1
|
Morales-Puerto M, Ruiz-Díaz M, García-Mayor S, León-Campos Á, Morales-Asencio JM, Canca-Sánchez JC, Gavira-Guerra S, Toledo-Fernandez C, Aranda-Gallardo M. Spanish transcultural adaptation of the 4AT score for the evaluation of delirium in the emergency department: a prospective diagnostic test accuracy study. BMC Nurs 2024; 23:101. [PMID: 38321514 PMCID: PMC10845719 DOI: 10.1186/s12912-023-01638-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 12/05/2023] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Delirium is one of the most common adverse events in older people during hospitalization, especially in the emergency department. Reliable, easy-to-use instruments are necessary to properly manage delirium in this setting. This study aims to evaluate the diagnostic validity of the Spanish version of the 4 'A's Test (4AT) in the ED. METHODS A diagnostic accuracy study was conducted in patients over 65 years old admitted to the Emergency Department who did not have a formal diagnosis of dementia or a severe mental health disorder. Face and content validity were evaluated by an expert panel. Emergency nurses performed the evaluation with 4AT, whilst blinded and trained researchers assessed patients with the Revised Delirium Rating Scale as the gold standard. The content validity index, sensitivity, specificity, positive and negative predictive values, likelihood ratios, Youden's Index and ROC curves were calculated to evaluate the diagnostic accuracy of the instrument. RESULTS Of 393 eligible patients, 380 were finally analyzed. Content validity yielded a median content validity index of 4 (interquartile range: 0). The Spanish 4AT sensitivity (95.83%; 95% ECI: 78.9-99.9%), specificity (92.98%; 95% CI: 89.8-95.4%), positive predictive value (47.92%) and negative predictive value (99.7%) were satisfactory. Youden's index was 0.89. Positive likelihood ratio was 13.65, and negative likelihood ratio 0.045. The area under the curve was 0.97. CONCLUSIONS The Spanish version of the 4AT for use in the Emergency Departments is easy-to-use and applicable. The validation results indicate that it is a valid instrument with sufficient predictive validity to identify patients at risk of delirium in the Emergency Departments. Moreover, it is a tool that facilitates the management of an adverse event that is associated with increased mortality and morbidity.
Collapse
Affiliation(s)
- Marta Morales-Puerto
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
| | - María Ruiz-Díaz
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
| | - Silvia García-Mayor
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain
| | - Álvaro León-Campos
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain.
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain.
| | - José Miguel Morales-Asencio
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain
| | - José Carlos Canca-Sánchez
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain
| | - Sonia Gavira-Guerra
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
| | - Cecilia Toledo-Fernandez
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
| | - Marta Aranda-Gallardo
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), Instituto de Salud Carlos III, Bizkaia, Spain
| |
Collapse
|
2
|
MacLullich AMJ, Hosie A, Tieges Z, Davis DHJ. Three key areas in progressing delirium practice and knowledge: recognition and relief of distress, new directions in delirium epidemiology and developing better research assessments. Age Ageing 2022; 51:afac271. [PMID: 36441120 PMCID: PMC9704028 DOI: 10.1093/ageing/afac271] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Indexed: 11/29/2022] Open
Abstract
Delirium presents formidable challenges: it affects one in four of older hospitalised adults, greatly elevates the risk of multiple short- and long-term complications including dementia and causes significant distress. Delirium care remains generally poor. Yet, there are clear grounds for optimism; the last decade has seen impactful policy advances and a tripling of research output. Here, we highlight three linked areas which have strong potential to transform delirium practice and knowledge in the near term. Delirium-related distress is strikingly underrepresented in practice guidance and research. Proactive recognition combined with effective clinical responses based on good communication provides a critical and largely untapped opportunity to improve care. Delirium epidemiology research is well positioned to produce novel insights through advanced prospective designs in populations such as emergency medical patients with detailed pre-, intra- and post-delirium assessments allied with fluid, imaging and other biomarkers. Research-grade assessment of delirium currently involves a chaotic array of tools, methods and diagnostic algorithms. Areas for development: expand and analytically distinguish the range of features assessed (including distress), optimise feature assessment including use of validated neuropsychological tests where possible, produce standardised algorithms which articulate explicit pathways from features to diagnosis, and create new fine-grained approaches to the measurement of severity. Delirium practice and knowledge show accelerating growth. This is encouraging but much of the necessary progress is still to come. Innovation in these three highlighted areas, as well as many others, will open up exciting possibilities in enhancing the care of patients with this common and often devastating condition.
Collapse
Affiliation(s)
- Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Annmarie Hosie
- School of Nursing and Midwifery, The University of Notre Dame Australia, Darlinghurst, NSW, Australia
- The Cunningham Centre for Palliative Care, St Vincent’s Health Network Sydney, Darlinghurst, NSW, Australia
- IMPACCT – Improving Palliative, Aged and Chronic Care through Research and Translation, University of Technology Sydney, Ultimo, NSW, Australia
| | - Zoë Tieges
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
- SMART Technology Centre, School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Glasgow, UK
| | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| |
Collapse
|
3
|
Young M, Holmes N, Kishore K, Marhoon N, Amjad S, Serpa-Neto A, Bellomo R. Natural language processing diagnosed behavioral disturbance vs confusion assessment method for the intensive care unit: prevalence, patient characteristics, overlap, and association with treatment and outcome. Intensive Care Med 2022; 48:559-569. [PMID: 35322288 PMCID: PMC9050783 DOI: 10.1007/s00134-022-06650-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 02/15/2022] [Indexed: 12/19/2022]
Abstract
PURPOSE To compare the prevalence, characteristics, drug treatment for delirium, and outcomes of patients with Natural Language Processing (NLP) diagnosed behavioral disturbance (NLP-Dx-BD) vs Confusion Assessment Method for intensive care unit (CAM-ICU) positivity. METHODS In three combined medical-surgical ICUs, we obtained data on demographics, treatment with antipsychotic medications, and outcomes. We applied NLP to caregiver progress notes to diagnose behavioral disturbance and analyzed simultaneous CAM-ICU. RESULTS We assessed 2313 patients with a median lowest Richmond Agitation-Sedation Scale (RASS) score of - 2 (- 4.0 to - 1.0) and median highest RASS score of 1 (0 to 1). Overall, 1246 (53.9%) patients were NLP-Dx-BD positive (NLP-Dx-BDpos) and 578 (25%) were CAM-ICU positive (CAM-ICUpos). Among NLP-Dx-BDpos patients, 539 (43.3%) were also CAM-ICUpos. In contrast, among CAM-ICUpos patients, 539 (93.3%) were also NLP-Dx-BDpos. The use of antipsychotic medications was highest in patients in the CAM-ICUpos and NLP-Dx-BDpos group (24.3%) followed by the CAM-ICUneg and NLP-Dx-BDpos group (10.5%). In NLP-Dx-BDneg patients, antipsychotic medication use was lower at 5.1% for CAM-ICUpos and NLP-Dx-BDneg patients and 2.3% for CAM-ICUneg and NLP-Dx-BDneg patients (overall P < 0.001). Regardless of CAM-ICU status, after adjustment and on time-dependent Cox modelling, NLP-Dx-BD was associated with greater antipsychotic medication use. Finally, regardless of CAM-ICU status, NLP-Dx-BDpos patients had longer duration of ICU and hospital stay and greater hospital mortality (all P < 0.001). CONCLUSION More patients were NLP-Dx-BD positive than CAM-ICU positive. NLP-Dx-BD and CAM-ICU assessment describe partly overlapping populations. However, NLP-Dx-BD identifies more patients likely to receive antipsychotic medications. In the absence of NLP-Dx-BD, treatment with antipsychotic medications is rare.
Collapse
Affiliation(s)
- Marcus Young
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
- Department of Critical Care, School of Medicine, The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Natasha Holmes
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
| | - Kartik Kishore
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
| | - Nada Marhoon
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
| | - Sobia Amjad
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
- School of Computing and Information Systems, The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Ary Serpa-Neto
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia.
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
- Department of Intensive Care, Austin Hospital, 145 Studley Rd, Heidelberg, VIC, Australia.
- Department of Critical Care, School of Medicine, The University of Melbourne, Parkville, Melbourne, VIC, Australia.
| |
Collapse
|
4
|
Helfand BKI, Detroyer E, Milisen K, Adamis D, Metzger ED, Boudreaux ED, Inouye SK, Jones RN. Harmonization of Four Delirium Instruments: Creating Crosswalks and the Delirium Item-Bank (DEL-IB). Am J Geriatr Psychiatry 2022; 30:284-294. [PMID: 34417086 PMCID: PMC8799777 DOI: 10.1016/j.jagp.2021.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/11/2021] [Accepted: 07/15/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Over 30 instruments are in current, active use for delirium identification. In a recent systematic review, we recommended 4 commonly used and well-validated instruments for clinical and research use. The goal of this study is to harmonize the four instruments on the same metric using modern methods in psychometrics. DESIGN Secondary data analysis from 3 studies, and a simulation study based on the observed data. SETTING Hospitalized (non-ICU) adults over 65 years old in the United States, Ireland, and Belgium. PARTICIPANTS The total sample comprised 600 participants, contributing 1,623 assessments. MEASUREMENTS Confusion Assessment Method (long-form and short-form), Delirium Observation Screening Scale, Delirium Rating Scale-Revised-98 (DRS-R-98) (total and severity scores), and Memorial Delirium Assessment Scale. RESULTS Using item response theory, we linked scores across instruments, placing all four instruments and their separate scorings on the same metric (the propensity to delirium). Kappa statistics comparing agreement in delirium identification among the instruments ranged from 0.37 to 0.75, with the highest agreement between the DRS-R-98 total score and MDAS. After linking scores, we created a harmonized item bank, called the Delirium Item Bank (DEL-IB), consisting of 50 items. The DEL-IB allowed us to create six crosswalks, to allow scores to be translated across instruments. CONCLUSIONS With our results, individual instrument scores can be directly compared to aid in clinical decision-making, and quantitatively combined in meta-analyses.
