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Mohamad Faizal NS, Tan JK, Tan MM, Khoo CS, Sahibulddin SZ, Zolkafli N, Hod R, Tan HJ. Electroencephalography as a tool for assessing delirium in hospitalized patients: A single-center tertiary hospital experience. J Cent Nerv Syst Dis 2024; 16:11795735241274203. [PMID: 39156830 PMCID: PMC11329912 DOI: 10.1177/11795735241274203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 06/13/2024] [Accepted: 06/26/2024] [Indexed: 08/20/2024] Open
Abstract
Background Delirium is a prevalent yet underdiagnosed disorder characterized by acute cognitive impairment. Various screening tools are available, including the Confusion Assessment Method (CAM) and 4 A's test (4AT). However, the results of these assessments may vary among raters. Therefore, we investigated the objective use of electroencephalography (EEG) in delirium and its clinical associations and predictive value. Method This cross-sectional observational study was conducted at Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan, Malaysia, from April 2021 to April 2023. This study included patients aged ≥18 years with a preliminary diagnosis of delirium. Demographic and clinical data were collected along with EEG recordings evaluated by certified neurologists to classify abnormalities and compare the associated factors between patients with delirium with or without EEG abnormalities. Results One hundred and twenty patients were recruited, with 80.0% displaying EEG abnormalities, mostly generalized slowing (moderate to severe) and primarily generalized slowing (mild to severe), and were characterized by theta activity. Age was significantly associated with EEG abnormalities, with patients aged 75 and older demonstrating the highest incidence (88.2%). The CAM scores were strongly correlated with EEG abnormalities (r = 0.639, P < 0.001) and was a predictor of EEG abnormalities (P < 0.012), indicating that EEG can complement clinical assessments for delirium. The Richmond Agitation and Sedation Scale (RASS) scores (r = -0.452, P < 0.001) and Barthel index (BI) (r = -0.582, P < 0.001) were negatively correlated with EEG abnormalities. Additionally, a longer hospitalization duration was associated with EEG abnormalities (r = 0.250, P = 0.006) and emerged as a predictor of such changes (P = 0.030). Conclusion EEG abnormalities are prevalent in patients with delirium, particularly in elderly patients. CAM scores and the duration of hospitalization are valuable predictors of EEG abnormalities. EEG can be an objective tool for enhancing delirium diagnosis and prognosis, thereby facilitating timely interventions.
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Affiliation(s)
- Nur Shairah Mohamad Faizal
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Department of Medicine, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia
| | - Juen Kiem Tan
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Department of Medicine, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia
| | | | - Ching Soong Khoo
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Department of Medicine, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia
| | | | | | - Rozita Hod
- Department of Public Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Hui Jan Tan
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Department of Medicine, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia
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Sirota M, Kodama L, Woldemariam S, Tang A, Li Y, Kornak J, Allen IE, Raphael E, Oskotsky T. Sex-stratified analyses of comorbidities associated with an inpatient delirium diagnosis using real world data. RESEARCH SQUARE 2024:rs.3.rs-4765249. [PMID: 39108477 PMCID: PMC11302686 DOI: 10.21203/rs.3.rs-4765249/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
Delirium is a detrimental mental condition often seen in older, hospitalized patients and is currently hard to predict. In this study, we leverage electronic health records (EHR) to identify 7,492 UCSF patients and 19,417 UC health system patients with an inpatient delirium diagnosis and the same number of control patients without delirium. We found significant associations between comorbidities or laboratory values and an inpatient delirium diagnosis, including metabolic abnormalities and psychiatric diagnoses. Some associations were sex-specific, including dementia subtypes and infections. We further explored the associations with anemia and bipolar disorder by conducting longitudinal analyses from the time of first diagnosis to development of delirium, demonstrating a significant relationship across time. Finally, we show that an inpatient delirium diagnosis leads to increased risk of mortality. These results demonstrate the powerful application of the EHR to shed insights into prior diagnoses and laboratory values that could help predict development of inpatient delirium and the importance of sex when making these assessments.
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Carpenter CR, Lee S, Kennedy M, Arendts G, Schnitker L, Eagles D, Mooijaart S, Fowler S, Doering M, LaMantia MA, Han JH, Liu SW. Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments. Acad Emerg Med 2024. [PMID: 38757369 DOI: 10.1111/acem.14935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening. METHODS We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds. RESULTS Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%. CONCLUSIONS The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.
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Affiliation(s)
| | - Sangil Lee
- University of Iowa, Iowa City, Iowa, USA
| | - Maura Kennedy
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Glenn Arendts
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Linda Schnitker
- Bolton Clarke Research Institute, Bolton Clarke School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | | | - Simon Mooijaart
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, The Netherlands
| | - Susan Fowler
- University of Connecticut Health Sciences, Farmington, Connecticut, USA
| | - Michelle Doering
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | | | - Jin H Han
- Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Sano M, Cummings J, Auer S, Bergh S, Fischer CE, Gerritsen D, Grossberg G, Ismail Z, Lanctôt K, Lapid MI, Mintzer J, Palm R, Rosenberg PB, Splaine M, Zhong K, Zhu CW. Agitation in cognitive disorders: Progress in the International Psychogeriatric Association consensus clinical and research definition. Int Psychogeriatr 2024; 36:238-250. [PMID: 36880250 PMCID: PMC10684256 DOI: 10.1017/s1041610222001041] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
BACKGROUND The International Psychogeriatric Association (IPA) published a provisional consensus definition of agitation in cognitive disorders in 2015. As proposed by the original work group, we summarize the use and validation of criteria in order to remove "provisional" from the definition. METHODS This report summarizes information from the academic literature, research resources, clinical guidelines, expert surveys, and patient and family advocates on the experience of use of the IPA definition. The information was reviewed by a working group of topic experts to create a finalized definition. RESULTS We present a final definition which closely resembles the provisional definition with modifications to address special circumstances. We also summarize the development of tools for diagnosis and assessment of agitation and propose strategies for dissemination and integration into precision diagnosis and agitation interventions. CONCLUSION The IPA definition of agitation captures a common and important entity that is recognized by many stakeholders. Dissemination of the definition will permit broader detection and can advance research and best practices for care of patients with agitation.
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Affiliation(s)
- Mary Sano
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, NYC NY and James J. Peters VAMC, Bronx NY
| | - Jeffrey Cummings
- Joy Chambers-Grundy Professor of Brain Science, Director, Chambers-Grundy Center for Transformative Neuroscience, Co-Director, Pam Quirk Brain Health and Biomarker Laboratory, Department of Brain Health, School of Integrated Health Sciences. University of Nevada Las Vegas (UNLV)
| | - Stefanie Auer
- Centre for Dementia Studies, University for Continuing Education Krems, Austria
| | - Sverre Bergh
- The research centre for age-related functional decline and disease, Innlandet hospital trust, Ottestad, Norway
| | - Corinne E. Fischer
- Faculty of Medicine, Department of Psychiatry, University of Toronto, Canada
| | - Debby Gerritsen
- Department of Primary and Community Care, Radboud university medical center, Radboud Institute for Health Sciences, Radboud Alzheimer Center, Nijmegen, the Netherlands
| | - George Grossberg
- Department of Psychiatry & Behavioral Neuroscience, Division of Geriatric Psychiatry St Louis University School of Medicine
| | - Zahinoor Ismail
- Departments Psychiatry, Neurology, Epidemiology, and Pathology, Hotchkiss Brain Institute & O’Brien Institute for Public Health University of Calgary
| | - Krista Lanctôt
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute; and Departments of Psychiatry and Pharmacology/Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Maria I Lapid
- Mayo Clinic Department of Psychiatry and Psychology, Rochester, MN, USA
| | - Jacobo Mintzer
- Psychiatrist, Ralph. H. Johnson VA Medical Center, Charleston, SC and Professor, College of Health Professions, Medical University of South Carolina, Charleston, SC
| | - Rebecca Palm
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, 58455 Witten, Germany
| | - Paul B. Rosenberg
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Michael Splaine
- Owner Splaine Consulting, Managing Partner, Recruitment Partners LLC
| | - Kate Zhong
- Department of Brain Health, School of Integrated Health Sciences, University of Nevada, Las Vegas
| | - Carolyn W. Zhu
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, NYC, NY and James J. Peters VAMC, Bronx NY
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Demirtakan T, Cakmak F, Ipekci A, Akdeniz YS, Biberoglu S, Ikızceli I, Ozkan S. Clinical assessment and short-term mortality prediction of older adults with altered mental status using RASS and 4AT tools. Am J Emerg Med 2024; 75:14-21. [PMID: 37897915 DOI: 10.1016/j.ajem.2023.10.022] [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: 11/02/2022] [Revised: 10/07/2023] [Accepted: 10/08/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Altered mental status (AMS) in older adults is a common reason for admission to emergency departments (EDs) and usually results from delirium, stupor, or coma. It is important to proficiently identify underlying factors and anticipate clinical outcomes for those patients. AIM The primary objective of this study was to reveal and compare the clinical outcomes and etiologic factors of older patients with delirium, stupor, and coma. The secondary objective was to identify the 30-day mortality risk for those patients. METHOD The study was conducted as prospective and observational research. We included patients aged 65 years and older who presented with new-onset neurological and cognitive symptoms or worsening in baseline mental status. Patients who presented no change in their baseline mental status within 48 h and those who needed urgent interventions were excluded. Selected patients were assessed using RASS and 4AT tools and classified into three groups: stupor/coma, delirium, and no stupor/coma or delirium (no-SCD). Appropriate statistical tests were applied to compare these 3 groups. The 30-day mortality risks were identified by Cox survival analysis and Kaplan-Meier curve. RESULTS A total of 236 patients were eligible for the study. Based on their RASS and 4AT test scores: 56 (23.7%), 94 (40.6%), and 86 (36.4%) patients formed the stupor/coma, delirium and no-SCD groups, respectively. There was no statistical difference in the three groups for gender, mean age, and medical comorbidities. Neurological (34.7%), infectious (19.4%), and respiratory (19.0%) diseases were the leading factors for AMS. Post-hoc tests showed that CCI scores of the delirium (6, IQR = 3) and stupor/coma (7, IQR = 3) groups were not significantly different. The 30-day mortality rates of stupor/coma, delirium, and no-SCD groups were 42.%, 15.9%, and 12.8%, respectively (p < 0.005). The hazard ratio of the stupor/coma group was 2.79 (CI: 95%, 1.36-5.47, p = 0.005). CONCLUSION AMS remains a significant clinical challenge in EDs. Using the RASS and 4AT tests provides benefits and advantages for emergency medicine physicians. Neurological, infectious, and respiratory diseases can lead to life-threatening mental deterioration. Our study revealed that long-term mortality predictor CCI scores were quite similar among patients with delirium, stupor, or coma. However, the short-term mortality was significantly increased in the stupor/coma patients and they had 2.8 times higher 30-day mortality risk than others.
