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Ibrahim MHED, Elmasry M, Nagy F, Abdelghani A. Prevalence and risk factors of delirium and subsyndromal delirium in older adults. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2021. [DOI: 10.1186/s43162-021-00042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Delirium is a common geriatric problem associated with poor outcomes. Subsyndromal delirium (SSD) is characterized by the presence of certain symptoms of delirium yet, not satisfying the definition of full-blown delirium, defined by categorical elements, and is usually referred to as the presence of one or more symptoms in the confusion assessment method (CAM). This study aimed to investigate the prevalence and risk factors of delirium and SSD in older adults admitted to the hospital. Five hundred eighty-eight elderly (above 65 years) Egyptian patients were recruited from January 2019 to February 2020. After explaining the purpose of the study and assuring the confidentiality of all participants, an informed consent was obtained from the participant or a responsible care giver for those who were not able to give consent. All patients were subjected ‘on admission’ to thorough history taking, clinical examination, and comprehensive geriatric assessment including confusion assessment tools, mini-mental state examination, and functional assessment using Barthel index score.
Results
The current study showed that 19.6% of patients had delirium and 14.1% of patients had SSD with combined prevalence of 33.7%. Most common causes included metabolic, infection, organic brain syndrome, and dehydration. The current study reported significant proportionate relation between cognitive assessment and functional ability, so patients with a score of 23 MMSE had good functional ability, while cognitive assessment using mini-mental score shows inversed relation to delirium and SSD using CAM score.
Conclusion
Delirium is independently associated with adverse short-term and long-term outcomes, including an increase in mortality, length of hospital stay, discharge to an institution, and functional decline on discharge. Subsyndromal delirium (SSD) is characterized by the presence of certain symptoms of delirium, not yet satisfying the definition of full-blown delirium but it can identify patients with early cognitive and functional disabilities, and because of high prevalence of delirium and SSD. Efforts to prevent or early detection may identify patients who warrant clinical attention.
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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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Hasemann W, Tolson D, Godwin J, Spirig R, Frei IA, Kressig RW. Nurses' Recognition of Hospitalized Older Patients With Delirium and Cognitive Impairment Using the Delirium Observation Screening Scale: A Prospective Comparison Study. J Gerontol Nurs 2018; 44:35-43. [DOI: 10.3928/00989134-20181018-02] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 09/14/2018] [Indexed: 11/20/2022]
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Abstract
Delirium Tremens (DT) falls in the most severe spectrum of alcohol withdrawal, which could potentially result in death, unless managed promptly and adequately. The prevalence of DT in general population is <1% and nearly 2% in patients with alcohol dependence. DT presents with a combination of severe alcohol withdrawal symptoms and symptoms of delirium with agitation and sometimes hallucination. Clinical and laboratory parameters which predict DT have been discussed. Assessment of DT includes assessment of severity of alcohol withdrawal, evaluation of delirium, and screening for underlying medical co-morbidities. Liver disease as a co-morbidity is very common in patients with DT and that could complicate the clinical presentation, determine the treatment choice, and influence the outcome. Benzodiazepines are the mainstay of treatment for DT. Diazepam and lorazepam are preferred benzodiazepine, depending upon the treatment regime and clinical context. In benzodiazepine refractory cases, Phenobarbital, propofol, and dexmedetomidine could be used.
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Li DJ, Tseng PT, Stubbs B, Chen TY, Lin PY, Chen SL, Thompson T, Adamis D, Chu CS. Low peripheral levels of insulin growth factor-1 are associated with high incidence of delirium among elderly patients: A systematic review and meta-analysis. Arch Gerontol Geriatr 2018; 77:13-18. [PMID: 29605680 DOI: 10.1016/j.archger.2018.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/21/2018] [Accepted: 03/18/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Delirium, a serious condition observed in critically ill patients, clinically presents with impaired cognition and consciousness. The relationship between delirium and peripheral levels of insulin growth factor-1 (IGF-1) is unclear. Thus we conducted a meta-analysis to address this issue. METHODS Seven major electronic databases were searched from inception until October 2, 2017 to obtain relevant clinical variables to compare the difference in IGF-1 levels between delirious and non-delirious elderly in-patients. A random effects meta-analysis was conducted. RESULTS We studies 10 articles involving 294 delirious patients (mean age 73.0 years) and 604 non-delirious patients (mean age 76.9 years). We found that peripheral levels of IGF-1 in patients with delirium were significantly lower than in those without delirium (Hedges' g = -0.209, 95% confidence interval [CI] = -0.393 to -0.026, p = 0.025). Meta-regression analyses found that no variables such as percentage of cognitive impairment, mean age, and female proportion contribute to heterogeneity in terms of the entire population. CONCLUSIONS Our data suggests that lower peripheral levels of IGF-1 could be associated with a higher incidence of delirium among elderly patients. Further prospective studies with larger sample sizes are needed to investigate the association between peripheral levels of IGF-1 and delirium.
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Affiliation(s)
- Dian-Jeng Li
- Department of Addiction Science, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Taiwan
| | - Ping-Tao Tseng
- WinShine Clinics in Specialty of Psychiatry, Kaohsiung City, Taiwan
| | - Brendon Stubbs
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK; Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, De Crespigny Park, London, UK; Faculty of Health, Social Care and Education, Anglia Ruskin University, Chelmsford, UK
| | - Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan; Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan
| | - Pao-Yen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Shiou-Lan Chen
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Taiwan
| | - Trevor Thompson
- Faculty of Education and Health, University of Greenwich, London, SE9 2UG, UK
| | - Dimitrios Adamis
- Sligo Mental Health Services Clarion Rd Sligo, Ireland; Research and Academic Institute of Athens, Greece
| | - Che-Sheng Chu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Center for Geriatric and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
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Poikajärvi S, Salanterä S, Katajisto J, Junttila K. Validation of Finnish Neecham Confusion Scale and Nursing Delirium Screening Scale using Confusion Assessment Method algorithm as a comparison scale. BMC Nurs 2017; 16:7. [PMID: 28115914 PMCID: PMC5247801 DOI: 10.1186/s12912-016-0199-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 12/27/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Delirium is a common clinical problem with acute and fluctuating onset. Early notification of its symptoms can lead to earlier detection and management of this state. Valid and reliable instruments are required for successful nursing practice. The purpose of the study was to psychometrically test the Finnish versions of the Neecham Confusion Scale (NEECHAM) and the Nursing Delirium Screening Scale (Nu-DESC) in surgical nursing care, utilizing the Confusion Assessment Method (CAM) algorithm as a comparison scale. METHODS This randomized, blinded, instrument testing study was conducted at one university hospital in one surgical unit. Study patients (n = 112) meeting the pre-set criteria were assessed by the principal investigator (PI) and a registered nurse (RN, n = 18). Internal consistency, inter-rater reliability, and concurrent validity of the scales were calculated and face validity and usability evaluated. RESULTS Internal consistency was from .76 to .86 for all three scales. Inter-rater reliability between PI and RNs was .87 with NEECHAM, .60 with CAM and .47 with Nu-DESC. Concurrent validity was .56 and .59 between CAM and NEECHAM, and .68 and .72 between NEECHAM and Nu-DESC. In the PI group, the correlation between CAM and Nu-DESC was .91, in the RN's group .42. Nu-DESC was evaluated as the most usable scale. CONCLUSION The findings strengthen the earlier research on the scales and indicate that the Finnish NEECHAM and Nu-DESC correlates with CAM algorithm and with each other. They seem to be clinically viable in assessing patients' delirium in surgical wards but more validity testing is needed.
