Detecting delirium among hospitalized older patients

Diagnostic Approach to the Patient with Altered Mental Status

Acute encephalopathy is a common presenting symptom in the emergency room and complicates many hospital and intensive care unit admissions. The evaluation of patients with encephalopathy poses several challenges: limited history and examination due to the patient's mental status, broad differential diagnosis of systemic and neurologic etiologies, low yield of neurodiagnostic testing due to the high base rate of systemic causes, and the importance of identifying less common neurologic causes of encephalopathy that can be life-threatening if not identified and treated. This article discusses the differential diagnosis of acute encephalopathy, presents an approach to the history and examination in a patient with encephalopathy, reviews the literature on the yield of neurodiagnostic testing in this population, and provides a diagnostic framework for the evaluation of patients with altered mental status.

Delirium assessment tools among hospitalized older adults: A systematic review and metaanalysis of diagnostic accuracy

Delirium is a common neuropsychiatric syndrome that is often overlooked in clinical settings. The most accurate instrument for screening delirium has not been established. This study aimed to compare the diagnostic accuracy of the 4 'A's Test (4AT), Nursing Delirium Screening Scale (Nu-DESC), and Confusion Assessment Method (CAM) in detecting delirium among older adults in clinical settings. These assessment tools feature concise item sets and straightforward administration procedures. Five electronic databases were systematically searched from their inception to September 7, 2022. Studies evaluating the sensitivity and specificity of the 4AT, Nu-DESC, and CAM against the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases as the reference standard were included. Bivariate random effects model was used to summarize the sensitivity and specificity results. A total of 38 studies involving 7378 patients were included. The 4AT, Nu-DESC, and CAM had comparable sensitivity in detecting delirium (0.76, 0.78, and 0.80, respectively). However, the specificity of the CAM was higher than that of the 4AT (0.98 vs 0.89, P = .01) and Nu-DESC 0.99 vs 0.90, P = .003). Diagnostic accuracy was moderated by the percentage of women, acute care setting, sample size, and assessors. The three tools exhibit comparable sensitivity, and the CAM has the highest specificity. Based on the feasibility of the tools, nurses and clinical staffs could employ the Nu-DESC and the 4AT on screening out positive delirium cases and integrate these tools into daily practice. Further investigations are warranted to verify our findings.

Translational cognitive systems: focus on attention

Cognitive dysfunction, particularly attentional impairment, is a core feature of many psychiatric disorders, yet is inadequately addressed by current treatments. Development of targeted therapeutics for the remediation of attentional deficits requires knowledge of underlying neurocircuit, cellular, and molecular mechanisms that cannot be directly assayed in the clinic. This level of detail can only be acquired by testing animals in cross-species translatable attentional paradigms, in combination with preclinical neuroscience techniques. The 5-choice continuous performance test (5C-CPT) and rodent continuous performance test (rCPT) represent the current state of the art of preclinical assessment of the most commonly studied subtype of attention: sustained attention, or vigilance. These tasks present animals with continuous streams of target stimuli to which they must respond (attention), in addition to non-target stimuli from which they must withhold responses (behavioral inhibition). The 5C-CPT and rCPT utilize the same measures as gold-standard clinical continuous performance tests and predict clinical efficacy of known pro-attentional drugs. They also engage common brain regions across species, although efforts to definitively establish neurophysiological construct validity are ongoing. The validity of these tasks as translational vigilance assessments enables their use in characterizing the neuropathology underlying attentional deficits of animal models of psychiatric disease, and in determining therapeutic potential of drugs ahead of clinical testing. Here, we briefly review the development and validation of such tests of attentional functioning, as well as the data they have generated pertaining to inattention, disinhibition, and impulsivity in psychiatric disorders.

The Thai version of the nursing delirium screening scale-Thai: Adaptation and validation study in postoperative patients

Background

The Nursing Delirium Screening Scale (Nu-DESC) is an effective instrument for assessing postoperative delirium (POD). This study translated the Nu-DESC into Thai (“Nu-DESC-Thai”), validated it, and compared its accuracy with the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5).

Methods

The translation process followed the International Society for Pharmacoeconomics Outcome Research guidelines. Recruited participants were ≥ 70 years old, fluent in Thai, and scheduled for surgery. The exclusion criteria were cancellation or postponement of an operation, severe visual or auditory impairment, and patients with a Richmond Agitation Sedation Scale score of –4 or less before delirium assessment. Post-anesthesia care unit (PACU) nurses and residents on wards each used the Nu-DESC to assess delirium in 70 participants (i.e., 140 assessments) after the operation and after patient arrival at wards, respectively. Geriatricians confirmed the diagnoses using video observations and direct patient contact.

Results

The participants’ mean age was 76.5 ± 4.6 years. The sensitivity and specificity of the Nu-DESC-Thai at a threshold of ≥ 2 were 55% (95% CI, 31.5–76.9%) and 90.8% (84.2–95.3%), respectively, with an area under a receiver operating characteristic curve (AUC) of 0.73. At a threshold of ≥ 1, the sensitivity and specificity were 85% (62.1–96.8%) and 71.7% (62.7–79.5%), respectively (AUC, 0.78). Adding 1 point for failing backward-digit counting (30–1) to the Nu-DESC-Thai and screening at a threshold of ≥ 2 increased its sensitivity to 85% (62.1–96.8%) with the same specificity of 90.8% (84.2–95.3%).

Conclusion

The Nu-DESC-Thai showed good validity and reliability for postoperative use. Its sensitivity was inadequate at a cutoff ≥ 2. However, the sensitivity improved when the threshold was ≥ 1 or with the addition of backward counting to Nu-DESC-Thai and screening at a threshold of ≥ 2.

Incidence, predictors and health outcomes of delirium in very old hospitalized patients: a prospective cohort study

Background

Delirium is a common complication that leads to poor health outcomes in older patients undergoing treatment. Due to severe consequences, early recognition of high-risk patients and risk factors for delirium are crucial in the prompt initiation of prevention measures. However, research in medically hospitalized patients aged ≥80 years remains limited. This study aimed to determine the incidence, predictors and health outcomes of delirium in very old (aged ≥80 years) hospitalized patients in China.

Methods

A prospective study was conducted in individuals aged ≥80 years admitted to geriatric departments. Potential risk factors were assessed within 24 h after hospital admission. Screening for delirium was performed on admission and every 48 h thereafter for 14 days and assessed if acute mental status changes were observed. During hospitalization, health outcomes were recorded daily.

Results

Incident delirium occurred in 109 of 637 very old hospitalized patients (17.1%). The independent predictors of delirium in hospitalized patients aged 80 and over were cognitive function impairment [OR 17.42, 95% CI:(7.47–40.64)], depression [OR 9.30, 95% CI: (4.59–18.84)], CCI ≥ 5 [OR 4.21, 95% CI: (1.48–12.01)], sleep deprivation [OR 3.89, 95% CI: (1.71–8.82)], infection [OR 3.33, 95% CI: (1.70–6.54)], polypharmacy (≥5 medications) [OR 2.85, 95% CI: (1.51–5.39)], constipation [OR 2.58, 95% CI: (1.33–5.02)], and emergency admission [OR 2.13, 95% CI: (1.02–4.45)]. Patients with delirium had significantly longer hospital stays(P < 0.001) and higher percentages of physical restraint use(P < 0.001) and falls (P = 0.001) than those without delirium,.