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Affiliation(s)
- Turker Demirtakan
- Emergency Department, University of Health Science, Kanuni Sultan Süleyman Research and Training Hospital, Istanbul, Turkey.
| | - Fatih Cakmak
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Afsin Ipekci
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Yonca Senem Akdeniz
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Serap Biberoglu
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Ibrahim Ikızceli
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Seda Ozkan
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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Proehl JA, Barnason S, Kaiser J, Bradford JY, Gilmore L, Horigan AE, MacPherson-Dias R, Slivinski A, Van Dusen K, Vanhoy MA, Bishop-Royse J, Delao AM. ENA Clinical Practice Guideline Synopsis: Screening Older Adults for Cognitive Impairment. J Emerg Nurs 2024; 50:17-21. [PMID: 38212096 DOI: 10.1016/j.jen.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 09/06/2023] [Indexed: 01/13/2024]
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Fuller BM, Driver BE, Roberts MB, Schorr CA, Thompson K, Faine B, Yeary J, Mohr NM, Pappal RD, Stephens RJ, Yan Y, Johnson NJ, Roberts BW. Awareness with paralysis and symptoms of post-traumatic stress disorder among mechanically ventilated emergency department survivors (ED-AWARENESS-2 Trial): study protocol for a pragmatic, multicenter, stepped wedge cluster randomized trial. Trials 2023; 24:753. [PMID: 38001507 PMCID: PMC10675941 DOI: 10.1186/s13063-023-07764-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Awareness with paralysis (AWP) is memory recall during neuromuscular blockade (NMB) and can cause significant psychological harm. Decades of effort and rigorous trials have been conducted to prevent AWP in the operating room, where prevalence is 0.1-0.2%. By contrast, AWP in mechanically ventilated emergency department (ED) patients is common, with estimated prevalence of 3.3-7.4% among survivors given NMB. Longer-acting NMB use is a critical risk for AWP, and we have shown an association between ED rocuronium use and increased AWP prevalence. As NMB are given to more than 90% of ED patients during tracheal intubation, this trial provides a platform to test an intervention aimed at reducing AWP. The overall objective is to test the hypothesis that limiting ED rocuronium exposure will significantly reduce the proportion of patients experiencing AWP. METHODS This is a pragmatic, stepped wedge cluster randomized trial conducted in five academic EDs, and will enroll 3090 patients. Per the design, all sites begin in a control phase, under observational conditions. At 6-month intervals, sites sequentially enter a 2-month transition phase, during which we will implement the multifaceted intervention, which will rely on use of nudges and defaults to change clinician decisions regarding ED NMB use. During the intervention phase, succinylcholine will be the default NMB over rocuronium. The primary outcome is AWP, assessed with the modified Brice questionnaire, adjudicated by three independent, blinded experts. The secondary outcome is the proportion of patients developing clinically significant symptoms of post-traumatic stress disorder at 30 and 180 days after hospital discharge. We will also assess for symptoms of depression and anxiety, and health-related quality of life. A generalized linear model, adjusted for time and cluster interactions, will be used to compare AWP in control versus intervention phases, analyzed by intention-to-treat. DISCUSSION The ED-AWARENESS-2 Trial will be the first ED-based trial aimed at preventing AWP, a critical threat to patient safety. Results could shape clinical use of NMB in the ED and prevent more than 10,000 annual cases of AWP related to ED care. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT05534243 . Registered 06, September 2022.
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Affiliation(s)
- Brian M Fuller
- Department of Anesthesiology, Division of Critical Care, Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, 63110, USA.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, 55415, USA
| | - Michael B Roberts
- Department of Institutional Research, Department of Psychology, Philadelphia College of Osteopathic Medicine, Rowland Hall, 514B, 4190 City Avenue, Philadelphia, PA, 19131, USA
| | - Christa A Schorr
- Cooper Research Institute, Cooper University Health Care, One Cooper Plaza, Dorrance, Camden, NJ, 08103, USA
| | - Kathryn Thompson
- Department of Emergency Medicine, University of Washington/Harborview Medical Center, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Brett Faine
- Departments of Emergency Medicine and Pharmacy, Roy J. and Lucille A. Carver College of Medicine, University of Iowa College of Pharmacy, 200 Hawkins Drive, 1008 RCP, Iowa City, IA, 52242, USA
| | - Julianne Yeary
- Emergency Department, Charles F. Knight Emergency and Trauma Center, Barnes-Jewish Hospital, 1 Barnes Jewish Hospital Plaza, St. Louis, MO, 63110, USA
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Drive, 1008 RCP, Iowa City, IA, 52242, USA
| | - Ryan D Pappal
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Robert J Stephens
- Department of Medicine, Division of Critical Care Medicine, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Division of Biostatistics, Washington University School of Medicine, 418E, 2Nd Floor, 600 South Taylor Ave., St. Louis, MO, 63110, USA
| | - Nicholas J Johnson
- Departments of Emergency Medicine and Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington/Harborview Medical Center, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza, K152, Camden, NJ, 08103, USA
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Lee S, Howard MA, Han JH. Delirium and Delirium Prevention in the Emergency Department. Clin Geriatr Med 2023; 39:535-551. [PMID: 37798064 DOI: 10.1016/j.cger.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
This article covers the epidemiology of delirium and the overlapping condition of altered mental status and encephalopathy that is relevant to those who practice in the emergency department.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, 312 Oxford House, Nashville, TN 37232-4700, USA; Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, 1310 24th Avenue South, Nashville, TN 37212-2637, USA
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Lee S, Cavalier FR, Hayes JM, Doering M, Lo AX, Khoujah D, Howard MA, de Wit K, Liu SW. Delirium, confusion, or altered mental status as a risk for abnormal head computed tomogram findings in older adults in the emergency department: A Geriatric Emergency Department Guidelines 2.0 systematic review and meta-analysis. Am J Emerg Med 2023; 71:190-194. [PMID: 37423026 DOI: 10.1016/j.ajem.2023.06.034] [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: 02/16/2023] [Accepted: 06/17/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Altered mental status (including delirium) is a common presentations among older adults to the emergency department (ED). We aimed to report the association between altered mental status in older ED patients and acute abnormal findings on head computed tomogram (CT). METHODS A systematic review was conducted using Ovid Medline, Embase, Clinicaltrials.gov, Web of Science, and Cochrane Central from conception to April 8th, 2021. We included citations if they described patients aged 65 years or older who received head imaging at the time of ED assessment, and reported whether patients had delirium, confusion, or altered mental status. Screening, data extraction, and bias assessment were performed in duplicate. We estimated the odds ratios (OR) for abnormal neuroimaging in patients with altered mental status. RESULTS The search strategy identified 3031 unique citations, of which two studies reporting on 909 patients with delirium, confusion or altered mental status were included. No identified study formally assessed for delirium. The OR for abnormal head CT findings in patients with delirium, confusion or altered mental status was 0.35 (95% CI 0.031 to 3.97) compared to patients without delirium, confusion or altered mental status. CONCLUSION We did not find a statistically significant association between delirium, confusion or altered mental status and abnormal head CT findings in older ED patients.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, United States of America.
| | - Faithe R Cavalier
- College of Liberal Arts and Sciences, University of Iowa, Iowa City, IA, United States of America
| | - Jane M Hayes
- Harvard Affiliated Emergency Medicine Residency, Mass General Brigham, Boston, MA, United States of America
| | - Michelle Doering
- Bernard Becker Medical Library, Washington University School of Medicine in St. Louis, St. Louis, MO, United States of America
| | - Alexander X Lo
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Danya Khoujah
- Department of Emergency Medicine, Tampa AdventHealth, FL, United States of America; Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, United States of America
| | - Kerstin de Wit
- Department of Emergency Medicine, Queens University, Kingston, Ontario, Canada; Division of Emergency Medicine, Department of Medicine,McMaster University, Hamilton, Ontario, Canada
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Department of Emergency Medicine, Harvard Medical School, Boston, MA, United States of America
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Pouw MA, Calf AH, Georg RR, de Rooij SE, Ter Maaten JC, van Munster BC. Diagnostic accuracy of the Dutch version of the 4AT for delirium detection in a mixed patient population and setting. Aging Clin Exp Res 2023:10.1007/s40520-023-02447-2. [PMID: 37285074 PMCID: PMC10363057 DOI: 10.1007/s40520-023-02447-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/17/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Delirium is an acute disturbance in attention, awareness and cognition. Immediate detection in older adults is recommended because delirium is associated with adverse outcomes. The 4 'A's Test (4AT) is a short screening instrument for delirium. The aim of this study is to evaluate diagnostic accuracy of the Dutch version of the screening tool 4AT for delirium detection in different settings. METHODS Prospective observational study conducted in two hospitals in patients aged ≥ 65 years in geriatric wards and the Emergency Department (ED). Each participant underwent two assessments; the index test 4AT, followed by the reference standard for delirium performed by a geriatric care specialist. The reference standard delirium is according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. RESULTS A total of 71 geriatric inpatients and 49 older ED patients were included. The prevalence of delirium was 11.6% in the acute geriatric ward and 6.1% in the ED. The sensitivity and specificity of the 4AT in the acute geriatric ward were 0.88 and 0.69, respectively. In the ED, the sensitivity and specificity were 0.67 and 0.83, respectively. The area under the receiver operating characteristic curve was 0.80 for the acute geriatric ward setting and 0.74 for the ED setting. CONCLUSION The Dutch version of the 4AT is a reliable screening tool for delirium detection in both acute geriatric wards and ED. Due to its brevity and practicality (i.e., no special training is required to administer the tool), it is useful in clinical practice.
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Affiliation(s)
- Maaike A Pouw
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Agneta H Calf
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Rita R Georg
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Sophia E de Rooij
- Amstelland Hospital, Laan van de Helende Meesters 8, 1186 AM, Amstelveen, The Netherlands
| | - Jan C Ter Maaten
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Barbara C van Munster
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
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Chary AN, Torres B, Brickhouse E, Santangelo I, Godwin KM, Naik AD, Carpenter CR, Liu SW, Kennedy M. Language discordance in emergency department delirium screening: Results from a qualitative interview-based study. J Am Geriatr Soc 2023; 71:1328-1331. [PMID: 36451059 PMCID: PMC10089935 DOI: 10.1111/jgs.18147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 10/12/2022] [Accepted: 11/10/2022] [Indexed: 12/05/2022]
Affiliation(s)
- Anita N. Chary
- Department of Emergency Medicine, Baylor College of Medicine
- Department of Medicine, Baylor College of Medicine
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center
| | - Beatrice Torres
- University of Texas School of Public Health, UT Health Science Center, Houston, Texas
| | | | | | - Kyler M. Godwin
- Department of Medicine, Baylor College of Medicine
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center
- University of Texas School of Public Health, UT Health Science Center, Houston, Texas
- University of Texas Health Consortium on Aging, Houston, Texas
| | - Christopher R. Carpenter
- Department of Emergency Medicine, Barnes Jewish Hospital, Washington University School of Medicine, Emergency Care Research Core
| | - Shan W. Liu
- Department of Emergency Medicine, Massachusetts General Hospital
- Harvard Medical School
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital
- Harvard Medical School
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12
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Gu S, Wang Y, Ke K, Tong X, Gu J, Zhang Y. Development and validation of a RASS-related nomogram to predict the in-hospital mortality of neurocritical patients: a retrospective analysis based on the MIMIC-IV clinical database. Curr Med Res Opin 2022; 38:1923-1933. [PMID: 35972210 DOI: 10.1080/03007995.2022.2113690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Richmond agitation-sedation scale (RASS) is a simple and widely used tool for evaluating sedation and agitation in adult ICU patients. Early deep sedation has been shown to be an important independent predictor of death, however, studies on the role of RASS in the prognostic assessment of neurocritical patients are lacking. The purpose of this study was to investigate the relationship between RASS and in-hospital mortality in neurocritical patients, and to develop and validate an effective predictive model based on this. METHODS This was a retrospective study of neurocritical patients from a large clinical database. A total of 2651 patients were collected, including general demographic characteristics, past medical history, biochemical test data and physical examination within 24 h of admission, and related medical records. Univariate and multivariate logistic regression analyses were used to screen out significant variables. Finally, 11 significant predictors were included into the logistic regression to establish the nomogram. RESULTS The area under the curve (AUC) of the nomogram was 0.9087(0.8950-0.9224) and the corrected c index was 0.9043, which gave the model better discriminatory ability compared with critical care related scales, such as SOFA and SAPSII scores. Besides, tools including calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC) were used to verify that the model had good discrimination, calibration, and clinical applicability. CONCLUSIONS RASS score was an independent prognostic predictor of in-hospital death in neurocritical patients, and patients who are deeply sedated have a worse prognosis. RASS-related nomogram could be applied to predict the prognosis of neurocritical patients and to take effective intervention measures in early stage.