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Affiliation(s)
- Satu Poikajärvi
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
- Helsinki University Hospital, Perioperative, Intensive Care and Pain Medicine, PO Box 266, Helsinki, FI00029 HUS Finland
| | - Sanna Salanterä
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
- Department of Nursing, Turku University Hospital, Turku, Finland
| | - Jouko Katajisto
- Department of Mathematics and Statistics, Faculty of Mathematics and Natural Sciences, University of Turku, Turku, Finland
| | - Kristiina Junttila
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
- Helsinki University Hospital, Group Administration, Helsinki, Finland
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Sinvani L, Kozikowski A, Pekmezaris R, Akerman M, Wolf-Klein G. Delirium: A Survey of Healthcare Professionals’ Knowledge, Beliefs, and Practices. J Am Geriatr Soc 2016; 64:e297-e303. [DOI: 10.1111/jgs.14544] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Liron Sinvani
- Division of Hospital Medicine; Department of Medicine; Northwell Health; Manhasset New York
| | | | | | - Meredith Akerman
- The Feinstein Institute for Medical Research; Manhasset New York
| | - Gisele Wolf-Klein
- Division of Geriatric and Palliative Medicine; Department of Medicine; Northwell Health; Manhasset New York
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van Velthuijsen EL, Zwakhalen SMG, Warnier RMJ, Mulder WJ, Verhey FRJ, Kempen GIJM. Psychometric properties and feasibility of instruments for the detection of delirium in older hospitalized patients: a systematic review. Int J Geriatr Psychiatry 2016; 31:974-89. [PMID: 26898375 DOI: 10.1002/gps.4441] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 01/06/2016] [Accepted: 01/20/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Delirium is a serious and common complication among older hospitalized patients and is a predictor of many adverse outcomes. However, up to 72% of delirium incidents are unrecognized or misdiagnosed. The aim of this systematic review is to determine the validity, reliability, and feasibility of instruments for the detection of delirium in older hospitalized patients. METHODS A systematic literature search was conducted. The inclusion criteria were a mean or median age of 65+ years, the use of the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases-10 as a reference standard, and publication in English. All included studies underwent a quality assessment (QUADAS-2). RESULTS Forty-three of the 3.790 identified studies were relevant to the review, describing 28 instruments. Quality assessment resulted in 37 studies with a positive quality assessment, describing 23 instruments. Five instruments (Delirium Observation Scale (DOS), Nursing Delirium Screening Scale (Nu-DESC), Confusion Assessment Method (CAM), CAM-Intensive Care Unit (ICU), and Delirium Rating Scale-Revised-98) were described in three or more methodologically sound studies. The Delirium Observation Screening Scale (DOS) and Nu-DESC are observational instruments with good psychometric properties, but the Nu-DESC is shorter and has been validated in more languages. The CAM, CAM-ICU, and Delirium Rating Scale-Revised-98 (DRS-R-98) are instruments with both observational and interactive components. The CAM is the most widely studied and demonstrates the best psychometric properties. CONCLUSION Timely detection of delirium might reduce the negative outcomes of delirium in the long term. The Nu-DESC and CAM appear to be the most adequate instruments for detecting delirium. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Eveline L van Velthuijsen
- CAPHRI School for Public Health and Primary Care and Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Sandra M G Zwakhalen
- CAPHRI School for Public Health and Primary Care and Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Ron M J Warnier
- CAPHRI School for Public Health and Primary Care and Department of Health Services Research, Maastricht University, Maastricht, The Netherlands.,Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wubbo J Mulder
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Frans R J Verhey
- Alzheimer Center Limburg, MHeNS School for Mental Health and NeuroScience and Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands
| | - Gertrudis I J M Kempen
- CAPHRI School for Public Health and Primary Care and Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
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Ashraf JM, Schweiger M, Vallurupalli N, Bellantonio S, Cook JR. Effects of oral premedication on cognitive status of elderly patients undergoing cardiac catheterization. J Geriatr Cardiol 2015; 12:257-62. [PMID: 26089850 PMCID: PMC4460169 DOI: 10.11909/j.issn.1671-5411.2015.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 02/11/2015] [Accepted: 02/14/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Sedatives and analgesics are often administered to achieve conscious sedation for diagnostic and therapeutic procedures. Appropriate concerns have been raised regarding post procedure delirium related to peri-procedural medication in the elderly. The objective of this study was to investigate the effect of premedication on new onset delirium and procedural care in elderly patients. METHODS Patients ≥ 70 years old and scheduled for elective cardiac catheterization were randomly assigned to receive either oral diphenhydramine and diazepam (25 mg/5 mg) or no premedication. All patients underwent a mini mental state exam and delirium assessment using confusion assessment method prior to the procedure and repeated at 4 h after the procedure and prior to discharge. Patients' cooperation during the procedure and ease of post-procedure were measured using Visual Analog Scale (VAS). The degree of alertness was assessed immediately on arrival to the floor, and twice hourly afterwards using Observer's Assessment of Alertness/Sedation Scale (OAA/S). RESULTS A total of 93 patients were enrolled. The mean age was 77 years, and 47 patients received premedication prior to the procedure. None of the patients in either group developed delirium. Patients' cooperation and the ease of procedure was greater and pain medication requirement less both during and after the procedure in the pre-medicated group (P < 0.05 for both). Nurses reported an improvement with patient management in the pre-medicated group (P = 0.08). CONCLUSIONS In conclusion, premedication did not cause delirium in elderly patients undergoing cardiac catheterization. The reduced pain medication requirement, perceived procedural ease and post procedure management favors premedication in elderly patients undergoing cardiac catheterization.
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Affiliation(s)
- Javed M Ashraf
- Department of Cardiology, Truman Medical Center, UMKC School of Medicine, Kansas City, MO, USA
| | - Marc Schweiger
- Departments of Cardiology, Baystate Medical Center, Tufts University School of Medicine, MA, USA
| | - Neelima Vallurupalli
- Departments of Cardiology, Baystate Medical Center, Tufts University School of Medicine, MA, USA
| | - Sandra Bellantonio
- Department of Internal Medicine and Geriatrics, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, USA
| | - James R Cook
- Departments of Cardiology, Baystate Medical Center, Tufts University School of Medicine, MA, USA
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Abstract
BACKGROUND The Confusion Assessment Method (CAM) is the most widely used delirium screening instrument. The aim of this study was to evaluate the reliability and validity of the European Portuguese version of CAM. METHODS The sample included elderly patients (≥65 years), admitted for at least 48 h, into two intermediate care units (ICMU) of Intensive Medicine and Surgical Services in a university hospital. Exclusion criteria were: score ≤11 on the Glasgow Coma Scale (GCS), blindness/deafness, inability to communicate and to speak Portuguese. For concurrent validity, a blinded assessment was conducted by a psychiatrist (DSM-IV-TR, as a reference standard) and by a trained researcher (CAM). This instrument was also compared with other cognitive measures to evaluate convergent validity. Inter-rater reliability was also assessed. RESULTS In this sample (n = 208), 25% (n = 53) of the patients had delirium, according to DSM-IV-TR. Using this reference standard, the CAM had a moderate sensitivity of 79% and an excellent specificity of 99%. The positive predictive value was 95%, indicating a strong ability to confirm delirium with a positive test result, and the negative predictive value was lower (93%). Good convergent validity was also found, in particular with Mini-Mental State Examination (MMSE) (rs = -0.676; p ≤0.01) and Digit Span Test (DST) forward (rs = -0.605; p ≤0.01), as well as a high inter-rater reliability (diagnostic k = 1.00; single items' k between 0.65 and 1.00). CONCLUSION Robust results on concurrent and convergent validity and good reliability were achieved. This version was shown to be a valid and reliable instrument for delirium detection in elderly patients hospitalized in intermediate care units.