Conclusion

The incidence of delirium was high in hospitalized patients aged ≥80 years admitted to the geriatric department and was associated with prolonged hospital stay and higher rates of physical restraint use and falls. In this population, the most important independent risk factors for incident delirium were cognitive function impairment and depression. Health care professionals should recognize and initiate interventions for delirium early in geriatric patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02932-9.

The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study

BACKGROUND

Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost.

METHODS

Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted.

RESULTS

Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067.

LIMITATIONS

Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness.

CONCLUSIONS

These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years.

FUTURE WORK

Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN53388093.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.

Plasma biomarkers of inflammation, coagulation, and brain injury as predictors of delirium duration in older hospitalized patients

Background

Delirium's pathophysiology is poorly understood. We sought to determine if plasma biomarkers of inflammation, coagulation, endothelial activation, and blood brain barrier (BBB) injury were associated with emergency department (ED) delirium duration.

Methods

We enrolled hospitalized patients who were 65 years or older from the ED. Plasma biomarkers of inflammation (interleukin-6 [IL-6], IL-8, soluble tumor necrosis factor receptor I [sTNFRI]), coagulation (Protein C), endothelial activation (plasminogen activating inhibitor-1 [PAI-1]), and BBB injury (S100B) at were measured using blood obtained at enrollment. The dependent variable was ED delirium duration which was determined by the Brief Confusion Assessment Method assessed in the ED and hospitalization. Proportional odds logistic regression analyses were performed adjusted for relevant confounders and allowing for interaction by baseline dementia status.

Results

A total of 156 patients were enrolled. IL-6 (POR = 1.59, 95%CI: 1.09–2.32) and PAI-1 (POR = 2.96, 95%CI: 1.48 to 6.85) were independently associated with more prominent ED delirium duration in subjects without dementia only. No significant associations between IL-8, Protein C, sTNRFI, and S100B and ED delirium duration were observed.

Conclusions

Plasma Biomarkers of systemic inflammation and endothelial activation are associated with ED delirium duration in older ED patients without dementia.

Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method

BACKGROUND

Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 'A's Test (4AT, www.the4AT.com ) is a short delirium assessment tool designed for routine use without special training. The primary objective was to assess the accuracy of the 4AT for delirium detection. The secondary objective was to compare the 4AT with another commonly used delirium assessment tool, the Confusion Assessment Method (CAM).

METHODS

This was a prospective diagnostic test accuracy study set in emergency departments or acute medical wards involving acute medical patients aged ≥ 70. All those without acutely life-threatening illness or coma were eligible. Patients underwent (1) reference standard delirium assessment based on DSM-IV criteria and (2) were randomised to either the index test (4AT, scores 0-12; prespecified score of > 3 considered positive) or the comparator (CAM; scored positive or negative), in a random order, using computer-generated pseudo-random numbers, stratified by study site, with block allocation. Reference standard and 4AT or CAM assessments were performed by pairs of independent raters blinded to the results of the other assessment.

RESULTS

Eight hundred forty-three individuals were randomised: 21 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome, and 785 were included in the analysis. Mean age was 81.4 (SD 6.4) years. 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT had an area under the receiver operating characteristic curve of 0.90 (95% CI 0.84-0.96). The 4AT had a sensitivity of 76% (95% CI 61-87%) and a specificity of 94% (95% CI 92-97%). The CAM had a sensitivity of 40% (95% CI 26-57%) and a specificity of 100% (95% CI 98-100%).

CONCLUSIONS

The 4AT is a short, pragmatic tool which can help improving detection rates of delirium in routine clinical care.

TRIAL REGISTRATION

International standard randomised controlled trial number (ISRCTN) 53388093 . Date applied 30/05/2014; date assigned 02/06/2014.

Attention, arousal and other rapid bedside screening instruments for delirium in older patients: a systematic review of test accuracy studies

Objective

delirium occurs frequently in frail patients but is easily missed. Screening with a rapid, easy-to-use and highly sensitive instrument might help improve recognition. The aim of this study was to review attention, arousal and other rapid bedside screening instruments for delirium in older patients.

Methods

a literature search was performed in PubMed, PsycINFO and Embase. We scrutinized forward citations in Google Scholar, and references of included articles and prior reviews. We included studies among older patients that investigated the sensitivity and specificity of delirium screening instruments that could be administered in 3 min or less, and did not require surrogate information. We extracted study characteristics, risk of bias, sensitivity and specificity.

Results

we identified 27 studies among 4,766 patients in hospitals and nursing homes. They tested many different single and several combined screening instruments. Prevalence of delirium varied between 4% and 57%. Only one study scored a low risk of bias on all domains. Sensitivity varied between 17% and 100%, and specificity between 38% and 99%. Of the 22 tests with sensitivity ≥90%, seven also had specificity ≥80% in older patients in general. These results were approximately reproduced for the Observational Scale of Level of Arousal (OSLA) and Richmond Agitation and Sedation Scale (RASS): sensitivity and specificity were >80%.

Conclusion

two arousal tests-OSLA and RASS-had reproduced high sensitivity and specificity in older patients. Nurses can administer these tests during daily interaction with patients. Test accuracy studies about rapid screening tools for delirium superimposed on dementia were scarce.

Five short screening tests in the detection of prevalent delirium: diagnostic accuracy and performance in different neurocognitive subgroups

BACKGROUND

Delirium is prevalent and serious, yet remains under-recognised. Systematic screening could improve detection; however, consensus is lacking as to the best approach. Our aim was to assess the diagnostic accuracy of five simple cognitive tests in delirium screening: six-item cognitive impairment test (6-CIT), clock-drawing test, spatial span forwards, months of the year backwards (MOTYB) and intersecting pentagons (IPT).

METHODS

A cross-sectional study was conducted. Within 36 h of admission, older medical patients were assessed for delirium using the Revised Delirium Rating Scale. They also underwent testing using the five cognitive tests outlined above. Sensitivity, specificity, positive and negative predictive values (PPV; NPV) were calculated for each method. Where appropriate, area under the receiver operating characteristic curve (AUC) was also calculated.

RESULTS

Four hundred seventy patients were included, and 184 had delirium. Of the tests scored on a scale, the 6-CIT had the highest AUC (0.876), the optimum cut-off for delirium screening being 8/9 (sensitivity 89.9%, specificity 62.7%, NPV 91.2%, PPV 59.2%). The MOTYB, scored in a binary fashion, also performed well (sensitivity 84.6%, specificity 58.4%, NPV 87.4%, PPV 52.8). On discriminant analysis, 6-CIT was the only test to discriminate between patients with delirium and those with dementia (without delirium), Wilks' Lambda = 0.748, p < 0.001.