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Affiliation(s)
- Shenyan Gu
- Department of Neurology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Yuqin Wang
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Kaifu Ke
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Xin Tong
- Department of Neurology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Jiahui Gu
- Department of Neurology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Yuanyuan Zhang
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
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13
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Pirola GM, Rubilotta E, Castellani D, Pancani F, Rosadi S, Giannantoni A, Asimakopoulos AD, Gubbiotti M. Increased risk of transurethral and suprapubic catheter self-extraction in COVID-19 patients: real-life experience. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:S24-S30. [PMID: 35559699 DOI: 10.12968/bjon.2022.31.9.s24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION This study evaluated the prevalence of transurethral catheter self-removal in critically-ill COVID-19 non-sedated adult patients compared with non-COVID-19 controls. METHODS COVID-19 patients who self-extracted transurethral or suprapubic catheters needing a urological intervention were prospectively included (group A). Demographic data, medical and nursing records, comorbidities and nervous system symptoms were evaluated. Agitation, anxiety and delirium were assessed by the Richmond Agitation and Sedation Scale (RASS). The control group B were non-COVID-19 patients who self-extracted transurethral/suprapubic catheter in a urology unit (subgroup B1) and geriatric unit (subgroup B2), requiring a urological intervention in the same period. RESULTS 37 men and 11 women were enrolled in group A. Mean RASS score was 3.1 ± 1.8. There were 5 patients in subgroup B1 and 11 in subgroup B2. Chronic comorbidities were more frequent in group B than the COVID-19 group (P<0.01). COVID-19 patients had a significant difference in RASS score (P<0.006) and catheter self-extraction events (P<0.001). Complications caused by traumatic catheter extractions (severe urethrorrhagia, longer hospital stay) were greater in COVID-19 patients. CONCLUSION This is the first study focusing on the prevalence and complications of catheter self-removal in COVID-19 patients. An increased prevalence of urological complications due to agitation and delirium related to COVID-19 has been demonstrated-the neurological sequelae of COVID-19 must be considered during hospitalisation.
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Affiliation(s)
- Giacomo Maria Pirola
- Medical Doctor, Urologist, Department of Urology, San Donato Hospital, Arezzo, Italy
| | | | - Daniele Castellani
- Medical Doctor, Urologist, Department of Urology, Ospedali Riuniti di Ancona, Le Marche Polytechnic University, Ancona, Italy
| | - Flavia Pancani
- Medical Doctor, Anaesthetist, Department of Anaesthesia, San Donato Hospital, Arezzo, Italy
| | - Stefano Rosadi
- Medical Doctor, Urologist, Department of Urology, San Donato Hospital, Arezzo, Italy
| | - Antonella Giannantoni
- Professor, Medical Doctor, Urologist, Department of Medical and Surgical Sciences and Neurosciences, Functional and Surgical Urology Unit, University of Siena, Italy
| | | | - Marilena Gubbiotti
- Medical Doctor, Urologist, Department of Urology, San Donato Hospital, Arezzo, Italy
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Navia KL, Anthony BK, Berlau DJ. A case for continuing statin medications in the intensive care unit: Reducing the risk for delirium. Am J Health Syst Pharm 2022; 79:1431-1437. [PMID: 35526279 DOI: 10.1093/ajhp/zxac132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE The objective of this review is to detail the utility of statin medications in the prevention and treatment of intensive care unit (ICU) delirium. SUMMARY Delirium is a syndrome characterized by altered mental status, inattention, and disorganized thinking. It is particularly concerning in the ICU where specific risk factors are much more prevalent. Nonpharmacological therapy is the mainstay of treatment, aimed at increasing patient awareness; pharmacological therapies have also been explored with varying success. The utility of statin medications in this scenario has been investigated because of the numerous pleiotropic effects of these drugs. Although the benefits in terms of treating delirium are uncertain, statins may be good candidates for prevention. The peak anti-inflammatory effect of statins is delayed, so initiating a statin on admission will likely have little protective benefit, whereas continuation of a home regimen seems more likely to exert an effect. CONCLUSION Statin medications are very commonly used, and, while their role in treating delirium is unclear, continuation of these medications from a home regimen is reasonable to decrease the odds of delirium in the intensive care population.
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Affiliation(s)
- Kyra L Navia
- Regis University School of Pharmacy, Denver, CO, USA
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15
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Grek AA, Rogers ER, Peacock SH, Hartjes TM, White LJ, Li Z, Naessens JM, Franco PM. REadmission PREvention in SepSis: Development and Validation of a Prediction Model. J Healthc Qual 2022; 44:161-168. [PMID: 34543250 DOI: 10.1097/jhq.0000000000000323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Hospital 30-day readmissions remain a major quality and cost indicator. Traditional readmission risk scores, such as LACE (length of stay, acuity of admission, Charlson comorbidity index, and emergency department visits), may be suboptimal in special patient populations, such as those with sepsis. As sepsis survivorship improves, there is a need to determine which variables might be associated with a decrease in 30-day readmission. We completed a retrospective analysis reviewing patients with sepsis who had unplanned 30-day readmissions. Multivariate regression analysis was performed for the REadmission PREvention in SepSis (REPRESS) model, which evaluated age, length of stay, Charlson disease count, Richmond Agitation-Sedation Scale score, discharge to a skilled nursing facility, and mobility for predictive significance in hospital readmission. Our REPRESS model performed better when compared with LACE for predicting readmission risk in a sepsis population.
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16
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Brefka S, Eschweiler GW, Dallmeier D, Denkinger M, Leinert C. Comparison of delirium detection tools in acute care : A rapid review. Z Gerontol Geriatr 2022; 55:105-115. [PMID: 35029755 PMCID: PMC8921069 DOI: 10.1007/s00391-021-02003-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/06/2021] [Indexed: 11/28/2022]
Abstract
Background Delirium is a frequent psychopathological syndrome in geriatric patients. It is sometimes the only symptom of acute illness and bears a high risk for complications. Therefore, feasible assessments are needed for delirium detection. Objective and methods Rapid review of available delirium assessments based on a current Medline search and cross-reference check with a special focus on those implemented in acute care hospital settings. Results A total of 75 delirium detection tools were identified. Many focused on inattention as well as acute onset and/or fluctuating course of cognitive changes as key features for delirium. A range of assessments are based on the confusion assessment method (CAM) that has been adapted for various clinical settings. The need for a collateral history, time resources and staff training are major challenges in delirium assessment. Latest tests address these through a two-step approach, such as the ultrabrief (UB) CAM or by optional assessment of temporal aspects of cognitive changes (4 As test, 4AT). Most delirium screening assessments are validated for patient interviews, some are suitable for monitoring delirium symptoms over time or diagnosing delirium based on collateral history only. Conclusion Besides the CAM the 4AT has become well-established in acute care because of its good psychometric properties and practicability. There are several other instruments extending and improving the possibilities of delirium detection in different clinical settings. Supplementary Information The online version of this article (10.1007/s00391-021-02003-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Simone Brefka
- Institute for Geriatric Research, Ulm University, Ulm, Germany. .,Geriatric Center Ulm/Alb Donau, Ulm, Germany. .,Agaplesion Bethesda Hospital Ulm, Zollernring 26, 89073, Ulm, Germany.
| | - Gerhard Wilhelm Eschweiler
- Geriatric Center, University Hospital Tuebingen, Tuebingen, Germany.,University Hospital for Psychiatry and Psychotherapy Tuebingen, Tuebingen, Germany
| | - Dhayana Dallmeier
- Geriatric Center Ulm/Alb Donau, Ulm, Germany.,Agaplesion Bethesda Hospital Ulm, Zollernring 26, 89073, Ulm, Germany.,Dept. of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Michael Denkinger
- Institute for Geriatric Research, Ulm University, Ulm, Germany.,Geriatric Center Ulm/Alb Donau, Ulm, Germany.,Agaplesion Bethesda Hospital Ulm, Zollernring 26, 89073, Ulm, Germany
| | - Christoph Leinert
- Institute for Geriatric Research, Ulm University, Ulm, Germany.,Geriatric Center Ulm/Alb Donau, Ulm, Germany.,Agaplesion Bethesda Hospital Ulm, Zollernring 26, 89073, Ulm, Germany
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17
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Zhou W, Zheng Q, Huang M, Zhang C, Zhang H, Yang L, Wu T, Gan X. Knowledge, attitude, and practice toward delirium and subtype assessment among Chinese clinical nurses and determinant factors: A multicentre cross-section study. Front Psychiatry 2022; 13:1017283. [PMID: 36819944 PMCID: PMC9929153 DOI: 10.3389/fpsyt.2022.1017283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/23/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Delirium, a confused transient state of consciousness, can be divided into hyperactive, hypoactive, mixed, and no motor subtypes, according to different clinical manifestations. Several studies have investigated delirium subtypes in the knowledge dimension, but few studies have investigated delirium subtype in the attitude and practice dimensions. The barriers, knowledge sources, and practice details regarding subtype assessment are unclear. OBJECTIVES This study had three objectives. First, we planned to investigate the KAP status regarding delirium and subtypes for nurses. Second, we wanted to identify factors affecting clinical nurses' KAP scores. Third, this study expected to explore more details regarding delirium and subtypes assessment, including assessment barriers, assessment instruments, and knowledge sources. METHODS This multicentre cross-section study was conducted in 10 tertiary hospitals in three provinces, China, from January to April 2022. We investigated 477 nurses from six departments with a high prevalence. The self-developed KAP questionnaire regarding delirium and subtypes assessment had four parts: knowledge, attitude, practice, and source. Its reliability and validity were verified effectively by 2-round Delphi expert consultation. RESULTS A total of 477 nurses from the general intensive care unit (ICU), specialty ICU, orthopedics, thoracic surgery, operating room, and geriatrics were 28.3, 22.4, 22.2, 10.5, and 5.2%, respectively. The total KAP score regarding delirium and subtypes assessment was 60.01 ± 6.98, and the scoring rate was 73.18%. The scoring rate for knowledge, attitude, and practice was 58.55, 83.94, and 51.70%, respectively. More than half (54.1%) were unaware of the delirium subtypes assessment instruments. A total of 451 (94.6%) participants recognized the importance of nursing work for delirium prevention. A total of 250 (52.4%) nurses occasionally or sometimes assessed delirium subtypes, and 143 (30.0%) never assessed for delirium subtypes. We found that age, department, technical title, familiarity with delirium, familiarity with delirium subtypes, delirium training, and subtype training affected the total KAP scores. ICU nurses achieved the highest scores. CONCLUSION Chinese nurses' KAP status regarding delirium and subtypes assessment were barely acceptable, and the attitude score was positive, but knowledge and practice needed improvement. Meanwhile, the department was one of the significant KAP factors, and ICU nurses did better in delirium and subtype assessment in knowledge and practice dimension than other departments. Systematic and scientific training processes including subtype content and assessment tools are required. Experience still drives nurses' assessments of delirium and subtype. Adding the delirium assessment into routine tasks should be considered.