Collapse
Affiliation(s)
- Benjamin K I Helfand
- Department of Emergency Medicine (BKIH, EDB), University of Massachusetts Medical School, Worcester, MA; Department of Psychiatry and Human Behavior (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Neurology (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Public Health and Primary Care (ED, KM) , Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium; Department of Geriatrics (ED, KM), University Hospitals Leuven, Leuven, Belgium; Cognitive Impairment Research Group, Sligo Mental Health Services; Sligo, Ireland and Centre for Interventions in Infection, Inflammation & Immunity, Graduate Entry Medical School (DA), University of Limerick, Limerick, Ireland; Department of Psychiatry (EDM), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Departments of Psychiatry, and Population and Quantitative Health Sciences (EDB), University of Massachusetts Medical School, Worcester, MA; Department of Medicine (SKI), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, Aging Brain Center (SKI, RNJ, EDM), Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA.
| | - Elke Detroyer
- Department of Emergency Medicine (BKIH, EDB), University of Massachusetts Medical School, Worcester, MA; Department of Psychiatry and Human Behavior (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Neurology (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Public Health and Primary Care (ED, KM) , Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium; Department of Geriatrics (ED, KM), University Hospitals Leuven, Leuven, Belgium; Cognitive Impairment Research Group, Sligo Mental Health Services; Sligo, Ireland and Centre for Interventions in Infection, Inflammation & Immunity, Graduate Entry Medical School (DA), University of Limerick, Limerick, Ireland; Department of Psychiatry (EDM), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Departments of Psychiatry, and Population and Quantitative Health Sciences (EDB), University of Massachusetts Medical School, Worcester, MA; Department of Medicine (SKI), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, Aging Brain Center (SKI, RNJ, EDM), Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Koen Milisen
- Department of Emergency Medicine (BKIH, EDB), University of Massachusetts Medical School, Worcester, MA; Department of Psychiatry and Human Behavior (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Neurology (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Public Health and Primary Care (ED, KM) , Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium; Department of Geriatrics (ED, KM), University Hospitals Leuven, Leuven, Belgium; Cognitive Impairment Research Group, Sligo Mental Health Services; Sligo, Ireland and Centre for Interventions in Infection, Inflammation & Immunity, Graduate Entry Medical School (DA), University of Limerick, Limerick, Ireland; Department of Psychiatry (EDM), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Departments of Psychiatry, and Population and Quantitative Health Sciences (EDB), University of Massachusetts Medical School, Worcester, MA; Department of Medicine (SKI), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, Aging Brain Center (SKI, RNJ, EDM), Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Dimitrios Adamis
- Department of Emergency Medicine (BKIH, EDB), University of Massachusetts Medical School, Worcester, MA; Department of Psychiatry and Human Behavior (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Neurology (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Public Health and Primary Care (ED, KM) , Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium; Department of Geriatrics (ED, KM), University Hospitals Leuven, Leuven, Belgium; Cognitive Impairment Research Group, Sligo Mental Health Services; Sligo, Ireland and Centre for Interventions in Infection, Inflammation & Immunity, Graduate Entry Medical School (DA), University of Limerick, Limerick, Ireland; Department of Psychiatry (EDM), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Departments of Psychiatry, and Population and Quantitative Health Sciences (EDB), University of Massachusetts Medical School, Worcester, MA; Department of Medicine (SKI), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, Aging Brain Center (SKI, RNJ, EDM), Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Eran D Metzger
- Department of Emergency Medicine (BKIH, EDB), University of Massachusetts Medical School, Worcester, MA; Department of Psychiatry and Human Behavior (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Neurology (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Public Health and Primary Care (ED, KM) , Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium; Department of Geriatrics (ED, KM), University Hospitals Leuven, Leuven, Belgium; Cognitive Impairment Research Group, Sligo Mental Health Services; Sligo, Ireland and Centre for Interventions in Infection, Inflammation & Immunity, Graduate Entry Medical School (DA), University of Limerick, Limerick, Ireland; Department of Psychiatry (EDM), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Departments of Psychiatry, and Population and Quantitative Health Sciences (EDB), University of Massachusetts Medical School, Worcester, MA; Department of Medicine (SKI), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, Aging Brain Center (SKI, RNJ, EDM), Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Edwin D Boudreaux
- Department of Emergency Medicine (BKIH, EDB), University of Massachusetts Medical School, Worcester, MA; Department of Psychiatry and Human Behavior (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Neurology (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Public Health and Primary Care (ED, KM) , Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium; Department of Geriatrics (ED, KM), University Hospitals Leuven, Leuven, Belgium; Cognitive Impairment Research Group, Sligo Mental Health Services; Sligo, Ireland and Centre for Interventions in Infection, Inflammation & Immunity, Graduate Entry Medical School (DA), University of Limerick, Limerick, Ireland; Department of Psychiatry (EDM), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Departments of Psychiatry, and Population and Quantitative Health Sciences (EDB), University of Massachusetts Medical School, Worcester, MA; Department of Medicine (SKI), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, Aging Brain Center (SKI, RNJ, EDM), Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Sharon K Inouye
- Department of Emergency Medicine (BKIH, EDB), University of Massachusetts Medical School, Worcester, MA; Department of Psychiatry and Human Behavior (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Neurology (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Public Health and Primary Care (ED, KM) , Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium; Department of Geriatrics (ED, KM), University Hospitals Leuven, Leuven, Belgium; Cognitive Impairment Research Group, Sligo Mental Health Services; Sligo, Ireland and Centre for Interventions in Infection, Inflammation & Immunity, Graduate Entry Medical School (DA), University of Limerick, Limerick, Ireland; Department of Psychiatry (EDM), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Departments of Psychiatry, and Population and Quantitative Health Sciences (EDB), University of Massachusetts Medical School, Worcester, MA; Department of Medicine (SKI), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, Aging Brain Center (SKI, RNJ, EDM), Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA.
| | - Richard N Jones
- Department of Emergency Medicine (BKIH, EDB), University of Massachusetts Medical School, Worcester, MA; Department of Psychiatry and Human Behavior (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Neurology (BKIH, RNJ), Warren Alpert Medical School of Brown University, Providence, RI; Department of Public Health and Primary Care (ED, KM) , Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium; Department of Geriatrics (ED, KM), University Hospitals Leuven, Leuven, Belgium; Cognitive Impairment Research Group, Sligo Mental Health Services; Sligo, Ireland and Centre for Interventions in Infection, Inflammation & Immunity, Graduate Entry Medical School (DA), University of Limerick, Limerick, Ireland; Department of Psychiatry (EDM), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Departments of Psychiatry, and Population and Quantitative Health Sciences (EDB), University of Massachusetts Medical School, Worcester, MA; Department of Medicine (SKI), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, Aging Brain Center (SKI, RNJ, EDM), Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| |
Collapse
|
5
|
Oh ES, Rosenberg PB, Wang N, Sieber FE, Neufeld KJ. Delirium detection methodologies: Implications for outcome measurement in clinical trials in postoperative delirium. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5695. [PMID: 35170079 PMCID: PMC9303755 DOI: 10.1002/gps.5695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 02/03/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Delirium is a common postoperative complication of hip fracture. Various methods exist to detect delirium as a reference standard. The goal of this study was to characterize the properties of the measures obtained in a randomized controlled trial, to document their relationship to the Diagnostic and Statistical Manual of Mental Disorders:Text Revision based diagnosis of postoperative delirium by a consensus panel, and to describe the method in detail to allow replication by others. METHODS A secondary analysis of the randomized trial STRIDE (A Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients) was conducted. Delirium assessments were performed in 200 consecutive hip fracture repair patients ≥65 years old. Assessors underwent extensive training in delirium assessment and the final delirium diagnosis was adjudicated by a consensus panel of three physicians with expertise in delirium assessment. RESULTS A total of 680 consensus panel delirium diagnoses were completed. There were only 19 (2.8%, 19/678) evaluations where the delirium adjudication by the consensus panel differed from delirium findings by the Confusion Assessment Method (CAM). In 16 (84%, 16/19) of the cases, CAM was negative but the consensus panel diagnosed the patient as having delirium based on all of the available information including the CAM. CONCLUSION The consensus panel diagnosis was more sensitive compared to CAM alone, however the magnitude of the difference was not large. When assessors are well trained and delirium assessments are closely supervised throughout the study, CAM may be adequate for delirium diagnosis in a clinical trial. Future studies are needed to test this hypothesis.
Collapse
Affiliation(s)
- Esther S. Oh
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA,Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA,Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA,Johns Hopkins University School of NursingBaltimoreMarylandUSA
| | - Paul B. Rosenberg
- Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Nae‐Yuh Wang
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Frederick E. Sieber
- Department of Anesthesiology and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Karin J. Neufeld
- Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA,Johns Hopkins University School of NursingBaltimoreMarylandUSA
| |
Collapse
|
6
|
The detection of delirium in admitted oncology patients: a scoping review. Eur Geriatr Med 2022; 13:33-51. [PMID: 35032322 PMCID: PMC8860783 DOI: 10.1007/s41999-021-00586-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/03/2021] [Indexed: 02/07/2023]
Abstract
Aim To understand the validation of delirium detection tools in medical oncology, as well as identify data on incidence, prevalence and reversibility in this setting. Findings Of twelve studies, only four used case ascertainment methods following published recommendations, six studies had a low risk of bias. Message In delirium tool validation studies in the oncology setting, choice of appropriate gold standard for case ascertainment is a critical factor. New tools and new validations are not recommended, rather the critical application of existing tools depending on appropriate validation and clinical practicality for the setting. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00586-1. Purpose Delirium leads to poor outcomes for patients and careers and has negative impacts on staff and service provision. Cancer rates in elderly populations are increasing and frequently, cancer diagnoses are a co-morbidity in the context of frailty. Data relating to the epidemiology of delirium in hospitalised cancer patients are limited. With the overarching purpose of improving delirium detection and reducing the morbidity and mortality of delirium in cancer patients, we reviewed the epidemiological data and approach to delirium detection in hospitalised, adult oncology patients. Methods MEDLINE, EMBASE, CINAHL, PsycINFO, and SCOPUS databases were searched from January 1996 to August 2017. Key concepts were delirium, cancer, inpatient oncology and delirium screening/detection. Results Of 896 unique studies identified; 91 met full-text review criteria. Of 12 eligible studies, four applied recommended case ascertainment methods to all patients, three used delirium screening tools alone or with case ascertainment tools sub-optimally applied, four used tools not recommended for delirium screening or case ascertainment, one used the Confusion Assessment Method with insufficient information to determine if it met case ascertainment status. Two studies presented delirium incidence rates: 7.8%, and 17% respectively. Prevalence rates ranged from 18–33% for general medical or oncology wards; 42–58% for Acute Palliative Care Units (APCU); and for older cancer patients: 22% and 57%. Three studies reported reversibility; 26% and 49% respectively (APCUs) and 30% (older patients with cancer). Six studies had a low risk of bias according to QUADAS-2 criteria; all studies in the APCU setting were rated at higher risk of bias. Tool selection, study flow and recruitment bias reduced study quality. Conclusion The knowledge base for improved interventions and clinical care for adults with cancer and delirium is limited by the low number of studies. A clear distinction between screening tools and diagnostic tools is required to provide an improved understanding of the rates of delirium and its reversibility in this population. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00586-1.