CONCLUSION

The 6-CIT measures attention, temporal orientation and short-term memory and shows promise as a delirium screening test. This study suggests that it may also have potential in distinguishing the cognitive impairment of delirium from that of dementia in older patients. Copyright © 2016 John Wiley & Sons, Ltd.

Pre-admission functional decline in hospitalized persons with dementia: The influence of family caregiver factors

Older adults with dementia are more likely than those who do not have dementia to be hospitalized. Admission functional (ADL) performance is a salient factor predicting functional performance in older adults at discharge. The days preceding hospitalization are often associated with functional loss related to the acute illness. An understanding of functional changes during this transition will inform interventions to prevent functional decline. This secondary analysis examined data from a study that evaluated a family educational empowerment model and included 136 dyads (persons with dementia and their family caregiver). AMOS structural equation modeling examined the effects of family caregiver factors upon change in patient ADL performance (Barthel Index) from baseline (two week prior to hospitalization) to the time of admission, controlling for patient characteristics. Eighty-two percent of the patients had decline prior to admission. Baseline function, depression, and dementia severity, as well as Family caregiver strain, were significantly associated with change in pre-admission ADL performance and explained 40% of the variance. There was a good fit of the model to the data (Χ²⁼12.9, p=0.305, CFI=0.97, TLI=0.90, RMSEA=0.05). Findings suggest the need for a function-focused approach when admitting patients with dementia to the hospital. FCG strain prior to hospitalization may be a factor impacting trajectory of functional changes in older person with dementia, especially in those with advanced dementia. FCG strain is an important assessment parameter in the risk assessment for functional decline, to be considered when engaging the FCG in the plan for functional recovery.

Validation of a Nurse-Based Delirium-Screening Tool for Hospitalized Patients

BACKGROUND

Guidelines recommend daily delirium monitoring of hospitalized patients. Available delirium-screening tools have not been validated for use by nurses among diverse inpatients.

OBJECTIVE

We sought to validate the Nursing Delirium-Screening Scale (Nu-DESC) under these circumstances.

METHODS

A blinded cross-sectional and quality-improvement study was conducted from August 2015-February 2016. Nurses׳ Nu-DESC scores were compared to delirium diagnosis according to Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) criteria. A total of 405 consecutive hospitalized patients were included. Nu-DESC-positive (threshold score ≥2) patients were matched with equal numbers of Nu-DESC-negative patients, by sex, age, and nursing unit. Nurses recorded a Nu-DESC score for each patient on every 12-hour shift. A Nu-DESC-blinded evaluator interviewed patients for 2 consecutive days. Delirium diagnosis was determined by physicians using DSM-5 criteria applied to collected research data. Sensitivity and specificity of the Nu-DESC were calculated. In an exploratory analysis, the performance of the Nu-DESC was analyzed with the addition of bedside measures of attention.

RESULTS

The sensitivity of the Nu-DESC at a threshold of ≥2 was 42% (95% CI: 33-53%). Specificity was 98% (97-98%). At a threshold of ≥1, sensitivity was 67% (52-80%) and specificity 93% (90-95%). Similar results were found with the addition of attention tasks.

CONCLUSION

The Nu-DESC is a specific delirium detection tool, but it is not sensitive at the usually proposed cut point of ≥2. Using a threshold of ≥1 or adding a test of attention increase sensitivity with a minor decrease in specificity.

Exploring Delirium's Heterogeneity: Association Between Arousal Subtypes at Initial Presentation and 6-Month Mortality in Older Emergency Department Patients

OBJECTIVES

To determine how delirium subtyped by level of arousal at initial presentation affects 6-month mortality.

DESIGN

This was a preplanned secondary analysis of two prospective cohort studies.

SETTING

Academic tertiary care emergency department (ED).

PARTICIPANTS

1,084 ED patients who were 65 years old or older.

MEASUREMENTS

At the time of enrollment, trained research personnel performed the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation Sedation Score to determine delirium and level of arousal, respectively. Patients were categorized as having no delirium, delirium with normal arousal, delirium with decreased arousal, or delirium with increased arousal. Death was ascertained by medical record review and the Social Security Death Index. Cox proportional hazard regression was used to analyze the association between delirium arousal subtypes and 6-month mortality.

RESULTS

Delirium with normal arousal was the only subtype that was significantly associated with increased 6-month mortality (hazard ratio [HR]: 3.1, 95% confidence interval [CI]: 1.3-7.4) compared with the no delirium group after adjusting for confounders. The HRs for delirium with decreased and increased arousal were 1.4 (95% CI: 0.9-2.1) and 1.3 (95% CI: 0.3-5.4), respectively.

CONCLUSIONS

Delirious ED patients with normal arousal at initial presentation had a threefold increased hazard of death within 6 months compared with patients without delirium. There was a trend towards increased hazard of death in delirious ED patients with decreased arousal, but this relationship did not reach statistical significance. These data suggest that subtyping delirium by arousal may have prognostic value but requires confirmation with a larger study.

Psychometric properties and feasibility of instruments for the detection of delirium in older hospitalized patients: a systematic review

OBJECTIVE

Delirium is a serious and common complication among older hospitalized patients and is a predictor of many adverse outcomes. However, up to 72% of delirium incidents are unrecognized or misdiagnosed. The aim of this systematic review is to determine the validity, reliability, and feasibility of instruments for the detection of delirium in older hospitalized patients.

METHODS

A systematic literature search was conducted. The inclusion criteria were a mean or median age of 65+ years, the use of the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases-10 as a reference standard, and publication in English. All included studies underwent a quality assessment (QUADAS-2).

RESULTS

Forty-three of the 3.790 identified studies were relevant to the review, describing 28 instruments. Quality assessment resulted in 37 studies with a positive quality assessment, describing 23 instruments. Five instruments (Delirium Observation Scale (DOS), Nursing Delirium Screening Scale (Nu-DESC), Confusion Assessment Method (CAM), CAM-Intensive Care Unit (ICU), and Delirium Rating Scale-Revised-98) were described in three or more methodologically sound studies. The Delirium Observation Screening Scale (DOS) and Nu-DESC are observational instruments with good psychometric properties, but the Nu-DESC is shorter and has been validated in more languages. The CAM, CAM-ICU, and Delirium Rating Scale-Revised-98 (DRS-R-98) are instruments with both observational and interactive components. The CAM is the most widely studied and demonstrates the best psychometric properties.

CONCLUSION

Timely detection of delirium might reduce the negative outcomes of delirium in the long term. The Nu-DESC and CAM appear to be the most adequate instruments for detecting delirium. Copyright © 2016 John Wiley & Sons, Ltd.

Randomized, double-blind, placebo-controlled study of methylphenidate for the treatment of depression in SSRI-treated cancer patients receiving palliative care

OBJECTIVE

To determine the effectiveness of methylphenidate for depression treatment in patients with advanced cancer.

DESIGN

An 18-day randomized, double-blind, placebo-controlled clinical trial of methylphenidate for treatment of depression in selective serotonin reuptake inhibitor-treated patients with advanced cancer in hospice or receiving palliative care. The primary outcome was depression remission, defined as a ≥50% reduction in score on the Montgomery-Asberg Depression Rating Scale.

