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Arnold E, Finucane AM, Taylor S, Spiller JA, O’Rourke S, Spenceley J, Carduff E, Tieges Z, MacLullich AMJ. The 4AT, a rapid delirium detection tool for use in hospice inpatient units: Findings from a validation study. Palliat Med 2024; 38:535-545. [PMID: 38767241 PMCID: PMC11170929 DOI: 10.1177/02692163241242648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Delirium is a serious neuropsychiatric syndrome with adverse outcomes, which is common but often undiagnosed in terminally ill people. The 4 'A's test or 4AT (www.the4AT.com), a brief delirium detection tool, is widely used in general settings, but validation studies in terminally ill people are lacking. AIM To determine the diagnostic accuracy of the 4AT in detecting delirium in terminally ill people, who are hospice inpatients. DESIGN A diagnostic test accuracy study in which participants underwent the 4AT and a reference standard based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The reference standard was informed by Delirium Rating Scale Revised-98 and tests assessing arousal and attention. Assessments were conducted in random order by pairs of independent raters, blinded to the results of the other assessment. SETTING/PARTICIPANTS Two hospice inpatient units in Scotland, UK. Participants were 148 hospice inpatients aged ⩾18 years. RESULTS A total of 137 participants completed both assessments. Three participants had an indeterminate reference standard diagnosis and were excluded, yielding a final sample of 134. Mean age was 70.3 (SD = 10.6) years. About 33% (44/134) had reference standard delirium. The 4AT had a sensitivity of 89% (95% CI 79%-98%) and a specificity of 94% (95% CI 90%-99%). The area under the receiver operating characteristic curve was 0.97 (95% CI 0.94-1). CONCLUSION The results of this validation study support use of the 4AT as a delirium detection tool in hospice inpatients, and add to the literature evaluating methods of delirium detection in palliative care settings. TRIAL REGISTRY ISCRTN 97417474.
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Affiliation(s)
| | - Anne M Finucane
- Marie Curie Hospice Edinburgh, Edinburgh, UK
- Clinical Psychology, University of Edinburgh, Edinburgh, UK
| | | | | | | | | | | | - Zoë Tieges
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Computing, School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Scotland, UK
| | - Alasdair MJ MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
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Raquer AP, Fong CT, Walters AM, Souter MJ, Lele AV. Delirium and Its Associations with Critical Care Utilizations and Outcomes at the Time of Hospital Discharge in Patients with Acute Brain Injury. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:304. [PMID: 38399591 PMCID: PMC10890045 DOI: 10.3390/medicina60020304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/30/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: We analyzed delirium testing, delirium prevalence, critical care associations outcomes at the time of hospital discharge in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), non-traumatic subarachnoid hemorrhage (SAH), non-traumatic intraparenchymal hemorrhage (IPH), and traumatic brain injury (TBI) admitted to an intensive care unit. Materials and Methods: We examined the frequency of assessment for delirium using the Confusion Assessment Method for the intensive care unit. We assessed delirium testing frequency, associated factors, positive test outcomes, and their correlations with clinical care, including nonpharmacological interventions and pain, agitation, and distress management. Results: Amongst 11,322 patients with ABI, delirium was tested in 8220 (726%). Compared to patients 18-44 years of age, patients 65-79 years (aOR 0.79 [0.69, 0.90]), and those 80 years and older (aOR 0.58 [0.50, 0.68]) were less likely to undergo delirium testing. Compared to English-speaking patients, non-English-speaking patients (aOR 0.73 [0.64, 0.84]) were less likely to undergo delirium testing. Amongst 8220, 2217 (27.2%) tested positive for delirium. For every day in the ICU, the odds of testing positive for delirium increased by 1.11 [0.10, 0.12]. Delirium was highest in those 80 years and older (aOR 3.18 [2.59, 3.90]). Delirium was associated with critical care resource utilization and with significant odds of mortality (aOR 7.26 [6.07, 8.70] at the time of hospital discharge. Conclusions: In conclusion, we find that seven out of ten patients in the neurocritical care unit are tested for delirium, and approximately two out of every five patients test positive for delirium. We demonstrate disparities in delirium testing by age and preferred language, identified high-risk subgroups, and the association between delirium, critical care resource use, complications, discharge GCS, and disposition. Prioritizing equitable testing and diagnosis, especially for elderly and non-English-speaking patients, is crucial for delivering quality care to this vulnerable group.
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Affiliation(s)
- Alex P. Raquer
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA;
| | - Christine T. Fong
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (M.J.S.)
| | - Andrew M. Walters
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (M.J.S.)
| | - Michael J. Souter
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (M.J.S.)
- Neurocritical Care Service, Harborview Medical Center, Seattle, WA 98104, USA
| | - Abhijit V. Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (M.J.S.)
- Neurocritical Care Service, Harborview Medical Center, Seattle, WA 98104, USA
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Nix HP, Meeker S, King CE, Andrew M, Davis IRC, Koto PS, Sim M, Murdoch J, Patriquin G, Theriault C, Reidy S, Rockwood M, Sampalli T, Searle SD, Rockwood K. Preventing Respiratory Viral Illness Invisibly (PRiVII): protocol for a pragmatic cluster randomized trial evaluating far-UVC light devices in long-term care facilities to reduce infections. Trials 2024; 25:88. [PMID: 38279184 PMCID: PMC10811883 DOI: 10.1186/s13063-024-07909-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/03/2024] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND Respiratory viral illness (RVI)-e.g., influenza, COVID-19-is a serious threat in long-term care (LTC) facilities. Standard infection control measures are suboptimal in LTC facilities because of residents' cognitive impairments, care needs, and susceptibility to loneliness and mental illness. Further, LTC residents living with high degrees of frailty who contract RVIs often develop the so-called atypical symptoms (e.g., delirium, worse mobility) instead of typical cough and fever, delaying infection diagnosis and treatment. Although far-UVC (222 nm) light devices have shown potent antiviral activity in vitro, clinical efficacy remains unproven. METHODS Following a study to assay acceptability at each site, this multicenter, double-blinded, cluster-randomized, placebo-controlled trial aims to assess whether far-UVC light devices impact the incidence of RVIs in LTC facilities. Neighborhoods within LTC facilities are randomized to receive far-UVC light devices (222 nm) or identical placebo light devices that emit only visible spectrum light (400-700 nm) in common areas. All residents are monitored for RVIs using both a standard screening protocol and a novel screening protocol that target atypical symptoms. The 3-year incidence of RVIs will be compared using intention-to-treat analysis. A cost-consequence analysis will follow. DISCUSSION This trial aims to inform decisions about whether to implement far-UVC light in LTC facilities for RVI prevention. The trial design features align with this pragmatic intent. Appropriate additional ethical protections have been implemented to mitigate participant vulnerabilities that arise from conducting this study. Knowledge dissemination will be supported through media engagement, peer-reviewed presentations, and publications. TRIAL REGISTRATION ClinicalTrials.gov NCT05084898. October 20, 2021.
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Affiliation(s)
- Hayden P Nix
- Geriatric Medicine Research, Halifax, NS, Canada.
- Department of Medicine, Dalhousie University, Halifax, NS, Canada.
| | | | - Caroline E King
- Research, Innovation and Discovery, Nova Scotia Health, Halifax, NS, Canada
| | - Melissa Andrew
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
- Division of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Ian R C Davis
- Division of Infectious Diseases, Department of Medicine, Nova Scotia Health, Halifax, NS, Canada
- Department of Pathology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Prosper S Koto
- Research Methods Unit, Nova Scotia Health, Halifax, NS, Canada
| | - Meaghan Sim
- Research, Innovation and Discovery, Nova Scotia Health, Halifax, NS, Canada
| | - Jennifer Murdoch
- Research, Innovation and Discovery, Nova Scotia Health, Halifax, NS, Canada
| | - Glenn Patriquin
- Department of Pathology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
- Division of Microbiology, Department of Pathology and Laboratory Medicine, Nova Scotia Health, Halifax, NS, Canada
| | - Chris Theriault
- Research Methods Unit, Nova Scotia Health, Halifax, NS, Canada
| | - Stephanie Reidy
- Geriatric Medicine Research, Halifax, NS, Canada
- Division of Rheumatology, Nova Scotia Health, Halifax, NS, Canada
| | | | - Tara Sampalli
- Research, Innovation and Discovery, Nova Scotia Health, Halifax, NS, Canada
| | - Samuel D Searle
- Division of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
- Frailty & Elder Care Network, Nova Scotia Health, Halifax, NS, Canada
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Brannigan R, Hughes JE, Moriarty F, Wallace E, Kirke C, Williams D, Bennett K, Cahir C. Potentially Inappropriate Prescribing and Potential Prescribing Omissions and Their Association with Adverse Drug Reaction-Related Hospital Admissions. J Clin Med 2024; 13:323. [PMID: 38256457 PMCID: PMC10816937 DOI: 10.3390/jcm13020323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/19/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND This study aimed to determine the prevalence of potentially inappropriate prescribing (PIP) and potential prescribing omissions (PPOs) and their association with ADR-related hospital admissions in patients aged ≥ 65 years admitted acutely to the hospital. METHODS Information on medications and morbidities was extracted from the Adverse Drug Reactions in an Ageing Population (ADAPT) cohort (N = 798: N = 361 ADR-related admissions; 437 non-ADR-related admissions). PIP and PPOs were assessed using Beers Criteria 2019 and STOPP/START version 2. Multivariable logistic regression (adjusted odds ratios (aOR), 95%CI) was used to examine the association between PIP, PPOs and ADR-related admissions, adjusting for covariates (age, gender, comorbidity, polypharmacy). RESULTS In total, 715 (90%; 95% CI 87-92%) patients had ≥1 Beers Criteria, 555 (70%; 95% CI 66-73%) had ≥ 1 STOPP criteria and 666 patients (83%; 95% CI 81-86%) had ≥ 1 START criteria. Being prescribed at least one Beers (aOR = 1.66, 95% CI = 1.00-2.77), or meeting STOPP (aOR = 1.07, 95% CI = 0.79-1.45) or START (aOR = 0.72; 95%CI = 0.50-1.06) criteria or the number of PIP/PPO criteria met was not significantly associated with ADR-related admissions. Patients prescribed certain drug classes (e.g., antiplatelet agents, diuretics) per individual PIP criteria were more likely to have an ADR-related admission. CONCLUSION There was a high prevalence of PIP and PPOs in this cohort but no association with ADR-related admissions.
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Affiliation(s)
- Ross Brannigan
- School of Population Health, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland; (R.B.); (K.B.)
| | - John E. Hughes
- School of Population Health, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland; (R.B.); (K.B.)
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland;
| | - Emma Wallace
- Department of General Practice, University College Cork, T12 R229 Cork, Ireland;
| | - Ciara Kirke
- National Quality and Patient Safety Directorate at Health Service Executive, D08 W2A8 Dublin, Ireland;
| | - David Williams
- Department of Geriatric and Stroke Medicine, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland;
- Department of Geriatric and Stroke Medicine Beaumont Hospital, D05 E840 Dublin, Ireland
| | - Kathleen Bennett
- School of Population Health, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland; (R.B.); (K.B.)
| | - Caitriona Cahir
- School of Population Health, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland; (R.B.); (K.B.)
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Lin CJ, Su IC, Huang SW, Chen PY, Traynor V, Chang HCR, Liu IH, Lai YS, Lee HC, Rolls K, Chiu HY. Delirium assessment tools among hospitalized older adults: A systematic review and metaanalysis of diagnostic accuracy. Ageing Res Rev 2023; 90:102025. [PMID: 37527704 DOI: 10.1016/j.arr.2023.102025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/08/2023] [Accepted: 07/28/2023] [Indexed: 08/03/2023]
Abstract
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.