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Affiliation(s)
- Wen Zhou
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Nursing, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Qiulan Zheng
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Nursing, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Miao Huang
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Nursing, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Chuanlai Zhang
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Intensive Care Unit, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Huan Zhang
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Nursing, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Li Yang
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Nursing, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Taiqin Wu
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Nursing, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Xiuni Gan
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Nursing, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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18
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Oberhaus J, Wang W, Mickle AM, Becker J, Tedeschi C, Maybrier HR, Upadhyayula RT, Muench MR, Lin N, Schmitt EM, Inouye SK, Avidan MS. Evaluation of the 3-Minute Diagnostic Confusion Assessment Method for Identification of Postoperative Delirium in Older Patients. JAMA Netw Open 2021; 4:e2137267. [PMID: 34902038 PMCID: PMC8669542 DOI: 10.1001/jamanetworkopen.2021.37267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Delirium is a common postoperative complication in older patients that often goes undetected and might lead to worse outcomes. The 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) might be a practical tool for routine clinical diagnosis of delirium. OBJECTIVE To assess the 3D-CAM for detecting postoperative delirium compared with the long-form CAM used for research purposes. DESIGN, SETTING, AND PARTICIPANTS This cohort study of older patients enrolled in ongoing clinical trials between 2015 and 2018 was conducted at a single tertiary US hospital. Included participants were aged 60 years or older undergoing major elective surgical procedures that required at least a 2-day hospital stay. Data were analyzed between February and April 2019. EXPOSURES Surgical procedures of at least 2 hours in length requiring general anesthesia with planned extubation. MAIN OUTCOMES AND MEASURES Patients were concurrently assessed for delirium using the 3D-CAM assessment and the long-form CAM, scored based on a standardized cognitive assessment. Agreement between these 2 methods was tested using Cohen κ with repeated measures, a generalized linear mixed-effects model, and Bland-Altman analysis. RESULTS Sixteen raters conducted 471 concurrent CAM and 3D-CAM interviews including 299 patients (mean [SD] age, 69 [6.5] years), the majority of whom were men (152 [50.8%]), were White (263 [88.0%]), and had noncardiac operations (211 [70.6%]). Both instruments had good intraclass correlation (0.84 for the CAM and 0.98 for the 3D-CAM). Cohen κ demonstrated good overall agreement between the CAM and 3D-CAM (κ = 0.71; 95% CI, 0.58 to 0.83). According to the mixed-effects model, there was statistically significant disagreement between the 3D-CAM and CAM (estimated difference in fixed effect, -0.68; 95% CI, -1.32 to -0.05; P = .04). Bland-Altman analysis showed the probability of a delirium diagnosis with the 3D-CAM was more than twice the probability of a delirium diagnosis with the CAM (probability ratio, 2.78; 95% CI, 2.44 to 3.23). CONCLUSIONS AND RELEVANCE The 3D-CAM instrument demonstrated agreement with the long-form CAM and might provide a pragmatic and sensitive clinical tool for detecting postoperative delirium, with the caveat that the 3D-CAM might overdiagnose delirium.
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Affiliation(s)
- Jordan Oberhaus
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Wei Wang
- Department of Mathematics and Statistics, Washington University in St Louis, St Louis, Missouri
| | - Angela M. Mickle
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Jennifer Becker
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Catherine Tedeschi
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Hannah R. Maybrier
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Ravi T. Upadhyayula
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Maxwell R. Muench
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Nan Lin
- Department of Mathematics and Statistics, Washington University in St Louis, St Louis, Missouri
- Division of Biostatistics, Washington University in St Louis, St Louis, Missouri
| | - Eva M. Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts
| | - Sharon K. Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
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[Disorientation and delirium assessment : A secondary analysis of a prospective, observational study]. Med Klin Intensivmed Notfmed 2021; 117:419-427. [PMID: 34432084 PMCID: PMC9452438 DOI: 10.1007/s00063-021-00850-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/08/2021] [Accepted: 07/03/2021] [Indexed: 10/25/2022]
Abstract
Disorientation may present as a warning sign of developing delirium. The most commonly used delirium assessment tool in Germany, the Confusion Assessment Method for Intensive Care Unit (CAM-ICU), does not rate "disorientation", since intubated patients cannot communicate verbally. However, the majority of German ICU patients are not orally intubated, so they could be examined for their orientation. This study was carried out to investigate whether the delirium feature "disorientation" in extubated patients yields diverging findings in comparison to the CAM-ICU and whether the sensitivity of the CAM-ICU may be improved when combined with the feature "disorientation" (CAM-IMC). A total of 86 paired assessments were completed in 50 extubated patients. Delirium was found in 19.8% (N = 17). The CAM-ICU had a sensitivity of 71% (95% confidence interval [CI] 44-90%) and a specificity of 100% (95-100%). Disorientation, if taken as the only delirium feature, had a sensitivity of 77% (50-93%) and a specificity of 93% (89-100%). The CAM-IMC reached a sensitivity of 88% (64-99%) and a specificity of 100% (95-100%). The receiver operating characteristics (ROC) analyses found an area under the curve (AUC) of 0.941 (95%CI 0.851-1.000) for the CAM-IMC, which was the highest compared to the other delirium tests (CAM-ICU, AUC 0.853 [0.720-0.986]; disorientation, AUC 0.868 [0.745-0.991]). This research emphasizes the importance of the feature "disorientation" for delirium assessments in patients able to verbally communicate and explains some controversial delirium ratings in daily practice. The CAM-IMC appears to be an attractive tool for delirium assessment in nonintubated patients and deserves further research.
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Arnold E, Finucane AM, Spiller JA, Tieges Z, MacLullich AM. Validation of the 4AT tool for delirium assessment in specialist palliative care settings: protocol of a prospective diagnostic test accuracy study [version 1; peer review: 2 approved]. AMRC OPEN RESEARCH 2021; 3:16. [PMID: 35966135 PMCID: PMC7613285 DOI: 10.12688/amrcopenres.12973.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Delirium is a serious and distressing neuropsychiatric condition, which is prevalent across all palliative care settings. Hypoactive delirium is particularly common, but difficult to recognize, partly due to overlapping symptoms with depression and dementia. Delirium screening tools can lead to earlier identification and hence better management of patients. The 4AT (4 'A's Test) is a brief tool for delirium detection, designed for use in clinical practice. It has been validated in 17 studies in over 3,700 patients. The test is currently used in specialist palliative care units, but has not been validated in this setting. The aim of the study is to determine the diagnostic accuracy of the 4AT for delirium detection against a reference standard, in hospice inpatients. METHODS 240 participants will be recruited from the inpatient units of two hospices in Scotland. If a patient lacks capacity to consent, agreement will be sought from a legal proxy. Each participant will complete the 4AT and a reference standard assessment based on the diagnostic delirium criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This will be supplemented by tests of cognition and attention, including reverse days of the week, counting down from 20 to 1, Vigilance 'A', the Observational Scale for Level of Arousal, the modified Richmond Agitation Sedation Scale and the Delirium Rating Scale-Revised-98. The assessments will be conducted in a randomized order by two independent clinicians, who will be blinded to the results until both are complete. Primary outcomes will be the sensitivity and specificity of the 4AT in detecting delirium. DISCUSSION The findings will inform clinical practice regarding delirium assessment in palliative care settings. TRIAL REGISTRATION ISRCTN ISRCTN97417474 (21/02/2020).
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Affiliation(s)
- Elizabeth Arnold
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, Scotland, EH10 7DR, UK
| | - Anne M. Finucane
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, Scotland, EH10 7DR, UK
| | - Juliet A. Spiller
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, Scotland, EH10 7DR, UK
| | - Zoë Tieges
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland, EH16 4SA, UK
| | - Alasdair M.J. MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland, EH16 4SA, UK
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21
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Morandi A, Grossi E, Lucchi E, Zambon A, Faraci B, Severgnini J, MacLullich A, Smith H, Pandharipande P, Rizzini A, Galeazzi M, Massariello F, Corradi S, Raccichini A, Scrimieri A, Morichi V, Gentile S, Lucchini F, Pecorella L, Mossello E, Cherubini A, Bellelli G. The 4-DSD: A New Tool to Assess Delirium Superimposed on Moderate to Severe Dementia. J Am Med Dir Assoc 2021; 22:1535-1542.e3. [PMID: 33823162 DOI: 10.1016/j.jamda.2021.02.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/22/2021] [Accepted: 02/18/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The purpose of this study was to create, standardize, and validate a new instrument, named 4-DSD, and determine its diagnostic accuracy in the diagnosis of delirium in subjects with moderate to severe dementia. DESIGN Multicenter cross-sectional observational study. SETTING AND PARTICIPANTS Older patients consecutively admitted to acute and rehabilitation hospital wards. MEASURES The DSM-5 was used as the reference standard delirium assessment. The presence and severity of dementia was defined using the AD8 and the Global Deterioration Scale (GDS). The 4-DSD is a 4-item tool that ranges from 0 to 12. Item 1 measures alertness, item 2 altered function, item 3 attention, and item 4 acute change or fluctuation in mental status. RESULTS A total of 134 patients were included in the study. Most of the patients were enrolled in acute hospital wards (60%), with 40% in rehabilitation settings. A minority of the patients were categorized with moderate dementia, with a GDS score of 5 (4%). Most of the patients were in the moderate-severe stage with a GDS score ≤6 (77%); 19% were classed as severe, with a GDS score of 7. A 4-DSD cutoff score ≥5 had a sensitivity of 80% and specificity of 80% with a positive predictive value (PPV) of 67% and a negative predictive value (NPV) of 89%. In the subgroup with moderate-severe dementia (n = 108), the sensitivity and the specificity were 79% and 82%, respectively, with a PPV and NPV of 62% and 92%. In the subgroup with severe dementia (n = 26) the sensitivity was 82% and the specificity 56% with a PPV of 78% and a NPV of 63%. CONCLUSIONS AND IMPLICATIONS The availability of a specific tool to detect delirium in patients with moderate-severe dementia has important clinical and research implications, allowing all health care providers to improve their ability to identify it.
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Affiliation(s)
- Alessandro Morandi
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy; Geriatric Research Group, Brescia, Italy; Parc Sanitari Pere Virgili and Vall d'Hebrón Institute of Research, Barcelona, Spain.
| | - Eleonora Grossi
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy; Geriatric Research Group, Brescia, Italy
| | - Elena Lucchi
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy; Geriatric Research Group, Brescia, Italy
| | - Antonella Zambon
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy; Department of Statistics and Quantitative Methods, University di Milano-Bicocca, Milan, Italy; Istituto Auxologico Italiano, IRCCS, Biostatistic Unit, Milan, Italy
| | - Bianca Faraci
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy; Geriatric Research Group, Brescia, Italy
| | - Jessica Severgnini
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy
| | - Alasdair MacLullich
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland
| | - Heidi Smith
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Andrea Rizzini
- AFSSL, Social Healthcare Academy, PoliS Lombardia, Milan, Italy
| | | | | | | | | | - Antonia Scrimieri
- Geriatria, Accettazione geriatrica e centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Valeria Morichi
- Geriatria, Accettazione geriatrica e centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Simona Gentile
- Department of Rehabilitation, Fondazione Camplani Casa di Cura "Ancelle della Carità", Cremona, Italy; Geriatric Research Group, Brescia, Italy
| | - Flaminia Lucchini
- University of Florence, Careggi University Hospital, Florence, Italy
| | - Laura Pecorella
- University of Florence, Careggi University Hospital, Florence, Italy
| | - Enrico Mossello
- University of Florence, Careggi University Hospital, Florence, Italy
| | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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22
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Lee S, Angel C, Han JH. Succinct Approach to Delirium in the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2021; 9:11-18. [PMID: 33758677 PMCID: PMC7971395 DOI: 10.1007/s40138-021-00226-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 11/25/2022]
Abstract
Purpose of Review This study aims to provide a concise delirium review for practicing emergency medicine providers using the Assess, Diagnose, Evaluate, Prevent, and Treat (ADEPT) framework. Recent Findings Delirium is a form of acute brain dysfunction that results in significant mortality and morbidity for older emergency department (ED) patients. Delirium is frequently missed by healthcare providers, but monitoring for this syndrome using brief delirium assessments may improve recognition. Once delirium is diagnosed, emergency medicine providers' primary goal is to perform a comprehensive history and physical examination to uncover the underlying etiology for delirium. This includes obtaining history from a collateral historian and obtaining an accurate medication history. If posssible, emergency physicians (EPs) should treat the medical etiology that precipitated the delirium. If agitated, non-pharmacologic interventions such that minimize the use of tethers are preferred. Pharmacologic agents such as antipsychotic medications should be used as a last resort. Summary Delirium is a common geriatric emergency and requires the EP to assess, diagnose, evaluate, prevent, and treat. Delirium is a key geriatric syndrome that geriatric ED providers should routinely screen for. A strong emphasis is on the widespread use of delirium screening, followed by prevention and treatment efforts.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA USA
| | - Clay Angel
- Department of Hospital Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA USA
| | - Jin H. Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN USA
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN USA
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23
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Eagles D, Khoujah D. Rapid Fire: Acute Brain Failure in Older Emergency Department Patients. Emerg Med Clin North Am 2021; 39:287-305. [PMID: 33863460 DOI: 10.1016/j.emc.2020.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Delirium is common in older emergency department (ED) patients. Although associated with significant morbidity and mortality, it often goes unrecognized. A consistent approach to evaluation of mental status, including use of validated tools, is key to diagnosing delirium. Identification of the precipitating event requires thorough evaluation, including detailed history, medication reconciliation, physical examination, and medical work-up, for causes of delirium. Management is aimed at identifying and treating the underlying cause. Meaningful improvements in delirium care can be achieved when prevention, identification, and management of older delirious ED patients is integrated by physicians and corresponding frameworks implemented at the health system level.