RESULTS

Among 47 enrolled participants, 34 were randomized. At study day 18, 85% of the methylphenidate and 60% of the placebo group were in depression remission (P = .22). Mean time to depression remission was 10.3 days [standard error (SE) 1.8] in the methylphenidate and 8.1 (SE 1.3) in the placebo group (P = .48). The mean baseline score for the Hospital Anxiety and Depression Scale (HADS) was 10.4 in each group and decreased by 3.6 (SE 1.1) in the methylphenidate and 2.3 (SE 1.2) in the placebo group (P = .51) by day 18. Once in remission, 1 methylphenidate and 5 placebo participants relapsed to depression (P = .18). There was no difference in mortality between the groups during the trial. Trial results were limited by small sample size attributed to difficulties in recruiting terminally ill patients.

CONCLUSIONS

This trial failed to demonstrate that methylphenidate treatment in selective serotonin reuptake inhibitor-treated patients had a significant effect on depression remission in patients with advanced cancer. This study underscores the difficulties in conducting trials for symptom management in patients with shortened life expectancy.

Intraoperative tight glucose control using hyperinsulinemic normoglycemia increases delirium after cardiac surgery

BACKGROUND

Postoperative delirium is common in patients recovering from cardiac surgery. Tight glucose control has been shown to reduce mortality and morbidity. Therefore, the authors sought to determine the effect of tight intraoperative glucose control using a hyperinsulinemic-normoglycemic clamp approach on postoperative delirium in patients undergoing cardiac surgery.

METHODS

The authors enrolled 198 adult patients having cardiac surgery in this randomized, double-blind, single-center trial. Patients were randomly assigned to either tight intraoperative glucose control with a hyperinsulinemic-normoglycemic clamp (target blood glucose, 80 to 110 mg/dl) or standard therapy (conventional insulin administration with blood glucose target, <150 mg/dl). Delirium was assessed using a comprehensive delirium battery. The authors considered patients to have experienced postoperative delirium when Confusion Assessment Method testing was positive at any assessment. A positive Confusion Assessment Method was defined by the presence of features 1 (acute onset and fluctuating course) and 2 (inattention) and either 3 (disorganized thinking) or 4 (altered consciousness).

RESULTS

Patients randomized to tight glucose control were more likely to be diagnosed as being delirious than those assigned to routine glucose control (26 of 93 vs. 15 of 105; relative risk, 1.89; 95% CI, 1.06 to 3.37; P = 0.03), after adjusting for preoperative usage of calcium channel blocker and American Society of Anesthesiologist physical status. Delirium severity, among patients with delirium, was comparable with each glucose management strategy.

CONCLUSION

Intraoperative hyperinsulinemic-normoglycemia augments the risk of delirium after cardiac surgery, but not its severity.

Anxiety in family caregivers of hospitalized persons with dementia: contributing factors and responses

BACKGROUND

Baseline health and functional vulnerabilities increase the risk for complications in persons with dementia and predispose family caregivers (FCGs) to increased stress.

METHODS

This secondary analysis used a combined quantitative and qualitative approach. Regression analyses examined the contribution of patient and FCG characteristics to FCG anxiety. Interviews with FCGs explored the experiences and responses of FCGs during hospitalization of their family member with dementia.

RESULTS

Lower patient physical function and higher caregiver strain were associated with higher FCG anxiety. FCGs described the following themes related to the hospitalization: (1) added strain, (2) care-related worries, (3) keeping vigil, (4) need to be heard, and (5) enablers of FCGs.

CONCLUSIONS

Routine evaluation of caregiver strain and baseline patient function is integral to informing the transitional planning for persons with dementia. The FCG responses suggest that a multifactorial approach (family-centered policies of partnership in care, staff education addressing the specialized needs of patients and family members, and attention to promoting functional recovery) may benefit both hospitalized patients with dementia as well as FCGs and warrants future research.

Validation study of the European Portuguese version of the Confusion Assessment Method (CAM)

BACKGROUND

The Confusion Assessment Method (CAM) is the most widely used delirium screening instrument. The aim of this study was to evaluate the reliability and validity of the European Portuguese version of CAM.

METHODS

The sample included elderly patients (≥65 years), admitted for at least 48 h, into two intermediate care units (ICMU) of Intensive Medicine and Surgical Services in a university hospital. Exclusion criteria were: score ≤11 on the Glasgow Coma Scale (GCS), blindness/deafness, inability to communicate and to speak Portuguese. For concurrent validity, a blinded assessment was conducted by a psychiatrist (DSM-IV-TR, as a reference standard) and by a trained researcher (CAM). This instrument was also compared with other cognitive measures to evaluate convergent validity. Inter-rater reliability was also assessed.

RESULTS

In this sample (n = 208), 25% (n = 53) of the patients had delirium, according to DSM-IV-TR. Using this reference standard, the CAM had a moderate sensitivity of 79% and an excellent specificity of 99%. The positive predictive value was 95%, indicating a strong ability to confirm delirium with a positive test result, and the negative predictive value was lower (93%). Good convergent validity was also found, in particular with Mini-Mental State Examination (MMSE) (rs = -0.676; p ≤0.01) and Digit Span Test (DST) forward (rs = -0.605; p ≤0.01), as well as a high inter-rater reliability (diagnostic k = 1.00; single items' k between 0.65 and 1.00).

CONCLUSION

Robust results on concurrent and convergent validity and good reliability were achieved. This version was shown to be a valid and reliable instrument for delirium detection in elderly patients hospitalized in intermediate care units.

Objective assessment of attention in delirium: a narrative review

OBJECTIVE

Inattention is a core feature of delirium, and valid assessment of attention is central to diagnosis. Methods of measuring attention in delirium can be divided into two broad categories: (i) objective neuropsychological testing; and (ii) subjective grading of behaviour during interview and clinical examination. Here, we review and critically evaluate studies of objective neuropsychological testing of attention in delirium. We examine the implications of these studies for delirium detection and monitoring in clinical practice and research, and how these studies inform understanding of the nature of attentional deficits in delirium.

METHODS

Searches of MEDLINE and ISI Web of Knowledge databases were performed to identify studies in which objective tests of attention had been administered to patients with delirium, who had been diagnosed using DSM or ICD criteria.

RESULTS

Sixteen publications were identified. The attention tests administered in these studies were grouped into the following categories: measures of attention span, vigilance tests, other pen-and-paper tests (e.g. Trail Making Test) and computerised tests of speeded reaction, vigilance and sustained attention. Patients with delirium showed deficits on all tasks, although most tasks were not considered pure measures of attention. Five papers provided data on differential diagnosis from dementia. Cancellation tests, spatial span tests and computerised tests of sustained attention discriminated delirium from dementia. Five studies presented reliability or validity statistics.

CONCLUSIONS

The existing evidence base on objective assessment of attention in delirium is small. Objective testing of attention is underdeveloped but shows considerable promise in clinical practice and research.

Delirium diagnosis methodology used in research: a survey-based study

OBJECTIVE

To describe methodology used to diagnose delirium in research studies evaluating delirium detection tools.