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Affiliation(s)
- Chia-Jou Lin
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - I-Chang Su
- Department of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Neurosurgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Sheng-Wen Huang
- Division of Neurosurgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Pin-Yuan Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan
| | - Victoria Traynor
- Illawarra Health and Medical Research Institute, Northfields Ave, Wollongong, NSW 2522, Australia; School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Hui-Chen Rita Chang
- School of Nursing and Midwifery, Western Sydney University, Parramatta South Campus, Australia
| | - I-Hsing Liu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Yun-Shuan Lai
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Hsin-Chien Lee
- Department of Psychiatry, Taipei Medical University Hospital, Taipei, Taiwan; Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kaye Rolls
- Illawarra Health and Medical Research Institute, Northfields Ave, Wollongong, NSW 2522, Australia; School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Hsiao-Yean Chiu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Taipei Medical University Hospital, Taipei, Taiwan.
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Pouw MA, Calf AH, Georg RR, de Rooij SE, Ter Maaten JC, van Munster BC. Diagnostic accuracy of the Dutch version of the 4AT for delirium detection in a mixed patient population and setting. Aging Clin Exp Res 2023:10.1007/s40520-023-02447-2. [PMID: 37285074 PMCID: PMC10363057 DOI: 10.1007/s40520-023-02447-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/17/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Delirium is an acute disturbance in attention, awareness and cognition. Immediate detection in older adults is recommended because delirium is associated with adverse outcomes. The 4 'A's Test (4AT) is a short screening instrument for delirium. The aim of this study is to evaluate diagnostic accuracy of the Dutch version of the screening tool 4AT for delirium detection in different settings. METHODS Prospective observational study conducted in two hospitals in patients aged ≥ 65 years in geriatric wards and the Emergency Department (ED). Each participant underwent two assessments; the index test 4AT, followed by the reference standard for delirium performed by a geriatric care specialist. The reference standard delirium is according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. RESULTS A total of 71 geriatric inpatients and 49 older ED patients were included. The prevalence of delirium was 11.6% in the acute geriatric ward and 6.1% in the ED. The sensitivity and specificity of the 4AT in the acute geriatric ward were 0.88 and 0.69, respectively. In the ED, the sensitivity and specificity were 0.67 and 0.83, respectively. The area under the receiver operating characteristic curve was 0.80 for the acute geriatric ward setting and 0.74 for the ED setting. CONCLUSION The Dutch version of the 4AT is a reliable screening tool for delirium detection in both acute geriatric wards and ED. Due to its brevity and practicality (i.e., no special training is required to administer the tool), it is useful in clinical practice.
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Affiliation(s)
- Maaike A Pouw
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Agneta H Calf
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Rita R Georg
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Sophia E de Rooij
- Amstelland Hospital, Laan van de Helende Meesters 8, 1186 AM, Amstelveen, The Netherlands
| | - Jan C Ter Maaten
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Barbara C van Munster
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
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Liu Y, Li Z, Li Y, Ge N, Yue J. Detecting delirium: a systematic review of ultrabrief identification instruments for hospital patients. Front Psychol 2023; 14:1166392. [PMID: 37251016 PMCID: PMC10214704 DOI: 10.3389/fpsyg.2023.1166392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/21/2023] [Indexed: 05/31/2023] Open
Abstract
Objective Early identification of delirium, which often occurs in older patients, can effectively reduce adverse prognoses. One way to increase the detection rate of delirium is to use an effective ultrabrief instrument for higher-frequency screening. The purpose of this review is to evaluate the diagnostic accuracy of ultrabrief screening tools for delirium. Methods The Cochrane Library, PubMed and EMBASE were searched from January 1, 1974, to November 31, 2022. We assessed the measurement properties of screening instruments using the consensus-based standards for selecting health measurement instruments (COSMIN) checklist and evaluated the risk bias of the included studies using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. The diagnostic test accuracy of instruments for delirium was reported using sensitivity, specificity, positive likelihood ratio (PLR) and negative likelihood ratio (NLR). Result Of the 4,914 items identified, 26 met the eligibility criteria, resulting in 5 different delirium identification tools. The overall study quality assessed by the QUADAS-2 tool was moderate to good. Of the five screening tools, two instruments had sensitivity ≥80% and specificities ≥80%: 4AT and UB-2. The most comprehensive is the 4AT scale, which has a sensitivity of 0.80 [95% confidence interval (CI):0.68, 0.88] and a specificity of 0.89 (95%CI: 0.83, 0.93) and contains 4 items. UB-2 has a sensitivity of 0.88 (95%CI: 0.72, 0.96) and a specificity of 0.64 (95%CI: 0.56, 0.70). Conclusion UB-2 and MOTYB had excellent sensitivity for delirium screening at an early stage. In terms of sensitivity and intentionality, the 4AT is the best recommended scale.
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Affiliation(s)
- Yadong Liu
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
| | - Zhenzhen Li
- Health Management Center, General Practice Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Sichuan, China
| | - Ying Li
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
| | - Ning Ge
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
| | - Jirong Yue
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
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Chang Y, Ragheb SM, Oravec N, Kent D, Nugent K, Cornick A, Hiebert B, Rudolph JL, MacLullich AMJ, Arora RC. Diagnostic accuracy of the "4 A's Test" delirium screening tool for the postoperative cardiac surgery ward. J Thorac Cardiovasc Surg 2023; 165:1151-1160.e8. [PMID: 34243932 DOI: 10.1016/j.jtcvs.2021.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 05/12/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Delirium is prevalent and underdetected among cardiac surgery patients on the postoperative ward. This study aimed to validate the 4 A's Test delirium screening tool and evaluate its accuracy both when used by research assistants and when subsequently implemented by nursing staff on the ward. METHODS This single-center, prospective observational study evaluated the performance of the 4 A's Test administered by research assistants (phase 1) and nursing staff (phase 2). Assessments were undertaken during the patients' first 3 postoperative days on the postcardiac surgery ward along with previous routine nurse-led Confusion Assessment Method assessments. These index tests were compared with a reference standard diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Surveys regarding delirium screening were administered to nurses pre- and postimplementation of the 4 A's Test in phase 2 of the study. RESULTS In phase 1, a total of 137 patients were enrolled, of whom 24.8% experienced delirium on the postoperative cardiac ward. The 4 A's Test had a sensitivity of 85% (95% confidence interval, 73-93) and a specificity of 90% (95% confidence interval, 85-93) compared with the reference standard. The nurse-assessed Confusion Assessment Method had a sensitivity of 23% (95% confidence interval, 13-37) and specificity of 100% (95% confidence interval, 99-100). In phase 2, nurses (n = 51) screened 179 patients for delirium using the 4 A's Test. Compared with the reference rater, the 4 A's Test had a sensitivity of 58% (95% confidence interval, 28-85) and specificity of 94% (95% confidence interval, 85-98). Postimplementation, 64% of nurses thought that the 4 A's Test improved their confidence in delirium detection, and 76% of nurses would consider routine 4 A's Test use. CONCLUSIONS The 4 A's Test demonstrated moderate sensitivity and high specificity to detect delirium in a real-world setting after cardiac surgery on the postoperative ward. A modified model of use with less frequent administration, along with increased engagement of the postoperative team, is recommended to improve early delirium detection on the cardiac surgery postoperative ward.
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Affiliation(s)
- Yue Chang
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sandra M Ragheb
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nebojsa Oravec
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Kent
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Kristina Nugent
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Alexandra Cornick
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Brett Hiebert
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - James L Rudolph
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, and Brown University, Providence, RI
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada.
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Diagnostic accuracy of the 4AT for delirium: A systematic review and meta-analysis. Asian J Psychiatr 2023; 80:103374. [PMID: 36584541 DOI: 10.1016/j.ajp.2022.103374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 09/13/2022] [Accepted: 10/29/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Despite common, serious, costly, and often fatal conditions affecting up to 50 % of older patients, delirium is often unrecognized and overlooked. We examine the accuracy of the 4AT for detecting older patients with delirium. METHODS We performed a systematic search of PubMed, Web of Science, PsycINFO, and EMBASE databases from inception to April 2020 and updated to January 2022. Four independently reviewers extracted study data and assessed the methodological quality using the revised quality assessment of diagnostic accuracy studies tool (QUADAS-2). Pooled estimates of sensitivity and specificity were generated using a bivariate random effects model. All statistical analyses were performed with STATA version 15.1 and Meta-DiSc version 1.4 software. RESULTS Eleven studies with 2789 participants were included. The pooled sensitivity and specificity were 0.87 (95 % CI: 0.81-0.91) and 0.87 (95 % CI: 0.79-0.92), respectively, and the positive and negative likelihood ratios were 6.66 (95 % CI: 4.12-10.74) and 0.15 (95 % CI: 0.10-0.23), respectively. Deeks' test indicated no significant publication bias (t = 0.83, P = 0.43). Univariable meta-regression showed that patient selection and flow and timing significantly influenced the pooled sensitivity (P < 0.05), settings significantly influenced the pooled specificity (P < 0.05). CONCLUSION Our meta-analysis demonstrates that 4AT is a sensitive and specific screening tool for delirium in older patients. Its brevity and simplicity support its use in routine clinical practice, particularly in time-poor settings. Clinicians should come to a conclusion based largely on the 4AT findings in conjunction with clinical judgment.
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Cahir C, Curran C, Walsh C, Hickey A, Brannigan R, Kirke C, Williams DJ, Bennett K. Adverse drug reactions in an ageing PopulaTion (ADAPT) study: Prevalence and risk factors associated with adverse drug reaction-related hospital admissions in older patients. Front Pharmacol 2023; 13:1029067. [PMID: 36712658 PMCID: PMC9880441 DOI: 10.3389/fphar.2022.1029067] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/23/2022] [Indexed: 01/15/2023] Open
Abstract
Background: Older people experience greater morbidity with a corresponding increase in medication use resulting in a potentially higher risk of adverse drug reactions (ADRs). Objectives: The aim of this study was to; 1) determine the prevalence and characteristics of ADR-related hospital admissions among older patients (≥65 years) in Ireland; and 2) identify the risk factors associated with ADR-related hospital admissions. Methods: A cross-sectional study of ADR prevalence in patients aged ≥65 years admitted acutely to hospital in Ireland over a 8 month period (November 2016- June 2017). A multifaceted review of each hospital admission was undertaken to assess the likelihood of an ADR being a reason for admission (cause of admission or contributing to admission) in the context of the patient's medication, clinical conditions, comorbidities and investigations. A number of decision aids were applied by two independent reviewers to assess ADR causality, avoidability and severity. A random sample of patients, determined not to have a suspected ADR on screening, were assigned to a non-ADR control group. Multivariable logistic regression was used to assess the association between potential risk factors for ADR-related admissions compared with non-ADR-related admissions. Results: In total, 3,760 hospital admission episodes (in 3,091 patients) were screened and 377 admissions were considered ADR-related (10.0%, 95% CI 9.1%, 11.0%). 219 (58.1%) ADR-related admissions were caused by an ADR, while ADRs contributed to 158 (41.9%) admissions. 268 (71.1%) of all ADR-related admissions were deemed definitely or possibly preventable/avoidable. 350 (92.8%) ADRs were classified as being of moderate severity, with 27 (7.2%) classified as severe. Antithrombotic agents, mainly aspirin and warfarin, were the drugs most frequently associated with ADR-related admissions (gastrointestinal and vascular haemorrhagic disorders). In multivariable analysis, immobility, frailty, having delirium or ulcer disease and taking anticoagulant and antiplatelet medication on admission were significantly associated with an ADR-related hospital admission. Conclusion: One in ten hospital admissions, among those aged 65 + years, were considered ADR-related, with approximately 70% potentially avoidable. Reliable and validated ADR detection and prediction tools are needed to develop prevention strategies.
