Early detection of postoperative delirium and confusion in a surgical ward using the NEECHAM confusion scale

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

Background

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

Methods

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

Results

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

Conclusion

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

Postoperative delirium assessed by post anesthesia care unit staff utilizing the Nursing Delirium Screening Scale: a prospective observational study of 1000 patients in a single Swiss institution

BACKGROUND

Delirium has become better studied, but is still only partially understood and significantly underestimated. There are some well-known risk factors, but little is known about the incidence of delirium in the diverse patient population of a post anesthesia care unit (PACU). The aim of this study was to investigate the presence of delirium using the Nursing Delirium Screening Scale (NU-DESC).

METHODS

1000 consecutive patients in the PACU were prospectively evaluated at the point when being ready to be transferred to the normal ward by the registered nurses of the PACU.

RESULTS

The data of 1,000 patients was recorded. 242 of the patients (24.2%) were preoperatively classified as ASA I physical status, 664 patients (66.4%) as ASA II. A total of 43 patients (4.3%) presented with a delirium at the time point where they would have been transferred to the normal ward (138.4 ± 55.2 min after arrival in the PACU). 287 patients (28.7%) of the entire group were over the age of 70 years. Considering only this subgroup, delirium was diagnosed in 30 individuals (10.5%).

CONCLUSIONS

Delirium screening with the NU-DESC, collected by nursing staff of a PACU is easily feasible and demonstrated a low incidence of delirium in the presented setting.

TRIAL REGISTRATION

German Clinical Trials Register (Deutsches Register Klinischer Studien, www.drks.de ; DRKS 000005426 ; date of registration 4th December 2013).

Haloperidol prophylaxis does not prevent postoperative delirium in elderly patients: a randomized, open-label prospective trial

PURPOSE

Postoperative delirium is the most common postoperative complication in the elderly. The purpose of this study was to evaluate the safety and effectiveness of the preventive administration of low-dose haloperidol on the development of postoperative delirium after abdominal or orthopedic surgery in elderly patients.

SUBJECTS

A total of 119 patients aged 75 years or older who underwent elective surgery for digestive or orthopedic disease were included in this study.

METHODS

Patients were divided into those who did (intervention group, n = 59) and did not (control group, n = 60) receive 2.5 mg of haloperidol at 18:00 daily for 3 days after surgery; a randomized, open-label prospective study was performed on these groups. The primary endpoint was the incidence of postoperative delirium during the first 7 days after the operation.

RESULTS

The incidence of postoperative delirium in all patients was 37.8%. No side effects involving haloperidol were noted; however, the incidences of postoperative delirium were 42.4 and 33.3% in the intervention and control groups, respectively, which were not significantly different (p = 0.309). No significant effect of the treatment was observed on the severity or persistence of postoperative delirium.

CONCLUSIONS

The preventive administration of low-dose haloperidol did not induce any adverse events, but also did not significantly decrease the incidence or severity of postoperative delirium or shorten its persistence.

An update on delirium in the postoperative setting: prevention, diagnosis and management

Delirium is a serious and pervasive problem in the postoperative setting. Research to date has identified a number of key risk factors implicated in the development of delirium after surgical intervention, including advanced age, pre-existing cognitive impairment, lower pre-morbid functional status and history of psychiatric illness. Efforts to prevent postoperative delirium in the form of multi-component programs and prophylactic administration of medications have yielded some positive results. Studies investigating the effectiveness of various antipsychotics in the treatment of postoperative delirium have demonstrated somewhat mixed outcomes. Recent research has identified more sophisticated management of pain and sedation protocols as a way to prevent or mitigate delirium, with promising results. This chapter reviews the most recent literature pertaining to the prevention, diagnosis and management of postoperative delirium.

Long-acting morphine following hip or knee replacement: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Patients undergoing total hip or knee replacement surgery experience unmanaged pain during postoperative physiotherapy sessions. It was theorized that a baseline opioid would improve pain management.

OBJECTIVES

To examine the effectiveness of adding long-acting oral morphine to a routine postoperative regimen for total hip or knee replacement surgery.

