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

Heterogeneity in the definition of delirium in ICUs and association with the intervention effect in randomized controlled trials: a meta-epidemiological study

PURPOSE

To evaluate the heterogeneity in the definition of delirium in randomized controlled trials (RCTs) included in meta-analyses of delirium in intensive care units (ICUs) and to explore whether intervention effect depends on the definition used.

METHODS

We searched PubMed for meta-analyses including RCTs evaluating prevention or treatment strategies of delirium in ICU. The definition of delirium was collected from RCTs and classified as validated (DSM criteria, CAM-ICU, ICDSC, NEECHAM, DRS-R98) or non-validated (non-validated scales, set of symptoms, physician appreciation or not reported). We conducted a meta-epidemiological analysis to compare intervention effects between trials using or not a validated definition by a two-step method as primary analysis and a multilevel model as secondary analysis. A ratio of odds ratios (ROR) < 1 indicated larger intervention effects in trials using a non-validated definition.

RESULTS

Of 149 RCTs (41 meta-analyses), 109 (73.1%) used a validated definition and 40 (26.8%) did not (including 31 [20.8%] not reporting the definition). The primary analysis of 7 meta-analyses (30 RCTs) found no significant difference in intervention effects between trials using a validated definition and the others (ROR = 0.54, 95% CI 0.27-1.08), whereas the secondary multilevel analysis including 12 meta-analyses (67 RCTs) found significantly larger effects for trials using a non-validated versus a validated definition (ROR = 0.36, 95% CI 0.21-0.62).

CONCLUSION

The definition of delirium was heterogeneous across RCTs, with one-fifth not reporting how they evaluated delirium. We did not find a significant association with intervention effect in the primary analysis. The secondary analysis including more studies revealed significantly larger intervention effects in trials using a non-validated versus a validated definition.

Silent cerebral ischemia detected by magnetic resonance imaging can predict postoperative delirium after total arch replacement for aneurysm

Objective

To identify whether preoperative magnetic resonance imaging findings of the brain can predict postoperative delirium in patients who undergo arch replacement for aneurysms.

Methods

Overall, 193 patients who underwent aortic replacement for the first time at a single institution between April 2014 and September 2020 were enrolled in this retrospective study. After we excluded patients with acute aortic dissection, no preoperative magnetic resonance imaging findings of the brain, and postoperative cerebral infarction, 50 patients were included and divided into 2 groups, according to their confusion scale results: postoperative delirium (group D) and nonpostoperative delirium (group ND). Preoperative magnetic resonance imaging findings of the brain were classified into lacunar stroke, periventricular hyperintensity, and deep subcortical white matter hyperintensity groups; the latter 2 groups were further classified based on the Fazekas scale, grade 0 to 3.

Results

There were 23 patients (46%) in group D and 27 (54%) in group ND. The mean age was significantly greater in group D than in group ND (75 vs 70 years; P = .007). The mean operative time was significantly longer in group D than in group ND (447 vs 384 minutes; P = .024). As for preoperative magnetic resonance imaging findings of the brain, there were significantly more lacunar stroke cases in group D than in group ND (P = .027). In multivariable logistic regression with stepwise selection, high-grade periventricular hyperintensity was significantly related to postoperative delirium (odds ratio, 9.38; 95% confidence interval, 1.55-56.56; P = .015).

Conclusions

Silent cerebral ischemia detected by preoperative magnetic resonance imaging of the brain was a significant risk factor for postoperative delirium.

Prevention of postoperative delirium in elderly patients planned for elective surgery: systematic review and meta-analysis

Introduction: Vulnerable or “frail” patients are susceptible to the development of delirium when exposed to triggers such as surgical procedures. Once delirium occurs, interventions have little effect on severity or duration, emphasizing the importance of primary prevention. This review provides an overview of interventions to prevent postoperative delirium in elderly patients undergoing elective surgery.

Methods: A literature search was conducted in March 2018. Randomized controlled trials (RCTs) and before-and-after studies on interventions with potential effects on postoperative delirium in elderly surgical patients were included. Acute admission, planned ICU admission, and cardiac patients were excluded. Full texts were reviewed, and quality was assessed by two independent reviewers. Primary outcome was the incidence of delirium. Secondary outcomes were severity and duration of delirium. Pooled risk ratios (RRs) were calculated for incidences of delirium where similar intervention techniques were used.