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Affiliation(s)
- Caitriona Cahir
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin, Ireland,*Correspondence: Caitriona Cahir,
| | - Carmel Curran
- Department of Geriatric and Stroke Medicine Beaumont Hospital, Dublin, Ireland
| | - Caroline Walsh
- National Centre for Pharmacoeconomics, St. James’s Hospital, Dublin, Ireland,Discipline of Pharmacology and Therapeutics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Anne Hickey
- Department of Psychology, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Ross Brannigan
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Ciara Kirke
- National Quality and Patient Safety Directorate at Health Service Executive, Dublin, Ireland
| | - David J. Williams
- Department of Geriatric and Stroke Medicine Beaumont Hospital, Dublin, Ireland,Department of Geriatric and Stroke Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Kathleen Bennett
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Chary AN, Naik AD, Kennedy M. Reply to: Expanding options to include language barriers for predicting postoperative delirium in geriatric patients. J Am Geriatr Soc 2023; 71:294-295. [PMID: 36254368 DOI: 10.1111/jgs.18083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/18/2022] [Indexed: 01/25/2023]
Abstract
This letter comments on the letter by Streetman et al.
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Affiliation(s)
- Anita N Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Aanand D Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- University of Texas School of Public Health, UT Health Science Center, Houston, Texas, USA
- University of Texas Health Consortium on Aging, Houston, Texas, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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12
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Bayer TA, Van Patten R, Hershkowitz D, Epstein-Lubow G, Rudolph JL. Comorbidity and Management of Concurrent Psychiatric and Medical Disorders. Psychiatr Clin North Am 2022; 45:745-763. [PMID: 36396277 DOI: 10.1016/j.psc.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aging increases susceptibility to medical and psychiatric comorbidity via interrelated biological, psychological, and social mechanisms. Mental status changes or other psychiatric symptoms occurring in older adults with medical disorders most often result from delirium, depression, or the onset of Alzheimer's disease and related dementias (ADRD). Clinicians can use evidence-based tools to evaluate such symptoms including the 4A's Test for delirium, the Saint Louis University Mental Status Exam, and the Geriatric Depression Scale. Innovative models such as collaborative care can improve the outcome of care of older adults with medical disorders requiring treatment for depression or ADRD..
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Affiliation(s)
- Thomas A Bayer
- Long-term Services and Supports Center of Innovation, Providence VA Medical Center, 353-373 Niagara St., Providence, RI 02907, USA; Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, 593 Eddy St., POB 438, Providence, RI 02903, USA.
| | - Ryan Van Patten
- Providence VA Medical Center, 830 Chalkstone Ave, Providence, RI 02908, USA; Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, 593 Eddy Street, APC9 Providence, RI 02903, USA
| | - Dylan Hershkowitz
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, 593 Eddy Street, APC9 Providence, RI 02903, USA
| | - Gary Epstein-Lubow
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, 593 Eddy Street, APC9 Providence, RI 02903, USA; Department of Health Services, Policy and Practice, Brown University School of Public Health, 121 S. Main Street, Providence, RI 02903, USA; Butler Hospital, 345 Blackstone Blvd, Providence, RI 02906, USA
| | - James L Rudolph
- Long-term Services and Supports Center of Innovation, Providence VA Medical Center, 353-373 Niagara St., Providence, RI 02907, USA; Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, 593 Eddy St., POB 438, Providence, RI 02903, USA; Department of Health Services, Policy and Practice, Brown University School of Public Health, 121 S. Main Street, Providence, RI 02903, USA
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Aldwikat RK, Manias E, Holmes A, Tomlinson E, Nicholson P. Validation of Two Screening Tools for Detecting Delirium in Older Patients in the Post-Anaesthetic Care Unit: A Diagnostic Test Accuracy Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16020. [PMID: 36498093 PMCID: PMC9738308 DOI: 10.3390/ijerph192316020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 06/17/2023]
Abstract
(1) Background: Delirium is a common complication among surgical patients after major surgery, but it is often underdiagnosed in the post-anaesthetic care unit (PACU). Valid and reliable tools are required for improving diagnoses of delirium. The objective of this study was to evaluate the diagnostic test accuracy of the Three-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM) and the 4A's Test (4AT) as screening tools for detection of delirium in older people in the PACU. (2) Methods: A prospective diagnostic test accuracy study was conducted in the PACU and surgical wards of a university-affiliated tertiary care hospital in Victoria, Australia. A consecutive prospective cohort of elective and emergency patients (aged 65 years or older) admitted to the PACU were recruited between July 2021 and December 2021 following a surgical procedure performed under general anaesthesia and expected to stay in the hospital for at least 24 h following surgery. The outcome measures were sensitivity, specificity positive predictive value and negative predictive value for 3D-CAM and 4AT. (3) Results: A total of 271 patients were recruited: 16.2% (44/271) had definite delirium. For a diagnosis of definite delirium, the 3D-CAM (area under curve (AUC) = 0.96) had a sensitivity of 100% (95% CI 92.0 to 100.0) in the PACU and during the first 5 days post-operatively. Specificity ranged from 93% (95% CI 87.8 to 95.2) to 91% (95% CI 85.9 to 95.2) in the PACU and during the first 5 days post-operatively. The 4AT (AUC = 0.92) had a sensitivity of 93% (95% CI 81.7 to 98.6) in the PACU and during the first 5 days post-operatively, and specificity ranged from 89% (95% CI 84.6 to 93.1) to 87% (95%CI 80.9 to 91.8) in the PACU and during the first 5 days post-operatively. (4) Conclusions: The 3D-CAM and the 4AT are sensitive and specific screening tools that can be used to detect delirium in older people in the PACU. Screening with either tool could have an important clinical impact by improving the accuracy of delirium detection in the PACU and hence preventing adverse outcomes associated with delirium.
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Affiliation(s)
- Rami K. Aldwikat
- School of Nursing and Midwifery, Deakin University, Geelong, VIC 3220, Australia
- Centre for Quality and Patient Safety Research, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia
- Operating Theatre, The Royal Melbourne Hospital, Parkville, VIC 3050, Australia
| | - Elizabeth Manias
- School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC 3800, Australia
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Alex. Holmes
- Department of Psychiatry, The University of Melbourne, Parkville, VIC 3010, Australia
- Department of Mental Health, The Royal Melbourne Hospital, Parkville, VIC 3050, Australia
| | - Emily Tomlinson
- School of Nursing and Midwifery, Deakin University, Geelong, VIC 3220, Australia
- Centre for Quality and Patient Safety Research, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia
- Institute for Health Transformation, Deakin University, Geelong, VIC 3220, Australia
| | - Patricia Nicholson
- School of Nursing and Midwifery, Deakin University, Geelong, VIC 3220, Australia
- Centre for Quality and Patient Safety Research, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia
- Institute for Health Transformation, Deakin University, Geelong, VIC 3220, Australia
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Muzzana C, Mantovan F, Huber MK, Trevisani K, Niederbacher S, Kugler A, Ausserhofer D. Delirium in elderly postoperative patients: A prospective cohort study. Nurs Open 2022; 9:2461-2472. [PMID: 35716398 PMCID: PMC9374408 DOI: 10.1002/nop2.1263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/11/2022] [Accepted: 05/06/2022] [Indexed: 11/06/2022] Open
Abstract
AIM To describe the incidence, time in days and risk factors for postoperative delirium in elderly patients. DESIGN Prospective cohort study. METHODS Patients over 65 years were daily screened with the 4A's Test and the Delirium Observation Screening Scale for postoperative delirium. A psychiatrist assessed according to the DSM-V. We performed descriptive and logistic regression analyses. RESULTS From 202 patients, 7.5% (N = 15) had a diagnosed postoperative delirium, whereby 73.3% (N = 11) developed the delirium during the first 48 hr after surgery. The median duration was 1 day. Patients over 80 years suffering from heart failure with surgical drains, bladder catheter, central venous catheter had higher odds for developing a postoperative delirium. The incidence of postoperative delirium in our sample was lower compared with other surgical and ortho-geriatric populations. Despite age, several modifiable postoperative factors were associated with the occurrence of postoperative delirium.
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Affiliation(s)
- Chiara Muzzana
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy
| | - Franco Mantovan
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy.,Hospital of Bruneck-Brunico, SABES-ASDAA, Bruneck-Brunico, Italy
| | | | - Katia Trevisani
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy
| | | | - Alexander Kugler
- Hospital of Bruneck-Brunico, SABES-ASDAA, Bruneck-Brunico, Italy
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Hur HJ, Jang YN, Park HY, Lee YS, Ro DH, Kang B, Song KH, Park HY. A prospective study of remote delirium screening using the modified K-4AT for COVID-19 inpatients. Front Psychiatry 2022; 13:976228. [PMID: 36061272 PMCID: PMC9433641 DOI: 10.3389/fpsyt.2022.976228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background Delirium is a neuropsychiatric condition strongly associated with poor clinical outcomes such as high mortality and long hospitalization. In the patients with Coronavirus disease 2019 (COVID-19), delirium is common and it is considered as one of the risk factors for mortality. For those admitted to negative-pressure isolation units, a reliable, validated and contact-free delirium screening tool is required. Materials and methods We prospectively recruited eligible patients from multiple medical centers in South Korea. Delirium was evaluated using the Confusion Assessment Method (CAM) and 4'A's Test (4AT). The attentional component of the 4AT was modified such that respondents are required to count days, rather than months, backward in Korean. Blinded medical staff evaluated all patients and determined whether their symptoms met the delirium criteria of the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). An independent population of COVID-19 patients was used to validate the 4AT as a remote delirium screening tool. We calculated the area under the receiver operating characteristic curve (AUC). Results Out of 286 general inpatients, 28 (9.8%) inpatients had delirium. In this population, the patients with delirium were significantly older (p = 0.018) than the patients without delirium, and higher proportion of males were included in the delirium group (p < 0.001). The AUC of the 4AT was 0.992 [95% confidence interval (CI) 0.983-1.000] and the optimal cutoff was at 3. Of the independent COVID-19 patients, 13 of 108 (12.0%) had delirium. Demographically, the COVID-19 patients who had delirium only differed in employment status (p = 0.047) from the COVID-19 patients who did not have delirium. The AUC for remote screening using the 4AT was 0.996 (0.989-1.000). The optimal cutoff of this population was also at 3. Conclusion The modified K-4AT had acceptable reliability and validity when used to screen inpatients for delirium. More importantly, the 4AT efficiently screened for delirium during remote evaluations of COVID-19 patients, and the optimal cutoff was 3. The protocol presented herein can be used for remote screening of delirium using the 4AT.
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Affiliation(s)
- Hyun Jung Hur
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Yu Na Jang
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Hye Yoon Park
- Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Young Seok Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Du Hyun Ro
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Beodeul Kang
- Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea
| | - Kyoung-Ho Song
- Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Hye Youn Park
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seoul, South Korea
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Koca M, Öztürk Y, Boğa İ, Bürkük S, Eşme M, Akyürek Y, Şimşek S, Aydın DD, Çiçek F, Karabulut E, Halil M, Cankurtaran M, Tanrıöver MD, Doğu BB. A Quality Improvement Study on Delirium Awareness Day: In Pursuit of Missed Delirium Diagnoses. J Gerontol Nurs 2022; 48:43-51. [PMID: 35914081 DOI: 10.3928/00989134-20220630-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The current study aimed to screen for delirium in hospitalized older adults and assess the validity of the Turkish version of the 4A's Test (4AT-TR) as a feasible tool to integrate in routine patient care. The point prevalence of delirium according to clinical evaluation in routine practice was detected among all patients aged ≥60 years in 12 pilot wards. Delirium screening was then conducted by two arms: (a) nurses using the 4AT-TR and (b) geriatricians according to Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria. Prevalence of delirium according to clinical impression was 3.3% (n = 4), whereas prevalence was 12.4% (n = 17) according to DSM-5 criteria and 13.8% (n = 17) according to the 4AT-TR. The 4AT-TR performed by nurses had a sensitivity of 66.6% and specificity of 93.5%. Area under the receiver operating characteristic curve for delirium diagnosis was 0.819 (p < 0.001). Most delirium cases remain undetected unless a routine and formal delirium assessment is integrated in hospital care of high-risk patients. The 4AT-TR performed by nurses seems to be a valid tool for determining delirium in hospitalized older adults. [Journal of Gerontological Nursing, 48(8), 43-51.].