METHODS

The present study was a double-blind, randomized, placebo-controlled trial for patients undergoing total hip or knee replacement surgery. All patients received routine postoperative analgesia; in addition, the treatment group received long-acting oral morphine 30 mg orally twice daily for three days, while the control group received placebo capsules. The primary end point was a decrease in pain scores by two points on a 0- to 10-point pain rating scale. Secondary end points included adverse effects, acute confusion, pain-related interferences in function and sleep, length of stay and patient satisfaction.

RESULTS

Two hundred patients were enrolled in the present study (March 2004 to March 2006). Although the groups were large enough to yield statistical significance, most pain scores did not reach the predetermined improvement for clinical significance. Additionally, there was an increase in opioid usage (P<0.0001), vomiting (P=0.0148) and oversedation (P=0.08). There were no statistically significant changes in function or sleep. Improved satisfaction with pain management was minimal (P=0.052).

DISCUSSION

The present study was undertaken to determine the value of adding a long-acting opioid (morphine) to the usual care of patients undergoing total hip or total knee replacement surgery. The results yielded minimally improved pain scores and additional adverse effects (vomiting and oversedation). Published research in which long-acting opioids (oxycodone) were used for similar postoperative procedures did not robustly report improved pain scores. In addition, patients using a long-acting opioid (oxycodone) during the postoperative period reported somnolence, dizziness and confusion. Statistically, the patients in the present study showed higher confusion scores and no improvement for pain-related interferences with activity or walking. The treatment group did report increased satisfaction; however, the significance was weak.

CONCLUSIONS

Thirty milligrams twice per day of long-acting morphine from days 1 to 3 following total hip and total knee replacement surgery provided minimal improvements in pain scores, and more adverse effects in the treatment group. The overall strength of evidence for improved outcomes is minimal and thus not supported.

Early assessment of delirium in elderly patients after hip surgery

OBJECTIVE

This study is intended to identify predictive factors of delirium, including risk factors and prodromal symptoms.

METHODS

This study included sixty-five patients aged 65 years or older who had undergone hip surgery. Baseline assessments included age; gender; admission type (acute/elective); reason for surgery (fracture/replacement); C-reactive protein (CRP); Acute Physiology, Age, Chronic Health Evaluation (APACHE III); and the Mini-Mental State Examination (MMSE). The Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-98) was used to assess prodromal symptoms daily before the onset of delirium.

RESULTS

Almost 28% (n=18) of the 65 patients developed delirium after surgery. Delirium in elderly patients after hip surgery was observed more often in older patients and those with acute admission, hip fracture, higher APACHE III score, lower MMSE score, and higher CRP levels within early days after the operation. Sleep-wake cycle disturbances, thought process abnormalities, orientation, and long-term memory in symptom items of K-DRS-98 were showed significant difference on 4 days before delirium, lability of affect on 3 days before, perceptual disturbances and hallucination, and visuo-spatial ability on 2 days before, and delusion, motor agitation, and short-term memory on the day before the occurrence of delirium. CRP levels within 24 hours and 72 hours after hospitalization were significantly higher in the delirium group.

CONCLUSION

Medical professionals must pay attention to behavioral, cognitive changes and risk factors in elderly patients undergoing hip surgery and to the prodromal phase of delirium. K-DRS-98 may help in identifying the prodromal symptoms of delirium in elderly patients after hip surgery.

Predictive value and validation of the NEECHAM Confusion Scale using DSM-IV criteria for delirium as gold standard

BACKGROUND

Delirium is common among older people in hospital and various instruments have been developed for detecting delirium. One of these, the NEECHAM Confusion Scale, is easy for nurses to administrate but needs to be tested further.

AIMS AND OBJECTIVES

The aim of the present study was to assess the validity and predictive value of the NEECHAM Confusion Scale.

METHODS

The study was conducted among 149 patients aged ≥ 65, who had undergone surgery for a hip fracture. The patients were observed daily using DSM-IV criteria for delirium. The NEECHAM Confusion Scale was performed upon admission and prior to discharge.

RESULTS

The incidence of DSM-IV related delirium was 24%. Patients who scored below 25 points on the NEECHAM scale had a 12 times higher risk of developing DSM-IV related delirium. During admission, the sensitivity of NEECHAM was zero because all patients with DSM-IV delirium were excluded, the specificity was 75%. On discharge, it was 100% and 91% respectively.