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Rooney S, Qadir M, Adamis D, McCarthy G. Diagnostic and treatment practices of delirium in a general hospital. Aging Clin Exp Res 2014; 26:625-33. [PMID: 24789220 DOI: 10.1007/s40520-014-0227-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 04/08/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite the increase in research on delirium, it remains underdiagnosed and difficult to manage, and the outcome is poor especially in older people. AIMS To identify the clinically diagnosed rates of delirium, the possible aetiologies, to describe treatment, number and type of psychotropic medication used and to investigate the reasons for referral to a liaison psychiatric team. METHODS Retrospective study of medical records of inpatients admitted to Sligo Regional Hospital during an 18-month period. RESULTS One hundred and fifty-six files had a documentation of delirium (time prevalence 2%). Mean age of the sample was 82 years (SD = 7.2), 66 (42%) were male. Sixty-nine (44.2%) of the total sample had a previous history of dementia, and 57 (36.5%) had a previous history of delirium. In 67 (43.2%) samples, the cause was infection, while in 4, no specific cause was identified. Ninety (58%) were referred to the liaison service, but only in 26 (28.9 %), the reason for referral was "acute confusion" or "delirium". In a majority of referrals, the reason was an affective disorder more often depression. There were no significant differences between delirium subtypes and referrals (χ(2) = 3.868, df 3, p = 0.28). Examination of the amount of antipsychotics prescribed before, during and after delirium shows that there was a significant increase in use during the delirium (χ(2) = 17.512, df 8, p = 0.025) and decrease in z-hypnotics medication (zopiclone/zolpidem), (χ(2) = 20.114, df 4, p < 0.001), while benzodiazepines and antidepressants remained the same. CONCLUSIONS Delirium is often misdiagnosed and unrecognized in hospital settings; however, when identified the pharmacological management is appropriate.
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Affiliation(s)
- Siobhan Rooney
- Medical Education, Sligo Medical Academy, NUI Galway, Galway, Ireland,
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Çinar MA, Balikçi A, Sertoğlu E, Mehmet AK, Serdar MA, Özmenler KN. Role of CRP, TNF-a, and IGF-1 in Delirium Pathophysiology. Noro Psikiyatr Ars 2014; 51:376-382. [PMID: 28360657 DOI: 10.5152/npa.2014.6999] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 09/10/2013] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Delirium is a common and life-threatening neuropsychiatric syndrome. Diagnosing delirium can be challenging, which increases mortality and mortality rates and health care costs. The biologic model of delirium is not definite yet, but evidence supports a cholinergic deficiency model. Delirium may be the result of processes and drugs that trespass a compromised blood-brain barrier. We aimed to evaluate the possible diagnostic utilization and the role of certain biomarkers, such as C-reactive protein (CRP), tumor necrosis factor-alpha (TNF-α), and insulin like growth factor-1 (IGF-1), in delirium etiology. METHODS A total of 93 inpatients that planned to undergo cardiovascular surgery were informed; 35 of them completed the study. Medical history and current cognitive status were evaluated pre-operatively. Participants were followed using Delirium Rating Scale-Revised-98 Turkish (DRS-R98-T) for delirium symptoms, and blood samples were collected post-operatively. RESULTS Delirium was developed more in participants who had worse pre-operative cognitive status. Also, low pre-operative IGF-1 levels were detected in the delirium group. Pre-operative CRP and TNF-α levels were not different between groups. CONCLUSION Low IGF-1 levels can be used to predict delirium after surgery. However, the complex nature of cytokines and delirium itself make it difficult to utilize cytokines to predict delirium instead of psychometric tools.
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Affiliation(s)
- Mehmet Alper Çinar
- Department of Consultation Liaison Psychiatry, TAF Rehabilitation Center, Ankara, Turkey
| | - Adem Balikçi
- Department of Psychiatry, Gülhane Military Medical Academy, Ankara, Turkey
| | - Erdim Sertoğlu
- Biochemistry Service, Beytepe Military Hospital, Ankara, Turkey
| | - A K Mehmet
- Department of Psychiatry, Gülhane Military Medical Academy, Ankara, Turkey
| | - Muhittin A Serdar
- Department of Biochemistry, Gülhane Military Medical Academy, Ankara, Turkey
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Pilot study on the European Portuguese version of the Confusion Assessment Method. Acta Neuropsychiatr 2014; 26:321-4. [PMID: 25241759 DOI: 10.1017/neu.2014.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To present the pilot study on the European Portuguese validation of the Confusion Assessment Method (CAM). METHODS The translation process was carried out according to International Society Pharmacoeconomics and Outcomes Research guidelines with trained researchers and inter-rater reliability assessment. The study included 50 elderly patients, admitted (≥24 h) to two intermediate care units. Exclusion criteria were: Glasgow Coma Scale (total score ≤11), blindness/deafness, inability to communicate and not able to speak Portuguese. The sensitivity and specificity of CAM were assessed, with DSM-IV-TR criteria of delirium used as a reference standard. RESULTS Findings revealed excellent inter-rater reliability (k>0.81), moderate sensitivity (73%) and excellent specificity (95%). CONCLUSION These preliminary results suggested that this version emerges as a promising diagnostic instrument for delirium.
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Schrijver EJM, de Vries OJ, Verburg A, de Graaf K, Bet PM, van de Ven PM, Kamper AM, Diepeveen SH, Anten S, Siegel A, Kuipéri E, Lagaay AM, van Marum RJ, van Strien AM, Boelaarts L, Pons D, Kramer MHH, Nanayakkara PWB. Efficacy and safety of haloperidol prophylaxis for delirium prevention in older medical and surgical at-risk patients acutely admitted to hospital through the emergency department: study protocol of a multicenter, randomised, double-blind, placebo-controlled clinical trial. BMC Geriatr 2014; 14:96. [PMID: 25168927 PMCID: PMC4161272 DOI: 10.1186/1471-2318-14-96] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 08/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delirium is associated with substantial morbidity and mortality rates in elderly hospitalised patients, and a growing problem due to increase in life expectancy. Implementation of standardised non-pharmacological delirium prevention strategies is challenging and adherence remains low. Pharmacological delirium prevention with haloperidol, currently the drug of choice for delirium, seems promising. However, the generalisability of randomised controlled trial results is questionable since studies have only been performed in selected postoperative hip-surgery and intensive care unit patient populations. We therefore present the design of the multicenter, randomised, double-blind, placebo-controlled clinical trial on early pharmacological intervention to prevent delirium: haloperidol prophylaxis in older emergency department patients (The HARPOON study). METHODS/DESIGN In six Dutch hospitals, at-risk patients aged 70 years or older acutely admitted through the emergency department for general medicine and surgical specialties are randomised (n = 390) for treatment with prophylactic haloperidol 1 mg or placebo twice daily for a maximum of seven consecutive days. Primary outcome measure is the incidence of in-hospital delirium within seven days of start of the study intervention, diagnosed with the Confusion Assessment Method, and the Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria for delirium. Secondary outcome measures include delirium severity and duration assessed with the Delirium Rating Scale Revised 98; number of delirium-free days; adverse events; hospital length-of-stay; all-cause mortality; new institutionalisation; (Instrumental) Activities of Daily Living assessed with the Katz Index of ADL, and Lawton IADL scale; cognitive function assessed with the Six-item Cognitive Impairment Test, and the Dutch short form Informant Questionnaire on Cognitive Decline in the Elderly. Patients will be contacted by telephone three and six months post-discharge to collect data on cognitive- and physical function, home residency, all-cause hospital admissions, and all-cause mortality. DISCUSSION The HARPOON study will provide relevant information on the efficacy and safety of prophylactic haloperidol treatment for in-hospital delirium and its effects on relevant clinical outcomes in elderly at-risk medical and surgical patients. TRIAL REGISTRATION EudraCT Number: 201100476215; ClinicalTrials.gov Identifier: NCT01530308; Dutch Clinical Trial Registry: NTR3207.