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Sundakov-Krumins TE, Lubbe S, Wand APF. Homicide and Dementia: A Systematic Review. Dement Geriatr Cogn Disord 2022; 51:1-17. [PMID: 35306488 DOI: 10.1159/000521878] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/03/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Homicide by older offenders is rare and devastating. It likely occurs due to a complex interaction of personal, social, and environmental factors. Dementia is a progressive neurological condition which may amplify behavioural disturbances such as aggression. This systematic review aims to evaluate the factors associated with homicide committed by people with dementia in order to inform clinical practice. SUMMARY MEDLINE, PsychINFO, Embase, and PubMed databases were searched in accordance with PRISMA guidelines for empirical studies examining the characteristics and circumstances of people with dementia who committed homicides. Data on factors associated with the homicide were extracted and the quality of each study rated using standardized criteria. A total of 499 papers were screened and thirteen studies met the inclusion criteria. Study design included case reports (seven studies), case series (four studies), and two retrospective cohort studies, indicative of low levels of evidence. Sample sizes were 1-70. Study findings were predominantly descriptive. Quality ratings ranged from 50 to 100%. Factors associated with disinhibition such as dysexecutive syndrome, alcohol use, and delirium may predispose to severe impulsive aggression. Psychosis and personality pathology appeared to influence targeted assaults resulting in homicide by people with dementia. Victim vulnerability was also a key element. KEY MESSAGES The current evidence examining risk factors for homicide committed by people with dementia is limited. However, there are common characteristics reported in these descriptive studies including psychiatric factors and cognitive states causing disinhibition. Recommendations for clinical practice include early assessment of older people with dementia and changed behaviours to allow management of comorbidities and reversible risk factors, alongside education, and advice to carers (who may be targets of aggression). Specialized geriatric forensic psychiatry services and care settings should be developed.
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Affiliation(s)
| | - Sean Lubbe
- Older People's Mental Health, Sydney Local Health District, Sydney, New South Wales, Australia.,Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Anne Pamela Frances Wand
- Older People's Mental Health, Sydney Local Health District, Sydney, New South Wales, Australia.,Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Discipline of Psychiatry and Mental Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
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The detection of delirium in admitted oncology patients: a scoping review. Eur Geriatr Med 2022; 13:33-51. [PMID: 35032322 PMCID: PMC8860783 DOI: 10.1007/s41999-021-00586-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/03/2021] [Indexed: 02/07/2023]
Abstract
Aim To understand the validation of delirium detection tools in medical oncology, as well as identify data on incidence, prevalence and reversibility in this setting. Findings Of twelve studies, only four used case ascertainment methods following published recommendations, six studies had a low risk of bias. Message In delirium tool validation studies in the oncology setting, choice of appropriate gold standard for case ascertainment is a critical factor. New tools and new validations are not recommended, rather the critical application of existing tools depending on appropriate validation and clinical practicality for the setting. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00586-1. Purpose Delirium leads to poor outcomes for patients and careers and has negative impacts on staff and service provision. Cancer rates in elderly populations are increasing and frequently, cancer diagnoses are a co-morbidity in the context of frailty. Data relating to the epidemiology of delirium in hospitalised cancer patients are limited. With the overarching purpose of improving delirium detection and reducing the morbidity and mortality of delirium in cancer patients, we reviewed the epidemiological data and approach to delirium detection in hospitalised, adult oncology patients. Methods MEDLINE, EMBASE, CINAHL, PsycINFO, and SCOPUS databases were searched from January 1996 to August 2017. Key concepts were delirium, cancer, inpatient oncology and delirium screening/detection. Results Of 896 unique studies identified; 91 met full-text review criteria. Of 12 eligible studies, four applied recommended case ascertainment methods to all patients, three used delirium screening tools alone or with case ascertainment tools sub-optimally applied, four used tools not recommended for delirium screening or case ascertainment, one used the Confusion Assessment Method with insufficient information to determine if it met case ascertainment status. Two studies presented delirium incidence rates: 7.8%, and 17% respectively. Prevalence rates ranged from 18–33% for general medical or oncology wards; 42–58% for Acute Palliative Care Units (APCU); and for older cancer patients: 22% and 57%. Three studies reported reversibility; 26% and 49% respectively (APCUs) and 30% (older patients with cancer). Six studies had a low risk of bias according to QUADAS-2 criteria; all studies in the APCU setting were rated at higher risk of bias. Tool selection, study flow and recruitment bias reduced study quality. Conclusion The knowledge base for improved interventions and clinical care for adults with cancer and delirium is limited by the low number of studies. A clear distinction between screening tools and diagnostic tools is required to provide an improved understanding of the rates of delirium and its reversibility in this population. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00586-1.
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Mudge AM, Lee-Steere K, Treleaven E, Cahill M, Finnigan S, McRae P. Cognitive impairment in older hospital inpatients: prevalence, care needs and carer perceptions. AUST HEALTH REV 2021; 46:244-250. [PMID: 34856117 DOI: 10.1071/ah20286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 04/15/2021] [Indexed: 11/23/2022]
Abstract
ObjectivesThe aim of this study was to describe the prevalence of cognitive impairment in hospital inpatients, the associated need for assistance with activities of daily living (ADL) and carer perceptions of hospital care.MethodsA prospective cross-sectional observational study was conducted in a large metropolitan teaching hospital in Brisbane, Australia. Participants were inpatients aged ≥65 years and their carers. Cognitive impairment was measured by clinician auditors using the validated 4 'A's test (4AT), with a score >0 indicating cognitive impairment (1-3, probable dementia; >3, probable delirium). The need for supervision and/or assistance with ADL was recorded from daily nursing documentation. Carers were invited to complete a brief questionnaire.ResultsIn all, 92 of 216 older inpatients (43%) had cognitive impairment, including 52 (24%) with probable delirium. The need for supervision and/or assistance with ADL increased significantly with 4AT score. Fifty-two carers of patients with cognitive impairment reported feeling welcome and that care was safe. They identified opportunities for better information, greater support and more inclusion of carers.ConclusionsCognitive impairment is common in older inpatients and is associated with increased care needs. Workforce planning and health professional training need to acknowledge the needs of patients with cognitive impairment. There are opportunities for greater support and more involvement of carers.What is known about the topic?Cognitive impairment due to delirium and dementia increases with age, and is common in older medical and surgical inpatients. However, cognitive impairment remains under-recognised by healthcare staff. Australian guidelines now recommend routine screening using valid tools, and including carers, when appropriate, when assessing, caring for and communicating with people with cognitive impairment.What does this paper add?This cross-sectional study using the validated 4AT showed 43% of hospital inpatients aged ≥65 years had cognitive impairment. Participants with cognitive impairment had higher care needs and much longer hospitalisations. Carers of people with cognitive impairment reported unmet information needs in hospital and had limited involvement in assessment and care.What are the implications for practitioners?Cognitive impairment is common in older inpatients. Hospitals and healthcare professionals must be prepared and equipped to recognise cognitive impairment, and address the accompanying patient and carer needs.
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Affiliation(s)
- Alison M Mudge
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Karen Lee-Steere
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Elise Treleaven
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Margaret Cahill
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Simon Finnigan
- Centre for Functioning and Health Research, Metro South Hospitals and Health Service, Buranda, Qld, Australia
| | - Prue McRae
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
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Jones HT, Davis DH. What you need to know about: delirium in older adults in hospital. Br J Hosp Med (Lond) 2021; 82:1-10. [PMID: 34983227 DOI: 10.12968/hmed.2020.0603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Delirium is a clinical syndrome characterised by a disturbance of perception, consciousness and/or cognitive function, with an acute onset, fluctuating course and a severe deterioration arising over hours or days. Delirium is usually triggered by a combination of influences including acute illness, surgery, drugs and environmental factors. It is commonly seen in older people presenting to hospital, but can also develop during hospitalisation. There are three types of delirium: hypoactive, hyperactive and mixed. All patients over 65 years old presenting to hospital should be screened for delirium using the '4AT' tool. An alternate method for diagnosing hospital-acquired delirium is described. This article outlines a 10-stage method for diagnosing, managing and preventing delirium, with emphasis on which areas of the history and examination should be prioritised, what the salient investigations are and both non-pharmacological and pharmacological approaches to preventing and treating delirium. Finally, this article explores which patients require specialist referrals or investigations and how to best follow up patients with delirium.
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Affiliation(s)
- Howell T Jones
- NHS Foundation Trust, University College Hospital, University College Hospital, London, UK.,MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Daniel Hj Davis
- NHS Foundation Trust, University College Hospital, University College Hospital, London, UK.,MRC Unit for Lifelong Health and Ageing at UCL, London, UK
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21
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Barriers to completing the 4AT for delirium and its clinical implementation in two hospitals: a mixed-methods study. Eur Geriatr Med 2021; 13:163-172. [PMID: 34782986 PMCID: PMC8860947 DOI: 10.1007/s41999-021-00582-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 10/27/2021] [Indexed: 12/28/2022]
Abstract
Aim To assess the clinical implementation and barriers to completing the 4AT for delirium in general medical and geriatric patients over 75 years upon admission to Wellington and Kenepuru Hospitals. Findings The 4AT is a feasible and sustainable tool for the assessment of delirium in the hospital setting. Most of the identified barriers to completing the 4AT are potentially reversible. Message Implementation of the 4AT may improve through education about these barriers and emphasising its validity in specific groups. Purpose To assess the clinical implementation and barriers to completing the 4AT for delirium in general medical and geriatric patients over 75 years upon admission to Wellington and Kenepuru Hospitals during the first eight months of 2017, 2018 and 2019. Methods Retrospective data from electronic health records were analysed using an explanatory-sequential mixed-methods approach. The initial quantitative phase measured doctors’ adherence to the 4AT and the rate of positive 4ATs (≥ 4). The subsequent qualitative phase identified doctors’ main reasons for omitting the 4AT through conventional content analysis. Results The quantitative population included 7799 acute admissions (mean age 84, 58.2% female). There was good clinical implementation of the 4AT, evidenced by an overall adherence rate of 83.2% and a rate of positive 4ATs of 14.8% that is in keeping with expected delirium rates in similar settings. The qualitative sample consisted of 875 acute admissions (mean age 84, 56.3% female) with documented reasons for omitting the 4AT. The main barriers to completing the 4AT were: reduced patient alertness, communication barriers (language, deafness, aphasia and dysarthria), prioritising patients’ wellness and comfort (addressing critical illnesses, symptoms, end-of-life issues and promoting sleep), pre-existing cognitive disorders, and unstructured delirium assessments. Conclusion Adherence to the 4AT was high and sustainable in both hospitals. Most barriers to completing the 4AT were potentially avoidable. Education about the 4AT in relation to these barriers may improve its implementation.
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22
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Ševčíková B, Matějovská Kubešová H, Šáteková L, Gurková E. The validation of the Czech version of the Delirium Observation Scale and the Nursing Delirium Screening Scale for delirium screening in patients with locomotive apparatus trauma. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2021. [DOI: 10.15452/cejnm.2021.12.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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23
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Ocagli H, Bottigliengo D, Lorenzoni G, Azzolina D, Acar AS, Sorgato S, Stivanello L, Degan M, Gregori D. A Machine Learning Approach for Investigating Delirium as a Multifactorial Syndrome. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18137105. [PMID: 34281037 PMCID: PMC8297073 DOI: 10.3390/ijerph18137105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 12/12/2022]
Abstract
Delirium is a psycho-organic syndrome common in hospitalized patients, especially the elderly, and is associated with poor clinical outcomes. This study aims to identify the predictors that are mostly associated with the risk of delirium episodes using a machine learning technique (MLT). A random forest (RF) algorithm was used to evaluate the association between the subject’s characteristics and the 4AT (the 4 A’s test) score screening tool for delirium. RF algorithm was implemented using information based on demographic characteristics, comorbidities, drugs and procedures. Of the 78 patients enrolled in the study, 49 (63%) were at risk for delirium, 32 (41%) had at least one episode of delirium during the hospitalization (38% in orthopedics and 31% both in internal medicine and in the geriatric ward). The model explained 75.8% of the variability of the 4AT score with a root mean squared error of 3.29. Higher age, the presence of dementia, physical restraint, diabetes and a lower degree are the variables associated with an increase of the 4AT score. Random forest is a valid method for investigating the patients’ characteristics associated with delirium onset also in small case-series. The use of this model may allow for early detection of delirium onset to plan the proper adjustment in healthcare assistance.