Collapse
|
7
|
Grossi E, Lucchi E, Kreisel SH, Toepper M, Boedecker S, Inzitari M, Bellelli G, Gentile S, Morandi A. A retrospective multicentre cohort study of the performances on attention tests in outpatients with cognitive dysfunctions without delirium. Aging Clin Exp Res 2022; 34:39-48. [PMID: 34047932 DOI: 10.1007/s40520-021-01891-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 05/17/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Attention is the cardinal feature of delirium, but attentional domains may also be affected by dementia and its severity. It is, therefore, of interest to study the correlation between the severity of cognitive impairment in non-delirious patients and different measurements of attentional performance, to identify attention subdomains less affected by severity of cognitive impairment. METHODS Neuropsychological data from non-delirious outpatients (age ≥ 65 years), presenting at two memory clinics were analysed retrospectively. Scores for selective, divided, and sustained attention were correlated with cognitive impairment as defined by the score of the Mini-Mental State Examination. RESULTS A total of 1658 outpatients were included. The mean age was 77.15 (± 8.17) years, with a mean MMSE score of 22.67 (± 4.91). Compared to the type of attention, the tests that are less influenced by the severity of cognitive impairment are those of selective attention, in particular the Digit Span Forward (DSF). CONCLUSIONS This is the first study to correlate deficits in attention subdomains with the degree of cognitive impairment in non-delirious patients. The results suggest that measurements of selective attention (i.e. DSF) might be better suited to discriminate delirium from dementia. Indeed, a lower score on these tests might be indicative of an acute change and worsening of the baseline inattention and a longitudinal monitoring of these changes might be used to determine the delirium resolution.
Collapse
Affiliation(s)
- Eleonora Grossi
- Department of Rehabilitation, Fondazione Camplani Casa Di Cura "Ancelle Della Carità" Cremona, Cremona, Italy
| | - Elena Lucchi
- Department of Rehabilitation, Fondazione Camplani Casa Di Cura "Ancelle Della Carità" Cremona, Cremona, Italy
| | - Stefan H Kreisel
- Division of Geriatric Psychiatry, Department of Psychiatry and Psychotherapy, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Max Toepper
- Division of Geriatric Psychiatry, Department of Psychiatry and Psychotherapy, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Sebastian Boedecker
- Division of Geriatric Psychiatry, Department of Psychiatry and Psychotherapy, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | | | - Giuseppe Bellelli
- Geriatric Research Group, Brescia, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
- Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy
| | - Simona Gentile
- Department of Rehabilitation, Fondazione Camplani Casa Di Cura "Ancelle Della Carità" Cremona, Cremona, Italy
- Geriatric Research Group, Brescia, Italy
| | - Alessandro Morandi
- Department of Rehabilitation, Fondazione Camplani Casa Di Cura "Ancelle Della Carità" Cremona, Cremona, Italy.
- Geriatric Research Group, Brescia, Italy.
- Parc Sanitari Pere Virgili, Barcelona, Catalonia, Spain.
| |
Collapse
|
8
|
Watt CL, Scott M, Webber C, Sikora L, Bush SH, Kabir M, Boland JW, Woodhouse R, Sands MB, Lawlor PG. Delirium screening tools validated in the context of palliative care: A systematic review. Palliat Med 2021; 35:683-696. [PMID: 33588640 DOI: 10.1177/0269216321994730] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Delirium is a distressing neuropsychiatric disorder affecting patients in palliative care. Although many delirium screening tools exist, their utility, and validation within palliative care settings has not undergone systematic review. AIM To systematically review studies that validate delirium screening tools conducted in palliative care settings. DESIGN Systematic review with narrative synthesis (PROSPERO ID: CRD42019125481). A risk of bias assessment via Quality Assessment Tool for Diagnostic Accuracy Studies-2 was performed. DATA SOURCES Five electronic databases were systematically searched (January 1, 1982-May 3, 2020). Quantitative studies validating a screening tool in adult palliative care patient populations were included. Studies involving alcohol withdrawal, critical or perioperative care were excluded. RESULTS Dual-reviewer screening of 3749 unique titles and abstracts identified 95 studies for full-text review and of these, 17 studies of 14 screening tools were included (n = 3496 patients). Data analyses revealed substantial heterogeneity in patient demographics and variability in screening and diagnostic practices that limited generalizability between study populations and care settings. A risk of bias assessment revealed methodological and reporting deficits, with only 3/17 studies at low risk of bias. CONCLUSIONS The processes of selecting a delirium screening tool and determining optimal screening practices in palliative care are complex. One tool is unlikely to fit the needs of the entire palliative care population across all palliative care settings. Further research should be directed at evaluating and/or adapting screening tools and practices to fit the needs of specific palliative care settings and populations.
Collapse
Affiliation(s)
- Christine L Watt
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Mary Scott
- Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lindsey Sikora
- University of Ottawa, Health Sciences Library, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Rebecca Woodhouse
- Hull York Medical School and Department of Health Sciences, University of York, York, UK
| | - Megan B Sands
- University of New South Wales Prince of Wales Clinical School, Randwick, NSW, Australia
| | - Peter G Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| |
Collapse
|
9
|
Tieges Z, Quinn T, MacKenzie L, Davis D, Muniz-Terrera G, MacLullich AMJ, Shenkin SD. Association between components of the delirium syndrome and outcomes in hospitalised adults: a systematic review and meta-analysis. BMC Geriatr 2021; 21:162. [PMID: 33673804 PMCID: PMC7934253 DOI: 10.1186/s12877-021-02095-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/10/2021] [Indexed: 11/29/2022] Open
Abstract
Background Delirium is a heterogeneous syndrome with inattention as the core feature. There is considerable variation in the presence and degree of other symptom domains such as altered arousal, psychotic features and global cognitive dysfunction. Delirium is independently associated with increased mortality, but it is unclear whether individual symptom domains of delirium have prognostic importance. We conducted a systematic review and meta-analysis of studies in hospitalised adults in general settings to identify the relationship between symptom domains of delirium and outcomes. (PROSPERO: CRD42018093935). Methods We searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials from inception to November 2019. We included studies of hospitalised adults that reported associations between symptom domains of delirium and 30-day mortality (primary outcome), and other outcomes including mortality at other time points, length of stay, and dementia. Reviewer pairs independently screened articles, extracted data, and assessed risk of bias (Risk of Bias Assessment tool for Non-randomized Studies) and quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation framework. We performed random-effects meta-analyses stratified by delirium domain where possible. Results From 7092 citations we included 6 studies (6002 patients, 1112 with delirium). Higher mortality (ranging from in-hospital to follow-up beyond 12 months) was associated with altered arousal (pooled Odds Ratio (OR) 2.80, 95% Confidence Interval (CI) 2.33–3.37; moderate-quality evidence), inattention (pooled OR 2.57, 95% CI 1.74–3.80; low-quality evidence), and in single studies with disorientation, memory deficits and disorganised thoughts. Risk of bias varied across studies but was moderate-to-high overall, mainly due to selection bias, lack of blinding of assessments and unclear risk of selective outcome reporting. We found no studies on the association between psychotic features, visuospatial deficits or affective disturbances in delirium and outcomes, or studies reporting non-mortality outcomes. Conclusions Few studies have related symptom domains of delirium to outcomes, but the available evidence suggests that altered arousal and inattention in delirium are associated with higher mortality than normal arousal and attention in people with or without delirium. Measurable symptom domains of delirium may have value in predicting survival and stratifying patients for treatment. We recommend that future delirium studies report outcomes by symptom domain. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02095-z.