METHODS

The authors used a survey to address reference rater methodology for delirium diagnosis, including rater characteristics, sources of patient information, and diagnostic process, completed via web or telephone interview according to respondent preference. Participants were authors of 39 studies included in three recent systematic reviews of delirium detection instruments in hospitalized patients.

RESULTS

Authors from 85% (N = 33) of the 39 eligible studies responded to the survey. The median number of raters per study was 2.5 (interquartile range: 2-3); 79% were physicians. The raters' median duration of clinical experience with delirium diagnosis was 7 years (interquartile range: 4-10), with 5% having no prior clinical experience. Inter-rater reliability was evaluated in 70% of studies. Cognitive tests and delirium detection tools were used in the delirium reference rating process in 61% (N = 21) and 45% (N = 15) of studies, respectively, with 33% (N = 11) using both and 27% (N = 9) using neither. When patients were too drowsy or declined to participate in delirium evaluation, 70% of studies (N = 23) used all available information for delirium diagnosis, whereas 15% excluded such patients.

CONCLUSION

Significant variability exists in reference standard methods for delirium diagnosis in published research. Increasing standardization by documenting inter-rater reliability, using standardized cognitive and delirium detection tools, incorporating diagnostic expert consensus panels, and using all available information in patients declining or unable to participate with formal testing may help advance delirium research by increasing consistency of case detection and improving generalizability of research results.

Factors that contribute to underrecognition of delirium by registered nurses in acute care settings: a scoping review of the literature to explain this phenomenon

AIMS AND OBJECTIVES

In order to obtain more information regarding this phenomenon, a scoping review of the literature was undertaken to analyse current research on the recognition of delirium by registered nurses in acute care settings.

BACKGROUND

Delirium is often manifested as a sign of an underlying undiagnosed condition that requires immediate intervention and is frequently manifested in acute care settings. Unfortunately, registered nurses often do not recognise delirium and its occurrence goes under-reported.

DESIGN/METHODS

Based on six inclusion criteria, a search in numerous databases using terms such as delirium detection, recognition and diagnosis by registered nurses was undertaken. Eight quantitative studies were deemed relevant and analysed for this scoping review.

RESULTS

Seven major categories emerged: the fluctuating nature of delirium, the impact of delirium education on its recognition, communication barriers, inadequate use of delirium assessment tools, lack of conceptual understanding of delirium, delirium as a burden and the likeness of delirium and dementia. A brief summary of the findings in each category is reported here.

CONCLUSIONS

The scoping review revealed that delirium remains underrecognised by registered nurses, which potentially contributes to reduced quality of nursing care for clients experiencing this condition. Further research on delirium and the processes that registered nurses use to recognise it is timely and will facilitate the development of evidence-based interventions to manage it.

RELEVANCE TO CLINICAL PRACTICE

While acute care registered nurses have historically reported dramatic changes in cognitive and neuro-biological functions in ill older adults, the literature highlighted in this scoping review revealed the following: (1) the need for further research to validate delirium assessment tools and, (2) the need for education and training for registered nurses on the use of these assessment tools to promote early recognition and thereby decrease the incidence of delirium in older adults.

Attention! A good bedside test for delirium?

BACKGROUND

Routine delirium screening could improve delirium detection, but it remains unclear as to which screening tool is most suitable. We tested the diagnostic accuracy of the following screening methods (either individually or in combination) in the detection of delirium: MOTYB (months of the year backwards); SSF (Spatial Span Forwards); evidence of subjective or objective 'confusion'.

METHODS

We performed a cross-sectional study of general hospital adult inpatients in a large tertiary referral hospital. Screening tests were performed by junior medical trainees. Subsequently, two independent formal delirium assessments were performed: first, the Confusion Assessment Method (CAM) followed by the Delirium Rating Scale-Revised 98 (DRS-R98). DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) criteria were used to assign delirium diagnosis. Sensitivity and specificity ratios with 95% CIs were calculated for each screening method.

RESULTS

265 patients were included. The most precise screening method overall was achieved by simultaneously performing MOTYB and assessing for subjective/objective confusion (sensitivity 93.8%, 95% CI 82.8 to 98.6; specificity 84.7%, 95% CI 79.2 to 89.2). In older patients, MOTYB alone was most accurate, whereas in younger patients, a simultaneous combination of SSF (cut-off 4) with either MOTYB or assessment of subjective/objective confusion was best. In every case, addition of the CAM as a second-line screening step to improve specificity resulted in considerable loss in sensitivity.

CONCLUSIONS

Our results suggest that simple attention tests may be useful in delirium screening. MOTYB used alone was the most accurate screening test in older people.

Personality as a moderator of cognitive stimulation in older adults at high risk for cognitive decline

This exploratory study examined the moderating effects of personality traits on cognitive function following a cognitively stimulating individualized activity intervention delivered to individuals at high risk for cognitive decline: those with delirium superimposed on dementia. Data were taken from an ongoing randomized clinical trial with the addition of a personality measure. The results for 71 participants randomized to intervention or control groups are reported. Significant moderating effects of personality traits were found such that participants with higher agreeableness were more likely to have improved delayed recall and those with lower extraversion were more likely to have improved executive function, as a result of the intervention. Lower openness, higher agreeableness, and lower conscientiousness were associated with greater engagement in the intervention. A cognitive stimulation intervention for older adults at high risk for further cognitive decline may be differentially effective based on certain personality traits.

Burden in caregivers of cognitively impaired elderly adults at time of hospitalization: a cross-sectional analysis

OBJECTIVES

To describe the factors associated with burden that caregivers of cognitively impaired older adults (dementia, delirium, or both) at the time of hospitalization experienced.

DESIGN

Cross-sectional data analyses.

SETTING

Three hospitals-one academic tertiary hospital and two associated community hospitals.

PARTICIPANTS

Caregivers (N = 495) of cognitively impaired older adults at the time of hospital admission.

MEASUREMENTS

Multivariable linear regression was performed to analyze the effect of the independent variables (caregiver: demographic characteristics, depressive symptoms, self-efficacy; older adult: neuropsychiatric symptoms, delirium, functional deficits) on caregiver burden.

RESULTS

Higher burden was associated with younger caregiver age (P = .02), being a spouse (P = .03), depressive symptoms (P < .001), caregivers' lower perceived self-efficacy in managing care recipient symptoms (P = .002), and limited finances at the end of the month (P = .01). Caregiver burden was also strongly associated with the care recipient factors distressing neuropsychiatric symptoms (P = .001), delirium (P = .001), and greater functional deficits in basic activities of daily living (P = .001).

CONCLUSION

These findings suggest that caregivers of older adults who were cognitively impaired at hospital admission experience burden. Understanding the factors that contribute to burden at the time of hospitalization for caregivers of persons with cognitive impairment can inform the development of interventions targeted throughout the hospitalization that have the potential to decrease burden.