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Affiliation(s)
- Edmée J M Schrijver
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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Fortini A, Morettini A, Tavernese G, Facchini S, Tofani L, Pazzi M. Delirium in elderly patients hospitalized in internal medicine wards. Intern Emerg Med 2014; 9:435-41. [PMID: 23771269 DOI: 10.1007/s11739-013-0968-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 06/05/2013] [Indexed: 11/30/2022]
Abstract
A prospective observational study was conducted to evaluate the impact of delirium on geriatric inpatients in internal medical wards and to identify predisposing factors for the development of delirium. The study included all patients aged 65 years and older, who were consecutively admitted to the internal medicine wards of two public hospitals in Florence, Italy. On admission, 29 baseline risk factors were examined, cognitive impairment was evaluated by Short Portable Mental Status Questionnaire, and prevalent delirium cases were diagnosed by Confusion Assessment Method (CAM). Enrolled patients were evaluated daily with CAM to detect incident delirium cases. Among the 560 included patients, 19 (3 %) had delirium on admission (prevalent) and 44 (8 %) developed delirium during hospitalization (incident). Prevalent delirium cases were excluded from the statistical analysis. Incident delirium was associated with increased length of hospital stay (p < 0.01) and institutionalization (p < 0.01, OR 3.026). Multivariate analysis found that cognitive impairment on admission (p < 0.0002), diabetes (p < 0.05, OR 1.936), chronic kidney failure (p < 0.05, OR 2.078) and male gender (p < 0.05, OR 2.178) was significantly associated with the development of delirium during hospitalization. Results show that delirium impact is relevant to older patients hospitalized in internal medicine wards. The present study confirms cognitive impairment as a risk factor for incident delirium. The cognitive evaluation proved to be an important instrument to improve identification of patients at high risk for delirium. In this context, our study may contribute to improve application of preventive strategies.
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Affiliation(s)
- Alberto Fortini
- Internal Medicine Unit, Serristori Hospital Figline Valdarno, Florence, Italy,
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Tauro R. Delirium awareness - Improving recognition and management through education and use of a care pathway. BMJ QUALITY IMPROVEMENT REPORTS 2014; 2:bmjquality_uu203195.w1451. [PMID: 26732370 PMCID: PMC4663845 DOI: 10.1136/bmjquality.u203195.w1451] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 12/06/2013] [Accepted: 01/28/2014] [Indexed: 11/17/2022]
Abstract
Delirium occurs in 10–20% of medical patients on admission and a further 10–30% develop delirium as an inpatient. Delirium is associated with increased length of stay, morbidity, mortality, and risk of institutional placement. There is poor knowledge of delirium recognition and management, and a need to raise awareness and training of all staff. NICE have produced guidelines for diagnosis, prevention and management of delirium. A retrospective departmental audit demonstrated that delirium was under-recognised i.e. only 5.7% of discharges in one year. A staff questionnaire revealed poor knowledge of types of delirium and a significant underestimation of prevalence, with poor identification of risk factors. A multi-professional group was formed to raise staff awareness and develop a care pathway for delirium. A 19 bed acute elderly care ward was identified for the project. Ward based and departmental educational meetings were held. A Trust based awareness programme was also provided. Information leaflets on delirium were produced for patients, carers and families and posters at ward level. Environmental changes (signage) at ward level were introduced to improve the environment for patients. A delirium care pathway was created to encourage documentation of mental score, assessment of delirium, review of reversible medical causes and a nursing care plan. This pathway was reviewed regularly on ward rounds and feedback given to staff present. Following these interventions the notes of 106 consecutive discharges were reviewed over an 11-week period. 99% of at risk patients were screened for delirium. 35% of patients were diagnosed with delirium increasing the recognition rate from 5.7%. There was significant improvement among the staff in recognizing and managing patients with delirium through the use of a delirium care pathway. Education improves understanding and awareness of delirium and a care pathway focuses attention on this area, improving patient safety and quality of care.
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Affiliation(s)
- Ruben Tauro
- Ulster Hospital, South Eastern Health and Social Care Trust, Northern Ireland
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Nurse’ prediction prevention and management on post-operative delirium in geriatric patients with hip fracture: The development of a protocol to guide care. Int J Orthop Trauma Nurs 2014. [DOI: 10.1016/j.ijotn.2013.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Savikko N, Pitkälä KH, Strandberg TE, Tilvis RS, Laurila JV. Diagnostic Agreement on Delirium Between the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; International Classification of Diseases, Tenth Revision; Confusion Assessment Method (CAM); and the Five-Item CAM in Older Adults with Dem. J Am Geriatr Soc 2013; 61:662-4. [DOI: 10.1111/jgs.12184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Niina Savikko
- Department of General Practice and Primary Health Care; University of Helsinki; Helsinki Finland
- Unit of Primary Health Care; Helsinki University Central Hospital; Helsinki Finland
| | - Kaisu H. Pitkälä
- Department of General Practice and Primary Health Care; University of Helsinki; Helsinki Finland
- Unit of Primary Health Care; Helsinki University Central Hospital; Helsinki Finland
| | - Timo E. Strandberg
- Institute of Health Sciences/Geriatrics; University of Oulu; Oulu Finland
- Unit of General Practice; Oulu University Hospital; Oulu Finland
- University of Helsinki and Helsinki University Central Hospital Clinics of General Internal Medicine and Geriatrics; Helsinki Finland
| | - Reijo S. Tilvis
- Clinics of General Internal Medicine and Geriatrics; Helsinki University Central Hospital; Helsinki Finland
| | - Jouko V. Laurila
- Department of General Practice and Primary Health Care; University of Helsinki; Helsinki Finland
- Clinics of General Internal Medicine and Geriatrics; Helsinki University Central Hospital; Helsinki Finland
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Shi Q, Warren L, Saposnik G, Macdermid JC. Confusion assessment method: a systematic review and meta-analysis of diagnostic accuracy. Neuropsychiatr Dis Treat 2013; 9:1359-70. [PMID: 24092976 PMCID: PMC3788697 DOI: 10.2147/ndt.s49520] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Delirium is common in the early stages of hospitalization for a variety of acute and chronic diseases. OBJECTIVES To evaluate the diagnostic accuracy of two delirium screening tools, the Confusion Assessment Method (CAM) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). METHODS We searched MEDLINE, EMBASE, and PsychInfo for relevant articles published in English up to March 2013. We compared two screening tools to Diagnostic and Statistical Manual of Mental Disorders IV criteria. Two reviewers independently assessed studies to determine their eligibility, validity, and quality. Sensitivity and specificity were calculated using a bivariate model. RESULTS Twenty-two studies (n = 2,442 patients) met the inclusion criteria. All studies demonstrated that these two scales can be administered within ten minutes, by trained clinical or research staff. The pooled sensitivities and specificity for CAM were 82% (95% confidence interval [CI]: 69%-91%) and 99% (95% CI: 87%-100%), and 81% (95% CI: 57%-93%) and 98% (95% CI: 86%-100%) for CAM-ICU, respectively. CONCLUSION Both CAM and CAM-ICU are validated instruments for the diagnosis of delirium in a variety of medical settings. However, CAM and CAM-ICU both present higher specificity than sensitivity. Therefore, the use of these tools should not replace clinical judgment.
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Affiliation(s)
- Qiyun Shi
- Health and Rehabilitation Sciences, Western University, London, Ontario, Canada ; Stroke Outcomes Research Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Alce TM, Page V, Vizcaychipi MP. Delirium Uncovered. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Delirium is defined as an acute confusional state with a disturbance of consciousness and a change in cognition which is fluctuating and self-limited in the vast majority of the cases. It is common in intensive care, most frequently in its hypoactive manifestation, and is associated with increased morbidity and mortality. This article reviews the pathogenesis, risk factors, diagnostic assessment, prevention and management of delirium.