Collapse
Affiliation(s)
- Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK. .,School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, UK.
| | - Terence Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Lorn MacKenzie
- Academic and Clinical Central Office for Research and Development, University of Edinburgh, Edinburgh, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at University College London, London, UK
| | - Graciela Muniz-Terrera
- Centre for Clinical Brain Sciences and Dementia Prevention, University of Edinburgh, Edinburgh, UK
| | - Alasdair M J MacLullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Susan D Shenkin
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| |
Collapse
|
10
|
Sands MB, Sharma S, Carpenter L, Hartshorn A, Lee JT, Lujic S, Congdon ME, Buchanan AM, Agar M, Vardy JL. "SQiD, the Single Question in Delirium; can a single question help clinicians to detect delirium in hospitalised cancer patients?" running heading Single Question in Delirium" (Bcan-D-20-01665). BMC Cancer 2021; 21:75. [PMID: 33461523 PMCID: PMC7814717 DOI: 10.1186/s12885-020-07504-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/07/2020] [Indexed: 12/01/2022] Open
Abstract
Aim A serious syndrome for cancer in-patients, delirium risk increases with age and medical acuity. Screening tools exist but detection is frequently delayed or missed. We test the ‘Single Question in Delirium’ (SQiD), in comparison to psychiatrist clinical interview. Methods Inpatients in two comprehensive cancer centres were prospectively screened. Clinical staff asked informants to respond to the SQiD: “Do you feel that [patient’s name] has been more confused lately?”. The primary endpoint was negative predictive value (NPV) of the SQiD versus psychiatrist diagnosis (Diagnostic and Statistics Manual criteria). Secondary endpoints included: NPV of the Confusion Assessment Method (CAM), sensitivity, specificity and Cohen’s Kappa coefficient. Results Between May 2012 and July 2015, the SQiD plus CAM was applied to 122 patients; 73 had the SQiD and psychiatrist interview. Median age was 65 yrs. (interquartile range 54–74), 46% were female; median length of hospital stay was 12 days (5–18 days). Major cancer types were lung (19%), gastric or other upper GI (15%) and breast (14%). 70% of participants had stage 4 cancer. Diagnostic values were similar between the SQiD (NPV = 74, 95% CI 67–81; kappa = 0.32) and CAM (NPV = 72, 95% CI 67–77, kappa = 0.32), compared with psychiatrist interview. Overall the CAM identified only a small number of delirious cases but all were true positives. The specificity of the SQiD was 87% (74–95) The SQiD had higher sensitivity than CAM (44% [95% CI 41–80] vs 26% [10–48]). Conclusion The SQiD, administered by bedside clinical staff, was feasible and its psychometric properties are now better understood. The SQiD can contribute to delirium detection and clinical care for hospitalised cancer patients. Supplementary information Supplementary information accompanies this paper at 10.1186/s12885-020-07504-x.
Collapse
Affiliation(s)
- Megan B Sands
- University of New South Wales, Prince of Wales Clinical School, Sydney, NSW, Australia. .,Department of Palliative and Supportive Care, Nelune Comprehensive Cancer Centre, Prince of Wales Hospital and Community Health Service, Randwick, NSW, 2031, Australia.
| | - Swapnil Sharma
- University of New South Wales, Prince of Wales Clinical School, Sydney, NSW, Australia
| | - Lindsay Carpenter
- University of New South Wales, Prince of Wales Clinical School, Sydney, NSW, Australia.,Psychological Medicine Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrew Hartshorn
- Concord Cancer Centre, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Jessica T Lee
- Concord Cancer Centre, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Sanja Lujic
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Megan E Congdon
- University of New South Wales, Prince of Wales Clinical School, Sydney, NSW, Australia
| | | | - Meera Agar
- Centre of Cardiovascular and Chronic Care, University of Technology Sydney Faculty of Health, Ultimo, Australia
| | - Janette L Vardy
- Concord Cancer Centre, Concord Repatriation General Hospital, Sydney, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
11
|
Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, Slooter AJC, Ely EW. Delirium. Nat Rev Dis Primers 2020; 6:90. [PMID: 33184265 PMCID: PMC9012267 DOI: 10.1038/s41572-020-00223-4] [Citation(s) in RCA: 451] [Impact Index Per Article: 112.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 02/06/2023]
Abstract
Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.
Collapse
Affiliation(s)
- Jo Ellen Wilson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Psychiatry and Behavioral Sciences, Division of General Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew F Mart
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Republic of Ireland
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy D Girard
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN, USA
| |
Collapse
|
12
|
Helfand BKI, D'Aquila ML, Tabloski P, Erickson K, Yue J, Fong TG, Hshieh TT, Metzger ED, Schmitt EM, Boudreaux ED, Inouye SK, Jones RN. Detecting Delirium: A Systematic Review of Identification Instruments for Non-ICU Settings. J Am Geriatr Soc 2020; 69:547-555. [PMID: 33135780 DOI: 10.1111/jgs.16879] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/14/2020] [Accepted: 09/20/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND/OBJECTIVES Delirium manifests clinically in varying ways across settings. More than 40 instruments currently exist for characterizing the different manifestations of delirium. We evaluated all delirium identification instruments according to their psychometric properties and frequency of citation in published research. DESIGN We conducted the systematic review by searching Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Excerpta Medica Database (Embase), PsycINFO, PubMed, and Web of Science from January 1, 1974, to January 31, 2020, with the keywords "delirium" and "instruments," along with their known synonyms. We selected only systematic reviews, meta-analyses, or narrative literature reviews including multiple delirium identification instruments. MEASUREMENTS Two reviewers assessed the eligibility of articles and extracted data on all potential delirium identification instruments. Using the original publication on each instrument, the psychometric properties were examined using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) framework. RESULTS Of 2,542 articles identified, 75 met eligibility criteria, yielding 30 different delirium identification instruments. A count of citations was determined using Scopus for the original publication for each instrument. Each instrument underwent methodological quality review of psychometric properties using COSMIN definitions. An expert panel categorized key domains for delirium identification based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III through DSM-5. Four instruments were notable for having at least two of three of the following: citation count of 200 or more, strong validation methodology in their original publication, and fulfillment of DSM-5 criteria. These were, alphabetically, Confusion Assessment Method, Delirium Observation Screening Scale, Delirium Rating Scale-Revised-98, and Memorial Delirium Assessment Scale. CONCLUSION Four commonly used and well-validated instruments can be recommended for clinical and research use. An important area for future investigation is to harmonize these measures to compare and combine studies on delirium.
Collapse
Affiliation(s)
- Benjamin K I Helfand
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA.,Departments of Psychiatry and Human Behavior and Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Madeline L D'Aquila
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Patricia Tabloski
- William F. Connell School of Nursing, Boston College, Boston, Massachusetts, USA
| | - Kristen Erickson
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Tamara G Fong
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Tammy T Hshieh
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Division of Gerontology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Eran D Metzger
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Eva M Schmitt
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Edwin D Boudreaux
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Sharon K Inouye
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard N Jones
- Departments of Psychiatry and Human Behavior and Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| |
Collapse
|
13
|
MacLullich AM, Shenkin SD, Goodacre S, Godfrey M, Hanley J, Stíobhairt A, Lavender E, Boyd J, Stephen J, Weir C, MacRaild A, Steven J, Black P, Diernberger K, Hall P, Tieges Z, Fox C, Anand A, Young J, Siddiqi N, Gray A. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess 2020; 23:1-194. [PMID: 31397263 DOI: 10.3310/hta23400] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. METHODS Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. RESULTS Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. LIMITATIONS Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. CONCLUSIONS These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. FUTURE WORK Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. TRIAL REGISTRATION Current Controlled Trials ISRCTN53388093. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.
Collapse
Affiliation(s)
| | - Susan D Shenkin
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Steve Goodacre
- Emergency Medicine, University of Sheffield, Sheffield, UK
| | - Mary Godfrey
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Janet Hanley
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Antaine Stíobhairt
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Elizabeth Lavender
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Katharina Diernberger
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Peter Hall
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Christopher Fox
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Atul Anand
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - John Young
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Najma Siddiqi
- Psychiatry, University of York, York.,Hull York Medical School, York, UK.,Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Alasdair Gray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| |
Collapse
|
14
|
Nacul FE, Paul N, Spies CD, Sechting H, Hecht T, Dullinger JS, Piper SK, Luetz A, Balzer FS, Wernecke KD, Sa AK, Barros Ferreira da Costa C, Eymold L, Chenitir C, Weiss B. Influence of Sedation Level and Ventilation Status on the Diagnostic Validity of Delirium Screening Tools in the ICU-An International, Prospective, Bi-Center Observational Study (IDeAS). ACTA ACUST UNITED AC 2020; 56:medicina56080411. [PMID: 32823781 PMCID: PMC7466203 DOI: 10.3390/medicina56080411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/02/2022]
Abstract
Background and objectives: The use of delirium screening instruments (DSIs) is recommended in critical care practice for a timely detection of delirium. We hypothesize that the patient-related factors “level of sedation” and “mechanical ventilation” impact test validity of DSIs. Materials and Methods: This is a prospective, bi-center observational study (clinicaltrials.gov: NCT01720914). Critically ill patients were screened for delirium daily for up to seven days after enrollment using the Nursing Delirium Screening Scale (Nu-DESC), Intensive Care Delirium Screening Checklist (ICDSC), and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Reference standard for delirium diagnosis was the neuropsychiatric examination using the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Immediately before delirium assessment, ventilation status and sedation levels were documented. Results: 160 patients were enrolled and 151 patients went into final analysis. Delirium incidence was 23.2%. Nu-DESC showed a sensitivity and specificity of 88.5%, a positive predictive value (PPV) of 71.9%, and a negative predictive value (NPV) of 95.8%. ICDSC had a sensitivity of 62.5%, a specificity of 92.4%, a PPV of 71.4%, and a NPV of 89.0%. CAM-ICU showed a sensitivity of 75.0%, a specificity of 94.7%, a PPV of 85.7%, and a NPV of 90.0%. For Nu-DESC and ICDSC, test validity was significantly better for non-sedated patients (Richmond Agitation Sedation Scale (RASS) 0/−1), whereas test validity for CAM-ICU in a severity scale version showed no significant differences for different sedation levels. No DSI showed a significant difference in test validity between noninvasively and invasively ventilated patients. Conclusions: Test validities of DSIs were comparable to previous studies. The observational scores ICDSC and Nu-DESC showed a significantly better performance in awake and drowsy patients (RASS 0/−1) when compared with other sedation levels. Physicians should refrain from sedation whenever possible to avoid suboptimal performance of DSIs.
Collapse
Affiliation(s)
- Flavio E. Nacul
- Surgical Critical Care Medicine, Hospital Pro-Cardiaco, Rio de Janeiro, RJ 22280-003, Brazil; (F.E.N.); (A.K.S.); (C.B.F.d.C.)
| | - Nicolas Paul
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Claudia D. Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Henriette Sechting
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Thomas Hecht
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Jörn S. Dullinger
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Sophie K. Piper
- Institute of Biometry and Clinical Epidemiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (S.K.P.); (K.-D.W.)