Results: Thirty-one RCTs and four before-and-after studies were included for analysis. In 19 studies, intervention decreased the incidences of postoperative delirium. Severity was reduced in three out of nine studies which reported severity of delirium. Duration was reduced in three out of six studies. Pooled analysis showed a significant reduction in delirium incidence for dexmedetomidine treatment, and bispectral index (BIS)-guided anaesthesia. Based on sensitivity analyses, by leaving out studies with a high risk of bias, multicomponent interventions and antipsychotics can also significantly reduce the incidence of delirium.

Conclusion: Multicomponent interventions, the use of antipsychotics, BIS-guidance, and dexmedetomidine treatment can successfully reduce the incidence of postoperative delirium in elderly patients undergoing elective, non-cardiac surgery. However, present studies are heterogeneous, and high-quality studies are scarce. Future studies should add these preventive methods to already existing multimodal and multidisciplinary interventions to tackle as many precipitating factors as possible, starting in the pre-admission period.

Validation of Finnish Neecham Confusion Scale and Nursing Delirium Screening Scale using Confusion Assessment Method algorithm as a comparison scale

BACKGROUND

Delirium is a common clinical problem with acute and fluctuating onset. Early notification of its symptoms can lead to earlier detection and management of this state. Valid and reliable instruments are required for successful nursing practice. The purpose of the study was to psychometrically test the Finnish versions of the Neecham Confusion Scale (NEECHAM) and the Nursing Delirium Screening Scale (Nu-DESC) in surgical nursing care, utilizing the Confusion Assessment Method (CAM) algorithm as a comparison scale.

METHODS

This randomized, blinded, instrument testing study was conducted at one university hospital in one surgical unit. Study patients (n = 112) meeting the pre-set criteria were assessed by the principal investigator (PI) and a registered nurse (RN, n = 18). Internal consistency, inter-rater reliability, and concurrent validity of the scales were calculated and face validity and usability evaluated.

RESULTS

Internal consistency was from .76 to .86 for all three scales. Inter-rater reliability between PI and RNs was .87 with NEECHAM, .60 with CAM and .47 with Nu-DESC. Concurrent validity was .56 and .59 between CAM and NEECHAM, and .68 and .72 between NEECHAM and Nu-DESC. In the PI group, the correlation between CAM and Nu-DESC was .91, in the RN's group .42. Nu-DESC was evaluated as the most usable scale.

CONCLUSION

The findings strengthen the earlier research on the scales and indicate that the Finnish NEECHAM and Nu-DESC correlates with CAM algorithm and with each other. They seem to be clinically viable in assessing patients' delirium in surgical wards but more validity testing is needed.

Effectiveness of standard of care protocol on patient satisfaction and perceived staff caring

BACKGROUND

Nurse caring has been linked to many clinical outcomes, including patient satisfaction, well-being, and healing. In addition, it is valued by nursing staff and viewed as being essential to clinical practice.

OBJECTIVES

The purpose of this program evaluation study was to determine the difference in patient satisfaction with overall nursing care and perceived nurse caring when a nursing staff standard of care protocol, which included caring activities, was implemented within a nursing department at a National Cancer Institute-designated comprehensive cancer center.

METHODS

A pre-experimental pre-/post-test design with comparison group and a post-test-only design were used to test the effect of the caring protocol on patient satisfaction with nursing care and perceived nurse caring. The study was conducted on seven inpatient units.

FINDINGS

Patient satisfaction with nursing care increased for some items, and perceived nurse caring was ranked highly immediately before discharge. Additional program evaluation studies involving a modified caring protocol may improve satisfaction with nursing care in other settings.

Psychometric properties and feasibility of instruments for the detection of delirium in older hospitalized patients: a systematic review

OBJECTIVE

Delirium is a serious and common complication among older hospitalized patients and is a predictor of many adverse outcomes. However, up to 72% of delirium incidents are unrecognized or misdiagnosed. The aim of this systematic review is to determine the validity, reliability, and feasibility of instruments for the detection of delirium in older hospitalized patients.

METHODS

A systematic literature search was conducted. The inclusion criteria were a mean or median age of 65+ years, the use of the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases-10 as a reference standard, and publication in English. All included studies underwent a quality assessment (QUADAS-2).