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Affiliation(s)
- Timothy M Alce
- Clinical Research Fellow, Watford General Hospital, Watford
| | - Valerie Page
- Consultant in Intensive Care and Anaesthesia, Watford General Hospital, Watford
| | - Marcela P Vizcaychipi
- Consultant in Anaesthesia & Intensive Care, Chelsea and Westminster Hospital, London
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Ringdal GI, Ringdal K, Juliebø V, Wyller TB, Hjermstad MJ, Loge JH. Using the Mini-Mental State Examination to screen for delirium in elderly patients with hip fracture. Dement Geriatr Cogn Disord 2012; 32:394-400. [PMID: 22301509 DOI: 10.1159/000335743] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The main aim of this paper was to examine the usefulness of the Mini-Mental State Examination (MMSE) for screening delirium in elderly patients with hip fracture. METHODS The sample included 364 elderly patients with hip fracture admitted to two hospitals in Oslo. Delirium was assessed by the Confusion Assessment Method (CAM) as an approximation of the gold standard, DSM-IV. To evaluate the psychometric properties of the MMSE scale, we used the Mokken nonparametric latent trait model for unidimensional scaling. RESULTS In total, 76 (21%) patients were diagnosed with delirium based on the CAM, and 141 (43%) had preexisting cognitive impairment. As a screening tool, the recommended MMSE cut-point of 24 showed an acceptable sensitivity of 88% with a specificity of 54%. The prediction of delirium, based on logistic regression on the MMSE total score and on the 5 items selected by the stepwise logistic regression procedure, gave clearly less acceptable results. CONCLUSIONS Our study indicates that the MMSE may be useful in screening for delirium, but the high percentage of false positives shows that it does not have diagnostic potential in patients with hip fracture.
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Affiliation(s)
- G I Ringdal
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway.
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Grover S, Kate N. Assessment scales for delirium: A review. World J Psychiatry 2012; 2:58-70. [PMID: 24175169 PMCID: PMC3782167 DOI: 10.5498/wjp.v2.i4.58] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Revised: 06/19/2012] [Accepted: 07/21/2012] [Indexed: 02/05/2023] Open
Abstract
Over the years many scales have been designed for screening, diagnosis and assessing the severity of delirium. In this paper we review the various instruments available to screen the patients for delirium, instruments available to diagnose delirium, assess the severity, cognitive functions, motoric subtypes, etiology and associated distress. Among the various screening instruments, NEECHAM confusion scale and delirium observation scale appear to be most suitable screening instrument for patients’ in general medical and surgical wards, depending on the type of rater (physician or nurse). In general, the instruments which are used for diagnosis [i.e., confusion assessment method (CAM), CAM for intensive care unit (CAM-ICU), Delirium Rating Scale-revised version (DRS-R-98), memorial selirium assessment scale, etc.] are based on various Diagnostic and Statistical Manual criteria and have good to excellent reliability and fair to good validity. Among the various diagnostic instruments, CAM is considered to be most useful instrument because of its accuracy, brevity, and ease of use by clinicians and lay interviewers. In contrast, DRS-R-98 appears to be a comprehensive instrument useful for diagnosis, severity rating and is sensitive to change and hence can be used for monitoring patients over a period. In the ICU setting, evidence suggests that CAM-ICU and Nursing Delirium Screening Scale had comparable sensitivities, but CAM-ICU has higher specificity. With regard to assessment of delirium in pediatric age group, certain instruments like Pediatric Anesthesia Emergence Delirium scale and pediatric CAM-ICU has been designed and have been found to be useful.
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Affiliation(s)
- Sandeep Grover
- Sandeep Grover, Natasha Kate, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Thomas C, Kreisel SH, Oster P, Driessen M, Arolt V, Inouye SK. Diagnosing delirium in older hospitalized adults with dementia: adapting the confusion assessment method to international classification of diseases, tenth revision, diagnostic criteria. J Am Geriatr Soc 2012; 60:1471-7. [PMID: 22881707 DOI: 10.1111/j.1532-5415.2012.04066.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare performance characteristics of the Confusion Assessment Method (CAM) algorithm for screening and delirium diagnosis with criteria for delirium from the International Classification of Diseases, Tenth Revision (ICD-10) and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) in high-risk individuals. DESIGN Prospective cohort study. SETTING Academic geriatric hospital. PARTICIPANTS One hundred two individuals aged 80 to 100 hospitalized for acute medical illness. MEASUREMENTS Complete CAM instrument (nine items), scored using the four-item CAM diagnostic algorithm. Criterion standard classification of delirium was rated independently according to expert consensus based on DSM-IV and ICD-10 criteria for delirium. RESULTS In 79 hospitalized participants, the CAM performed well for delirium screening (delirium prevalence of 24% according to DSM-IV and 14% according to ICD-10). Of all CAM features, acute onset and fluctuating course are most important for diagnosis (area under the receiver operating characteristic curve (AUC) = 0.92 in DSM-IV and 0.83 in ICD-10). The CAM diagnostic algorithm had a sensitivity of 0.74, a specificity of 1.0, and an AUC of 0.88 compared with the DSM-IV reference standard and a sensitivity of 0.82, a specificity of 0.91, and an AUC of 0.85 compared with the ICD-10. Compared with the ICD-10, adding psychomotor change to the CAM algorithm improved specificity to 97%, but sensitivity fell to 55% (AUC = 0.96). Applying psychomotor change sequentially only to the group that the CAM algorithm identified as having no delirium improved sensitivity to 91% with specificity of 85% (AUC = 0.95). CONCLUSION Although the CAM diagnostic algorithm performed well against a DSM-IV reference standard, adding psychomotor change to the CAM algorithm improved specificity and diagnostic value against ICD-10 criteria overall in older adults with dementia and improved sensitivity and screening performance when applied sequentially in CAM-negative individuals.
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Affiliation(s)
- Christine Thomas
- Department of Geriatric Psychiatry, Centre of Psychiatry and Psychotherapy, Ev. Hospital Bielefeld-Bethel, Bielefeld, Germany.
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Salih SA, Paul S, Klein K, Lakhan P, Gray L. Screening for delirium within the interRAI acute care assessment system. J Nutr Health Aging 2012; 16:695-700. [PMID: 23076511 DOI: 10.1007/s12603-012-0074-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To develop and validate a screening strategy for delirium within the inter RAI acute care comprehensive assessment system. DESIGN Prospective validation cohort study. SETTING Acute general medical wards in two acute care metropolitan hospitals in Brisbane, Australia. PARTICIPANTS Two hundreds thirty-nine subjects with and without delirium, aged 70 and older. MEASUREMENTS Trained research nurses assessed subjects within 36 hours of hospital admission using the inter-RAI acute care (AC) system which includes four observational delirium items: Acute change mental status from baseline (ACMS), mental function varies over the course of the day (MFV), episode of disorganised speech (EDS), and easily distracted (ED). Geriatricians assessed subjects face to face within 4 hours of nurses' assessment using the Diagnostic and statistical manual of mental disorders (DSM IV) criteria and clinical judgement to determine delirium presence. Based on the performance of each delirium feature and to achieve highest predictive accuracy, a combination algorithm of either ACMS or MFV was developed and compared with the reference standard diagnosis determined by geriatricians. RESULTS Geriatricians diagnosed delirium in 52 of 239 (21.7%) subjects aged 70-102 years. The area under the receiver operator characteristics (AUC) for interRAI-AC delirium screener algorithm was 0.87 (95% CI; 0.80, 0.93), sensitivity 82%, specificity 91%, positive and negative predictive value of 0.72% and 95%, and likelihood ratio of 9.6 achieving the highest predictive accuracy of all possible combination of 4 delirium features. Underlying pre-morbid cognitive impairment did not undermine validity of the screening strategy, AUC 0.85 (95% CI; 0.74, 0.95), sensitivity 90% and specificity 69%. CONCLUSION The interRAI AC delirium screening strategy is a valid measure of delirium in older subjects in acute medical wards.
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Affiliation(s)
- S A Salih
- Centre for research in Geriatric Medicine, The University of Queensland, Woolloongabba, Brisbane, Australia.