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Affiliation(s)
- Honoria Ocagli
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Loredan 18, 35121 Padova, Italy; (H.O.); (D.B.); (G.L.); (D.A.)
| | - Daniele Bottigliengo
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Loredan 18, 35121 Padova, Italy; (H.O.); (D.B.); (G.L.); (D.A.)
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Loredan 18, 35121 Padova, Italy; (H.O.); (D.B.); (G.L.); (D.A.)
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Loredan 18, 35121 Padova, Italy; (H.O.); (D.B.); (G.L.); (D.A.)
- Department of Medical Science, University of Ferrara, Via Fossato di Mortara 64B, 44121 Ferrara, Italy
| | - Aslihan S. Acar
- Department of Actuarial Sciences, Hacettepe University, Ankara 06800, Turkey;
| | - Silvia Sorgato
- Health Professional Management Service (DPS) of the University Hospital of Padova, 35128 Padova, Italy; (S.S.); (L.S.); (M.D.)
| | - Lucia Stivanello
- Health Professional Management Service (DPS) of the University Hospital of Padova, 35128 Padova, Italy; (S.S.); (L.S.); (M.D.)
| | - Mario Degan
- Health Professional Management Service (DPS) of the University Hospital of Padova, 35128 Padova, Italy; (S.S.); (L.S.); (M.D.)
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Loredan 18, 35121 Padova, Italy; (H.O.); (D.B.); (G.L.); (D.A.)
- Correspondence: ; Tel.: +39-049-827-5384
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24
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Tieges Z, Maclullich AMJ, Anand A, Brookes C, Cassarino M, O’connor M, Ryan D, Saller T, Arora RC, Chang Y, Agarwal K, Taffet G, Quinn T, Shenkin SD, Galvin R. Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis. Age Ageing 2021; 50:733-743. [PMID: 33951145 PMCID: PMC8099016 DOI: 10.1093/ageing/afaa224] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 'A's Test (4AT) is a short (<2 minutes) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection. METHODS We searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials, from 2011 (year of 4AT release on the website www.the4AT.com) until 21 December 2019. Inclusion criteria were: older adults (≥65 years); diagnostic accuracy study of the 4AT index test when compared to delirium reference standard (standard diagnostic criteria or validated tool). Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model. RESULTS Seventeen studies (3,702 observations) were included. Settings were acute medicine, surgery, a care home and the emergency department. Three studies assessed performance of the 4AT in stroke. The overall prevalence of delirium was 24.2% (95% CI 17.8-32.1%; range 10.5-61.9%). The pooled sensitivity was 0.88 (95% CI 0.80-0.93) and the pooled specificity was 0.88 (95% CI 0.82-0.92). Excluding the stroke studies, the pooled sensitivity was 0.86 (95% CI 0.77-0.92) and the pooled specificity was 0.89 (95% CI 0.83-0.93). The methodological quality of studies varied but was moderate to good overall. CONCLUSIONS The 4AT shows good diagnostic test accuracy for delirium in the 17 available studies. These findings support its use in routine clinical practice in delirium detection. PROSPERO REGISTRATION NUMBER CRD42019133702.
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Affiliation(s)
- Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, UK
| | - Alasdair M J Maclullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Atul Anand
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland, UK
| | - Claire Brookes
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Marica Cassarino
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Margaret O’connor
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Damien Ryan
- Retrieval, Emergency and Disaster Medicine Research and Development Unit (REDSPoT), Emergency Department, University Hospital Limerick, Limerick, Ireland
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Rakesh C Arora
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Yue Chang
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kathryn Agarwal
- Section of Geriatrics, Baylor College of Medicine, Houston, TX, USA
- Houston Methodist Hospital, Houston, TX, USA
| | - George Taffet
- Section of Geriatrics, Baylor College of Medicine, Houston, TX, USA
- Houston Methodist Hospital, Houston, TX, USA
| | - Terence Quinn
- Institute of Cardiovascular Medicine, University of Glasgow, Glasgow, Scotland, UK
| | - Susan D Shenkin
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
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25
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Codling D, Hood C, Bassett P, Smithard D, Crawford MJ. Delirium screening and mortality in patients with dementia admitted to acute hospitals. Aging Ment Health 2021; 25:889-895. [PMID: 32081035 DOI: 10.1080/13607863.2020.1725804] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: Delirium is associated with increased mortality in older adults. National guidance recommends that all people with dementia who are admitted to hospital are screened for delirium. However, the impact of screening for delirium among inpatients with dementia has not been examined. This study aims to examine this relationship.Methods: Secondary analysis of data from 10,047 patients admitted to 199 hospitals in England and Wales that took part in the third round of the National Audit of Dementia. Multilevel logistic regression was used to examine associations between delirium screening and cognitive testing with inpatient mortality, adjusted for age, gender, diagnosis and hospital site as potential confounders.Results: The mean age of study patients was 84 years (SD = 7.9), 40.1% were male and 82.1% white British. 1285 patients (12.8%) died during their admission to hospital. Overall, 4466 (44.5%) patients were screened for delirium, of whom 2603 (58.6%) screened positive. The odds of mortality were lower in patients who underwent delirium screening (OR 0.84, 95% confidence interval 0.73 to 0.96) and in those receiving cognitive testing (OR 0.74, 95%CI 0.63-0.76).Conclusion: These results suggest that, among people with dementia who are admitted to hospital, screening for delirium and assessment of cognitive functioning may be associated with lower mortality. While we cannot be certain that these associations are causal, the findings support efforts that are being made to increase levels of screening for delirium among people with dementia who are admitted to hospital.
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Affiliation(s)
- David Codling
- South London and Maudsley NHS Foundation Trust, Beckenham, London, UK
| | - Chloe Hood
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | | | | | - Mike J Crawford
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK.,Centre for Psychiatry, Imperial College, London, UK
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26
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Evensen S, Hylen Ranhoff A, Lydersen S, Saltvedt I. The delirium screening tool 4AT in routine clinical practice: prediction of mortality, sensitivity and specificity. Eur Geriatr Med 2021; 12:793-800. [PMID: 33813725 PMCID: PMC8321971 DOI: 10.1007/s41999-021-00489-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/17/2021] [Indexed: 11/27/2022]
Abstract
Aim Investigate if 4AT score predicts 1 year mortality and explore the sensitivity and specificity of the 4AT when applied as part of a clinical routine. Findings 4AT score is one of several clinical characteristics predicting 1 year mortality. The 4AT has reasonable sensitivity and specificity to detect delirium in a clinical routine setting. Message The 4AT seems to be a useful tool for delirium screening and may predict mortality. Purpose Delirium is common and associated with poor outcomes, partly due to underdetection. We investigated if the delirium screening tool 4 A’s test (4AT) score predicts 1 year mortality and explored the sensitivity and specificity of the 4AT when applied as part of a clinical routine. Methods Secondary analyses of a prospective study of 228 patients acutely admitted to a Medical Geriatric Ward. Physicians without formal training conducted the index test (the 4AT); a predefined cut-off ≥ 4 suggested delirium. Reference standard was delirium diagnosed by two geriatricians using the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). We calculated hazard ratios (HR) using Cox regression based on the groups 4AT = 0, 1–3, 4–7 and ≥ 8, first unadjusted, then adjusted for the covariates age, comorbidity, and personal activities of daily living. We calculated sensitivity, specificity, and the area under the receiver operating curve (AUC). Results Mean age of patients was 86.6 years, 139 (61.0%) were female, 78 (34.2%) had DSM-5 delirium; of these, 56 had 4AT-delirium. 1 year mortality was 27.6% (63 patients). Compared to 4AT score 0, the group 4AT ≥ 8 had increased 1 year mortality (HR 2.86, 95% confidence interval 1.28–6.37, p = 0.010). The effect was reduced in multiadjusted analyses (HR 1.69, 95% confidence interval 0.70–4.07, p = 0.24). Sensitivity, specificity, and AUC were 0.72, 0.84, and 0.88, respectively. Conclusions 4AT ≥ 8 indicates increased mortality, but the effect was reduced in multiadjusted analyses. 4AT had acceptable sensitivity and specificity when applied as a clinical routine.
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Affiliation(s)
- Sigurd Evensen
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491, Trondheim, Norway
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - Anette Hylen Ranhoff
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Stian Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491, Trondheim, Norway.
- Department of Geriatrics, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
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Morandi A, Grossi E, Lucchi E, Zambon A, Faraci B, Severgnini J, MacLullich A, Smith H, Pandharipande P, Rizzini A, Galeazzi M, Massariello F, Corradi S, Raccichini A, Scrimieri A, Morichi V, Gentile S, Lucchini F, Pecorella L, Mossello E, Cherubini A, Bellelli G. The 4-DSD: A New Tool to Assess Delirium Superimposed on Moderate to Severe Dementia. J Am Med Dir Assoc 2021; 22:1535-1542.e3. [PMID: 33823162 DOI: 10.1016/j.jamda.2021.02.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/22/2021] [Accepted: 02/18/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The purpose of this study was to create, standardize, and validate a new instrument, named 4-DSD, and determine its diagnostic accuracy in the diagnosis of delirium in subjects with moderate to severe dementia. DESIGN Multicenter cross-sectional observational study. SETTING AND PARTICIPANTS Older patients consecutively admitted to acute and rehabilitation hospital wards. MEASURES The DSM-5 was used as the reference standard delirium assessment. The presence and severity of dementia was defined using the AD8 and the Global Deterioration Scale (GDS). The 4-DSD is a 4-item tool that ranges from 0 to 12. Item 1 measures alertness, item 2 altered function, item 3 attention, and item 4 acute change or fluctuation in mental status. RESULTS A total of 134 patients were included in the study. Most of the patients were enrolled in acute hospital wards (60%), with 40% in rehabilitation settings. A minority of the patients were categorized with moderate dementia, with a GDS score of 5 (4%). Most of the patients were in the moderate-severe stage with a GDS score ≤6 (77%); 19% were classed as severe, with a GDS score of 7. A 4-DSD cutoff score ≥5 had a sensitivity of 80% and specificity of 80% with a positive predictive value (PPV) of 67% and a negative predictive value (NPV) of 89%. In the subgroup with moderate-severe dementia (n = 108), the sensitivity and the specificity were 79% and 82%, respectively, with a PPV and NPV of 62% and 92%. In the subgroup with severe dementia (n = 26) the sensitivity was 82% and the specificity 56% with a PPV of 78% and a NPV of 63%. CONCLUSIONS AND IMPLICATIONS The availability of a specific tool to detect delirium in patients with moderate-severe dementia has important clinical and research implications, allowing all health care providers to improve their ability to identify it.
