and physical function, as measured by Digit Span Backwards and the Barthel index, in the current week. There was no effect of anticholinergic medication use on delirium severity, and APOE status did not moderate any outcomes. Greater use of clinically relevant anticholinergic medications was related to longer length of stay but not discharge disposition. CONCLUSIONS For vulnerable older adults, anticholinergic exposure represents a potentially modifiable risk factor for poor attention, working memory, physical function, and greater length of stay during rehabilitation.
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Steis MR, Behrens L, Colancecco EM, Mogle J, Mulhall PM, Hill NL, Fick DM, Kolankowski AM. Licensed Nurse and Nursing Assistant Recognition of Delirium in Nursing Home Residents With Dementia. THE ANNALS OF LONG-TERM CARE : THE OFFICIAL JOURNAL OF THE AMERICAN MEDICAL DIRECTORS ASSOCIATION 2015; 23:15-20. [PMID: 28042285 PMCID: PMC5193367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Many nursing home residents experience delirium. Nursing home personnel, especially nursing assistants, have the opportunity to become familiar with residents' normal cognitive function and to recognize changes in a resident's cognitive function over time. The purpose of this study was to determine the accuracy of delirium recognition by licensed nurses and nursing assistants from eight nursing homes over a 12-month period. Participants were asked to complete five case vignette assessments at three different time points (in 6-month intervals) to test their ability to identify different subtypes of delirium and delirium superimposed on dementia (DSD). A total of 760 case vignettes were completed across the different time points. Findings reveal that staff recognition of delirium was poor. The case vignette describing hyperactive DSD was correctly identified by the greatest number participants, and the case vignette describing hypoactive DSD was correctly identified by the least number of participants. Recognition of the case vignette describing hypoactive delirium improved over time. Nursing assistants performed similarly to the licensed nurses, indicating that all licensed nursing home staff require further education to correctly recognize delirium in older adults.
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Fick DM, Inouye SK, Guess J, Ngo LH, Jones RN, Saczynski JS, Marcantonio ER. Preliminary development of an ultrabrief two-item bedside test for delirium. J Hosp Med 2015; 10:645-50. [PMID: 26369992 PMCID: PMC4665114 DOI: 10.1002/jhm.2418] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 06/04/2015] [Accepted: 06/09/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Delirium is common, morbid, and costly, yet is greatly under-recognized among hospitalized older adults. OBJECTIVE To identify the best single and pair of mental status test items that predict the presence of delirium. DESIGN, SETTING Diagnostic test evaluation study that enrolled medicine inpatients aged 75 years or older at an academic medical center. METHODS Patients underwent a clinical reference standard assessment involving a patient interview, medical record review, and interviews with family members and nurses to determine the presence or absence of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition defined delirium. Participants also underwent the three-dimensional Confusion Assessment Method (3D-CAM), a brief, validated assessment for delirium. Individual items and pairs of items from the 3D-CAM were evaluated to determine sensitivity and specificity relative to the reference standard delirium diagnosis. RESULTS Of the 201 participants (mean age 84 years, 62% female), 42 (21%) had delirium based on the clinical reference standard. The single item with the best test characteristics was "months of the year backwards" with a sensitivity of 83% (95% confidence interval [CI]: 69%-93%) and specificity of 69% (95% CI: 61%-76%). The best 2-item screen was the combination of "months of the year backwards" and "what is the day of the week?" with a sensitivity of 93% (95% CI: 81%-99%) and specificity of 64% (95% CI: 56%-70%). CONCLUSIONS We identified a single item with >80% and pair of items with >90% sensitivity for delirium. If validated prospectively, these items will serve as an initial innovative screening step for delirium identification in hospitalized older adults.
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