- Berlin Institute of Health (BIH), 10178 Berlin, Germany
| | - Alawi Luetz
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
- Department of Healthcare Management, Technische Universität Berlin, 10623 Berlin, Germany
| | - Felix S. Balzer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Klaus-Dieter Wernecke
- Institute of Biometry and Clinical Epidemiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (S.K.P.); (K.-D.W.)
| | - Anna Karinina Sa
- Surgical Critical Care Medicine, Hospital Pro-Cardiaco, Rio de Janeiro, RJ 22280-003, Brazil; (F.E.N.); (A.K.S.); (C.B.F.d.C.)
| | | | - Lisa Eymold
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Chokri Chenitir
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
| | - Björn Weiss
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany; (N.P.); (C.D.S.); (H.S.); (T.H.); (J.S.D.); (A.L.); (F.S.B.); (L.E.); (C.C.)
- Correspondence: ; Tel.: +49-30-450-631-027
| |
Collapse
|
15
|
Khachaturian AS, Hayden KM, Devlin JW, Fleisher LA, Lock SL, Cunningham C, Oh ES, Fong TG, Fick DM, Marcantonio ER, Iyengar V, Rockwood K, Kuchel GA, Eckenhoff RG, MacLullich AMJ, Jones RN, Davis D, D'Antonio PM, Fargo KN, Albert MS, Williamson JD, Ling SM, Weiss J, Karlawish J, Petersen RC, Blazer DG, Khachaturian ZS, Inouye SK. International drive to illuminate delirium: A developing public health blueprint for action. Alzheimers Dement 2020; 16:711-725. [PMID: 32212231 DOI: 10.1002/alz.12075] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Ara S Khachaturian
- Campaign to Prevent Alzheimer's Disease, A Maryland-based 501(c)(3) not-for-profit corporation, Rockville, Maryland, USA
| | - Kathleen M Hayden
- Division of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, North Carolina, USA
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, Massachusetts, USA
| | - Lee A Fleisher
- Department of Anesthesiology & Critical Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | | | - Colm Cunningham
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland
| | - Esther S Oh
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tamara G Fong
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Donna Marie Fick
- Penn State College of Nursing, Center of Geriatric Nursing Excellence, University Park, Pennsylvania, USA
| | - Edward R Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Vijeth Iyengar
- Administration for Community Living, U.S. Department of Health and Human Services, Washington, DC, USA
| | - Kenneth Rockwood
- Divisions of Geriatric Medicine & Neurology, Department of Medicine, Dalhousie University & Nova Scotia Health Authority, Halifax, Canada
| | - George A Kuchel
- Department of Geriatrics and Gerontology, University of Connecticut, Center on Aging, University of Connecticut, Farmington, Connecticut, USA
| | - Roderic G Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Richard N Jones
- Department of Psychiatry & Human Behavior, Warren Alpert Medical School, Brown University, Butler Hospital, Providence, Rhode Island, USA
| | - Daniel Davis
- MRC Unit for Lifelong Health & Ageing, Population Science & Experimental Medicine, Faculty of Pop Health Sciences, University College London, London, UK
| | | | | | - Marilyn S Albert
- Division of Cognitive Neuroscience, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeff D Williamson
- Gerontology and Geriatric Medicine, Winston-Salem, North Carolina, USA
| | - Shari M Ling
- Centers for Medicare and Medicaid Services (CMS), Baltimore, Maryland, USA
| | - Joan Weiss
- Division of Medicine and Dentistry, Bureau of Health Workforce, Health Resources and Services Administration, Rockville, Maryland, USA
| | - Jason Karlawish
- Division of Geriatrics, Department of Medicine, Ralston-Penn Center, Philadelphia, Pennsylvania, USA
| | - Ronald C Petersen
- Alzheimer's Disease Research Center, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dan G Blazer
- Psychiatry & Behavioral Sciences, Geriatric Behavioral Health, School of Medicine, Durham, North Carolina, USA
| | - Zaven S Khachaturian
- Campaign to Prevent Alzheimer's Disease, A Maryland-based 501(c)(3) not-for-profit corporation, Rockville, Maryland, USA
| | - Sharon K Inouye
- Harvard Medical School, Beth Israel Deaconess Medical Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Maryland, USA
| |
Collapse
|
16
|
Gibb K, Seeley A, Quinn T, Siddiqi N, Shenkin S, Rockwood K, Davis D. The consistent burden in published estimates of delirium occurrence in medical inpatients over four decades: a systematic review and meta-analysis study. Age Ageing 2020; 49:352-360. [PMID: 32239173 PMCID: PMC7187871 DOI: 10.1093/ageing/afaa040] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Delirium is associated with a wide range of adverse patient safety outcomes, yet it remains consistently under-diagnosed. We undertook a systematic review of studies describing delirium in adult medical patients in secondary care. We investigated if changes in healthcare complexity were associated with trends in reported delirium over the last four decades. METHODS We used identical criteria to a previous systematic review, only including studies using internationally accepted diagnostic criteria for delirium (the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases). Estimates were pooled across studies using random effects meta-analysis, and we estimated temporal changes using meta-regression. We investigated publication bias with funnel plots. RESULTS We identified 15 further studies to add to 18 studies from the original review. Overall delirium occurrence was 23% (95% CI 19-26%) (33 studies) though this varied according to diagnostic criteria used (highest in DSM-IV, lowest in DSM-5). There was no change from 1980 to 2019, nor was case-mix (average age of sample, proportion with dementia) different. Overall, risk of bias was moderate or low, though there was evidence of increasing publication bias over time. DISCUSSION The incidence and prevalence of delirium in hospitals appears to be stable, though publication bias may have masked true changes. Nonetheless, delirium remains a challenging and urgent priority for clinical diagnosis and care pathways.
Collapse
Affiliation(s)
- Kate Gibb
- MRC Unit for Lifelong Health and Ageing at UCL, Department of Population Science and Experimental Medicine, London, UK
- Acute Medical Unit, University College London Hospitals NHS Foundation Trust, UK
| | - Anna Seeley
- MRC Unit for Lifelong Health and Ageing at UCL, Department of Population Science and Experimental Medicine, London, UK
- Department of Medicine for the Elderly, University College London Hospitals NHS Foundation Trust, UK
| | - Terry Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, UK
| | - Susan Shenkin
- Department of Geriatric Medicine, University of Edinburgh, UK
| | - Kenneth Rockwood
- MRC Unit for Lifelong Health and Ageing at UCL, Department of Population Science and Experimental Medicine, London, UK
- Department of Medicine, Dalhousie University, Halifax, Canada
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, Department of Population Science and Experimental Medicine, London, UK
- Acute Medical Unit, University College London Hospitals NHS Foundation Trust, UK
- Department of Medicine for the Elderly, University College London Hospitals NHS Foundation Trust, UK
| |
Collapse
|
17
|
Oh ES, Akeju O, Avidan MS, Cunningham C, Hayden KM, Jones RN, Khachaturian AS, Khan BA, Marcantonio ER, Needham DM, Neufeld KJ, Rose L, Spence J, Tieges Z, Vlisides P, Inouye SK. A roadmap to advance delirium research: Recommendations from the NIDUS Scientific Think Tank. Alzheimers Dement 2020; 16:726-733. [PMID: 32291901 PMCID: PMC7317361 DOI: 10.1002/alz.12076] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Delirium is an acute disorder of attention and cognition. It occurs across the life span, yet it is particularly common among older adults, and is closely linked with underlying neurocognitive disorders. Evidence is mounting that intervening on delirium may represent an important opportunity for delaying the onset or progression of dementia. To accelerate the current understanding of delirium, the Network for Investigation of Delirium: Unifying Scientists (NIDUS) held a conference “Advancing Delirium Research: A Scientific Think Tank” in June 2019. This White Paper encompasses the major knowledge and research gaps identified at the conference: advancing delirium definition and measurement, understanding delirium pathophysiology, and prevention and treatment of delirium. A roadmap of research priorities is proposed to advance the field in a systematic, interdisciplinary, and coordinated fashion. A call is made for an international consortium and biobank targeted to delirium, as well as a public health campaign to advance the field.
Collapse
Affiliation(s)
- Esther S Oh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Colm Cunningham
- School of Biochemistry and Immunology & Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland
| | - Kathleen M Hayden
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | | | - Babar A Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Edward R Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karin J Neufeld
- Department of Psychiatry and Behavioral Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Jessica Spence
- Departments of Anesthesiology and Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Zoë Tieges
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, UK
| | - Phillip Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Sharon K Inouye
- Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | | |
Collapse
|
18
|
Bilotta F, Weiss B, Neuner B, Kramer S, Aldecoa C, Bettelli G, Sanders RD, Delp SM, Spies CD. Routine management of postoperative delirium outside the ICU: Results of an international survey among anaesthesiologists. Acta Anaesthesiol Scand 2020; 64:494-500. [PMID: 31883373 DOI: 10.1111/aas.13535] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 11/18/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative delirium (POD) is a severe brain dysfunction. Although data indicate a high relevance, no survey has investigated the routine practice to monitor delirium outside the ICU setting after surgery. Prior to publishing of the new European Society of Anaesthesiology (ESA) guidelines on POD, an international survey was conducted to assess current practice. METHODS European Society of Anaesthesiology-endorsed online survey; Trial Registration: NCT-identifier: 02513537. RESULTS In total, 566 respondents from 62 countries accessed, and 564 (99.6%) completed the survey (completion rate). Overall, 385 (68%) of the respondents reported that delirium is either "very relevant" or "relevant" for their daily clinical practice. In all, 38 (7%) of the respondents routinely monitor for delirium in >50% of all patients. Asked on the monitoring time point, more than half (n = 308, 55%) indicated to screen before or at recovery room discharge, 235 (42%) up to the first postoperative day, 143 (25%) up to 3 days, and 77 (14%) up to 5 postoperative days. Although there is a lack of long-term monitoring, nearly all respondents (n = 530, 94%) reported to treat delirium. Availability of EEG/EMG-based monitoring to assess the depth of anaesthesia was high in the study group (n = 547, 97%) and was used by more than one-third of the respondents to reduce risk of burst suppression (n = 189, 34%). CONCLUSION Although delirium is perceived as a relevant condition among anaesthesiologists, there is a high demand for implementing monitoring strategies after publishing of the POD Guideline. The survey shows that tools necessary for POD Guideline implementation are available in the centres represented by the respondents.