Epidemiology and risk factors for delirium across hospital settings

Delirium is one of the most common causes of acute end-organ dysfunction across hospital settings, occurring in as high as 80% of critically ill patients that require intensive care unit (ICU) care. The implications of this acute form of brain injury are profound. Across many hospital settings (emergency department, general medical ward, postoperative and ICU), a patient who experiences delirium is more likely to experience increased short- and long-term mortality, decreases in long-term cognitive function, increases in hospital length of stay and increased complications of hospital care. With the development of reliable setting-specific delirium-screening instruments, researchers have been able to highlight the predisposing and potentially modifiable risk factors that place patients at highest risk. Among the large number of risk factors discovered, administration of potent sedative medications, most notably benzodiazepines, is most consistently and strongly associated with an increased burden of delirium. Alternatively, in both the hospital and ICU, delirium can be prevented with the application of protocols that include early mobility/exercise. Future studies must work to understand the epidemiology across settings and focus upon modifiable risk factors that can be integrated into existing delirium prevention and treatment protocols.

Assessment scales for delirium: A review

Over the years many scales have been designed for screening, diagnosis and assessing the severity of delirium. In this paper we review the various instruments available to screen the patients for delirium, instruments available to diagnose delirium, assess the severity, cognitive functions, motoric subtypes, etiology and associated distress. Among the various screening instruments, NEECHAM confusion scale and delirium observation scale appear to be most suitable screening instrument for patients’ in general medical and surgical wards, depending on the type of rater (physician or nurse). In general, the instruments which are used for diagnosis [i.e., confusion assessment method (CAM), CAM for intensive care unit (CAM-ICU), Delirium Rating Scale-revised version (DRS-R-98), memorial selirium assessment scale, etc.] are based on various Diagnostic and Statistical Manual criteria and have good to excellent reliability and fair to good validity. Among the various diagnostic instruments, CAM is considered to be most useful instrument because of its accuracy, brevity, and ease of use by clinicians and lay interviewers. In contrast, DRS-R-98 appears to be a comprehensive instrument useful for diagnosis, severity rating and is sensitive to change and hence can be used for monitoring patients over a period. In the ICU setting, evidence suggests that CAM-ICU and Nursing Delirium Screening Scale had comparable sensitivities, but CAM-ICU has higher specificity. With regard to assessment of delirium in pediatric age group, certain instruments like Pediatric Anesthesia Emergence Delirium scale and pediatric CAM-ICU has been designed and have been found to be useful.

Twelve-month mortality among delirium subtypes

This study used data from the Delirium Among the Elderly in Rural Long-Term Care Facilities Study and data from the National Death Index (NDI) to examine mortality among 320 individuals. Individuals were grouped into noncases, subsyndromal cases, hypoactive delirium, hyperactive delirium, and mixed delirium on the basis of scoring using the Confusion Assessment Method (CAM), NEECHAM Scale, Mini-Mental State Examination (MMSE), Clinical Assessment of Confusion-A (CAC-A), and Vigilance A instruments. Risk ratios of mortality using "days of survival" did not reach statistical significance (α = .05) for any subgroup. Underlying cause of death (UCD) using International Classification of Disease, 10th version (ICD-10), showed typical UCD among older adults. There appeared to be clinical differences in UCD between delirium subgroups. Findings supported the conclusion that careful monitoring of patients with delirium and subsyndromal delirium is needed to avoid complications and injuries that could increase mortality.

Diagnosing delirium in elderly Thai patients: utilization of the CAM algorithm

Background

Delirium is a common illness among elderly hospitalized patients. However, under-recognition of the condition by non-psychiatrically trained personnel is prevalent. This study investigated the performance of family physicians when detecting delirum in elderly hospitalized Thai patients using the Thai version of the Confusion Assessment Method (CAM) algorithm.

Methods

A Thai version of the CAM algorithm was developed, and three experienced Thai family physicians were trained in its use. The diagnosis of delirium was also carried out by four fully qualified psychiatrists using DSM-IV TR criteria, which can be considered the gold standard. Sixty-six elderly patients were assessed with MMSE Thai 2002, in order to evaluate whether they had dementia upon admission. Within three days of admission, each patient was interviewed separately by a psychiatrist using DSM-IV TR, and a family physician using the Thai version of the CAM algorithm, with both sets of interviewers diagnosing for delirium.

Results

The CAM algorithm tool, as used by family physicians, demonstrated a sensitivity of 91.9% and a specificity of 100.0%, with a PPV of 100.0% and an NPV of 90.6%. Interrater agreement between the family physicians and the psychiatrists was good (Cohen's Kappa = 0.91, p < 0.0001). The mean of the time the family physicians spent using CAM algorithm was significantly briefer than that of the psychiatrists using DSM-IV TR.

Conclusions

Family physicians performed well when diagnosing delirium in elderly hospitalized Thai patients using the Thai version of the CAM algorithm, showing that this measurement tool is suitable for use by non-psychiatrically trained personnel, being short, quick, and easy to administer. However, proper training on use of the algorithm is required.

Delirium scales: A review of current evidence

OBJECTIVES

Delirium is a common neuropsychiatric condition with many adverse outcomes in elderly populations including death. Despite this, it is often misdiagnosed and mistreated. A number of scales can be used to detect delirium. We review scales that have been used in delirium studies and report their psychometric properties.

METHOD

An extensive MEDLINE database search and subsequent examination of reference lists was conducted to identify the various delirium scales that have been designed, primarily for use in the elderly.

RESULTS

Twenty-four scales were identified. Delirium instruments differed according to the classification system they were based on, length of time to administer, the rater and whether they were screening scales or measured symptom severity. The psychometric properties of each scale is reported.

CONCLUSION

A large number of scales exist, but not all are properly evaluated in terms of psychometric properties, and there is not unanimity about which scale is the best. However, a small number of scales may be considered already to be robust and useable: the CAM, the DRS, the MDAS and the NEECHAM.

Postoperative delirium in the elderly surgical patient

Delirium is a common complication in the geriatric population following cardiac and noncardiac procedures. Postoperative delirium is a significant financial burden on the United States health care system and is independently associated with prolonged hospital stay, increased risk of early and long term mortality, increased physical dependence, and an increased rate of nursing home placement. The Confusion Assessment Method (CAM) is a bedside rating scale developed to assist nonpsychiatrically trained clinicians in the rapid and accurate diagnosis of delirium. The CAM has been adapted for use in ventilated intensive care unit (ICU) patients in the form of the CAM-ICU. The onset of delirium involves an interaction between predisposing and precipitating risk factors for delirium. The mainstay of delirium management is prevention. The approach involves control or elimination of modifiable risk factors. It is controversial whether anesthetic technique determines delirium. However, important modifiable risk factors under the anesthesiologist's control include adequate postoperative pain management, careful drug selection, and embracing and participating in a multidisciplinary care model for these complicated patients.