CONCLUSIONS

This study adds to the body of knowledge that NEECHAM discriminates for delirium. It is a valid and reliable screening instrument for predicting delirium. The instrument can be used for clinical practice to identify patients who are at risk of contracting delirium and when considering prevention measures.

Assessment of the risk of postoperative delirium in elderly patients using E-PASS and the NEECHAM Confusion Scale

BACKGROUND

The incidences of surgery-field disorders such as femur neck fracture and colorectal cancer in elderly persons have increased with the rapid aging of society. In such patients, postoperative delirium is also frequent. Patients should be generally assessed from the aspect of both physical and mental conditions in order to predict a high-delirium risk group. If so, delirium may be prevented more efficiently. In this study, we investigated whether the early detection of postoperative delirium in elderly patients is possible using a simple, useful behavior-assessing scale, the NEECHAM Confusion Scale, and a method for comprehensively evaluating elderly persons' stress related to surgery, E-PASS.

METHODS

The subjects were 160 patients aged more than 75 years who underwent surgery. Among them, three patients had vascular surgery-field disorders, 67 had orthopedic-field disorders, and 90 had digestive surgery-field disorders. To comprehensively evaluate surgery-related stress, E-PASS was employed. In addition, we assessed recognition, activities of daily living (ADL), and the quality of life (QOL). For delirium diagnosis and severity assessment, we used the NEECHAM Confusion Scale. The cut-off value of the NEECHAM score was established as 20 points, and patients showing values less than this after surgery were regarded as having postoperative delirium. Evaluation was performed until 10 days after surgery.

RESULTS

Postoperative delirium was noted in 54.7% of the subjects. There was a decrease in the NEECHAM score between the first and fourth postoperative days, but it gradually increased thereafter. Both uni- and multivariate analyses showed that postoperative delirium was associated with an advanced age (more than 80 years), low preoperative NEECHAM and MMSE scores, the preoperative QOL, and E-PASS. In groups showing an MMSE score of less than 25 or a preoperative NEECHAM score of less than 27, the incidence of postoperative delirium was 76%.

CONCLUSION

The results suggest that E-PASS and the NEECHAM score facilitate assessment of the risk of postoperative delirium in elderly patients, contributing to early prevention/treatment.

Nutritional status and delirium in long-term care elderly individuals

Delirium is physiologically plausible in elderly individuals with a poor nutritional status. We explored body composition, serum protein levels, and delirium in a multicenter long-term care study using bioelectrical impedance analysis (BIA). Estimates from the BIA procedure included the body cell mass and fat-free mass (FFM) of nursing home elderly residents (N = 312). Increased delirium was identified in men and women who were leaner and had lower FFM. Clinical surveillance for delirium in frail elderly individuals with low serum albumin levels and polypharmacy is recommended because of their increased likelihood of having drug toxicities for medications with protein-binding properties.

A comparison of the CAM-ICU and the NEECHAM Confusion Scale in intensive care delirium assessment: an observational study in non-intubated patients

BACKGROUND

Several reports indicate a high incidence of intensive care delirium. To develop strategies to prevent this complication, validated instruments are needed. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is widely used. A binary result diagnoses delirium. The Neelon and Champagne (NEECHAM) Confusion Scale recently has been validated for use in the ICU and has a numeric assessment. This scale allows the patients to be classified in four categories: non-delirious, at risk, confused, and delirious. In this study, we investigated the results of the NEECHAM scale in comparison with the CAM-ICU.

METHODS

A consecutive sample of 172 non-intubated patients in a mixed ICU was assessed after a stay in the ICU for at least 24 hours. All adult patients with a Glasgow Coma Scale score of greater than 9 were included. A nurse researcher simultaneously assessed both scales once daily in the morning. A total of 599 paired observations were made.

RESULTS

The CAM-ICU showed a 19.8% incidence of delirium. The NEECHAM scale detected incidence rates of 20.3% for delirious, 24.4% for confused, 29.7% for at risk, and 25.6% for normal patients. The majority of the positive CAM-ICU patients were detected by the NEECHAM scale. The sensitivity of the NEECHAM scale was 87% and the specificity was 95%. The positive predictive value and the negative predictive value were 79% and 97%, respectively. The diagnostic capability in cardiac surgery patients proved to be lower than in other patients.