RESULTS

Forty-three of the 3.790 identified studies were relevant to the review, describing 28 instruments. Quality assessment resulted in 37 studies with a positive quality assessment, describing 23 instruments. Five instruments (Delirium Observation Scale (DOS), Nursing Delirium Screening Scale (Nu-DESC), Confusion Assessment Method (CAM), CAM-Intensive Care Unit (ICU), and Delirium Rating Scale-Revised-98) were described in three or more methodologically sound studies. The Delirium Observation Screening Scale (DOS) and Nu-DESC are observational instruments with good psychometric properties, but the Nu-DESC is shorter and has been validated in more languages. The CAM, CAM-ICU, and Delirium Rating Scale-Revised-98 (DRS-R-98) are instruments with both observational and interactive components. The CAM is the most widely studied and demonstrates the best psychometric properties.

CONCLUSION

Timely detection of delirium might reduce the negative outcomes of delirium in the long term. The Nu-DESC and CAM appear to be the most adequate instruments for detecting delirium. Copyright © 2016 John Wiley & Sons, Ltd.

Delirium Diagnostic and Screening Instruments in the Emergency Department: An Up-to-Date Systematic Review

BACKGROUND

Emergency care systems are at the core of modern healthcare and are the "point-of-entry/admission" into the hospital for many older/elderly patients. Among these, it is estimated that 15% to 30% will have delirium on admission and that over 50% will develop it during their stay. However, appropriate delirium diagnostic and screening still remains a critical area of need. The goal of this review is to update the field, exploring target areas in screening methods for delirium in the Emergency Department (ED), and/or acute care units, in the older population.

METHODS

A systematic review was conducted to search screening/diagnostic methods for delirium in the ED and/or acute care units within the ED.

RESULTS

Seven different scales were identified. Of the identified instruments, the Confusion Assessment Method (CAM) for the Intense Care Unit (CAM-ICU) was the most widely used. Of note, a brief two-step approach for delirium surveillance was defined with the Delirium Triage Screen (DTS) and the Brief Confusion Assessment Method (bCAM), and the diagnostic accuracy of the Richmond Agitation-Sedation Scale (RASS) for delirium had a good sensitivity and specificity in older patients.

CONCLUSION

The CAM-ICU appears as the potential reference standard for use in the ED, but research in a global approach of evaluation of actual and past cognitive changes is still warranted.

Assessment of people with cognitive impairment and hip fracture: a systematic review and meta-analysis

This study systematically assesses the literature pertaining to the diagnostic test accuracy of assessment instruments to evaluate patients following hip fracture surgery who present with cognitive impairment. A systematic review and meta-analysis was performed. Studies assessing the reliability, validity, sensitivity or specificity of assessment tools for patients following hip fracture who were cognitively impaired were included. An assessment of published (MEDLINE, EMBASE, CINHAL, AMED, Cochrane library, PEDro) and unpublished/trial registry (OpenGrey, the WHO International Clinical Trials Registry Platform, Current Controlled Trials, the UK National Research Register Archive) databases were undertaken. Methodological quality of the literature was assessed using the QUADAS-2 appraisal tool. Nine studies including 690 participants, with a mean age of 82.1 years were included. The literature demonstrated a high risk of bias for study methodology, but low risk of bias for applicability. Two assessment domains were recognized: pain and delirium. For pain, the Facial Action Coding System (FACS) and DOLOPLUS-2 tools possessed strong inter-rater reliability and internal consistency, with the FACS demonstrating concurrent validity with other pain scales. For delirium, the Delirium Rating Scale-Revisited-98 (DRS-R-98) demonstrated high inter-rater reliability and sensitivity and specificity, with the NEECHAM Confusion Scale possessing high internal consistency. To conclude, there is a paucity of literature assessing the reliability, validity and diagnostic test accuracy of instruments to assess people with cognitive impairment following hip fracture surgery. Based on the current available data, delirium may be best assessed using the NEECHAM Confusion Scale or DRS-R-98. Pain is most accurately evaluated using the FACS.

Cognitive dysfunction in hip fracture patients

Hip fractures represent a widespread morbidity among the geriatric population. In North America, more than 320,000 hip fractures are sustained annually, a number that is expected to increase dramatically as the population continues to age. Disorders of cognition, primarily dementia and delirium, also have a higher-than-average incidence and prevalence among the geriatric population. The co-occurrence of cognitive dysfunction and hip fracture is an important entity for orthopedic surgeons and other clinicians involved in hip fracture care to recognize. This article provides an overview of the currently available evidence regarding cognitive dysfunction, specifically dementia and delirium, in patients with hip fractures.