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Carpenter CR. Which medications are associated with incident delirium? Ann Emerg Med 2011; 59:321-2. [PMID: 21839541 DOI: 10.1016/j.annemergmed.2011.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 05/20/2011] [Accepted: 05/24/2011] [Indexed: 11/27/2022]
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Holmes C, Cunningham C, Zotova E, Culliford D, Perry VH. Proinflammatory cytokines, sickness behavior, and Alzheimer disease. Neurology 2011; 77:212-8. [PMID: 21753171 DOI: 10.1212/wnl.0b013e318225ae07] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In Alzheimer disease (AD), systemic inflammation is known to give rise to a delirium. However, systemic inflammation also gives rise to other centrally mediated symptoms in the absence of a delirium, a concept known as sickness behavior. Systemic inflammation is characterized by the systemic production of the proinflammatory cytokines tumor necrosis factor-α (TNFα) and interleukin-6 (IL-6) that mediate immune to brain communication and the development of sickness behavior. OBJECTIVE To determine if raised serum TNFα or IL-6 are associated with the presence of sickness behavior symptoms, independent of the development of delirium, in a prospective cohort study of subjects with AD. METHODS A total of 300 subjects with mild to severe AD were cognitively assessed at baseline and a blood sample taken for inflammatory markers. Cognitive assessments, including assessments to detect the development of a delirium, and blood samples were repeated at 2, 4, and 6 months. The development of neuropsychiatric symptoms in the subject with AD over the 6-month follow-up period was assessed independently by carer interview at 2, 4, and 6 months. RESULTS Raised serum TNFα and IL-6, but not CRP, were associated with an approximately 2-fold increased frequency of neuropsychiatric symptoms characteristic of sickness behavior. These relationships are independent of the development of delirium. CONCLUSIONS Increased serum proinflammatory cytokines are associated with the presence of symptoms characteristic of sickness behavior, which are common neuropsychiatric features found in AD. This association was independent of the presence of delirium.
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Affiliation(s)
- C Holmes
- University of Southampton, Memory Assessment and Research Centre, Botley Rd, Southampton, UK, SO30 3JB.
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Abstract
OBJECTIVES Delirium is a common neuropsychiatric condition with many adverse outcomes in elderly populations including death. Despite this, it is often misdiagnosed and mistreated. A number of scales can be used to detect delirium. We review scales that have been used in delirium studies and report their psychometric properties. METHOD An extensive MEDLINE database search and subsequent examination of reference lists was conducted to identify the various delirium scales that have been designed, primarily for use in the elderly. RESULTS Twenty-four scales were identified. Delirium instruments differed according to the classification system they were based on, length of time to administer, the rater and whether they were screening scales or measured symptom severity. The psychometric properties of each scale is reported. CONCLUSION A large number of scales exist, but not all are properly evaluated in terms of psychometric properties, and there is not unanimity about which scale is the best. However, a small number of scales may be considered already to be robust and useable: the CAM, the DRS, the MDAS and the NEECHAM.
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Radtke FM, Franck M, Schust S, Boehme L, Pascher A, Bail HJ, Seeling M, Luetz A, Wernecke KD, Heinz A, Spies CD. A Comparison of Three Scores to Screen for Delirium on the Surgical Ward. World J Surg 2010; 34:487-94. [DOI: 10.1007/s00268-009-0376-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Vreeswijk R, Timmers JF, de Jonghe JFM, Kalisvaart KJ. Assessment scales for delirium. ACTA ACUST UNITED AC 2009. [DOI: 10.2217/ahe.09.10] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Delirium is a severe psychiatric syndrome that is highly prevalent in elderly general hospital patients. However, the diagnosis of delirium is often missed. The use of rating scales can be helpful in detecting and measuring delirium symptom severity. This article reviews recent developments regarding psychometric qualities, measurement goals, content and rating procedures of some of the available rating scales in clinical practice. Literature from the Medline files up to 2008 were collected, using the following search entries: delirium, (acute) confusion, assessment/rating scale and screening. Articles were selected if their title or summary were related to the development or applicability of delirium rating scales. The reference lists of relevant articles were searched for additional references. The rating scales were split up according to their purposes, screening or severity rating and were discussed for the following aspects: content (theoretical background, rating domains and items), interview (duration, format and assessors’ expertise) and psychometric qualities (reliability and validity). There were eight screening scales (Confusion Assessment Method [CAM], CAM for the Intensive Care Unit [CAM-ICU], Intensive Care Delirium Screening Checklist [ICDSC], Delirium Symptom Interview [DSI], NEECHAM Confusion Scale [NEECHAM], Cognitive Test for Delirium [CTD], Delirium Observation Screening [DOS] and Nursing Delirium Screening Scale [Nu-DESC]) and seven severity rating scales (Delirium Rating Scales [DRS], Memorial Delirium Assessment Scales [MDAS], Confusional State Evaluation [CSE], Delirium Severity Scales [DSS], Delirium Index [DI], Delirium-O-Meter [DOM] and Delirium Detection Scale [DDS] ) selected for further research. The CAM, NEECHAM and DOS and the CAM-ICU for the ICU appear to be the most suitable as screening instruments, depending on the type of rater (trained) physician or nurse. The (revised) Delirium Rating Scale (DRS-R-98) and the DOM appear to be particularly useful for measuring delirium severity or monitoring change.
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Affiliation(s)
- Ralph Vreeswijk
- Department of Geriatric Medicine, Medical Center Alkmaar, 1800 AM Alkmaar, The Netherlands
| | | | - Jos FM de Jonghe
- Department of Geriatric Medicine, Medical Center Alkmaar, 1800 AM Alkmaar, The Netherlands
| | - Kees J Kalisvaart
- Kennemer Gasthuis, Department of Geriatric Medicine, Postbus 417 2000 AK Haarlem, The Netherlands
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Ryan K, Leonard M, Guerin S, Donnelly S, Conroy M, Meagher D. Validation of the confusion assessment method in the palliative care setting. Palliat Med 2009; 23:40-5. [PMID: 19010967 DOI: 10.1177/0269216308099210] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The Confusion Assessment Method (CAM) is widely used in the palliative care setting despite the fact that its performance in this population has not been validated. The aim of the study was to determine the sensitivity and specificity of the CAM when used by Non-Consultant Hospital Doctors (NCHDs) working in a specialist palliative care unit. A pilot phase was performed in which NCHDs received a 1-hour training session based on the original CAM training manual. 32 patients underwent 33 assessments in the pilot phase but the sensitivity of the CAM was only 0.5 (0.22-0.78) and specificity was 1.0 (0.81-1.0). An 'enhanced' training programme was devised that took place over two 1-hour sessions and involved case-based learning focused on the areas where the NCHDs were experiencing difficulty. 52 patients underwent 54 assessments in the main phase of the study and the performance of the CAM improved significantly. Sensitivity was 0.88 (0.62-0.98) and specificity was 1.0 (0.88-1.0). The results suggest that the CAM is a valid screening tool for delirium in the palliative care setting but its performance is dependent on the skill of the operator. NCHDs require a certain standard of training before becoming proficient in its use.
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Affiliation(s)
- K Ryan
- Department of Palliative Medicine, Mater Misericordiae University Hospital, Connolly Hospital Blanchardstown and St Francis Hospice, Raheny, Dublin.
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Kean J, Ryan K. Delirium detection in clinical practice and research: critique of current tools and suggestions for future development. J Psychosom Res 2008; 65:255-9. [PMID: 18707948 DOI: 10.1016/j.jpsychores.2008.05.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Revised: 05/01/2008] [Accepted: 05/15/2008] [Indexed: 11/29/2022]
Abstract
Delirium is underrecognized clinically. Many tools have been developed to assist with the diagnosis of delirium, and they vary greatly in purpose, quality, and administration time. It is suggested that future development of delirium assessment instruments be guided by a dichotomization of raters into expert and nonexpert groups. Careful consideration of the needs of the two groups suggests that assessment instruments designed for nonexperts should be entirely objective, whereas those instruments developed for experts should include the full range of constructs associated with the syndrome. This conceptualization is explored in detail, and existing assessment instruments are considered briefly in light of this position.