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Affiliation(s)
- Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Danya Khoujah
- Emergency Medicine, MedStar Franklin Square Medical Center, 9000 Franklin Square Dr, Baltimore, MD 21237, USA; Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA. https://twitter.com/DanyaKhoujah
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24
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Cortés-Beringola A, Vicent L, Martín-Asenjo R, Puerto E, Domínguez-Pérez L, Maruri R, Moreno G, Vidán MT, Bueno H. Diagnosis, prevention, and management of delirium in the intensive cardiac care unit. Am Heart J 2021; 232:164-176. [PMID: 33253676 DOI: 10.1016/j.ahj.2020.11.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 11/16/2020] [Indexed: 12/01/2022]
Abstract
Delirium is a frequent complication in patients admitted to intensive cardiac care units (ICCU) with potentially severe consequences including increased risks of mortality, cognitive impairment and dependence at discharge, and longer times on mechanical ventilation and hospital stay. Delirium has been widely documented and studied in general intensive care units and in patients after cardiac surgery, but it has barely been studied in acute nonsurgical cardiac patients. Moreover, delirium (especially in its hypoactive form) is commonly misdiagnosed. We propose a protocol for delirium prevention and management in ICCUs. A daily comprehensive assessment to improve detection should be done using validated scales (ie, confusion assessment method). Preventive measures are particularly relevance and constitute the basis of treatment as well, acting on reversible risk factors, including environmental interventions, such as quiet time, sleep promotion, family support, communication, and adequate treatment of pain and dyspnea. Pharmacological prophylaxis is not indicated with the exception of patients at risk of withdrawal syndrome but should only be used in patients with confirmed delirium. Dexmedetomidine is the drug of choice in patients with severe agitation, and those weaning from invasive mechanical ventilation. As the complexity of ICCUs increases, clinical scenarios posing challenges for the management of delirium become more frequent. Efforts should be done to improve the identification of patients at risk during admission in order to establish preventive interventions to avoid this complication. Patient-centered protocols will increase the awareness of the healthcare professionals for better prevention and earlier diagnosis and will positively impact on prognosis.
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Affiliation(s)
- Alejandro Cortés-Beringola
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Cardiology Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Lourdes Vicent
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Roberto Martín-Asenjo
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Elena Puerto
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Laura Domínguez-Pérez
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Ramón Maruri
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Guillermo Moreno
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - María T Vidán
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Department of Geriatric Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain
| | - Héctor Bueno
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
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25
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Calf AH, Pouw MA, van Munster BC, Burgerhof JGM, de Rooij SE, Smidt N. Screening instruments for cognitive impairment in older patients in the Emergency Department: a systematic review and meta-analysis. Age Ageing 2021; 50:105-112. [PMID: 33009909 PMCID: PMC7793600 DOI: 10.1093/ageing/afaa183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Indexed: 11/16/2022] Open
Abstract
Background cognitive impairment is highly prevalent among older patients attending the Emergency Department (ED) and is associated with adverse outcomes. Methods we conducted a systematic review and meta-analysis to evaluate the diagnostic accuracy of cognitive screening instruments to rule out cognitive impairment in older patients in the ED. A comprehensive literature search was performed in MEDLINE, EMBASE, CINAHL and CENTRAL. A risk of bias assessment using QUADAS-2 was performed. Results 23 articles, examining 18 different index tests were included. Only seven index tests could be included in the meta-analysis. For ruling out cognitive impairment irrespective of aetiology, Ottawa 3 Day Year (O3DY) (pooled sensitivity 0.90; (95% CI) 0.71–0.97) had the highest sensitivity. Fourteen articles focused on screening for cognitive impairment specifically caused by delirium. For ruling out delirium, the 4 A’s Test (4AT) showed highest sensitivity (pooled sensitivity 0.87, 95% confidence interval (95% CI) 0.74–0.94). Conclusions high clinical and methodological heterogeneity was found between included studies. Therefore, it is a challenge to recommend one diagnostic test for use as a screening instrument for cognitive impairment in the ED. The 4AT and O3DY seem most promising for ruling out cognitive impairment in older patients attending the ED. The review protocol was registered in PROSPERO (CRD42018082509).
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Affiliation(s)
- Agneta H Calf
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
| | - Maaike A Pouw
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
- Department of Internal Medicine, Martini Hospital, Groningen, The Netherlands
| | - Barbara C van Munster
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
- Department of Geriatrics, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Johannes G M Burgerhof
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sophia E de Rooij
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
- Medical Spectrum Twente, Medical School Twente, Enschede, The Netherlands
| | - Nynke Smidt
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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26
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Carpenter CR, Hammouda N, Linton EA, Doering M, Ohuabunwa UK, Ko KJ, Hung WW, Shah MN, Lindquist LA, Biese K, Wei D, Hoy L, Nerbonne L, Hwang U, Dresden SM. Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement. Acad Emerg Med 2021; 28:19-35. [PMID: 33135274 DOI: 10.1111/acem.14166] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions. METHODS GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci. RESULTS In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research. CONCLUSIONS Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.
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Affiliation(s)
- Christopher R. Carpenter
- From the Department of Emergency Medicine Washington University in St. Louis School of MedicineEmergency Care Research Core St. Louis MIUSA
| | - Nada Hammouda
- the Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
| | - Elizabeth A. Linton
- the Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
- the Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MDUSA
| | - Michelle Doering
- the Becker Medical Library Washington University in St. Louis School of Medicine St. Louis MOUSA
| | - Ugochi K. Ohuabunwa
- the Division of General Medicine and Geriatrics Emory University School of Medicine Atlanta GAUSA
| | - Kelly J. Ko
- Clinical Research West Health Institute La Jolla CAUSA
| | - William W. Hung
- James J. Peters VA Medical Center Bronx NYUSA
- and the Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
| | - Manish N. Shah
- the BerbeeWalsh Department of Emergency Medicine University of Wisconsin–Madison Madison WIUSA
| | - Lee A. Lindquist
- the Department of Medicine Northwestern University Feinberg School of Medicine Chicago ILUSA
| | - Kevin Biese
- the Departments of Emergency Medicine and Internal Medicine University of North Carolina at Chapel Hill Chapel Hill NCUSA
| | - Daniel Wei
- the BerbeeWalsh Department of Emergency Medicine University of Wisconsin–Madison Madison WIUSA
| | | | | | - Ula Hwang
- the Department of Emergency Medicine Yale School of Medicine New Haven CTUSA
| | - Scott M. Dresden
- and the Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL USA
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27
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Jeong E, Park J, Lee J. Diagnostic test accuracy of the Nursing Delirium Screening Scale: A systematic review and meta‐analysis. J Adv Nurs 2020; 76:2510-2521. [DOI: 10.1111/jan.14482] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/18/2020] [Accepted: 07/06/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Eunhye Jeong
- College of Nursing Korea University Seoul Republic of Korea
| | - Jinkyung Park
- College of Nursing Korea University Seoul Republic of Korea
| | - Juneyoung Lee
- Department of Biostatistics College of Medicine Korea University Seoul Republic of Korea
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28
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Lagarto L, Albuquerque E, Loureiro D, Vieira F, Esteves P, Neves S, Teixeira-Veríssimo M, Cerejeira J. Arousal changes and delirium in acute medically-ill male older patients with and without dementia: a prospective study during hospitalization. Aging Ment Health 2020; 24:820-827. [PMID: 30595038 DOI: 10.1080/13607863.2018.1548569] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objectives: Previous research has characterized the prevalence, natural course and outcomes of delirium superimposed in dementia but much less is known about the relation between preexisting dementia and the emergence of altered arousal (such as drowsiness, obtundation, stupor or agitation) during acute medical illness. This study aimed to determine the natural course of delirium and abnormal arousal states in acute medically-ill older patients with and without prior dementia during hospital stay.Methods: Observational prospective study in an acute male geriatric ward. Patients aged ≥ 65 years old were assessed by a psychiatrist within the first 72h of admission and in every other day until discharge to determine the level of arousal and the presence of delirium. Prior cognitive impairment, sociodemographic data, chronic comorbidities, psychotropic prescription and functional status were assessed at baseline.Results: 43.5% of participants in the final sample (n= 269) had dementia. Prior dementia was associated with higher rates of moderate/severe hypoarousal (29.9% vs. 4.6%; p<0.001) and delirium (20.5% vs. 7.2%; p<0.001) at admission. RASS ≤ -3 at admission predicted a 4-fold increased intra-hospital mortality risk and RASS ≠ 0 had a sensitivity of 82.8% and a specificity of85.9% for delirium.Conclusions: Moderate/severe hypoarousal is associated with adverse outcomes and should be assessed as part of delirium spectrum, particularly in subjects with prior dementia.
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Affiliation(s)
- Luísa Lagarto
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Elisabete Albuquerque
- Department of Psychiatry, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Diana Loureiro
- Department of Psychiatry, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Filipe Vieira
- Department of Psychiatry, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Pedro Esteves
- Department of Psychiatry, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Sandra Neves
- Department of Psychiatry, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Manuel Teixeira-Veríssimo
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Deparment of Internal Medicine, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Joaquim Cerejeira
- Department of Psychiatry, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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29
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Reznik ME, Daiello LA, Thompson BB, Wendell LC, Mahta A, Potter NS, Yaghi S, Levy MM, Fehnel CR, Furie KL, Jones RN. Fluctuations of consciousness after stroke: Associations with the confusion assessment method for the intensive care unit (CAM-ICU) and potential undetected delirium. J Crit Care 2020; 56:58-62. [PMID: 31855707 DOI: 10.1016/j.jcrc.2019.12.008] [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: 07/28/2019] [Revised: 09/22/2019] [Accepted: 12/09/2019] [Indexed: 01/22/2023]
Abstract
PURPOSE To examine associations between fluctuating consciousness and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) assessments in stroke patients compared to non-neurological patients. MATERIALS AND METHODS We linked all recorded CAM-ICU assessments with corresponding Richmond Agitation Sedation Scale (RASS) measurements in patients with stroke or sepsis from a single-center ICU database. Fluctuating consciousness was defined by RASS variability using standard deviations (SD) over 24-h periods; regression analyses were performed to determine associations with RASS variability and CAM-ICU rating. RESULTS We identified 16,509 paired daily summaries of CAM-ICU and RASS measurements in 546 stroke patients and 1586 sepsis patients. Stroke patients had higher odds of positive (OR 4.2, 95% CI 3.3-5.5) and "unable to assess" (UTA; OR 5.2, 95% CI 4.0-6.8) CAM-ICU ratings compared to sepsis patients, and CAM-ICU-positive and UTA assessment-days had higher RASS variability than CAM-ICU-negative assessment-days, especially in stroke patients. Based on model-implied associations of RASS variability (OR 2.0 per semi-IQR-difference in RASS-SD, 95% CI 1.7-2.2) and stroke diagnosis (OR 2.7, 95% CI 2.0-3.7) with CAM-ICU-positive assessments, over one-third of probable delirium cases among stroke patients were potentially missed by the CAM-ICU. CONCLUSIONS Post-stroke delirium may frequently go undetected by the CAM-ICU, even in the setting of fluctuating consciousness.