Collapse
Affiliation(s)
- Federico Bilotta
- Department of Anesthesiology Critical Care and Pain Medicine, "Sapienza" University of Rome Rome Italy
| | - Bjoern Weiss
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Bruno Neuner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Sylvia Kramer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - César Aldecoa
- Department of Anaesthesiology & Intensive Care Hospital Universitario Rio Hortega Valladolid Spain
| | - Gabriella Bettelli
- Department of Geriatric Surgery Italian National Research Centres on Aging/IRCCS Ancona Italy
- Department of Anaesthesia, Analgesia and Intensive Care Italian National Research Centres on Aging/IRCCS Ancona Italy
| | | | - Simon M. Delp
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Claudia D. Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| |
Collapse
|
19
|
Koirala B, Hansen BR, Hosie A, Budhathoki C, Seal S, Beaman A, Davidson PM. Delirium point prevalence studies in inpatient settings: A systematic review and meta‐analysis. J Clin Nurs 2020; 29:2083-2092. [DOI: 10.1111/jocn.15219] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/06/2020] [Accepted: 02/07/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Binu Koirala
- Johns Hopkins School of Nursing Baltimore Maryland
| | | | - Annmarie Hosie
- School of Nursing Sydney The University of Notre Dame Australia Darlinghurst NSW Australia
| | | | - Stella Seal
- Johns Hopkins University and Medicine Welch Medical Library Baltimore Maryland
| | - Adam Beaman
- Johns Hopkins School of Nursing Baltimore Maryland
- University of Technology Sydney Sydney NSW Australia
| | - Patricia M. Davidson
- Johns Hopkins School of Nursing Baltimore Maryland
- University of Technology Sydney Sydney NSW Australia
| |
Collapse
|
20
|
Fischer T, Hosie A, Luckett T, Agar M, Phillips J. Strategies for Pain Assessment in Adult Patients With Delirium: A Scoping Review. J Pain Symptom Manage 2019; 58:487-502.e11. [PMID: 31195076 DOI: 10.1016/j.jpainsymman.2019.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 05/31/2019] [Accepted: 05/31/2019] [Indexed: 01/19/2023]
Abstract
CONTEXT Pain and delirium are highly prevalent in the same patient groups. Disturbances in attention, awareness, and cognition are characteristics for delirium and can compromise pain assessment. OBJECTIVES The aim of this review was to examine and map models and understandings of pain and delirium as well as pain assessment instruments and strategies for adult patients with delirium. METHODS A scoping review of all publications that reported on pain assessment in adult patients with delirium was conducted with no time and language constraints, searching Medline, CINAHL, Scopus, Embase, and PsycINFO and systematically assessing for inclusion. Standardized data extraction and a narrative synthesis followed. RESULTS A total of 90 publications were included in the final analysis. Despite being recommended for practice, no evidence for the use of self-report or behavioral pain assessment instruments in patients with delirium was identified, with the exception of limited evidence for the validity of the Critical Care Pain Observation Tool and Behavioral Pain Scale in delirious intensive care patients. Proxy ratings of pain and comprehensive pain assessment hierarchies were also recommended, but not supported by evidence. Current models and/or understandings of pain and delirium were not applied in most publications. CONCLUSION The current literature is insufficient to guide clinical practice in pain assessment in patients with delirium. Future research will be needed to address the validity of existing pain assessment instruments, apply theoretical and conceptual understandings of pain and delirium, and build on prior studies to close evidence gaps.
Collapse
Affiliation(s)
| | - Annmarie Hosie
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Tim Luckett
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Meera Agar
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Jane Phillips
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| |
Collapse
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Morandi A, Thompson JL, Bellelli G, Lucchi E, Turco R, Gentile S, Trabucchi M, MacLullich A, Meagher D, Ely EW, Pandharipande P, Smith H. Delirium in patients with dementia and in children: Overlap of symptoms profile and possible role for future diagnosis. Eur J Intern Med 2019; 65:44-50. [PMID: 31151748 DOI: 10.1016/j.ejim.2019.04.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/23/2019] [Accepted: 04/30/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Delirium in the extremes of the age spectrum may show similarities in presentations, and these similarities may provide information to develop tools for the diagnosis of delirium superimposed on dementia (DSD). We sought to investigate the symptom profile and subtypes of delirium in patients with dementia, and in infants and preschool children. METHODS This was an exploratory analysis of previous prospective cohort studies that evaluated delirium with the DSM-IV criteria in patients with dementia, and in critically ill infants (< 2 years of age) and preschool children (2-5 years of age), respectively. Delirium subtypes were defined based on the Richmond Agitation-Sedation Scale. RESULTS We included 147 patients, 35 adult patients with delirium DSD, 80 infants, and 32 preschool children with delirium. Hypokinesia and apathy were common among both DSD (72%), infants (74%) and preschool children (75%) with delirium, whereas hallucinations and anxiety were less common in both adults with DSD (26%) and infants (10%) and preschool children (14%). Hypoactive delirium was most common delirium subtype among infants (68%) and preschoolers (76%), whereas RASS = 0 (alert) delirium was the most common among adult patients with DSD (55%). CONCLUSIONS The study reports similarities in the symptoms profile of delirium in a cohort of patients with dementia and delirium, and in infants and preschool-aged children with delirium. These preliminary findings might be informative to design future studies adapting delirium assessments used in in infants and preschool-aged children to patients with dementia, especially in the moderate to severe stages.
Collapse
Affiliation(s)
- Alessandro Morandi
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy; Geriatric Research Group, University of Tor Vergata, Rome, Italy.
| | - Jennifer L Thompson
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN, USA
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Elena Lucchi
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy; Geriatric Research Group, University of Tor Vergata, Rome, Italy
| | | | - Simona Gentile
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy; Geriatric Research Group, University of Tor Vergata, Rome, Italy
| | - Marco Trabucchi
- Geriatric Research Group, University of Tor Vergata, Rome, Italy; University of Tor Vergata, Rome, Italy
| | | | | | - E Wesley Ely
- Critical Illness, Brain Dysfunction, Survivorship (CIBS) Center, Vanderbilt University Medical Center, Department of Medicine, Nashville, TN, USA; Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), USA
| | - Pratik Pandharipande
- Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Heidi Smith
- Department of Anesthesiology and Pediatrics, Vanderbilt University Medical Center, TN, USA
| |
Collapse
|
23
|
Freundlich R, Boncyk C. Clearly-defined outcomes improve the quality of health outcomes research. Br J Anaesth 2019; 122:14-16. [DOI: 10.1016/j.bja.2018.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/02/2018] [Accepted: 11/04/2018] [Indexed: 12/11/2022] Open
|
24
|
Tieges Z, Evans JJ, Neufeld KJ, MacLullich AM. The neuropsychology of delirium: advancing the science of delirium assessment. Int J Geriatr Psychiatry 2018; 33:1501-1511. [PMID: 28393426 PMCID: PMC6704364 DOI: 10.1002/gps.4711] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 03/02/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The diagnosis of delirium depends on eliciting its features through mental status examination and informant history. However, there is marked heterogeneity in how these features are assessed, from binary subjective clinical judgement to more comprehensive methods supported by cognitive testing. The aim of this article is to review the neuropsychological research in delirium and suggest future directions in research and clinical practice. METHODS We reviewed the neuropsychological literature on formal assessment and quantification of the different domains in delirium, focusing on the core feature of inattention. RESULTS Few studies have characterised and quantified the features of delirium using objective methods commonly employed in neuropsychological research. The existing evidence confirms that patients with delirium usually show impairments on objective tests of attention compared with cognitively intact controls and, in most cases, compared with patients with dementia. Further, abnormal level of arousal appears to be a specific indicator of delirium. The neuropsychological evidence base for impairments in other cognitive domains in delirium, including visual perception, language and thought processes, is small. CONCLUSIONS Delirium diagnosis requires accurate testing for its features, but there is little neuropsychological research examining the nature of these features, or evaluating the reliability, validity and discriminatory power of existing assessment processes. More research using the neuropsychological approach has enormous potential to improve and standardise delirium assessment methods of the individual features of delirium, such as inattention, and in developing more robust reference standards to enable greater comparability between studies.
Collapse
Affiliation(s)
- Zoë Tieges
- Edinburgh Delirium Research GroupUniversity of EdinburghEdinburghUK,Centre for Cognitive Ageing and Cognitive EpidemiologyUniversity of EdinburghEdinburghUK
| | | | - Karin J. Neufeld
- Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Alasdair M.J. MacLullich
- Edinburgh Delirium Research GroupUniversity of EdinburghEdinburghUK,Centre for Cognitive Ageing and Cognitive EpidemiologyUniversity of EdinburghEdinburghUK
| |
Collapse
|
25
|
Aziz KT, Best MJ, Naseer Z, Skolasky RL, Ponnusamy KE, Sterling RS, Khanuja HS. The Association of Delirium with Perioperative Complications in Primary Elective Total Hip Arthroplasty. Clin Orthop Surg 2018; 10:286-291. [PMID: 30174803 PMCID: PMC6107810 DOI: 10.4055/cios.2018.10.3.286] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 05/03/2018] [Indexed: 12/21/2022] Open
Abstract
Background Our goal was to determine whether postoperative delirium is associated with inpatient complication rates after primary elective total hip arthroplasty (THA). Methods Using the National Inpatient Sample, we analyzed records of patients who underwent primary elective THA from 2000 through 2009 to identify patients with delirium (n = 13,551) and without delirium (n = 1,992,971) and to assess major perioperative complications (acute renal failure, death, myocardial infarction, pneumonia, pulmonary embolism, and stroke) and minor perioperative complications (deep vein thrombosis, dislocation, general procedural complication, hematoma, seroma, and wound infection). Patient age, sex, length of hospital stay, and number of comorbidities were assessed. We used multivariate logistic regression to determine the association of delirium with complication rates (significance, p < 0.01). Results Patients with delirium were older (mean, 75 ± 0.2 vs. 65 ± 0.1 years), were more likely to be male (56% vs. 52%), had longer hospital stays (mean, 5.7 ± 0.07 vs. 3.8 ± 0.02 days), and had more comorbidities (mean, 2.8 ± 0.03 vs. 1.4 ± 0.01) (all p < 0.001) versus patients without delirium. Patients with delirium were more likely to have major (11% vs. 3%) and minor (17% vs. 7%) perioperative complications versus patients without delirium (both p < 0.001). When controlling for age, sex, and number of comorbidities, delirium was independently associated with major and minor complications (odds ratio, 2.0; 95% confidence interval, 1.7 to 2.3). Conclusions Delirium is an independent risk factor for major and minor perioperative complications after primary elective THA.