Assessment scales for delirium

Delirium is a severe psychiatric syndrome that is highly prevalent in elderly general hospital patients. However, the diagnosis of delirium is often missed. The use of rating scales can be helpful in detecting and measuring delirium symptom severity. This article reviews recent developments regarding psychometric qualities, measurement goals, content and rating procedures of some of the available rating scales in clinical practice. Literature from the Medline files up to 2008 were collected, using the following search entries: delirium, (acute) confusion, assessment/rating scale and screening. Articles were selected if their title or summary were related to the development or applicability of delirium rating scales. The reference lists of relevant articles were searched for additional references. The rating scales were split up according to their purposes, screening or severity rating and were discussed for the following aspects: content (theoretical background, rating domains and items), interview (duration, format and assessors’ expertise) and psychometric qualities (reliability and validity). There were eight screening scales (Confusion Assessment Method [CAM], CAM for the Intensive Care Unit [CAM-ICU], Intensive Care Delirium Screening Checklist [ICDSC], Delirium Symptom Interview [DSI], NEECHAM Confusion Scale [NEECHAM], Cognitive Test for Delirium [CTD], Delirium Observation Screening [DOS] and Nursing Delirium Screening Scale [Nu-DESC]) and seven severity rating scales (Delirium Rating Scales [DRS], Memorial Delirium Assessment Scales [MDAS], Confusional State Evaluation [CSE], Delirium Severity Scales [DSS], Delirium Index [DI], Delirium-O-Meter [DOM] and Delirium Detection Scale [DDS] ) selected for further research. The CAM, NEECHAM and DOS and the CAM-ICU for the ICU appear to be the most suitable as screening instruments, depending on the type of rater (trained) physician or nurse. The (revised) Delirium Rating Scale (DRS-R-98) and the DOM appear to be particularly useful for measuring delirium severity or monitoring change.

The Confusion Assessment Method: a systematic review of current usage

OBJECTIVES

To examine the psychometric properties, adaptations, translations, and applications of the Confusion Assessment Method (CAM), a widely used instrument and diagnostic algorithm for identification of delirium.

DESIGN

Systematic literature review.

SETTING

Not applicable.

MEASUREMENTS

Electronic searches of PubMED, EMBASE, PsychINFO, CINAHL, Ageline, and Google Scholar, augmented by reviews of reference listings, were conducted to identify original English-language articles using the CAM from January 1, 1991, to December 31, 2006. Two reviewers independently abstracted key information from each article.

PARTICIPANTS

Not applicable.

RESULTS

Of 239 original articles, 10 (4%) were categorized as validation studies, 16 (7%) as adaptations, 12 (5%) as translations, and 222 (93%) as applications. Validation studies evaluated performance of the CAM against a reference standard. Results were combined across seven high-quality studies (N=1,071), demonstrating an overall sensitivity of 94% (95% confidence interval (CI)=91-97%) and specificity of 89% (95% CI=85-94%). The CAM has been adapted for use in the intensive care unit, emergency, and institutional settings and for scoring severity and subsyndromal delirium. The CAM has been translated into 10 languages where published articles are available. In application studies, CAM-rated delirium is most commonly used as a risk factor or outcome but also as an intervention or reference standard.

CONCLUSION

The CAM has helped to improve identification of delirium in clinical and research settings. To optimize performance, the CAM should be scored based on observations made during formal cognitive testing, and training is recommended. Future action is needed to optimize use of the CAM and to improve the recognition and management of delirium.

The diagnosis of delirium among elderly patients presenting to the emergency department of an acute hospital

Delirium is prevalent among elderly people presenting to an emergency department (ED). However, despite the fact that delirium is associated with longer hospital stays, an increased rate of institutionalization and higher mortality (especially in the case of undiagnosed delirium), this condition often goes undiagnosed by ED doctors. We examined the rate of mental status assessment and the prevalence of delirium in the ED among patients older than 65 years in a large teaching hospital in Southern Israel via a retrospective chart review. Surprisingly we found no diagnosis of delirium in the medical charts of representative sample of 319 elderly people. Furthermore, only 12.5% of people received either an adequate or even a partially adequate mental status assessment by the ED doctors. We attribute these negative findings not to a low incidence of delirium but probably to a combination of a heavy workload along with a lack of adequate training of ED physicians. We suggest that part of the solution involves providing appropriate education to ED physicians as well as adding a geriatric consultant to the ED roster.

Delirium in Older Adults With Cancer: Implications for Practice and Research

PURPOSE/OBJECTIVES

To provide a comprehensive review of the literature and existing evidence-based findings on delirium in older adults with cancer.

DATA SOURCES

Published articles, guidelines, and textbooks.

DATA SYNTHESIS

Although delirium generally is recognized as a common geriatric syndrome, a paucity of empirical evidence exists to guide early recognition and treatment of this sequelae of cancer and its treatment in older adults. Delirium probably is more prevalent than citations note because the phenomenon is under-recognized in clinical practice across varied settings of cancer care.

CONCLUSIONS

Extensive research is needed to formulate clinical guidelines to manage delirium. A focus on delirium in acute care and at the end of life precludes identification of this symptom in ambulatory care, where most cancer therapies are used. Particular emphasis should address the early recognition of prodromal signs of delirium to reduce symptom severity.

IMPLICATIONS FOR NURSING

Ongoing assessment opportunities and close proximity to patients' treatment experiences foster oncology nurses' mastery of this common exemplar of altered cognition in older adults with cancer. Increasing awareness of and knowledge delineating characteristics of delirium in older patients with cancer can promote early recognition, optimum treatment, and minimization of untoward consequences associated with the historically ignored example of symptom distress.

Detection of delirium by bedside nurses using the confusion assessment method

A prospective, descriptive study was used to assess the diagnostic validity of the Confusion Assessment Method (CAM) administered at the bedside by nurses in daily practice. Two different scoring methods of the CAM (the specific (SPEC) and sensitive (SENS) methods) were compared with a criterion standard (CAM completed by trained research nurses). During a 5-month period, all patients consecutively admitted to an acute geriatric ward of the University Hospitals of Leuven (Belgium) were enrolled in the study. The 258 elderly inpatients who were included underwent 641 paired but independent ratings of delirium by bedside and trained research nurses. Delirium was identified in 36 of the 258 patients (14%) or in 42 of the 641 paired observations (6.5%). The SENS method of the CAM algorithm as administered by bedside nurses had the greatest diagnostic accuracy, with 66.7% sensitivity and 90.7% specificity; the SPEC method had 23.8% sensitivity and 97.7% specificity. Bedside nurses had difficulties recognizing the features of acute onset, fluctuation, and altered level of consciousness. For both scoring methods, bedside nurses had difficulties with the identification of elderly patients with delirium but succeeded in diagnosing correctly those patients without delirium in more than 90% of observations. Given these results, additional education about delirium with special attention to guided training of bedside nurses in the use of an assessment strategy such as the CAM for the recognition of delirium symptoms is warranted.

The performance of the Clock Drawing Test in elderly medical inpatients: does it have utility in the identification of delirium?

The Clock Drawing Test is an often-used test for the detection of cognitive impairment, but the few studies that have evaluated its utility in delirium have produced rather inconsistent results. In a longitudinal study of delirium in elderly medical inpatients, we have investigated the relationships between the Clock Drawing Test, the presence and severity of delirium, and cognitive impairment. Using mixed linear model analysis we found that cognitive impairment was the major factor associated with low Clock Drawing Test scores (P < .0001): neither the presence nor the severity of delirium had additional significant effect on the Clock Drawing Test. Thus, we conclude that although the Clock Drawing Test is a good detector of cognitive impairment, it is not a suitable tool for detection of delirium in elderly medical inpatients.