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Affiliation(s)
- Alessandro Morandi
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy; Geriatric Research Group, Brescia, Italy; Parc Sanitari Pere Virgili and Vall d'Hebrón Institute of Research, Barcelona, Spain.
| | - Eleonora Grossi
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy; Geriatric Research Group, Brescia, Italy
| | - Elena Lucchi
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy; Geriatric Research Group, Brescia, Italy
| | - Antonella Zambon
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy; Department of Statistics and Quantitative Methods, University di Milano-Bicocca, Milan, Italy; Istituto Auxologico Italiano, IRCCS, Biostatistic Unit, Milan, Italy
| | - Bianca Faraci
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy; Geriatric Research Group, Brescia, Italy
| | - Jessica Severgnini
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy
| | - Alasdair MacLullich
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland
| | - Heidi Smith
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Andrea Rizzini
- AFSSL, Social Healthcare Academy, PoliS Lombardia, Milan, Italy
| | | | | | | | | | - Antonia Scrimieri
- Geriatria, Accettazione geriatrica e centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Valeria Morichi
- Geriatria, Accettazione geriatrica e centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Simona Gentile
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy; Geriatric Research Group, Brescia, Italy
| | - Flaminia Lucchini
- University of Florence, Careggi University Hospital, Florence, Italy
| | - Laura Pecorella
- University of Florence, Careggi University Hospital, Florence, Italy
| | - Enrico Mossello
- University of Florence, Careggi University Hospital, Florence, Italy
| | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Reppas-Rindlisbacher C, Panov ED, Cuperfain AB, Rawal S. A Survey of Nurses' Perspectives on Delirium Screening in Older Adult Medical Inpatients With Limited English Proficiency. J Gerontol Nurs 2021; 47:29-34. [PMID: 34038248 DOI: 10.3928/00989134-20210309-05] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The Confusion Assessment Method (CAM) is commonly used to detect delirium but its utility in patients with limited English proficiency (LEP) is not well-established. In the current study, internal medicine nurses at an acute care hospital in Canada were surveyed on the use of the CAM in older adults with LEP. Nurses' perspectives were explored with a focus on barriers to administration. Fifty participants were enrolled (response rate = 47.6%). Twenty-eight (56%) participants stated they could not confidently and accurately assess delirium in patients with LEP. Twenty-nine (58%) participants believed the CAM is not an effective delirium screening tool in the LEP population. Barriers to screening included: challenges with interpretation services, dependence on family members, and fear that the assessment itself may worsen confusion. Our study is the first to describe specific barriers to administering the CAM in patients with LEP. Strategies are required to address these barriers and optimize delirium screening for patients with LEP. [Journal of Gerontological Nursing, 47(4), 29-34.].
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Han TS, Lisk R, Osmani A, Sharmin R, El Gammel S, Yeong K, Fluck D, Fry CH. Increased Association With Malnutrition and Malnourishment in Older Adults Admitted With Hip Fractures Who Have Cognitive Impairment and Delirium, as Assessed by 4AT. Nutr Clin Pract 2020; 36:1053-1058. [PMID: 33368631 DOI: 10.1002/ncp.10614] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/16/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The Royal College of Physicians recently introduced the 4AT (Alertness, Abbreviated Mental Test-4, Attention, and Acute change or fluctuating course) for screening cognitive impairment and delirium. Here, we examined the association of the 4AT with nutrition status in patients admitted to a hospital with hip fractures between January 1, 2016, and June 6, 2019. METHODS Nutrition status was assessed using the Malnutrition Universal Screening Tool, and the 4AT was assessed within 1 day after hip surgery. χ2 Tests and logistic regression were conducted to assess the association of nutrition status with 4AT scores, adjusted for age and sex. RESULTS From 1082 patients aged 60-103 years, categorized into 4AT scores of 0, 1-3, or ≥4, the prevalence of malnutrition risk was 15.5%, 27.3%, and 39.6% and malnourishment was 4.1%, 13.2%, and 11.3%, respectively. Compared with the 4AT = 0 cohort, a 4AT score = 1-3 was associated with an increased malnutrition risk (odds ratio [OR], 2.3; 95% CI, 1.6-3.1) or malnourishment (OR, 3.6; 95% CI, 2.1-6.3). For a 4AT score ≥4, corresponding ORs were 4.0 (95% CI, 2.8-5.9) and 3.6 (95% CI, 1.9-6.8). Overall, there was a significant positive association: as 4AT scores increased, so did malnutrition risk. CONCLUSIONS Among older adults admitted with hip fractures, high 4AT scores, which are suggestive of cognitive impairment and delirium, identified patients at increased malnutrition risk. These findings lend further support for the use of 4AT to identify patients who are at increased health risk.
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Affiliation(s)
- Thang S Han
- Institute of Cardiovascular, Research, Royal Holloway, University of London, Egham, Surrey, UK
| | - Radcliffe Lisk
- Department of Orthogeriatrics, Ashford and St Peter's NHS Foundation Trust, Chertsey, Surrey, UK
| | - Ahmad Osmani
- Department of Orthogeriatrics, Ashford and St Peter's NHS Foundation Trust, Chertsey, Surrey, UK
| | - Rifat Sharmin
- Department of Orthogeriatrics, Ashford and St Peter's NHS Foundation Trust, Chertsey, Surrey, UK
| | - Sarah El Gammel
- Department of Orthogeriatrics, Ashford and St Peter's NHS Foundation Trust, Chertsey, Surrey, UK
| | - Keefai Yeong
- Department of Orthogeriatrics, Ashford and St Peter's NHS Foundation Trust, Chertsey, Surrey, UK
| | - David Fluck
- Department of Cardiology, Ashford and St Peter's NHS Foundation Trust, Chertsey, Surrey, UK
| | - Christopher H Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
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Strecker C, Hitch D. Perceptions of current occupational therapy practice with older adults experiencing delirium. Australas J Ageing 2020; 40:e190-e198. [PMID: 33185974 DOI: 10.1111/ajag.12882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 08/27/2020] [Accepted: 10/11/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To describe the perceptions of Australian occupational therapists of their role, knowledge and skills in enabling older adults with delirium to participate in meaningful occupations. METHODS This is a mixed-methods cross-sectional study. Participants (n = 91) completed an online survey, with quantitative data analysed descriptively and qualitative data subjected to content analysis. RESULTS Occupational therapists had good general delirium knowledge, but less understanding of specific risk factors. Participants asserted the importance of occupational therapy assessment and treatment for older people experiencing delirium and generally felt confident or somewhat confident in their skills. While all participants provided collaborative care with multidisciplinary team members, only a minority thought colleagues had a satisfactory knowledge of the occupational therapy role with delirium. CONCLUSION Currently, the role of occupational therapy with older people experiencing delirium remains emerging rather than established, and there are many opportunities for further research and development in this practice area.
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Affiliation(s)
| | - Danielle Hitch
- Deakin University, Geelong, Victoria, Australia.,Western Health, Sunshine Hospital, St. Albans, Victoria, Australia
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Jeong E, Park J, Lee J. Diagnostic Test Accuracy of the 4AT for Delirium Detection: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E7515. [PMID: 33076557 PMCID: PMC7602716 DOI: 10.3390/ijerph17207515] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 02/01/2023]
Abstract
Under-recognition of delirium is an international problem. For the early detection of delirium, a feasible and valid screening tool for healthcare professionals is needed. This study aimed to present a scientific reason for using the 4 'A's Test (4AT) through a systematic review and meta-analysis of studies on the diagnostic test accuracy. We systematically searched articles in the EMBASE, MEDLINE, CINAHL, and PsycINFO databases and selected relevant articles on the basis of the predefined inclusion criteria. The quality of the included articles was evaluated using the Quality Assessment of the Diagnostic Accuracy Studies-2 tool. We estimated the pooled values of diagnostic test accuracy by employing the bivariate model and the hierarchical summary receiver operating characteristic (HSROC) model in data synthesis. A total of 3729 patients of 13 studies were included in the analysis. The pooled estimates of sensitivity and specificity of the 4AT were 81.5% (95% confidence interval: 70.7%, 89.0%) and 87.5% (79.5%, 92.7%), respectively. Given the 4AT's evidence of accuracy and practicality, we suggest healthcare professionals to utilize this tool for routine screening of delirium. However, for detecting delirium in the dementia population, further work is required to evaluate the 4AT with other cut-off points or scoring methods in order for it to be more sensitive and specific.
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Affiliation(s)
- Eunhye Jeong
- College of Nursing, Korea University, Seoul 02841, Korea; (E.J.); (J.P.)
| | - Jinkyung Park
- College of Nursing, Korea University, Seoul 02841, Korea; (E.J.); (J.P.)
| | - Juneyoung Lee
- Department of Biostatistics, College of Medicine, Korea University, Seoul 02841, Korea
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MacLullich AM, Shenkin SD, Goodacre S, Godfrey M, Hanley J, Stíobhairt A, Lavender E, Boyd J, Stephen J, Weir C, MacRaild A, Steven J, Black P, Diernberger K, Hall P, Tieges Z, Fox C, Anand A, Young J, Siddiqi N, Gray A. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess 2020; 23:1-194. [PMID: 31397263 DOI: 10.3310/hta23400] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
| | - Susan D Shenkin
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Steve Goodacre
- Emergency Medicine, University of Sheffield, Sheffield, UK
| | - Mary Godfrey
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Janet Hanley
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Antaine Stíobhairt
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Elizabeth Lavender
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Katharina Diernberger
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Peter Hall
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Christopher Fox
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Atul Anand
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - John Young
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Najma Siddiqi
- Psychiatry, University of York, York.,Hull York Medical School, York, UK.,Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Alasdair Gray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
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Harris C, Spiller J, Finucane A. Managing delirium in terminally ill patients: perspective of palliative care nurse specialists. Br J Community Nurs 2020; 25:346-352. [PMID: 32614673 DOI: 10.12968/bjcn.2020.25.7.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Delirium occurs frequently at end of life. Palliative care clinical nurse specialists (CNSs) are involved in community palliative care provision. Many patients prefer being cared for at home, yet managing delirium in this setting presents unique challenges, potentially resulting in emergency hospital or hospice admission. We examined the experiences and practice of palliative care CNSs managing delirium in the community; 10 interviews were undertaken. Data were analysed using the framework approach. Challenges to delirium management in the community included limited time with patients, reliance on families and access to medications. Assessment tools were not used routinely; time limited visits and inconsistent retesting were perceived barriers. Management approaches differed depending on CNSs' previous delirium education. Strategies to prevent delirium were not used. Community delirium management presents challenges; support surrounding these could be beneficial. Routine assessment tool use and delirium prevention strategies should be included in further education and research.
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Affiliation(s)
- Clare Harris
- Medical student, University of Edinburgh Medical School
| | - Juliet Spiller
- Consultant in Palliative Medicine, Marie Curie Hospice, Edinburgh
| | - Anne Finucane
- Research lead, Marie Curie Hospice Edinburgh and Honorary Research Fellow, University of Edinburgh
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Lisk R, Yeong K, Enwere P, Jenkinson J, Robin J, Irvin-Sellers M, Fluck D, Osmani A, Sharmin R, Sharma P, Fry CH, Han TS. Associations of 4AT with mobility, length of stay and mortality in hospital and discharge destination among patients admitted with hip fractures. Age Ageing 2020; 49:411-417. [PMID: 31813951 DOI: 10.1093/ageing/afz161] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/07/2019] [Accepted: 11/18/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND the 4AT (Alertness, Abbreviated Mental Test-4, Attention and Acute change or fluctuating course), a tool to screen cognitive impairment and delirium, has recently been recommended by the Scottish Intercollegiate Guidelines Network. We examined its ability to predict health outcomes among patients admitted with hip fractures to a single hospital between January 2018 and June 2019. METHODS the 4AT was performed within 1 day after hip surgery. A 4AT score of 0 means unlikely delirium or severe cognitive impairment (reference group); a score of 1-3 suggests possible chronic cognitive impairment, without excluding possibility of delirium; a score ≥ 4 suggests delirium with or without chronic cognitive impairment. Logistic regression, adjusted for: age; sex; nutritional status; co-morbidities; polypharmacy; and anticholinergic burden, used the 4AT to predict mobility, length of stay (LOS), mortality and discharge destination, compared with the reference group. RESULTS from 537 (392 women, 145 men: mean = 83.7 ± standard deviation [SD] = 8.8 years) consecutive patients, 522 completed the 4AT; 132 (25%) had prolonged LOS (>2 weeks) and 36 (6.8%) died in hospital. Risk of failure to mobilise within 1 day of surgery was increased with a 4AT score ≥ 4 (OR = 2.4, 95% confidence interval [CI] = 1.3-4.3). Prolonged LOS was increased with 4AT scores of 1-3 (OR = 2.4, 95%CI = 1.4-4.1) or ≥4 (OR = 3.1, 95%CI = 1.9-6.7). In-patient mortality was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.2-8.2) but not with a 4AT score of 1-3. Change of residence on discharge was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.4-6.8). These associations persisted after excluding patients with dementia. 4AT score = 1-3 and ≥ 4 associated with increased LOS by 3 and 6 days, respectively. CONCLUSIONS for older adults with hip fracture, the 4AT independently predicts immobility, prolonged LOS, death in hospital and change in residence on discharge.