Collapse
Affiliation(s)
- Keith T Aziz
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Zan Naseer
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Karthik E Ponnusamy
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Robert S Sterling
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Harpal S Khanuja
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
26
|
Haugen CE, Mountford A, Warsame F, Berkowitz R, Bae S, Thomas A, Brown CH, Brennan DC, Neufeld KJ, Carlson MC, Segev DL, McAdams-DeMarco M. Incidence, Risk Factors, and Sequelae of Post-kidney Transplant Delirium. J Am Soc Nephrol 2018; 29:1752-1759. [PMID: 29685884 DOI: 10.1681/asn.2018010064] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/30/2018] [Indexed: 01/20/2023] Open
Abstract
Background Frail kidney transplant (KT) recipients may be particularly vulnerable to surgical stressors, resulting in delirium and subsequent adverse outcomes. We sought to identify the incidence, risk factors, and sequelae of post-KT delirium.Methods We studied 125,304 adult KT recipients (1999-2014) to estimate delirium incidence in national registry claims. Additionally, we used a validated chart abstraction algorithm to identify post-KT delirium in 893 adult recipients (2009-2017) from a cohort study of frailty. Delirium sequelae were identified using adjusted logistic regression (length of stay ≥2 weeks and institutional discharge [skilled nursing or rehabilitation facility]) and adjusted Cox regression (death-censored graft loss and mortality).Results Only 0.8% of KT recipients had a delirium claim. In the cohort study, delirium incidence increased with age (18-49 years old: 2.0%; 50-64 years old: 4.6%; 65-75 years old: 9.2%; and ≥75 years old: 13.8%) and frailty (9.0% versus 3.9%); 20.0% of frail recipients aged ≥75 years old experienced delirium. Frailty was independently associated with delirium (odds ratio [OR], 2.05; 95% confidence interval [95% CI], 1.02 to 4.13; P=0.04), but premorbid global cognitive function was not. Recipients with delirium had increased risks of ≥2-week length of stay (OR, 5.42; 95% CI, 2.76 to 10.66; P<0.001), institutional discharge (OR, 22.41; 95% CI, 7.85 to 63.98; P<0.001), graft loss (hazard ratio [HR], 2.73; 95% CI, 1.14 to 6.53; P=0.03), and mortality (HR, 3.12; 95% CI, 1.76 to 5.54; P<0.001).Conclusions Post-KT delirium is a strong risk factor for subsequent adverse outcomes, yet it is a clinical entity that is often missed.
Collapse
Affiliation(s)
| | | | | | | | - Sunjae Bae
- Departments of Surgery.,Departments of Epidemiology and
| | | | | | | | - Karin J Neufeld
- Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michelle C Carlson
- Mental Health, Johns Hopkins School of Public Health, Baltimore, Maryland; and.,Johns Hopkins University Center on Aging and Health, Baltimore, Maryland
| | - Dorry L Segev
- Departments of Surgery.,Departments of Epidemiology and
| | | |
Collapse
|
27
|
A Pilot Randomized Controlled Trial of the Feasibility of a Multicomponent Delirium Prevention Intervention Versus Usual Care in Acute Stroke. J Cardiovasc Nurs 2018; 32:E1-E10. [PMID: 27306854 DOI: 10.1097/jcn.0000000000000356] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Delirium after acute stroke is a serious complication. Numerous studies support a benefit of multicomponent interventions in minimizing delirium-related complications in at-risk patients, but this has not been reported in acute stroke patients. The purpose of this study was to explore the feasibility of conducting a randomized (delirium care) versus usual standardized stroke care (usual care) in reducing delirium in acute stroke. OBJECTIVE This pilot study assessed the feasibility of (1) enrollment within the 48-hour window when delirium risk is greatest, (2) measuring cognitive function using the Montreal Cognitive Assessment, (3) delivering interventions 7 days per week, and (4) determining delirium incidence in stroke-related cognitive dysfunction. METHODS A 2-group randomized controlled trial was conducted. Patients admitted with ischemic and hemorrhagic strokes and 50 years or older, English speaking, and without delirium on admit were recruited, consented, and randomized to usual care or delirium care groups. RESULTS Data from 125 subjects (delirium care, n = 59; usual care, n = 66) were analyzed. All Montreal Cognitive Assessment subscales were completed by 86% of subjects (delirium care, mean [SD], 18.14 [6.03]; usual care, mean [SD], 17.61 [6.29]). Subjects in the delirium care group received a mean of 6.10 therapeutic activities (range, 2-23) and daily medication review by a clinical pharmacist using anticholinergic drug calculations. Delirium incidence was 8% (10/125), 3 in the delirium care group and 7 in the usual care group. CONCLUSION Findings support the feasibility of delivering a multicomponent delirium prevention intervention in acute stroke and warrants testing intervention effects on delirium outcomes and anticholinergic medication administration.
Collapse
|
28
|
Todd A, Blackley S, Burton JK, Stott DJ, Ely EW, Tieges Z, MacLullich AMJ, Shenkin SD. Reduced level of arousal and increased mortality in adult acute medical admissions: a systematic review and meta-analysis. BMC Geriatr 2017; 17:283. [PMID: 29216846 PMCID: PMC5721682 DOI: 10.1186/s12877-017-0661-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/09/2017] [Indexed: 12/20/2022] Open
Abstract
Background Reduced level of arousal is commonly observed in medical admissions and may predict in-hospital mortality. Delirium and reduced level of arousal are closely related. We systematically reviewed and conducted a meta-analysis of studies in adult acute medical patients of the relationship between reduced level of arousal on admission and in-hospital mortality. Methods We conducted a systematic review (PROSPERO: CRD42016022048), searching MEDLINE and EMBASE. We included studies of adult patients admitted with acute medical illness with level of arousal assessed on admission and mortality rates reported. We performed meta-analysis using a random effects model. Results From 23,941 studies we included 21 with 14 included in the meta-analysis. Mean age range was 33.4 - 83.8 years. Studies considered unselected general medical admissions (8 studies, n=13,039) or specific medical conditions (13 studies, n=38,882). Methods of evaluating level of arousal varied. The prevalence of reduced level of arousal was 3.1%-76.9% (median 13.5%). Mortality rates were 1.7%-58% (median 15.9%). Reduced level of arousal was associated with higher in-hospital mortality (pooled OR 5.71; 95% CI 4.21-7.74; low quality evidence: high risk of bias, clinical heterogeneity and possible publication bias). Conclusions Reduced level of arousal on hospital admission may be a strong predictor of in-hospital mortality. Most evidence was of low quality. Reduced level of arousal is highly specific to delirium, better formal detection of hypoactive delirium and implementation of care pathways may improve outcomes. Future studies to assess the impact of interventions on in-hospital mortality should use validated assessments of both level of arousal and delirium. Electronic supplementary material The online version of this article (10.1186/s12877-017-0661-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Amy Todd
- Medicine of the Elderly, NHS Lothian, Royal Infirmary, Edinburgh, Scotland
| | - Samantha Blackley
- Medicine of the Elderly, NHS Lothian, Royal Infirmary, Edinburgh, Scotland
| | - Jennifer K Burton
- Alzheimer Scotland Dementia Research Centre, Edinburgh, Scotland.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland.,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences University of Glasgow, Glasgow, Scotland
| | - E Wesley Ely
- Tennessee Valley Veteran's Affairs Geriatric Research Education and Clinical Centre (GRECC), Nashville, TN, USA.,Vanderbilt University Medical Centre, Nashville, TN, USA
| | - Zoë Tieges
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland.,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland
| | - Alasdair M J MacLullich
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland.,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland
| | - Susan D Shenkin
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland. .,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland.
| |
Collapse
|
29
|
Commentary on Richardson et al. detecting delirium superimposed on dementia: diagnostic accuracy of a simple combined arousal and attention testing procedure. Int Psychogeriatr 2017; 29:1583-1584. [PMID: 28849751 DOI: 10.1017/s1041610217001594] [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: 11/07/2022]
Abstract
Consciousness consists of two components: arousal and awareness of the environment and self. Arousal refers to the behavioral continuum that occurs between sleep and wakefulness, while awareness to the content of consciousness (Laureys, 2014). In normal physiological states, with the exception of REM sleep, the level of arousal is positively correlated with awareness (Laureys, 2014) such that arousal is graded and measured by the degree to which it is diminished. This conceptualization appears to have led experts, including the DSM-5, to consider delirium as a condition to not associated with impairments in arousal (Schiff and Plum, 2000, American Psychiatric Association, 2013). However, arousal can be both diminished and heightened, not unlike the performance of an old-fashioned incandescent bulb at different voltages, giving barely sufficient light at low voltages and brightening up unbearably at high voltages (MacIsaac et al., 1999). Delirium is associated with both hypo-arousal and hyper-arousal (Han et al., 2017). A small but significant proportion of delirious older patients (10%; n = 155) in the emergency department in this study had normal arousal at the time of the short arousal assessment (Han et al., 2014).
Collapse
|
30
|
Abstract
Importance Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual's function and quality of life, as well as broad societal effects with substantial health care costs. Objective To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field. Evidence Review Search of Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011, until March 16, 2017, using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded. Findings Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment; 4 A's Test; and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method-Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of delirium, based on recent reviews of the evidence, recommend reserving use of antipsychotics and other sedating medications for treatment of severe agitation that poses risk to patient or staff safety or threatens interruption of essential medical therapies. Conclusions and Relevance Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial.