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Affiliation(s)
- Michael E Reznik
- Department of Neurology, Brown University, Alpert Medical School, United States of America; Department of Neurosurgery, Brown University, Alpert Medical School, United States of America.
| | - Lori A Daiello
- Department of Neurology, Brown University, Alpert Medical School, United States of America
| | - Bradford B Thompson
- Department of Neurology, Brown University, Alpert Medical School, United States of America; Department of Neurosurgery, Brown University, Alpert Medical School, United States of America
| | - Linda C Wendell
- Department of Neurology, Brown University, Alpert Medical School, United States of America; Department of Neurosurgery, Brown University, Alpert Medical School, United States of America
| | - Ali Mahta
- Department of Neurology, Brown University, Alpert Medical School, United States of America; Department of Neurosurgery, Brown University, Alpert Medical School, United States of America
| | - N Stevenson Potter
- Department of Neurology, Brown University, Alpert Medical School, United States of America; Department of Neurosurgery, Brown University, Alpert Medical School, United States of America
| | - Shadi Yaghi
- Department of Neurology, New York Langone Health, United States of America
| | - Mitchell M Levy
- Department of Medicine, Brown University, Alpert Medical School, United States of America
| | - Corey R Fehnel
- Marcus Institute for Aging Research, Hebrew SeniorLife, Beth Israel Deaconess Medical Center, United States of America
| | - Karen L Furie
- Department of Neurology, Brown University, Alpert Medical School, United States of America
| | - Richard N Jones
- Department of Neurology, Brown University, Alpert Medical School, United States of America; Department of Psychiatry and Human Behavior, Brown University, Alpert Medical School, United States of America
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30
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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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Deconstructing Poststroke Delirium in a Prospective Cohort of Patients With Intracerebral Hemorrhage*. Crit Care Med 2020; 48:111-118. [DOI: 10.1097/ccm.0000000000004031] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
PURPOSE Delirium superimposed on dementia (DSD) is a frequent and growing emerging clinical challenge, given the increasing prevalence of dementia. METHODS This narrative review focuses on and discusses the current knowledge on epidemiology, pathogenesis, diagnosis and management of DSD. RESULTS There is a close interaction between delirium and dementia since dementia is a risk factor for delirium and delirium is a known risk factor for newly developed dementia or worsening of dementia. The occurrence of DSD causes adverse clinical outcomes. However, DSD is often under-recognized or is frequently considered as the regular course of dementia. Indeed, especially in the advance stages of dementia, DSD diagnosis is challenging since a clear distinction between symptoms attributable to delirium and to dementia is difficult. Given the importance of DSD, it is essential to educate health care providers on the best approach for delirium management and treatment. It is now well recognized that delirium can be prevented using multicomponent interventions carried out by a multidisciplinary team targeting predisposing and precipitating risk factors for delirium. On the contrary, antipsychotics should only be used in patients with severe distressing symptoms and whose behavior means their safety or the safety of those around them is compromised, given the harmful of these medications in patients with pre-existing dementia. CONCLUSIONS It is essential to improve health care providers knowledge on DSD to improve the quality of care for an epidemiologically relevant though understudied population.
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Brich J, Baten V, Wußmann J, Heupel-Reuter M, Perlov E, Klöppel S, Busch HJ. Detecting delirium in elderly medical emergency patients: validation and subsequent modification of the German Nursing Delirium Screening Scale. Intern Emerg Med 2019; 14:767-776. [PMID: 30483989 DOI: 10.1007/s11739-018-1989-5] [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: 08/09/2018] [Accepted: 11/20/2018] [Indexed: 11/26/2022]
Abstract
Detecting delirium in elderly emergency patients is critical to their outcome. The Nursing Delirium Screening Scale (Nu-DESC) is a short, feasible instrument that allows nurses to systematically screen for delirium. This is the first study to validate the Nu-DESC in a German emergency department (ED). The Nu-DESC was implemented in a high-volume, interdisciplinary German ED. A consecutively recruited sample of medical patients aged ≥ 70 years was screened by assigned nurses who performed the Nu-DESC as part of their daily work routine. The results were compared to a criterion standard diagnosis of delirium. According to the criterion standard diagnosis, delirium was present in 47 (14.9%) out of the 315 patients enrolled. The Nu-DESC shows a good specificity level of 91.0% (95% CI 87.0-94.2), but a moderate sensitivity level of 66.0% (95% CI 50.7-79.1). Positive and negative likelihood ratios are 7.37 (95% CI 4.77-11.36) and 0.37 (95% CI 0.25-0.56), respectively. In an exploratory analysis, we find that operationalizing the Nu-DESC item "disorientation" by specifically asking patients to state the day of the week and the name of the hospital unit would raise Nu-DESC sensitivity to 77.8%, with a specificity of 84.6% (positive and negative likelihood ratio of 5.05 and 0.26, respectively). The Nu-DESC shows good specificity but moderate sensitivity when performed by nurses during their daily work in a German ED. We have developed a modified Nu-DESC version, resulting in markedly enhanced sensitivity while maintaining a satisfactory level of specificity.
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Affiliation(s)
- Jochen Brich
- Department of Neurology and Neuroscience, Medical Center, University of Freiburg, Freiburg, Germany.
| | - Verena Baten
- Department of Neurology and Neuroscience, Medical Center, University of Freiburg, Freiburg, Germany
- Department of Emergency Medicine, University Hospital of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Judith Wußmann
- Department of Emergency Medicine, University Hospital of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Miriam Heupel-Reuter
- Center of Geriatrics and Gerontology Freiburg, Medical Center, University of Freiburg, Freiburg, Germany
| | - Evgeniy Perlov
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Clinic for Psychiatry Luzern, St. Urban, Switzerland
| | - Stefan Klöppel
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Geriatric Medicine and Gerontology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- University Hospital of Old Age Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Hans-Jörg Busch
- Department of Emergency Medicine, University Hospital of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Shenkin SD, Fox C, Godfrey M, Siddiqi N, Goodacre S, Young J, Anand A, Gray A, Hanley J, MacRaild A, Steven J, Black PL, Tieges Z, Boyd J, Stephen J, Weir CJ, MacLullich AMJ. Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method. BMC Med 2019; 17:138. [PMID: 31337404 PMCID: PMC6651960 DOI: 10.1186/s12916-019-1367-9] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/13/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 'A's Test (4AT, www.the4AT.com ) is a short delirium assessment tool designed for routine use without special training. The primary objective was to assess the accuracy of the 4AT for delirium detection. The secondary objective was to compare the 4AT with another commonly used delirium assessment tool, the Confusion Assessment Method (CAM). METHODS This was a prospective diagnostic test accuracy study set in emergency departments or acute medical wards involving acute medical patients aged ≥ 70. All those without acutely life-threatening illness or coma were eligible. Patients underwent (1) reference standard delirium assessment based on DSM-IV criteria and (2) were randomised to either the index test (4AT, scores 0-12; prespecified score of > 3 considered positive) or the comparator (CAM; scored positive or negative), in a random order, using computer-generated pseudo-random numbers, stratified by study site, with block allocation. Reference standard and 4AT or CAM assessments were performed by pairs of independent raters blinded to the results of the other assessment. RESULTS Eight hundred forty-three individuals were randomised: 21 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome, and 785 were included in the analysis. Mean age was 81.4 (SD 6.4) years. 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT had an area under the receiver operating characteristic curve of 0.90 (95% CI 0.84-0.96). The 4AT had a sensitivity of 76% (95% CI 61-87%) and a specificity of 94% (95% CI 92-97%). The CAM had a sensitivity of 40% (95% CI 26-57%) and a specificity of 100% (95% CI 98-100%). CONCLUSIONS The 4AT is a short, pragmatic tool which can help improving detection rates of delirium in routine clinical care. TRIAL REGISTRATION International standard randomised controlled trial number (ISRCTN) 53388093 . Date applied 30/05/2014; date assigned 02/06/2014.
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Affiliation(s)
- Susan D. Shenkin
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
| | - Christopher Fox
- Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Mary Godfrey
- Elderly Care and Rehabilitation and Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, Hull York Medical School, Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Young
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
| | - Atul Anand
- Cardiovascular Sciences and Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | - Alasdair Gray
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Janet Hanley
- Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly L. Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher J. Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Alasdair M. J. MacLullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
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Abstract
Approximately 35% to 37% of older emergency department (ED) patients will have delirium or dementia, which can negatively affect safe and appropriate clinical care. This article describes the epidemiology of delirium and dementia in the ED and how it affects clinical care and patient outcomes. Screening for delirium and dementia in the context of the busy ED environment, as well as their diagnostic evaluation and management, is discussed.
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Affiliation(s)
- Jin H Han
- Department of Emergency Medicine, Center for Quality Aging, Vanderbilt University Medical Center, 311 Oxford House, Nashville, TN 37232, USA.
| | - Joe Suyama
- Department of Emergency Medicine, Magee-Womens Hospital of UPMC, University of Pittsburgh School of Medicine, 3600 Forbes Tower, Pittsburgh, PA 15213, USA
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Shenvi C, Wilson MP, Aldai A, Pepper D, Gerardi M. A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients. West J Emerg Med 2019; 20:393-402. [PMID: 30881563 PMCID: PMC6404700 DOI: 10.5811/westjem.2019.1.39262] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 01/25/2019] [Accepted: 01/29/2019] [Indexed: 11/11/2022] Open
Abstract
Introduction Agitation, mental illness, and delirium are common reasons for older adults to seek care in the emergency department (ED). There are significant knowledge gaps in understanding how to best screen older adults for these conditions and how to manage them. In addition, in areas where research has been performed, implementation has been slow. A working group convened to develop a set of high-priority research questions that would advance the understanding of optimal management of older adults with acute behavioral changes in the ED. This manuscript is the product of a breakout session on "Special Populations: Agitation in the Elderly" from the 2016 Coalition on Psychiatric Emergencies' first Research Consensus Conference on Acute Mental Illness. Methods Participants were identified with expertise in emergency medicine (EM), geriatric EM, and psychiatry. Background literature reviews were performed prior to the in-person meeting in four key areas: delirium; dementia; substance abuse or withdrawal; and mental illness in older adults. Input was solicited from all participants during the meeting, and questions were iteratively focused and revised, voted on, and ranked by importance. Results Fourteen questions were identified by the group with high consensus for their importance related to the care of older adults with agitation in the ED. The questions were grouped into three topic areas: screening and identification; management strategies; and the approach to delirium. Conclusion It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes, have the tools to screen older adults for those causes, and employ methods to treat the underlying causes and ameliorate their symptoms. Answers to the identified research questions have great potential to improve the care of older adults presenting with behavioral changes.
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Affiliation(s)
- Christina Shenvi
- University of North Carolina, Department of Emergency Medicine, Chapel Hill, North Carolina
| | - Michael P Wilson
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Little Rock, Arkansas
| | - Alessandra Aldai
- University of California, San Diego Medical Center, Department of Emergency Medicine San Diego, California
| | - David Pepper
- Hartford Hospital/Institute of Living, Department of Psychiatry, Hartford, Connecticut
| | - Michael Gerardi
- Morristown Medical Center, Department of Emergency Medicine, Morristown, New Jersey
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Pérez-Ros P, Martínez-Arnau FM. Delirium Assessment in Older People in Emergency Departments. A Literature Review. Diseases 2019; 7:E14. [PMID: 30704024 PMCID: PMC6473718 DOI: 10.3390/diseases7010014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/27/2019] [Accepted: 01/28/2019] [Indexed: 12/21/2022] Open
Abstract
Delirium is a neuropsychiatric syndrome often manifesting in acute disease conditions, and with a greater prevalence in the older generation. Delirium in the Emergency Department (ED) is a highly prevalent problem that typically goes unnoticed by healthcare providers. The onset of a delirium episode in the ED is associated with an increase in morbidity and mortality. Because delirium is a preventable syndrome, these statistics are unacceptable. Emergency Department staff therefore should strive to perform systematic screening in order to detect delirium. Different tools have been developed for the assessment of delirium by healthcare professionals other than psychiatrists or geriatricians. Emergency Departments require delirium assessment scales of high sensitivity and specificity, suited to the characteristics of the Department, since the time available is scarce. In addition, the presence of dementia in the assessment of delirium may induce sensitivity bias. Despite the existence of numerous delirium rating scales, scales taking less than three minutes to complete are recommended. The choice of the tool depends on the characteristics of the ED. The only scale affording high sensitivity and specificity in older people with and without dementia is the Four "A"s Test (4AT); it requires no training on the part of the rater, and can be performed in under two minutes.