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Affiliation(s)
- Radcliffe Lisk
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Keefai Yeong
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Peter Enwere
- Dementia Service, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | | | - Jonathan Robin
- Department of Acute Medicine, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Melanie Irvin-Sellers
- Department of Respiratory Medicine, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - David Fluck
- Department of Cardiology, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Ahmad Osmani
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Rifat Sharmin
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway, University of London, Surrey TW20 0EX, UK
- Department of Clinical Neuroscience, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Christopher H Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol BS8 1TD, UK
| | - Thang S Han
- Institute of Cardiovascular Research, Royal Holloway, University of London, Surrey TW20 0EX, UK
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35
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Recognition, prevention, and treatment of delirium in emergency department: An evidence-based narrative review. Am J Emerg Med 2020; 38:349-357. [DOI: 10.1016/j.ajem.2019.158454] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 12/19/2022] Open
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Abstract
Delirium is a common and underdiagnosed problem in hospitalized older adults. It is associated with an increased risk of poor cognitive and functional outcomes, institutionalization, and death. Timely diagnosis of delirium and non-pharmacological prevention and management strategies can improve patient outcomes. The Confusion Assessment Method (CAM) is the most widely used clinical assessment tool for the diagnosis of delirium. Multiple variations of the CAM have been developed for ease of administration and for the unique needs of specific patient populations, including the 3-min diagnostic CAM (3D CAM), CAM-Intensive Care Unit (CAM-ICU), Delirium Triage Screen (DTS)/Brief CAM (b-CAM), 4AT tool, and ultrabrief delirium assessment. Strong evidence supports the effectiveness of nonpharmacologic strategies as the primary intervention for the prevention of delirium. Multicomponent delirium prevention strategies can reduce the incidence of delirium by 40%. Investigation of underlying medical precipitants and optimization of non-pharmacological interventions are first line in the management of delirium. Despite a lack of evidence supporting use of antipsychotics, low dose antipsychotics remain second line for off-label treatment of distressing psychoses and/or agitated behaviors that are refractory to non-pharmacological behavioral interventions and pose an imminent risk of harm to self or others. Any antipsychotic prescription for delirium should be accompanied by an appropriate taper plan. Follow up with primary care providers on discharge from hospital for ongoing screening of cognitive impairment is important.
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Affiliation(s)
- Katie M Rieck
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sandeep Pagali
- Division of Hospital Internal Medicine, and Division of Geriatrics and Gerontology, Mayo Clinic, Rochester, MN, USA
| | - Donna M Miller
- Division of Hospital Internal Medicine, and Division of Geriatrics and Gerontology, Mayo Clinic, Rochester, MN, USA
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Menzenbach J, Guttenthaler V, Kirfel A, Ricchiuto A, Neumann C, Adler L, Kieback M, Velten L, Fimmers R, Mayr A, Wittmann M. Estimating patients' risk for postoperative delirium from preoperative routine data - Trial design of the PRe-Operative prediction of postoperative DElirium by appropriate SCreening (PROPDESC) study - A monocentre prospective observational trial. Contemp Clin Trials Commun 2019; 17:100501. [PMID: 31890984 PMCID: PMC6926123 DOI: 10.1016/j.conctc.2019.100501] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/14/2019] [Accepted: 11/21/2019] [Indexed: 11/09/2022] Open
Abstract
Background Postoperative Delirium (POD) is the most common complication of elderly patients after surgery associated with increased postoperative morbidity, persistent care dependency and even mortality. Prevention of POD requires detection of patients at high risk prior to surgery. PROPDESC intends to provide an instrument for preoperative routine screening of patients' risk for POD. Methods PROPDESC is a monocentric prospective observatory trial including 1000 patients older than 60 years from various disciplines of a university hospital planned for surgery of at least 60 min. To develop a score predicting the risk for POD, anesthesiological stratifications, laboratory values, medication and known risk factors as well as quality of life and cognitive performance are taken into account. POD assessment is performed daily on the first five days after the operation respectively the end of sedation in the intensive care units and normal wards. The score is evaluated from 600 data sets and subsequently validated internally. The most appropriate predictors are determined by a component-wise gradient boosting approach. Discussion Based on retrospective investigations, etiology of POD is considered multifactorial. By a prospective analysis of various factors, PROPDESC intends to provide an applicable tool to predict the risk for POD from preoperative routine data and assessment of cognitive function. Objective is to establish an automatically generating score in preoperative routine to screen patients for increased risk of POD as starting point for POD reduction and management. Model compilation requires a high significance and enhancement within compound as well as regular availability of the selected predictors. Trial registration DRKS, DRKS00015715. Registered 13 December 2018 - Retrospectively registered, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015715.
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Affiliation(s)
- Jan Menzenbach
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Vera Guttenthaler
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Andrea Kirfel
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Arcangelo Ricchiuto
- Institute for Medical Biometry, Informatics and Epidemiology at the University of Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Claudia Neumann
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Linda Adler
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Marjetka Kieback
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Lisa Velten
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Rolf Fimmers
- Institute for Medical Biometry, Informatics and Epidemiology at the University of Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Andreas Mayr
- Institute for Medical Biometry, Informatics and Epidemiology at the University of Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Maria Wittmann
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
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Brooke J. Differentiation of delirium, dementia and delirium superimposed on dementia in the older person. ACTA ACUST UNITED AC 2019; 27:363-367. [PMID: 29634336 DOI: 10.12968/bjon.2018.27.7.363] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Delirium is an acute clinical emergency that requires prompt clinical intervention. A predisposing factor for delirium is dementia, and delirium may highlight the vulnerability of a patient to developing dementia. However, delirium also occurs during an acute illness in patients diagnosed with dementia; this is classified as delirium superimposed on dementia. This complex interplay of both dementia syndromes and the condition of delirium has been extensively studied. However, delirium continues to be under-recognised in the acute setting, which impacts negatively on patient outcomes. Nurses are the health professionals best placed to recognise a change in a patient's cognitive symptoms, but nurses caring for the older person have suggested the identification of and differentiation between delirium, dementia and delirium superimposed on dementia remains very confusing. A need for further education with supportive guidelines and protocols is required to empower nurses caring for an older person to verbalise changes in patients' cognitive status in a reliable, robust and systematic manner.
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Affiliation(s)
- Joanne Brooke
- Reader of Complex Older Persons Care, Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, Oxford
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39
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Ševčíková B, Matějovská Kubešová H, Šáteková L, Gurková E. Delirium screening instruments administered by nurses for hospitalized patients - literature review. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2019. [DOI: 10.15452/cejnm.2019.10.0028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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40
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Shenkin SD, Fox C, Godfrey M, Siddiqi N, Goodacre S, Young J, Anand A, Gray A, Hanley J, MacRaild A, Steven J, Black PL, Tieges Z, Boyd J, Stephen J, Weir CJ, MacLullich AMJ. Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method. BMC Med 2019; 17:138. [PMID: 31337404 PMCID: PMC6651960 DOI: 10.1186/s12916-019-1367-9] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/13/2019] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Susan D. Shenkin
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
| | - Christopher Fox
- Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Mary Godfrey
- Elderly Care and Rehabilitation and Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, Hull York Medical School, Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Young
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
| | - Atul Anand
- Cardiovascular Sciences and Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | - Alasdair Gray
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Janet Hanley
- Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly L. Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher J. Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Alasdair M. J. MacLullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
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41
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Casey P, Dārziņš P, Webb-St Mart M, Baldwin C, Riddell K, Johnson C, Cross W. Evaluation of a method to estimate the point prevalence of cognitive impairment and delirium in a multi-campus Australian health service. Australas J Ageing 2019; 38:258-266. [PMID: 31087605 DOI: 10.1111/ajag.12666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 03/26/2019] [Accepted: 03/28/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To design, test (pilot) and implement a study to estimate the point prevalence of cognitive impairment (CI) and delirium in a multi-site health service. METHODS Clinicians were trained to use the 4 A's Test (4AT) to screen for cognitive impairment and delirium, and the 3-minute Diagnostic Interview for the Confusion Assessment Method (3D-CAM) to detect delirium in those with abnormal 4AT results. Outcomes of interest were as follows: (a) rates of cognitive impairment and delirium and (b) feasibility of the approach measured by participation rate, "direct survey activity" time, cost and surveyor preparation. RESULTS The rates of cognitive impairment and delirium were 43.8% (245/559) and 16.3% (91/559), respectively. 90.5% (563/622) of eligible adult patients from 25 acute and subacute wards were seen. "Direct survey activities" averaged 14 minutes (range 2-45) and cost $11.48 per patient. Training evaluation indicated additional education in the 4AT and 3D-CAM was needed. CONCLUSION Health services could use this streamlined, inexpensive method to estimate the point prevalence of cognitive impairment and delirium.
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Affiliation(s)
- Penelope Casey
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Box Hill, Victoria, Australia.,Eastern Health, Box Hill, Victoria, Australia
| | - Pēteris Dārziņš
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Box Hill, Victoria, Australia.,Eastern Health, Box Hill, Victoria, Australia
| | | | | | | | - Claire Johnson
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Box Hill, Victoria, Australia.,Eastern Health, Box Hill, Victoria, Australia
| | - Wendy Cross
- Federation University, Berwick, Victoria, Australia
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Di Santo L. Postoperative cognitive decline: the nurse's role in identifying this underestimated and misinterpreted condition. ACTA ACUST UNITED AC 2019; 28:414-420. [PMID: 30969864 DOI: 10.12968/bjon.2019.28.7.414] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND postoperative cognitive changes can increase morbidity and mortality, demand for postoperative care and social and health costs, and can lead to dementia. AIM this article discusses perioperative variables that can be used to identify patients who are more vulnerable to experiencing cognitive decline after surgery. It also highlights some screening tools that could be useful for early detection and for planning nursing care. METHOD a literature search was conducted using the Medline, CINAHL, PsychINFO and Cochrane Library databases from 2010 to 2018. Google Scholar was also consulted. The reference lists of relevant articles covering postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) were reviewed for further relevant papers. CONCLUSION assessment and evaluation of a patient's cognitive resources before and after surgery can lead to clinical interventions to support the person's coping mechanisms; health professionals can reduce the short- and long-term effects of cognitive decline. Screening tools could be used as part of a strategy to minimise postoperative cognitive changes.