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Affiliation(s)
- Jacob Kean
- Department of Speech and Hearing Sciences, Indiana University, 200 South Jordan Avenue, Bloomington, IN 47405, USA.
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Radtke FM, Franck M, Schneider M, Luetz A, Seeling M, Heinz A, Wernecke KD, Spies CD. Comparison of three scores to screen for delirium in the recovery room. Br J Anaesth 2008; 101:338-43. [PMID: 18603528 DOI: 10.1093/bja/aen193] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Delirium is often seen in the recovery room and is a predictor for postoperative delirium on the ward. However, monitoring to detect delirium in the recovery room as a basic prerequisite for early intervention is rarely used. The aim of this study was to identify a valid and easy-to-use test for early screening of delirium in the recovery room. METHODS One hundred and fifty-four adult patients admitted to the recovery room during regular working hours were included. A screening assessment for delirium was performed in the recovery room by a trained research team at the time when the patient was judged to be 'ready for discharge'. Delirium monitoring was performed with the Confusion Assessment Method (CAM), the Delirium Detection Score (DDS), and the Nursing Delirium Screening Scale (Nu-DESC). The Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria were used as the gold standard. RESULTS Delirium in the recovery room was seen in 21 patients (14%) with the DSM-IV criteria, in 11 patients (7%) with the CAM, in four patients (3%) with the DDS, and in 37 patients (24%) with the Nu-DESC. Sensitivity and specificity were 0.43 and 0.98 for the CAM, 0.14 and 0.99 for the DDS, and 0.95 and 0.87 for the Nu-DESC, respectively. CONCLUSIONS All scores used were very specific, but the CAM and the DDS were less sensitive compared with the gold standard. Overall, the Nu-DESC was the most sensitive test in the recovery room to detect delirium.
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Affiliation(s)
- F M Radtke
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Wei LA, Fearing MA, Sternberg EJ, Inouye SK. The Confusion Assessment Method: a systematic review of current usage. J Am Geriatr Soc 2008; 56:823-30. [PMID: 18384586 DOI: 10.1111/j.1532-5415.2008.01674.x] [Citation(s) in RCA: 493] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To examine the psychometric properties, adaptations, translations, and applications of the Confusion Assessment Method (CAM), a widely used instrument and diagnostic algorithm for identification of delirium. DESIGN Systematic literature review. SETTING Not applicable. MEASUREMENTS Electronic searches of PubMED, EMBASE, PsychINFO, CINAHL, Ageline, and Google Scholar, augmented by reviews of reference listings, were conducted to identify original English-language articles using the CAM from January 1, 1991, to December 31, 2006. Two reviewers independently abstracted key information from each article. PARTICIPANTS Not applicable. RESULTS Of 239 original articles, 10 (4%) were categorized as validation studies, 16 (7%) as adaptations, 12 (5%) as translations, and 222 (93%) as applications. Validation studies evaluated performance of the CAM against a reference standard. Results were combined across seven high-quality studies (N=1,071), demonstrating an overall sensitivity of 94% (95% confidence interval (CI)=91-97%) and specificity of 89% (95% CI=85-94%). The CAM has been adapted for use in the intensive care unit, emergency, and institutional settings and for scoring severity and subsyndromal delirium. The CAM has been translated into 10 languages where published articles are available. In application studies, CAM-rated delirium is most commonly used as a risk factor or outcome but also as an intervention or reference standard. CONCLUSION The CAM has helped to improve identification of delirium in clinical and research settings. To optimize performance, the CAM should be scored based on observations made during formal cognitive testing, and training is recommended. Future action is needed to optimize use of the CAM and to improve the recognition and management of delirium.
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Affiliation(s)
- Leslie A Wei
- Medical School, Brown University, Providence, Rhode Island, USA
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Abstract
For patients and their loved ones, delirium can be a frightening experience. A fluctuating mental status is important to identify because it often signals a need for additional treatment. The Confusion Assessment Method (CAM) diagnostic algorithm enables nurses to assess for delirium by identifying the four features of the disorder that distinguish it from other forms of cognitive impairment. It can be completed in five minutes and is easily incorporated into ongoing assessments of hospitalized patients. (This screening tool is included in the series Try This: Best Practices in Nursing Care to Older Adults, from the Hartford Institute for Geriatric Nursing at New York University's College of Nursing.) For a free online video demonstrating the use of this tool, go to http://links.lww.com/A209.
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Where's the Evidence for the CAM? Am J Nurs 2007. [DOI: 10.1097/01.naj.0000301020.72242.bc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pitkälä KH, Laurila JV. Managing delirium in hospitalized elderly patients. FUTURE NEUROLOGY 2007. [DOI: 10.2217/14796708.2.3.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This review highlights the key elements of guidelines developed for the management of delirium. Experts and expert panels in several countries have presented their own guidelines, which have similarities but also differences in their emphases. The essential elements in the management of delirium are appropriate detection and diagnosis, assessment and treatment of underlying conditions, symptom management, environmental and supportive interventions, post-delirium care and follow-up, and paying attention to risk factors and prevention. The level of evidence behind each recommendation of the guidelines is discussed, as well as some of the typical pitfalls in the care of patients with delirium. Although rigorous randomized intervention trials on full-blown delirium are still scarce, we have some trials suggesting how to manage each dimension of the care of delirium.
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Affiliation(s)
- Kaisu H Pitkälä
- University of Helsinki, Finland and, Helsinki University Hospital, Unit of General Practice, Finland
| | - Jouko V Laurila
- Helsinki University Central Hospital, Clinics of General Internal Medicine & Geriatrics, PL 340 00029, HUS, Helsinki, Finland
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Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing 2006; 35:350-64. [PMID: 16648149 DOI: 10.1093/ageing/afl005] [Citation(s) in RCA: 716] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite the acknowledged clinical importance of delirium, research evidence for measures to improve its management is sparse. A necessary first step to devising appropriate strategies is to understand how common it is and what its outcomes are in any particular setting. OBJECTIVE To determine the occurrence of delirium and its outcomes in medical in-patients, through a systematic review of the literature. METHOD We searched electronic medical databases, the Consultation-Liaison Literature Database and reference lists and bibliographies for potentially relevant studies. Studies were selected, quality assessed and data extracted according to preset protocols. RESULTS Results for the occurrence of delirium in medical in-patients were available for 42 cohorts. Prevalence of delirium at admission ranged from 10 to 31%, incidence of new delirium per admission ranged from 3 to 29% and occurrence rate per admission varied between 11 and 42%. Results for outcomes were available for 19 study cohorts. Delirium was associated with increased mortality at discharge and at 12 months, increased length of hospital stay (LOS) and institutionalisation. A significant proportion of patients had persistent symptoms of delirium at discharge and at 6 and 12 months. CONCLUSION Delirium is common in medical in-patients and has serious adverse effects on mortality, functional outcomes, LOS and institutionalisation. The development of appropriate strategies to improve its management should be a clinical and research priority. As delirium prevalent at hospital admission is a significant problem, research is also needed into preventative measures that could be applied in community settings.
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Affiliation(s)
- Najma Siddiqi
- Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, 15 Hyde Terrace, Leeds LS2 9LT, UK.
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Tabet N, Howard R. Prevention, diagnosis and treatment of delirium: staff educational approaches. Expert Rev Neurother 2006; 6:741-51. [PMID: 16734522 DOI: 10.1586/14737175.6.5.741] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Delirium is a common disorder especially among older people admitted to medical and surgical units. Research has demonstrated that many cases are underdiagnosed, misdiagnosed or not properly managed. Some of the difficulties encountered in the diagnosis, treatment and prevention may, in part, stem from a historical low emphasis on delirium in medical and nursing education. In recent years, attempts have been made to understand the impact of education on the prevention and management of delirium. In this review, diagnosis, treatment and prevention of delirium are considered in relation to the difficulties encountered in each of these areas. The role of increasing doctors' and nurses' awareness in the understanding of delirium through educational programs is also reviewed. The outcome of many cases of delirium is not changed by current treatment; however, there is increasing evidence that strategies employing appropriate multicomponent and/or educational staff intervention programs may decrease the prevalence of delirium.