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Affiliation(s)
- Pilar Pérez-Ros
- School of Nursing, Universidad Católica de Valencia San Vicente Mártir, Calle Espartero, 7, 46007 València, Spain.
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Han JH, Hayhurst CJ, Chandrasekhar R, Hughes CG, Vasilevskis EE, Wilson JE, Schnelle JF, Dittus RS, Ely EW. Delirium's Arousal Subtypes and Their Relationship with 6-Month Functional Status and Cognition. PSYCHOSOMATICS 2019; 60:27-36. [PMID: 29929733 PMCID: PMC6296894 DOI: 10.1016/j.psym.2018.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/01/2018] [Accepted: 05/01/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE We sought to determine how delirium subtyped by arousal affected 6-month function and cognition in acutely ill older patients. METHODS This was secondary analysis of a prospective cohort study which enrolled hospitalized patients ≥65 years old. Delirium and arousal were ascertained daily in the emergency department and the first 7 days of hospitalization using the modified Brief Confusion Assessment Method and Richmond Agitation Sedation Scale, respectively. For each day, patients were categorized as having no delirium, delirium with normal arousal, delirium with decreased arousal, or delirium with increased arousal. Preillness and 6-month functional status were determined using the Older American Resources and Services activities of daily living scale which ranges from 0 (completely dependent) to 28 (completely independent). Preillness and 6-month cognition were determined using the Informant Questionnaire on Cognitive Decline in the Elderly which ranges from 1 (markedly improved cognition) to 5 (severe cognitive impairment). Multiple linear regression was performed adjusted for preillness Older American Resources and Services activities of daily living and Informant Questionnaire on Cognitive Decline in the Elderly and other relevant confounders. RESULTS In 228 older patients, delirium with normal arousal was the only subtype independently associated with poorer 6-month function and cognition. For every day spent in this subtype, the 6-month Older American Resources and Services activities of daily living decreased by 0.84 points (95% confidence interval: -1.59 to -0.09) and the patient's 6-month Informant Questionnaire on Cognitive Decline in the Elderly significantly increased by 0.14 points (95% confidence interval: 0.06-0.23). CONCLUSIONS Delirium with normal arousal, as opposed to delirium with decreased or increased arousal, was the only arousal subtype significantly associated with worsening 6-month function and cognition. Subtyping delirium by arousal may have important prognostic value.
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Affiliation(s)
- Jin H Han
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN; Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN.
| | - Christina J Hayhurst
- Department of Anesthesia, Division of Critical Care; Vanderbilt University Medical Center, Nashville, TN
| | | | - Christopher G Hughes
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN; Department of Anesthesia, Division of Critical Care; Vanderbilt University Medical Center, Nashville, TN
| | - Eduard E Vasilevskis
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN; Division of General Internal Medicine and Public Health, Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
| | - Jo Ellen Wilson
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - John F Schnelle
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
| | - Robert S Dittus
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
| | - E Wesley Ely
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN
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Green S, Reivonen S, Rutter LM, Nouzova E, Duncan N, Clarke C, MacLullich AMJ, Tieges Z. Investigating speech and language impairments in delirium: A preliminary case-control study. PLoS One 2018; 13:e0207527. [PMID: 30475831 PMCID: PMC6261049 DOI: 10.1371/journal.pone.0207527] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 11/01/2018] [Indexed: 02/02/2023] Open
Abstract
Introduction Language impairment is recognized as as part of the delirium syndrome, yet there is little neuropsychological research on the nature of this dysfunction. Here we hypothesized that patients with delirium show impairments in language formation, coherence and comprehension. Methods This was a case-control study in 45 hospitalized patients (aged 65–97 years) with delirium, dementia without delirium, or no cognitive impairment (N = 15 per group). DSM-5 criteria were used for delirium. Speech was elicited during (1) structured conversational questioning, and (2) the "Cookie Theft" picture description task. Language comprehension was assessed through standardized verbal and written commands. Interviews were audio-recorded and transcribed. Results Delirium and dementia groups scored lower on the conversational assessment than the control group (p<0.01, moderate effect sizes (r) of 0.48 and 0.51, resp.). In the Cookie Theft task, the average length of utterances (i.e. unit of speech), indicating language productivity and fluency, distinguished patients with delirium from those with dementia (p<0.01, r = 0.50) and no cognitive impairment (p<0.01, r = 0.55). Patients with delirium performed worse on written comprehension tests compared to cognitively unimpaired patients (p<0.01, r = 0.63), but not compared to the dementia group. Conclusions Production of spontaneous speech, word quantity, speech content and verbal and written language comprehension are impaired in delirious patients compared to cognitively unimpaired patients. Additionally, patients with delirium produced significantly less fluent speech than those with dementia. These findings have implications for how speech and language are evaluated in delirium assessments, and also for communication with patients with delirium. A study limitation was that the delirium group included patients with co-morbid dementia, which precludes drawing conclusions about the specific language profile of delirium.
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Affiliation(s)
- Samantha Green
- Department of Psychology, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Satu Reivonen
- Department of Psychology, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, 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
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Caoimhe Clarke
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, 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, Edinburgh, Scotland, United Kingdom
| | - Zoë Tieges
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- * E-mail:
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Corradi JP, Thompson S, Mather JF, Waszynski CM, Dicks RS. Prediction of Incident Delirium Using a Random Forest classifier. J Med Syst 2018; 42:261. [PMID: 30430256 DOI: 10.1007/s10916-018-1109-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 10/24/2018] [Indexed: 12/26/2022]
Abstract
Delirium is a serious medical complication associated with poor outcomes. Given the complexity of the syndrome, prevention and early detection are critical in mitigating its effects. We used Confusion Assessment Method (CAM) screening and Electronic Health Record (EHR) data for 64,038 inpatient visits to train and test a model predicting delirium arising in hospital. Incident delirium was defined as the first instance of a positive CAM occurring at least 48 h into a hospital stay. A Random Forest machine learning algorithm was used with demographic data, comorbidities, medications, procedures, and physiological measures. The data set was randomly partitioned 80% / 20% for training and validating the predictive model, respectively. Of the 51,240 patients in the training set, 2774 (5.4%) experienced delirium during their hospital stay; and of the 12,798 patients in the validation set, 701 (5.5%) experienced delirium. Under-sampling of the delirium negative population was used to address the class imbalance. The Random Forest predictive model yielded an area under the receiver operating characteristic curve (ROC AUC) of 0.909 (95% CI 0.898 to 0.921). Important variables in the model included previously identified predisposing and precipitating risk factors. This machine learning approach displayed a high degree of accuracy and has the potential to provide a clinically useful predictive model for earlier intervention in those patients at greatest risk of developing delirium.
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Affiliation(s)
- John P Corradi
- Research Department, Hartford Hospital, 80 Seymour Street, ERD-223W, Hartford, CT, 06102, USA.
| | - Stephen Thompson
- Research Department, Hartford Hospital, 80 Seymour Street, ERD-223W, Hartford, CT, 06102, USA
| | - Jeffrey F Mather
- Research Department, Hartford Hospital, 80 Seymour Street, ERD-223W, Hartford, CT, 06102, USA
| | | | - Robert S Dicks
- Division of Geriatric Medicine, Hartford Hospital, Hartford, CT, USA
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41
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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.
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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
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Baten V, Busch H, Busche C, Schmid B, Heupel‐Reuter M, Perlov E, Brich J, Klöppel S. Validation of the Brief Confusion Assessment Method for Screening Delirium in Elderly Medical Patients in a German Emergency Department. Acad Emerg Med 2018; 25:1251-1262. [PMID: 29738102 DOI: 10.1111/acem.13449] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/17/2018] [Accepted: 04/26/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND Delirium is frequent in elderly patients presenting in the emergency department (ED). Despite the severe prognosis, the majority of delirium cases remain undetected by emergency physicians (EPs). At the time of our study there was no valid delirium screening tool available for EDs in German-speaking regions. We aimed to evaluate the brief Confusion Assessment Method (bCAM) for a German ED during the daily work routine. METHODS We implemented the bCAM into practice in a German interdisciplinary high-volume ED and evaluated the bCAM's validity in a convenience sample of medical patients aged ≥ 70 years. The bCAM, which assesses four core features of delirium, was performed by EPs during their daily work routine and compared to a criterion standard based on the criteria for delirium as described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. RESULTS Compared to the criterion standard, delirium was found to be present in 46 (16.0%) of the 288 nonsurgical patients enrolled. The bCAM showed 93.8% specificity (95% confidence interval [CI] = 90.0%-96.5%) and 65.2% sensitivity (95% CI = 49.8%-78.7%). Positive and negative likelihood ratios were 10.5 and 0.37, respectively, while the odds ratio was 28.4. Delirium was missed in 10 of 16 cases, since the bCAM did not indicate altered levels of consciousness and disorganized thinking. The level of agreement with the criterion standard increased for patients with low cognitive performance. CONCLUSION This was the first study evaluating the bCAM for a German ED and when performed by EPs during routine work. The bCAM showed good specificity, but only moderate sensitivity. Nevertheless, application of the bCAM most likely improves the delirium detection rate in German EDs. However, it should only be applied by trained physicians to maximize diagnostic accuracy and hence improve the bCAM's sensitivity. Future studies should refine the bCAM.