Psychometric properties of the Flemish translation of the NEECHAM Confusion Scale

BACKGROUND

Determination of a patient's cognitive status by use of a valid and reliable screening instrument is of major importance as early recognition and accurate diagnosis of delirium is necessary for effective management. This study determined the reliability, validity and diagnostic value of the Flemish translation of the NEECHAM Confusion Scale.

METHODS

A sample of 54 elderly hip fracture patients with a mean age of 80.9 years (SD = 7.85) were included. To test the psychometric properties of the NEECHAM Confusion Scale, performance on the NEECHAM was compared to the Confusion Assessment Method (CAM) and the Mini-Mental State Examination (MMSE), by using aggregated data based on 5 data collection measurement points (repeated measures). The CAM and MMSE served as gold standards.

RESULTS

The alpha coefficient for the total NEECHAM score was high (0.88). Principal components analysis yielded a two-component solution accounting for 70.8% of the total variance. High correlations were found between the total NEECHAM scores and total MMSE (0.75) and total CAM severity scores (-0.73), respectively. Diagnostic values using the CAM algorithm as gold standard showed 76.9% sensitivity, 64.6% specificity, 13.5% positive and 97.5% negative predictive values, respectively.

CONCLUSION

This validation of the Flemish version of the NEECHAM Confusion Scale adds to previous evidence suggesting that this scale holds promise as a valuable screening instrument for delirium in clinical practice. Further validation studies in diverse clinical populations; however, are needed.

Bioelectrical impedance analysis and other hydration parameters as risk factors for delirium in rural nursing home residents

BACKGROUND

The study investigators conducted a vigorous screening protocol for delirium in rural long-term care (LTC) facilities for a period of 28 days focusing on Bioelectrical Impedance Analysis (BIA) and other hydration parameters as risk factors.

METHODS

A two-stage cluster sampling procedure was used to randomly select participants (n = 313) from 13 LTC facilities located in southeastern Iowa, stratified on facility bed size. BIA was used to estimate intracellular water (ICW), extracellular water (ECW), and total body water (TBW) on four occasions--baseline and follow-up days 7, 14, and 28. Volume estimates were calculated as a percent of body weight (%WT). Serum electrolytes and hematology were also measured. Delirium was measured with four strict criteria: a NEECHAM Confusion Scale score < 25, Vigilance "A" score > 2, a Mini-Mental Status Examination < baseline, and a positive Confusion Assessment Method score.

RESULTS

There were n = 69 delirium cases (22.0%). Blood urea nitrogen/creatinine ratios greater than 21:1 (odds ratio = 1.76, 95% confidence interval 1.02-3.06). No significant risk for delirium was associated with ICW, ECW, or TBW as a percent of body weight.

CONCLUSIONS

Some changes were observed with a slight decrease in ICW between day 7 and day 14 of follow-up that tended to follow an increase in delirium events, but in general the BIA measures did not predict delirium events.

Delirium symptoms and low dietary intake in older inpatients are independent predictors of institutionalization: a 1-year prospective population-based study

OBJECTIVE

To assess the effects of delirium on the institutionalization rate, taking into account geriatric syndromes and nutritional status.

METHODS

This population-based study took place in an acute care unit and included participants older than 75 years, arriving from home and later discharged. Confusion Assessment Method (CAM) symptoms were recorded by the nurses within 24 hours after admission and every 3 days. Delirium was defined using the CAM algorithm, and subsyndromal delirium responded to symptoms not fulfilling the CAM algorithm. These delirium categories were either present at admission (prevalent) or occurred during the hospital stay (incident). Participants were classified as having a low dietary intake when energy intake was at any time lower than 600 kcal/d. Age, sex, known cognitive impairment, weight, functional dependency, and laboratory testing as well as diagnoses were also recorded. Step-by-step backward logistic regression was used to identify predictors of institutionalization.

RESULTS

Among 427 patients, 310 (72.6%) were discharged and were compared with 117 (27.4%) participants admitted to an institution. Female sex (odds ratio [OR]: OR 2.15, 95% confidence interval [CI]: CI 1.22-3.78), prevalent delirium (OR 3.19, 95% CI 1.33-7.64), subsyndromal delirium (OR 2.72, 95% CI 1.48-5.01), incident subsyndromal delirium (OR 4.27, 95% CI 2.17-8.39), low dietary intake (OR 2.50, 95% CI 1.35-4.63), and a fall (OR 2.16, 95% CI 1.22-3.84) or a diagnosis of stroke (OR 2.03, 95% CI 1.04-3.94) were independent predictors of institutionalization.

CONCLUSIONS

Symptoms of delirium and severe nutritional impairment led patients to geriatric institutions. Therefore, these institutions need to implement policies that address both of these issues.

Southwestern Internal Medicine Conference. Etiology and management of delirium

Delirium has been recognized for the last 3 millennia and is the most common complication found in hospitalized patients aged 65 and older in the United States. However, critical basic science and clinical research did not progress until the DSM III criteria clearly defined delirium 20 years ago. The term delirium then replaced many nonspecific entities, such as acute confusion state, acute brain syndrome, metabolic encephalopathy, and toxic psychosis. This review discusses the epidemiology, risk factors, interventions, causes, management, and outcomes of delirium. The pathophysiology of delirium has the potential to radically alter our management of delirium and is a controversial area of research.

Confusion assessment method in the diagnostics of delirium among aged hospital patients: would it serve better in screening than as a diagnostic instrument?

BACKGROUND

The Confusion Assessment Method (CAM) is an easy, four-step algorithmic diagnostic test developed to detect delirium.

OBJECTIVE

To determine how sensitive and specific the CAM is in diagnosing delirium when compared with fully operationalized criteria of delirium according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) editions III, III revised, and IV, and the International Classification of Diseases (ICD) 10th edition.

METHODS

A cross-sectional study with blinded assessments was performed on consecutive elderly patients (>70 years) (n=81) in two acute geriatric hospitals in Helsinki, Finland. The sensitivity, specificity, likelihood ratios, and positive and negative predictive values of CAM were assessed with the DSM-III, DSM-III-R, DSM-IV, and ICD-10 criteria of delirium used as reference standards.

RESULTS

Sensitivity rates of the CAM were proved to be only moderate (0.81-0.86) against all formal criteria of delirium. The specificity rates were lower (0.63-0.84), and far less than reported in previous studies using global assessment of the reference standard. Instead of the DSM-III-R, from which it is derived, the CAM seems more concordant with the DSM-IV criteria of delirium. The likelihood ratio for a positive CAM test was 5.06 and for a negative test 0.23, when compared with the DSM-IV.

CONCLUSION

The CAM seems to be an acceptable screening instrument for delirium, but the diagnosis should be ensured according to the formal criteria of delirium, preferably by the DSM-IV.