Collapse
Affiliation(s)
- Esther S Oh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tamara G Fong
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Aging Brain Center, Hebrew SeniorLife, Boston, Massachusetts
| | - Tammy T Hshieh
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sharon K Inouye
- Aging Brain Center, Hebrew SeniorLife, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
31
|
|
32
|
Numan T, van den Boogaard M, Kamper AM, Rood PJT, Peelen LM, Slooter AJC. Recognition of Delirium in Postoperative Elderly Patients: A Multicenter Study. J Am Geriatr Soc 2017; 65:1932-1938. [DOI: 10.1111/jgs.14933] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Tianne Numan
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus; University Medical Center Utrecht; Utrecht The Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care Medicine; Radboud University Medical Center Nijmegen; Nijmegen The Netherlands
| | - Adriaan M. Kamper
- Section of Geriatrics; Department of Internal Medicine; Isala Hospital; Zwolle The Netherlands
| | - Paul J. T. Rood
- Department of Intensive Care Medicine; Radboud University Medical Center Nijmegen; Nijmegen The Netherlands
| | - Linda M. Peelen
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus; University Medical Center Utrecht; Utrecht The Netherlands
- Department of Epidemiology; Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Arjen J. C. Slooter
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus; University Medical Center Utrecht; Utrecht The Netherlands
| | | |
Collapse
|
33
|
Brown CH, Laflam A, Max L, Lymar D, Neufeld KJ, Tian J, Shah AS, Whitman GJ, Hogue CW. The Impact of Delirium After Cardiac Surgical Procedures on Postoperative Resource Use. Ann Thorac Surg 2016; 101:1663-9. [PMID: 27041454 DOI: 10.1016/j.athoracsur.2015.12.074] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 12/07/2015] [Accepted: 12/22/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Delirium is a common complication after cardiac surgical procedures and is associated with increased morbidity and mortality. However, whether rigorously assessed postoperative delirium is associated with an increased length of stay in the intensive care unit (LOS-ICU), length of stay (LOS), and hospital charges is not clear. METHODS Patients (n = 66) undergoing coronary artery bypass or valve operations, or both, were enrolled in a nested cohort study. Rigorous delirium assessments were conducted using the Confusion Assessment Method. LOS-ICU and LOS were obtained from the medical record, and hospital charges were obtained from administrative data reported to the state. Because of the skewed distribution of outcome variables, outcomes were compared using rank-sum tests, as well as median regression incorporating propensity scores. RESULTS Patients who developed delirium (56%) versus no delirium (43%) had increased median LOS-ICU (75.6 hours [interquartile range (IQR): 43.6 to 136.8] vs. 29.7 hours [IQR: 21.7 to 46.0]; p = 0.002), increased median LOS (9 days [IQR: 6 to 16] vs. 7 days [IQR: 5 to 8]; p = 0.006), and increased median hospital charges ($51,805 [IQR: $44,041 to $80,238] vs. $41,576 [IQR: $35,748 to $43,660]; p = 0.002). In propensity score models adjusted for patient-related and surgical characteristics and complications, the results for LOS-ICU and cost remained highly significant, although the results for LOS were attenuated on the basis of the specific statistical model. Increased severity of delirium was associated with both increased LOS-ICU and increased charges in a dose-response manner. CONCLUSIONS Delirium after cardiac surgical procedures is independently associated with both increased LOS-ICU and higher hospital charges. Because delirium is potentially preventable, targeted delirium-prevention protocols for high-risk patients may represent an important strategy for quality improvement.
Collapse
Affiliation(s)
- Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore.
| | - Andrew Laflam
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Laura Max
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Daria Lymar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Karin J Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore
| | - Jing Tian
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ashish S Shah
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Glenn J Whitman
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore
| | - Charles W Hogue
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore
| |
Collapse
|
34
|
Neufeld KJ, Yue J, Robinson TN, Inouye SK, Needham DM. Antipsychotic Medication for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta-Analysis. J Am Geriatr Soc 2016; 64:705-14. [PMID: 27004732 DOI: 10.1111/jgs.14076] [Citation(s) in RCA: 248] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To evaluate the effectiveness of antipsychotic medications in preventing and treating delirium. DESIGN Systematic review and meta-analysis. SETTING PubMed, EMBASE, CINAHL, and ClinicalTrials.gov databases were searched from January 1, 1988, to November 26, 2013. PARTICIPANTS Adult surgical and medical inpatients. INTERVENTION Antipsychotic administration for delirium prevention or treatment in randomized controlled trials or cohort studies. MEASUREMENTS Two authors independently reviewed all citations, extracted relevant data, and assessed studies for potential bias. Heterogeneity was considered as chi-square P < .1 or I(2) > 50%. Using a random-effects model (I(2) > 50%) or a fixed-effects model (I(2) < 50%), odds ratios (ORs) were calculated for dichotomous outcomes (delirium incidence and mortality), and mean or standardized mean difference for continuous outcomes (delirium duration, severity, hospital and intensive care unit (ICU) length of stay (LOS)). Sensitivity analyses included postoperative prevention studies only, exclusion of studies with high risk of bias, and typical versus atypical antipsychotics. RESULTS Screening of 10,877 eligible records identified 19 studies. In seven studies comparing antipsychotics with placebo or no treatment for delirium prevention after surgery, there was no significant effect on delirium incidence (OR = 0.56, 95% confidence interval (CI) = 0.23-1.34, I(2) = 93%). Using data reported from all 19 studies, antipsychotic use was not associated with change in delirium duration, severity, or hospital or ICU LOS, with high heterogeneity among studies. No association with mortality was detected (OR = 0.90, 95% CI = 0.62-1.29, I(2) = 0%). CONCLUSION Current evidence does not support the use of antipsychotics for prevention or treatment of delirium. Additional methodologically rigorous studies using standardized outcome measures are needed.
Collapse
Affiliation(s)
- Karin J Neufeld
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Thomas N Robinson
- Department of Surgery, School of Medicine, University of Colorado, Aurora, Colorado
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.,Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
35
|
Hosie A, Lobb E, Agar M, Davidson P, Chye R, Lam L, Phillips J. Measuring delirium point-prevalence in two Australian palliative care inpatient units. Int J Palliat Nurs 2016; 22:13-21. [DOI: 10.12968/ijpn.2016.22.1.13] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Annmarie Hosie
- PhD Candidate, School of Nursing, The University of Notre Dame Australia
| | | | - Meera Agar
- Professor, Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney
| | | | - Richard Chye
- Director, St Vincent's Health Network, Darlinghurst, Australia
| | - Lawrence Lam
- Professor, Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney
| | - Jane Phillips
- Director, Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney
| |
Collapse
|
36
|
Fick DM, Inouye SK, Guess J, Ngo LH, Jones RN, Saczynski JS, Marcantonio ER. Preliminary development of an ultrabrief two-item bedside test for delirium. J Hosp Med 2015; 10:645-50. [PMID: 26369992 PMCID: PMC4665114 DOI: 10.1002/jhm.2418] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 06/04/2015] [Accepted: 06/09/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Delirium is common, morbid, and costly, yet is greatly under-recognized among hospitalized older adults. OBJECTIVE To identify the best single and pair of mental status test items that predict the presence of delirium. DESIGN, SETTING Diagnostic test evaluation study that enrolled medicine inpatients aged 75 years or older at an academic medical center. METHODS Patients underwent a clinical reference standard assessment involving a patient interview, medical record review, and interviews with family members and nurses to determine the presence or absence of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition defined delirium. Participants also underwent the three-dimensional Confusion Assessment Method (3D-CAM), a brief, validated assessment for delirium. Individual items and pairs of items from the 3D-CAM were evaluated to determine sensitivity and specificity relative to the reference standard delirium diagnosis. RESULTS Of the 201 participants (mean age 84 years, 62% female), 42 (21%) had delirium based on the clinical reference standard. The single item with the best test characteristics was "months of the year backwards" with a sensitivity of 83% (95% confidence interval [CI]: 69%-93%) and specificity of 69% (95% CI: 61%-76%). The best 2-item screen was the combination of "months of the year backwards" and "what is the day of the week?" with a sensitivity of 93% (95% CI: 81%-99%) and specificity of 64% (95% CI: 56%-70%). CONCLUSIONS We identified a single item with >80% and pair of items with >90% sensitivity for delirium. If validated prospectively, these items will serve as an initial innovative screening step for delirium identification in hospitalized older adults.
Collapse
Affiliation(s)
- Donna M. Fick
- College of Nursing, College of Medicine, Department of Psychiatry, Penn State University, University Park, Pennsylvania
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Address for correspondence and reprint requests: Donna M. Fick, PhD, Distinguished Professor, College of Nursing, Penn State University, Health and Human Development East, University Park, PA 16802; Telephone: 814-865-9325; Fax: 814-865-3779;
| | - Sharon K. Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jamey Guess
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Long H. Ngo
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Richard N. Jones
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Jane S. Saczynski
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Edward R. Marcantonio
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
37
|
Abstract
The following paper, entitled “A Comparison of Delirium Diagnosis in Elderly Medical Inpatients using the CAM, DRS-R98, DSM-IV and DSM-5 Criteria” by Adamis and colleagues, reports the results of a single delirium assessment of 200 medical inpatients, aged 70 years and older. The aim was to compare the prevalence of delirium using two different diagnostic classification systems (DSM-5 and DSM-IV) and two commonly used research tools (Confusion Assessment Method and the Delirium Rating Scale-Revised ‘98). This editorial focuses on the comparison of the two versions of the DSM. The authors conclude that, while both diagnostic systems identify a core concept of delirium, the DSM-IV criteria are the most inclusive of the four approaches and the DSM-5, the most restrictive, identifying a prevalence of 19.5% and 13%, respectively in this sample. Furthermore, they conclude that these two systems do not appear to detect the same patients: only 14 of 26 (54%) individuals identified as delirious by the more exclusive DSM-5 criteria were also identified as such by DSM-IV.
Collapse
|
38
|
|
39
|
Affiliation(s)
- Charles H Brown
- From the *Division of Cardiac Anesthesia, Department of Anesthesiology and Critical Care Medicine, †Department of Psychiatry and Behavioral Sciences, ‡Division of Pulmonary and Critical Care Medicine, and §Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | |
Collapse
|