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Affiliation(s)
- Luca Di Santo
- Research Nurse, Academic Neuroscience Centre, King's College Hospital, London
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Casey P, Cross W, Mart MW, Baldwin C, Riddell K, Dārziņš P. Hospital discharge data under‐reports delirium occurrence: results from a point prevalence survey of delirium in a major Australian health service. Intern Med J 2019; 49:338-344. [DOI: 10.1111/imj.14066] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/18/2018] [Accepted: 07/31/2018] [Indexed: 01/17/2023]
Affiliation(s)
- Penelope Casey
- Faculty of Medicine, Nursing and Health SciencesMonash University Melbourne Victoria Australia
- Eastern Health Melbourne Victoria Australia
| | - Wendy Cross
- Federation University Melbourne Victoria Australia
| | | | | | | | - Pēteris Dārziņš
- Faculty of Medicine, Nursing and Health SciencesMonash University Melbourne Victoria Australia
- Eastern Health Melbourne Victoria Australia
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Meehan AJ, Maher AB, Brent L, Copanitsanou P, Cross J, Kimber C, MacDonald V, Marques A, Peng L, Queirós C, Roigk P, Sheehan KJ, Skúladóttir SS, Hommel A. The International Collaboration of Orthopaedic Nursing (ICON): Best practice nursing care standards for older adults with fragility hip fracture. Int J Orthop Trauma Nurs 2019; 32:3-26. [DOI: 10.1016/j.ijotn.2018.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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45
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White S, Griffiths R, Baxter M, Beanland T, Cross J, Dhesi J, Docherty AB, Foo I, Jolly G, Jones J, Moppett IK, Plunkett E, Sachdev K. Guidelines for the peri-operative care of people with dementia. Anaesthesia 2019; 74:357-372. [DOI: 10.1111/anae.14530] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2018] [Indexed: 12/24/2022]
Affiliation(s)
- S. White
- Royal Sussex County Hospital; Co-Chair, Association of Anaesthetists Working Party; Brighton UK
| | - R. Griffiths
- Peterborough and Stamford Hospitals Foundation NHS Trust; Co-Chair, Association of Anaesthetists Working Party; Peterborough UK
| | - M. Baxter
- University Hospital Southampton; British Geriatrics Society; UK
| | | | - J. Cross
- Guy's and St. Thomas’ Hospitals NHS Trust; Royal College of Nursing; London UK
| | - J. Dhesi
- Guy's and St. Thomas’ Hospitals NHS Trust; British Geriatrics Society; London UK
| | - A. B. Docherty
- Department of Anaesthesia and Critical Care; University of Edinburgh; UK
| | - I. Foo
- Western General Hospital; Age Anaesthesia Association; Edinburgh UK
| | | | | | - I. K. Moppett
- Anaesthesia and Peri-operative Medicine; University of Nottingham; Royal College of Anaesthetists; UK
| | - E. Plunkett
- University Hospitals Birmingham; Association of Anaesthetists Trainees; UK
| | - K. Sachdev
- Homerton University Hospital NHS Foundation Trust; London UK
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Abstract
UNLABELLED ABSTRACTObjectives:Bedside tests of attention and organized thinking were performed in patients with cognitive impairment or dementia but without delirium, to provide estimates of false positive rates for detecting delirium superimposed on dementia (DSD). DESIGN AND SETTING This cross-sectional study was conducted in outpatients and institutionalized patients without delirium representing a wide spectrum of severity of cognitive impairments. PARTICIPANTS Patients with dementia or a cognitive disorder according to DSM IV criteria, after exclusion of (suspected) delirium according to DSM IV criteria. MEASUREMENTS Tests for inattention and disorganized thinking from the CAM-ICU were assessed. RESULTS The sample included 163 patients (mean age 83 years (SD 6; 64% women)), with Alzheimer's disease as most prevalent (45%) diagnosis and a mean MMSE-score of 16.8 (SD 7.5). False positive rates of the test of attention varied from 0.04 in patients with normal to borderline cognitive function to 0.8 in those with severe dementia. The false positive rate of the test of disorganized thinking was zero in the normal to borderline group, increasing to 0.67 in patients with severe dementia. When combining test results false positive rates decreased to 0.03 in patients with MMSE scores above 9. CONCLUSION Use of simple bedside tests of attention and organized thinking for the clinical diagnosis of DSD will result in high rates of false positive observations if used regardless of the severity of dementia. However, if test results are combined they may be useful to exclude DSD in patients with minimal to moderate degrees of dementia, but not in the severe group.
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Bearn A, Lea W, Kusznir J. Improving the identification of patients with delirium using the 4AT assessment. Nurs Older People 2018; 30:18-27. [PMID: 30426731 DOI: 10.7748/nop.2018.e1060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 06/09/2023]
Abstract
Delirium is a common neuropsychiatric disorder that all those working with older people will have encountered at some stage. Delirium is often poorly identified in hospital settings and therefore not optimally managed. After data collection on the acute medical unit in an acute hospital trust in the UK it was evident that patients with signs of delirium were not being formally assessed and therefore not appropriately managed in many cases. A quality improvement project introduced the 4AT delirium assessment tool to try to ensure that patients with delirium were being identified. The project team carried out several plan-do-studyact cycles to bring about our changes, which included a 4AT assessment sticker for nursing staff to complete and teaching for all healthcare staff. Through involvement of all members of the multidisciplinary team and ongoing feedback and changes we were able to increase assessment of delirium from 0% to 64%. There is ongoing work to be done to continue to improve delirium management, but by initially improving the assessment and identification of delirium we will make a difference to these patients' outcomes.
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Affiliation(s)
- Amelia Bearn
- York Teaching Hospital NHS Foundation Trust, York, England
| | - William Lea
- York Teaching Hospital NHS Foundation Trust, York, England
| | - Jennie Kusznir
- York Teaching Hospital NHS Foundation Trust, York, England
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Bauernfreund Y, Butler M, Ragavan S, Sampson EL. TIME to think about delirium: improving detection and management on the acute medical unit. BMJ Open Qual 2018; 7:e000200. [PMID: 30167472 PMCID: PMC6109807 DOI: 10.1136/bmjoq-2017-000200] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 06/29/2018] [Accepted: 07/08/2018] [Indexed: 11/09/2022] Open
Abstract
Delirium affects 18%–35% patients in the acute hospital setting, yet is often neither detected nor managed appropriately. It is associated with increased risk of falls, longer hospital stay and increased morbidity and mortality rates. It is a frightening and unpleasant experience for both patients and their families. We used quality improvement tools and a multicomponent intervention to promote detection and improve management of delirium on the acute medical unit (AMU). We reviewed whether a delirium screening tool (4AT) had been completed for all patients aged over 65 years admitted to the AMU over 1 week. If delirium was detected, we assessed whether investigation and management was adequate as per national guidance. After baseline data collection, we delivered focused sessions of delirium education for doctors and nursing staff, including training on use of the 4AT tool and the TIME (Triggers, Investigate, Manage, Engage) management bundle. We introduced TIME checklists, an online delirium order set and created a bedside orientation tool. We collected data following the interventions and identified areas for further improvement. Following our first PDSA (Plan, Do, Study, Act) cycle, use of the 4AT screening tool improved from 40% to 61%. Adequate assessment for the causes of and exacerbating factors for delirium increased from 73% to 94% of cases. Use of personal orientation tools improved from 0% to 38%. In summary, a targeted staff education programme and practical aids for the ward have improved the screening and management of delirium on the AMU. This may be improved further through more frequent training sessions to account for regular change-over of junior doctors and through implementing a nursing champion for delirium.
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Affiliation(s)
| | | | - Sumathi Ragavan
- Care of the Elderly Department, North Middlesex Hospital, London, UK
| | - Elizabeth L Sampson
- Division of Psychiatry, University College London Medical School, London, UK.,Barnet, Enfield and Haringey Mental Health Liaison Service, North Middlesex Hospital, London, UK
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Yu A, Wu S, Zhang Z, Dening T, Zhao S, Pinner G, Xia J, Yang D. Cholinesterase inhibitors for the treatment of delirium in non-ICU settings. Cochrane Database Syst Rev 2018; 6:CD012494. [PMID: 29952000 PMCID: PMC6513030 DOI: 10.1002/14651858.cd012494.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Delirium is a common clinical syndrome defined as alterations in attention with an additional disturbance in cognition or perception, which develop over a short period of time and tend to fluctuate during the course of the episode. Delirium is commonly treated in hospitals or community settings and is often associated with multiple adverse outcomes such as increased cost, morbidity, and even mortality. The first-line intervention involves a multicomponent non-pharmacological approach that includes ensuring effective communication and reorientation in addition to providing reassurance or a suitable care environment. There are currently no drugs approved specifically for the treatment of delirium. Clinically, however, various medications are employed to provide symptomatic relief, such as antipsychotic medications and cholinesterase inhibitors, among others. OBJECTIVES To evaluate the effectiveness and safety of cholinesterase inhibitors for treating people with established delirium in a non-intensive care unit (ICU) setting. SEARCH METHODS We searched ALOIS, which is the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, on 26 October 2017. We also cross-checked the reference lists of included studies to identify any potentially eligible trials. SELECTION CRITERIA We included randomised controlled trials, published or unpublished, reported in English or Chinese, which compared cholinesterase inhibitors to placebo or other drugs intended to treat people with established delirium in a non-ICU setting. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. The primary outcomes were duration of delirium, severity of delirium, and adverse events. The secondary outcomes were use of rescue medications, persistent cognitive impairment, length of hospitalisation, institutionalisation, mortality, cost of intervention, leaving the study early, and quality of life. For dichotomous outcomes, we calculated the risk ratio (RR) with 95% confidence intervals (CIs); for continuous outcomes we calculated the mean difference (MD) with 95% CIs. We assessed the quality of evidence using GRADE to generate a 'Summary of findings' table. MAIN RESULTS We included one study involving 15 participants from the UK. The included participants were diagnosed with delirium based on the Confusion Assessment Method (CAM) criteria. Eight males and seven females were included, with a mean age of 82.5 years. Seven of the 15 participants had comorbid dementia at baseline. The risk of bias was low in all domains.The study compared rivastigmine with placebo. We did not find any clear differences between the two groups in terms of duration of delirium (MD -3.6, 95% CI -15.6 to 8.4), adverse events (nausea, RR 0.30, 95% CI 0.01 to 6.29), use of rescue medications (RR 0.13, 95% CI 0.01 to 2.1), mortality (RR 0.10, 95% CI 0.01 to 1.56), and leaving the study early (RR 0.88, 95% CI 0.07 to 11.54). Evidence was not available regarding the severity of delirium, persistent cognitive impairment, length of hospitalisation, cost of intervention, or other predefined secondary outcomes.The quality of evidence is low due to the very small sample size. AUTHORS' CONCLUSIONS There is insufficient evidence to support or refute the use of cholinesterase inhibitors for the treatment of delirium in non-ICU settings. No clear benefits or harms associated with cholinesterase inhibitors were observed when compared with placebo due to the lack of data. More trials are required.
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Affiliation(s)
- Ailan Yu
- Liaocheng People's HospitalAnaesthesiologyNo.67 Dongchang West RoadLiaocheng CityShandongChina
| | - Shanshan Wu
- Liaocheng People's HospitalAnaesthesiologyNo.67 Dongchang West RoadLiaocheng CityShandongChina
| | - Zongwang Zhang
- Liaocheng People's HospitalAnaesthesiologyNo.67 Dongchang West RoadLiaocheng CityShandongChina
| | - Tom Dening
- The University of NottinghamDivision of Psychiatry & Applied PsychologyTriumph RoadNottinghamUKNG7 2TU
| | - Sai Zhao
- The Ingenuity Centre, The University of NottinghamSystematic Review Solutions LtdTriumph RoadNottinghamUKNG7 2TU
| | - Gillian Pinner
- The University of NottinghamOld Age PsychiatryNottinghamUKNG7 2TU
| | - Jun Xia
- Institute of Mental Health, University of NottinghamCochrane Schizophrenia GroupTriumph RoadNottinghamUKNG7 2TU
| | - Daogui Yang
- Liaocheng People's HospitalDepartment of Gastrointestinal SurgeryNo.67 Dongchang West RoadLiaochengShandongChina252000
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Dixon M. Assessment and management of older patients with delirium in acute settings. Nurs Older People 2018; 30:35-42. [PMID: 29717845 DOI: 10.7748/nop.2018.e969] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2018] [Indexed: 11/09/2022]
Abstract
This article aims to assist nurses and nursing students to consider the presentation of delirium in older patients and the resulting assessment and nursing interventions required. It considers the three types of delirium: hyperactive, hypoactive and mixed. It also discusses potential causes of delirium. Older patients are at increased risk of delirium due to factors such as cognitive impairment, co-morbidities and acute illness. Nurses should be confident in the use of the 4AT score to assess patients with delirium. Use of the mnemonic PINCH ME is suggested to guide management of delirious patients in acute settings. Families of patients with delirium have emotional and other care needs and there are several ways in which nurses can meet them.
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Affiliation(s)
- Martha Dixon
- Orthogeriatric care, Homerton University Hospital NHS Foundation Trust, London, England
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