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Feasibility and potential of a bedside mini-EEG for diagnosing delirium superimposed on dementia. Clin Neurophysiol 2022; 142:181-189. [PMID: 36041344 DOI: 10.1016/j.clinph.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/26/2022] [Accepted: 08/04/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Delirium superimposed on dementia (DSD) is difficult to diagnose because symptoms of delirium might be interpreted as symptoms of dementia. To improve diagnostic accuracy, we investigated the potential of a brief point-of-care EEG measurement. METHODS Thirty older patients were included, all with Major Neurocognitive Disorder (i.e. dementia) according to DSM-5 criteria. EEG was registered at right prefrontal and right temporal site, with eyes either open or closed for three minutes, simultaneously with the Discomfort Scale for Dementia of Alzheimer Type. The Confusion Assessment Method for the Intensive Care Unit was administered to determine the presence of symptoms of a delirium at the time of EEG administration. Video registrations were reviewed independently by two delirium experts. RESULTS Higher activities of delta and theta1, and lower activities of theta2, alpha, and beta activity, were found in DSD when compared to dementia only. The ratio of delta and theta power during eyes-open conditions had the highest accuracy (AUC = 0.80 [0.63-0.94]; p <.001) to distinguish DSD from dementia alone. All subjects were on benzodiazepines and half on clozapine, thus the effects of psychotropics on EEG cannot be fully excluded. CONCLUSIONS A brief point-of-care EEG at two sites of the head has the potential to aid in the detection of DSD. SIGNIFICANCE The diagnostic accuracy of EEG in recognizing or excluding delirium in patients who already have dementia is of large potential given the lack of proper diagnostic tools.
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Bajaj JS, Gentili A, Wade JB, Godschalk M. Specific Challenges in Geriatric Cirrhosis and Hepatic Encephalopathy. Clin Gastroenterol Hepatol 2022; 20:S20-S29. [PMID: 35940730 PMCID: PMC9373233 DOI: 10.1016/j.cgh.2022.04.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/14/2022] [Accepted: 04/20/2022] [Indexed: 02/07/2023]
Abstract
As the world's population ages, diseases predominantly found in the elderly now overlap with diseases that were thought to be the purview of younger patients. This includes chronic liver disease, which affects more than 2 billion people worldwide. Owing to the obesity epidemic (and associated metabolic diseases), nonalcoholic fatty liver disease has become the most common cause of chronic liver disease and cirrhosis. A major complication of cirrhosis is hepatic encephalopathy (HE), which becomes challenging to diagnose in elderly patients. HE is usually included in the differential diagnosis of acute delirium but not of reversible dementias. To illustrate this point, we present 2 cases of older patients that were misdiagnosed as having dementia and Parkinson's disease or a parkinsonian syndrome but had contributions from cirrhosis. Both cognitive impairment and tremor resolved with treatment of HE.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia.
| | - Angela Gentili
- Division of Geriatrics, Department of Medicine, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia
| | - James B Wade
- Division of Neuropsychology, Department of Psychiatry, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia
| | - Michael Godschalk
- Division of Geriatrics, Department of Medicine, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia
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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.
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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.
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Tieges Z, Stott DJ, Shaw R, Tang E, Rutter LM, Nouzova E, Duncan N, Clarke C, Weir CJ, Assi V, Ensor H, Barnett JH, Evans J, Green S, Hendry K, Thomson M, McKeever J, Middleton DG, Parks S, Walsh T, Weir AJ, Wilson E, Quasim T, MacLullich AMJ. A smartphone-based test for the assessment of attention deficits in delirium: A case-control diagnostic test accuracy study in older hospitalised patients. PLoS One 2020; 15:e0227471. [PMID: 31978127 PMCID: PMC6980392 DOI: 10.1371/journal.pone.0227471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 12/19/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Delirium is a common and serious acute neuropsychiatric syndrome which is often missed in routine clinical care. Inattention is the core cognitive feature. Diagnostic test accuracy (including cut-points) of a smartphone Delirium App (DelApp) for assessing attention deficits was assessed in older hospital inpatients. METHODS This was a case-control study of hospitalised patients aged ≥65 years with delirium (with or without pre-existing cognitive impairment), who were compared to patients with dementia without delirium, and patients without cognitive impairment. Reference standard delirium assessment, which included a neuropsychological test battery, was based on Diagnostic and Statistical Manual of Mental Disorders-5 criteria. A separate blinded assessor administered the DelApp arousal assessment (score 0-4) and attention task (0-6) yielding an overall score of 0 to 10 (lower scores indicate poorer performance). Analyses included receiver operating characteristic curves and sensitivity and specificity. Optimal cut-points for delirium detection were determined using Youden's index. RESULTS A total of 187 patients were recruited, mean age 83.8 (range 67-98) years, 152 (81%) women; n = 61 with delirium; n = 61 with dementia without delirium; and n = 65 without cognitive impairment. Patients with delirium performed poorly on the DelApp (median score = 4/10; inter-quartile range 3.0, 5.5) compared to patients with dementia (9.0; 5.5, 10.0) and those without cognitive impairment (10.0; 10.0, 10.0). Area under the curve for detecting delirium was 0.89 (95% Confidence Interval 0.84, 0.94). At an optimal cut-point of ≤8, sensitivity was 91.7% (84.7%, 98.7%) and specificity 74.2% (66.5%, 81.9%) for discriminating delirium from the other groups. Specificity was 68.3% (56.6%, 80.1%) for discriminating delirium from dementia (cut-point ≤6). CONCLUSION Patients with delirium (with or without pre-existing cognitive impairment) perform poorly on the DelApp compared to patients with dementia and those without cognitive impairment. A cut-point of ≤8/10 is suggested as having optimal sensitivity and specificity. The DelApp is a promising tool for assessment of attention deficits associated with delirium in older hospitalised adults, many of whom have prior cognitive impairment, and should be further validated in representative patient cohorts.
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Affiliation(s)
- Zoë Tieges
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Scotland, Edinburgh, United Kingdom
| | - David J. Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Robert Shaw
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Elaine Tang
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Lisa-Marie Rutter
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Eva Nouzova
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Nikki Duncan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Caoimhe Clarke
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Christopher J. Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Valentina Assi
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Hannah Ensor
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Jennifer H. Barnett
- Cambridge Cognition Ltd, Cambridge, United Kingdom
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Jonathan Evans
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Samantha Green
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Kirsty Hendry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Meigan Thomson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Jenny McKeever
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Duncan G. Middleton
- Medical Devices Unit, West Glasgow Ambulatory Care Hospital, Glasgow, Scotland, United Kingdom
| | - Stuart Parks
- Medical Devices Unit, West Glasgow Ambulatory Care Hospital, Glasgow, Scotland, United Kingdom
| | - Tim Walsh
- Critical Care Medicine and Anaesthesia, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Alexander J. Weir
- Medical Devices Unit, West Glasgow Ambulatory Care Hospital, Glasgow, Scotland, United Kingdom
| | - Elizabeth Wilson
- Critical Care Medicine and Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Tara Quasim
- Anaesthesia, Critical Care and Pain Medicine, Glasgow Royal Infirmary, Glasgow, Scotland, United Kingdom
| | - Alasdair M. J. MacLullich
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Scotland, Edinburgh, United Kingdom
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