CONCLUSION

In non-intubated patients, the NEECHAM scale identified most cases of delirium which were detected by the CAM-ICU. Additional confused patients were identified in the categorical approach of the scale. The NEECHAM scale proved to be a valuable screening tool compared with the CAM-ICU in the early detection of intensive care delirium by nurses.

Influence of bright light therapy on postoperative patients: A pilot study

Bright light therapy is a method of maintaining or restoring the natural circadian rhythm by assisting daytime awakening using bright lights. Postoperative delirium is one of the potential complications encountered by patients receiving postoperative care in the intensive care unit (ICU), but there have been no studies on the use of light for the prevention of postoperative delirium. The objective of this study was to examine whether the circadian rhythms of patients after surgery for oesophageal cancer can be adjusted and whether the postoperative delirium crisis rate can be reduced by bright light therapy. The subjects were 11 patients operated on for oesophageal cancer in Osaka University Hospital. After informed consent was obtained, they were divided into a study group and a control group by a random sampling method. After removal of the endotracheal tube, the study group was exposed to light. The light intensity was about 5000lx immediately before the eyes, and the distance from the light source was about 100 cm. The control group was placed in a natural lighting environment after extubation. In both groups, the rhythms of physical activities and autonomic activities were monitored after surgery, and delirium was evaluated. A significant difference was observed in the delirium score between the study group and control group on the morning of day 3 of bright light therapy by the Mann-Whitney U-test (P=0.014). The study group could begin ambulation about 2 days earlier than the control group. Bright light therapy may reduce the rate of postoperative delirium and make early ambulation possible. However, our study involved a very small sample size. We want to increase the sample in the future after having reviewed clinical application methods.

Early symptoms in the prodromal phase of delirium: a prospective cohort study in elderly patients undergoing hip surgery

OBJECTIVES

The authors investigated prodromal delirium symptoms in elderly patients undergoing hip surgery.

METHODS

This was a prospective cohort study in the setting of a large medical school-affiliated general hospital in Alkmaar, The Netherlands. Participants were patients undergoing hip surgery aged 70 and older at risk for delirium. Before surgery, patients were randomized to low-dose prophylactic haloperidol treatment or placebo. Daily assessments were based on patient interviews with the Mini-Mental State Examination and Digit Span test. The Delirium Rating Scale-Revised (DRS-R-98) was used to measure early symptoms during the prodromal phase before the onset of delirium.

RESULTS

Data of 66 patients with delirium were compared with those of 35 at-risk patients who did not develop delirium: 14 of 66 patients (21%) had delirium on the day of surgery or early the day after, 32 of 66 (48%) on the second day, 14 of 66 on the third, and six of 66 (9%) on the fourth. The average DRS-R-98 total scores on day -4 to day -1 before delirium were 1.9 for the comparison group patients and 5.0, 4.3, 5.8, and 10.7 for patients with postoperative delirium. Multivariate analysis showed that the early symptoms memory impairments, incoherence, disorientation, and underlying somatic illness predict delirium.

CONCLUSIONS

Most elderly patients undergoing hip surgery with postoperative delirium already have early symptoms in the prodromal phase of delirium. These findings are potentially useful for screening purposes and for optimizing prevention strategies targeted at reducing the incidence of postoperative delirium.

An evaluation strategy for the early detection of postoperative delirium

The aim of the present study was to identify clinical signs detective of the postoperative delirium at the early stage for nursing management. A total of 66 inpatients undergoing cardiac surgery were interviewed using the Delirium Rating Scale (DRS) and NEECHAM Confusion Scale (NCS) preoperatively and on days 1 and 3 postoperatively. The mean onset of delirium occurred on postoperative day 1.3. Development of delirium was detected early by cognitive impairments in the DRS subscales of perceptual disturbance, hallucination, and cognitive status, and the NCS subscales of attention, command, orientation, and verbal skill. These results suggest that assessment of cognitive status on postoperative day is an important strategy in the early detection of postoperative delirium.

Psychometric properties of the Flemish translation of the NEECHAM Confusion Scale

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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