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Affiliation(s)
- Naji Tabet
- University of Brighton, Postgraduate Medical School, Faculty of Health, Brighton, BN1 9PH, UK.
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Affiliation(s)
- Kate Irving
- Lecturer in Nursing, Dublin City University, School of Nursing, Dublin 9, IrelandAssociate Professor of Nursing, College of Health and Human Development, Associate Professor of Medicine, Department of Psychiatry, The Pennsylvania State University, University Park, PA, USAProfessor, Department of Medical-Surgical Nursing, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
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Abstract
This article reviews the significance of altered mental status in older emergency department patients. Specific diagnoses are discussed, including delirium, stupor and coma, and dementia, with a focus on delirium. Finally, an approach to all older patients is suggested that should result in increased clinician comfort with older patients, improved ability to communicate with other physicians, increased quality of care, and improved patient and family satisfaction.
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Affiliation(s)
- Scott T Wilber
- Emergency Medicine, Northeastern Ohio Universities College of Medicine, 4209 Street Route 44, Rootstown, OH 44272, USA.
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de Jonghe JFM, Kalisvaart KJ, Timmers JFM, Kat MG, Jackson JC. Delirium-O-Meter: a nurses' rating scale for monitoring delirium severity in geriatric patients. Int J Geriatr Psychiatry 2005; 20:1158-66. [PMID: 16315151 DOI: 10.1002/gps.1410] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Delirium is a common psychiatric disorder in general hospital elderly patients. Several delirium screening tests exist. Few nurse based delirium severity measures are available. The aim of this study was to evaluate the Delirium-O-Meter, a new nurses' behavioural rating scale that is an efficient and sensitive measure of delirium severity. METHODS Analysis of cross sectional and repeated assessments data. Participants were 92 elderly general hospital patients; 56 with delirium, 24 with dementia or other cognitive disturbances (no delirium) and 12 with other psychiatric disorders or no mental disorder. Measures were the Delirium-O-Meter (DOM), Delirium Rating Scale-Revised version (DRS-R-98), Delirium Observation Scale (DOS), Behavioural observation scale for geriatric inpatients (GIP) and Mini Mental State Examination (MMSE). RESULTS The majority of DOM items show a (near-) normal score distribution. Reliability of the DOM was high; Cronbach's alpha values ranged from 0.87-0.92; Intra Class Correlation (ICC) range was 0.84-0.91 for total scores and 0.40-0.97 for item scores. Factor analysis produced a 'Cognitive/Motivational' factor explaining almost half of variance and a smaller 'Psychotic/Behavioural' factor. The two-factor model results support the conceptual distinction between hyperactive and hypoactive delirium. DOM observations differentiated delirium from non delirium patients. DOM total scores were highly related to the DRS-R-98, DOS, MMSE and GIP apathy and cognitive sub scales, but less so to the GIP affective disturbances subscale, indicating convergent and divergent validity. Temporal difference scores calculated for DRS-R-98 and DOM assessments on subsequent days were also highly related (rho = 0.80-0.95). CONCLUSIONS The newly constructed DOM is a brief and valid nurses' behavioural rating scale that can be useful for measuring different aspects of delirium and for efficiently monitoring delirium severity in elderly patients.
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Affiliation(s)
- Jos F M de Jonghe
- Medical Center Alkmaar, Department of Clinical Psychology, Alkmaar, The Netherlands.
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Abstract
PURPOSE OF REVIEW To review recent studies on epidemiology, diagnosis, pathophysiology, treatment and prevention of delirium in elderly people. RECENT FINDINGS There is no evidence that the clinical picture of delirium in elderly people differs from that in younger patients, although it may run a more chronic course. Diagnosing delirium in demented patients, however, may be difficult due to overlap in symptoms of delirium and dementia. Systematic use of screening and diagnostic instruments may help to diminish the common underdiagnosis of delirium. Delirium is best understood as the result of multiple interacting predisposing and precipitating factors. In the elderly, predisposing factors that make patients more susceptible for delirium include cognitive dysfunction and older age, while important precipitating factors that directly cause delirium are any somatic events and the use of anticholinergic drugs. Delirium has a significant negative prognostic impact on functional and cognitive outcome, as well as on morbidity and mortality. Haloperidol remains the standard treatment for delirium, while there is some evidence for the efficacy of risperidone. Other atypical antipsychotics, as well as cholinesterase inhibitors, have not yet been sufficiently studied. Results of studies on the effectiveness of systematic screening of populations at risk and standardized interventions to prevent delirium have been inconclusive. SUMMARY In recent years, the emphasis in the approach to delirium has shifted from ad hoc treatment to systematic screening and prevention. Interest has been raised in treatment options other than haloperidol, such as atypical antipsychotics and procholinergic drugs.
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Affiliation(s)
- Albert F G Leentjens
- Department of Psychiatry, Maastricht University Hospital, Maastricht, The Netherlands.
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Bergeron N, Skrobik Y, Dubois MJ. Is disturbance of consciousness an important feature of ICU delirium? Intensive Care Med 2005; 31:887. [PMID: 15843916 DOI: 10.1007/s00134-005-2642-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2005] [Indexed: 10/25/2022]
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Abstract
As life expectancy and modern surgical and intensive care techniques develop, the number of old patients in surgery is rising. Associated are problems with the indication for surgical intervention and rising incidence of "typical" peri- and postoperative complications such as postoperative delirium. Geriatric assessment serves to identify patients at risk of developing complications, to describe the postoperative course of functional and cognitive abilities, and to adjust therapeutic strategies to the individual needs of these patients. The most important instruments of geriatric assessment are described. Postoperative delirium, the most prevalent complication in surgical geriatric patients, is discussed in detail with regard to risk factors, prevalence, diagnosis, and therapeutic options.
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Affiliation(s)
- U Hestermann
- Bethanien-Krankenhaus, Geriatrisches Zentrum am Klinikum der Universität Heidelberg.
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Schuurmans MJ, Deschamps PI, Markham SW, Shortridge-Baggett LM, Duursma SA. The measurement of delirium: review of scales. Res Theory Nurs Pract 2003; 17:207-24. [PMID: 14655974 DOI: 10.1891/rtnp.17.3.207.53186] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This review describes the characteristics and evaluates the psychometric qualities (process of testing and the results) of thirteen delirium instruments. Delirium instruments differ in goal (diagnosis, screening symptoms severity), type of data on which the rating is based (observation, interview or test of patients), the rater qualities required, the number of items and the rating time needed. Most instruments are based on the Diagnostic Statistical Manual criteria and measure signs and symptoms as described by these criteria. Reliability of delirium instruments shows good to excellent results. Validity of the delirium instruments is overall fair to good. Differences exist, however, in the degree to which reliability and validity were tested and the quality of the testing procedures. Most instruments are not further developed and tested after the initial study. Conclusion of this review is that most delirium instruments show promising results but need further testing. Testing is needed in different samples and on a broader range of aspects with regard to reliability and validity. Much emphasis should be given to the procedures used in future studies. Ease of use is an aspect of testing that is so far not taken into account, however, is important for use of instruments in clinical practice. A minority of instruments can be seen as "ready to use" instruments meaning well tested in more than one sample with good results. For screening high-risk, elderly hospitalized patients, the NEECHAM Confusion Scale and the Delirium Observation Screening Scale are recommended. The Confusion Assessment Method is the best diagnostic tool and the Delirium Rating Scale shows best results in screening symptom severity. For ICU patients the CAM-ICU is recommended. The MDAS is well tested in cancer patients. Nurses, however, have not yet tested the DRS and MDAS in practice.
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Affiliation(s)
- Marieke J Schuurmans
- Nursing Science, Faculty of Medicine, University of Utrecht, University Medical Center Utrecht, The Netherlands.
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