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Affiliation(s)
- Verena Baten
- Department of Neurology and Neuroscience Medical Center University of Freiburg FreiburgGermany
- Department of Emergency Medicine University Hospital of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| | - Hans‐Jörg Busch
- Department of Emergency Medicine University Hospital of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| | - Caroline Busche
- Department of Emergency Medicine University Hospital of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| | - Bonaventura Schmid
- Department of Emergency Medicine University Hospital of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| | - Miriam Heupel‐Reuter
- Center of Geriatrics and Gerontology Freiburg Medical Center University of Freiburg Freiburg Germany
| | - Evgeniy Perlov
- Department of Psychiatry and Psychotherapy Faculty of Medicine University of Freiburg FreiburgGermany
- Clinic for Psychiatry Luzern St. UrbanSwitzerland
| | - Jochen Brich
- Department of Neurology and Neuroscience Medical Center University of Freiburg FreiburgGermany
| | - Stefan Klöppel
- Department of Psychiatry and Psychotherapy Faculty of Medicine University of Freiburg FreiburgGermany
- Center for Geriatric Medicine and Gerontology Faculty of Medicine University of Freiburg FreiburgGermany
- University Hospital of Old Age Psychiatry and Psychotherapy University of Bern Bern Switzerland
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43
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Rutter LM, Nouzova E, Stott DJ, Weir CJ, Assi V, Barnett JH, Clarke C, Duncan N, Evans J, Green S, Hendry K, McGinlay M, McKeever J, Middleton DG, Parks S, Shaw R, Tang E, Walsh T, Weir AJ, Wilson E, Quasim T, MacLullich AMJ, Tieges Z. Diagnostic test accuracy of a novel smartphone application for the assessment of attention deficits in delirium in older hospitalised patients: a prospective cohort study protocol. BMC Geriatr 2018; 18:217. [PMID: 30223771 PMCID: PMC6142423 DOI: 10.1186/s12877-018-0901-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 08/28/2018] [Indexed: 11/17/2022] Open
Abstract
Background Delirium is a common and serious clinical syndrome which is often missed in routine clinical care. The core cognitive feature is inattention. We developed a novel bedside neuropsychological test for assessing inattention in delirium implemented on a smartphone platform (DelApp). We aim to evaluate the diagnostic performance of the DelApp in a representative cohort of older hospitalised patients. Methods This is a prospective study of older non-scheduled hospitalised patients (target n = 500, age ≥ 65), recruited from elderly care and acute orthopaedic wards. Exclusion criteria are: non-English speakers; severe vision or hearing impairment; photosensitive epilepsy. A structured reference standard delirium assessment based on DSM-5 criteria will be used, which includes a cognitive test battery administered by a trained assessor (Orientation-Memory-Concentration Test, Abbreviated Mental Test-10, Delirium Rating Severity Scale-Revised-98, digit span, months and days backwards, Vigilance A’ test) and assessment of arousal (Observational Scale of Level of Arousal, Richmond Agitation Sedation Scale). Prior change in cognition will be documented using the Informant Questionnaire on Cognitive Decline in the Elderly. Patients will be categorized as delirium (with/without dementia), possible delirium, dementia, no cognitive impairment, or undetermined. A separate assessor (blinded to diagnosis and assessments) will administer the DelApp index test within 3 h of the reference standard assessment. The DelApp comprises assessment of arousal (score 0-4) and sustained attention (score 0-6), yielding a total score between 0 and 10 (higher score = better performance). Outcomes (length of stay, mortality and discharge location) will be collected at 12 weeks. We will evaluate a priori cutpoints derived from a previous case-control study. Measures of the accuracy of DelApp will include sensitivity, specificity, positive and negative predictive values, and area under the ROC curve. We plan repeat assessments on up to 4 occasions in a purposive subsample of 30 patients (15 delirium, 15 no delirium) to examine changes over time. Discussion This study evaluates the diagnostic test accuracy of a novel smartphone test for delirium in a representative cohort of older hospitalised patients, including those with dementia. DelApp has the potential to be a convenient, objective method of improving delirium assessment for older people in acute care. Trial registration Clinical trials.gov, NCT02590796. Registered on 29 Oct 2015. Protocol version 5, dated 25 July 2016. Electronic supplementary material The online version of this article (10.1186/s12877-018-0901-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lisa-Marie Rutter
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK
| | - Eva Nouzova
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Valentina Assi
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Jennifer H Barnett
- Cambridge Cognition Ltd, Cambridge, UK.,Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Caoimhe Clarke
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Nikki Duncan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jonathan Evans
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Samantha Green
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK
| | - Kirsty Hendry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Meigan McGinlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jenny McKeever
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK
| | - Duncan G Middleton
- Medical Devices Unit, West Glasgow Ambulatory Care Hospital, Glasgow, UK
| | - Stuart Parks
- Medical Devices Unit, West Glasgow Ambulatory Care Hospital, Glasgow, UK
| | - Robert Shaw
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Elaine Tang
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Tim Walsh
- Critical Care Medicine and Anaesthesia, University of Edinburgh, Edinburgh, UK
| | - Alexander J Weir
- Medical Devices Unit, West Glasgow Ambulatory Care Hospital, Glasgow, UK
| | - Elizabeth Wilson
- Critical Care Medicine and Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Tara Quasim
- Anaesthesia, Critical Care and Pain Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, UK. .,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK.
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Quispel-Aggenbach DWP, Holtman GA, Zwartjes HAHT, Zuidema SU, Luijendijk HJ. Attention, arousal and other rapid bedside screening instruments for delirium in older patients: a systematic review of test accuracy studies. Age Ageing 2018; 47:644-653. [PMID: 29697753 DOI: 10.1093/ageing/afy058] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Indexed: 11/13/2022] Open
Abstract
Objective delirium occurs frequently in frail patients but is easily missed. Screening with a rapid, easy-to-use and highly sensitive instrument might help improve recognition. The aim of this study was to review attention, arousal and other rapid bedside screening instruments for delirium in older patients. Methods a literature search was performed in PubMed, PsycINFO and Embase. We scrutinized forward citations in Google Scholar, and references of included articles and prior reviews. We included studies among older patients that investigated the sensitivity and specificity of delirium screening instruments that could be administered in 3 min or less, and did not require surrogate information. We extracted study characteristics, risk of bias, sensitivity and specificity. Results we identified 27 studies among 4,766 patients in hospitals and nursing homes. They tested many different single and several combined screening instruments. Prevalence of delirium varied between 4% and 57%. Only one study scored a low risk of bias on all domains. Sensitivity varied between 17% and 100%, and specificity between 38% and 99%. Of the 22 tests with sensitivity ≥90%, seven also had specificity ≥80% in older patients in general. These results were approximately reproduced for the Observational Scale of Level of Arousal (OSLA) and Richmond Agitation and Sedation Scale (RASS): sensitivity and specificity were >80%. Conclusion two arousal tests-OSLA and RASS-had reproduced high sensitivity and specificity in older patients. Nurses can administer these tests during daily interaction with patients. Test accuracy studies about rapid screening tools for delirium superimposed on dementia were scarce.
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Affiliation(s)
- D W P Quispel-Aggenbach
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Geriatric Psychiatry, Parnassia BAVO Groep, Rotterdam, the Netherlands
| | - G A Holtman
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - H A H T Zwartjes
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - S U Zuidema
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - H J Luijendijk
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Bellelli G, Carnevali L, Corsi M, Morandi A, Zambon A, Mazzola P, Galeazzi M, Bonfanti A, Massariello F, Szabo H, Oliveri G, Haas J, d'Oro LC, Annoni G. The impact of psychomotor subtypes and duration of delirium on 6-month mortality in hip-fractured elderly patients. Int J Geriatr Psychiatry 2018; 33:1229-1235. [PMID: 29851194 DOI: 10.1002/gps.4914] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 03/19/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Studies exploring the incidence and impact of the psychomotor subtypes of postoperative delirium (POD) on the survival of hip fracture patients are few, and results are inconsistent. We sought to assess the incidence of POD subtypes and their impact, in addition to delirium duration, on 6-month mortality in older patients after hip-fracture surgery. METHODS This is a prospective study involving 571 individuals admitted to an Orthogeriatric Unit within a 5-year period with a diagnosis of hip fracture. Survival status was assessed 6 months after posthip fracture surgery. Postoperative delirium was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders. Postoperative delirium subtypes were classified according to Lipowski's criteria. Cox regressions were used to evaluate the associations between POD subtypes, POD duration, and 6-month mortality, adjusting for covariates. RESULTS The incidence of psychomotor POD subtypes was hypoactive 57 (10.0%), hyperactive 84 (14.7%), and mixed 79 (13.8%). Six-month mortality rates were 8.3%, 10.7%, 36.8%, and 29.1% in the no-delirium, hyperactive, hypoactive, and mixed-delirium subgroups, respectively. In adjusted models, the hypoactive subgroup (Hazard Ratio, HR = 3.14, 95% Confidence Intervals, CI, 1.63-6.04) and mixed subgroup (HR = 2.89, 95% CI, 1.49-5.62) showed high mortality rates and a significantly increased risk of mortality associated with POD duration as well. CONCLUSIONS Hyperactive delirium was the most common POD psychomotor subtype, but hypoactive and mixed POD were associated with 6-month mortality risk. Moreover, the risk of death 6 months after surgery increased for both subgroups (hypoactive and mixed) with increasing duration of POD.
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Affiliation(s)
- Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Acute Geriatric Unit, S. Gerardo Hospital, Monza, Italy
- Milan Center for Neuroscience (Neuro-Mi), Milan, Italy
| | | | - Maurizio Corsi
- Acute Geriatric Unit, S. Gerardo Hospital, Monza, Italy
- Milan Center for Neuroscience (Neuro-Mi), Milan, Italy
| | - Alessandro Morandi
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy
| | - Antonella Zambon
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Paolo Mazzola
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Milan Center for Neuroscience (Neuro-Mi), Milan, Italy
| | - Marianna Galeazzi
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | | | | | - Hajnalka Szabo
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Giulia Oliveri
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Justin Haas
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | | | - Giorgio Annoni
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Acute Geriatric Unit, S. Gerardo Hospital, Monza, Italy
- Milan Center for Neuroscience (Neuro-Mi), Milan, Italy
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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).
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Detecting delirium superimposed on dementia: diagnostic accuracy of a simple combined arousal and attention testing procedure. Int Psychogeriatr 2017; 29:1585-1593. [PMID: 28560945 DOI: 10.1017/s1041610217000916] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Detecting delirium superimposed on dementia (DSD) can be challenging because assessment partly relies on cognitive tests that may be abnormal in both conditions. We hypothesized that a combined arousal and attention testing procedure would accurately detect DSD. METHODS Patients aged ≥70 years were recruited from five hospitals across Europe. Delirium was diagnosed by physicians using DSM-5 criteria using information from nurses, carers, and medical records. Dementia was ascertained by the Informant Questionnaire on Cognitive Decline in the Elderly. Arousal was measured using the Observational Scale of Level of Arousal (OSLA), which assesses eye opening, eye contact, posture, movement, and communication. Attention was measured by participants signaling each time an "A" was heard when "S-A-V-E-A-H-A-A-R-T" was read out. RESULTS The sample included 114 persons (mean age 82 years (SD 7); 54% women). Dementia alone was present in 25% (n = 28), delirium alone in 18% (n = 21), DSD in 27% (n = 31), and neither in 30% (n = 34). Arousal and attention was assessed in n = 109 (96%). Using OSLA, 83% participants were correctly identified as having delirium (sensitivity 85%, specificity 82%, AUROC 0.92). The attention task correctly classified 76% of participants with delirium (sensitivity 90%, specificity 64%, AUROC 0.80). Combining scores correctly classified 91% of participants with delirium (sensitivity 84%, specificity 92%, AUROC 0.94). Diagnostic accuracy remained high in the subgroup with dementia (93% correctly classified, sensitivity 94%, specificity 92%, AUROC 0.98). CONCLUSIONS This combined arousal-attention assessment to detect DSD was brief yet had high diagnostic accuracy. Such an approach could have clinical utility for diagnosing DSD.
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Tamune H, Yasugi D. How can we identify patients with delirium in the emergency department? Am J Emerg Med 2017; 35:1332-1334. [DOI: 10.1016/j.ajem.2017.05.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 05/14/2017] [Accepted: 05/21/2017] [Indexed: 12/11/2022] Open
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Arendts G, Love J, Nagree Y, Bruce D, Hare M, Dey I. Rates of Delirium Diagnosis Do Not Improve with Emergency Risk Screening: Results of the Emergency Department Delirium Initiative Trial. J Am Geriatr Soc 2017; 65:1810-1815. [DOI: 10.1111/jgs.14904] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Glenn Arendts
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute for Medical Research; Fiona Stanley Hospital; Murdoch Western Australia Australia
- University of Western Australia; Nedlands Western Australia Australia
| | - Jennefer Love
- Western Australian Department of Health; Perth Western Australia Australia
| | - Yusuf Nagree
- University of Western Australia; Nedlands Western Australia Australia
| | - David Bruce
- University of Western Australia; Nedlands Western Australia Australia
| | - Malcolm Hare
- Western Australian Department of Health; Perth Western Australia Australia
| | - Ian Dey
- Western Australian Department of Health; Perth Western Australia Australia
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50
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Oldham MA, Flaherty JH, Rudolph JL. Debating the Role of Arousal in Delirium Diagnosis: Should Delirium Diagnosis Be Inclusive or Restrictive? J Am Med Dir Assoc 2017; 18:629-631. [DOI: 10.1016/j.jamda.2017.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 03/13/2017] [Indexed: 11/25/2022]
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