Undiagnosed delirium is frequent and difficult to predict: Results from a prevalence survey of a tertiary hospital

Melatonin does not reduce delirium severity in hospitalized older adults: Results of a randomized placebo-controlled trial

BACKGROUND

Delirium is common in older inpatients, causing distress, cognitive decline, and death. Current therapies are unsatisfactory, limited by lack of efficacy and adverse effects. There is an urgent need for effective delirium treatment. Sleep wake cycle is disturbed in delirium; endogenous Melatonin is perturbed, and exogenous Melatonin is a safe and effective medication for sleep disorders. This study aims to determine the effect of oral Melatonin 5 mg immediate release (IR) nightly for five nights on the severity of delirium in older (≥65 years) medical inpatients.

METHODS

This was a double-blinded, randomized controlled trial in general internal medicine units of a tertiary teaching hospital. Older inpatients with Confusion Assessment Method positive, hyperactive or mixed delirium within 48 h of admission or onset of in-hospital delirium were included. The primary outcome was change in delirium severity measured with the Memorial Delirium Assessment Scale (MDAS). A previous pilot trial showed 120 participants randomized 1:1 to Melatonin or Placebo would provide 90% power to demonstrate a 3-point reduction in the MDAS.

RESULTS

One hundred and twenty participants were randomized, 61 to Melatonin 5 mg and 59 to Placebo. The medication was well tolerated. The mean MDAS improvement was 4.9 (SD 7.6) in the Melatonin group and 5.4 (SD 7.2) in the Placebo group, p-value 0.42, a non-significant difference. A post-hoc analysis showed length of stay (LOS) was shorter in the intervention group (median 9 days [Interquartile Range (IQR) 4, 12] vs. Placebo group 10 [IQR 6, 16] p-value = 0.033, Wilcoxon Rank Sum test).

CONCLUSIONS

This trial does not support the hypothesis that Melatonin reduces the severity of delirium. This may be due to no effect of Melatonin, a smaller effect than anticipated, an effect not captured on a multidimensional delirium assessment scale, or a type II statistical error. Melatonin may improve LOS; this hypothesis should be studied.

Delirium detection tools show varying completion rates and positive score rates when used at scale in routine practice in general hospital settings: A systematic review

BACKGROUND

Multiple short delirium detection tools have been validated in research studies and implemented in routine care, but there has been little study of these tools in real-world conditions. This systematic review synthesized literature reporting completion rates and/or delirium positive score rates of detection tools in large clinical populations in general hospital settings.

METHODS

PROSPERO (CRD42022385166). Medline, Embase, PsycINFO, CINAHL, and gray literature were searched from 1980 to December 31, 2022. Included studies or audit reports used a validated delirium detection tool performed directly with the patient as part of routine care in large clinical populations (n ≥ 1000) within a general acute hospital setting. Narrative synthesis was performed.

RESULTS

Twenty-two research studies and four audit reports were included. Tools used alone or in combination were the Confusion Assessment Method (CAM), 4 'A's Test (4AT), Delirium Observation Screening Scale (DOSS), Brief CAM (bCAM), Nursing Delirium Screening Scale (NuDESC), and Intensive Care Delirium Screening Checklist (ICDSC). Populations and settings varied and tools were used at different stages and frequencies in the patient journey, including on admission only; inpatient, daily or more frequently; on admission and as inpatient; inpatient post-operatively. Tool completion rates ranged from 19% to 100%. Admission positive score rates ranged from: CAM 8%-51%; 4AT 13%-20%. Inpatient positive score rates ranged from: CAM 2%-20%, DOSS 6%-42%, and NuDESC 5-13%. Postoperative positive score rates were 21% and 28% (4AT). All but two studies had moderate-high risk of bias.

CONCLUSIONS

This systematic review of delirium detection tool implementation in large acute patient populations found clinically important variability in tool completion rates, and in delirium positive score rates relative to expected delirium prevalence. This study highlights a need for greater reporting and analysis of relevant healthcare systems data. This is vital to advance understanding of effective delirium detection in routine care.

Co-design and mixed methods evaluation of an interdisciplinary digital resource for undergraduate health profession students to improve the prevention, recognition, and management of delirium in Ireland: a study protocol

BACKGROUND

Delirium is a common symptom of acute illness which is potentially avoidable with early recognition and intervention. Despite being a growing concern globally, delirium remains underdiagnosed and poorly reported, with limited understanding of effective delirium education for undergraduate health profession students. Digital resources could be an effective approach to improving professional knowledge of delirium, but studies utilising these with more than one profession are limited, and no evidence-based, interdisciplinary, digital delirium education resources are reported. This study aims to co-design and evaluate a digital resource for undergraduate health profession students across the island of Ireland to improve their ability to prevent, recognise, and manage delirium alongside interdisciplinary colleagues.

METHODS

Utilising a logic model, three workstreams have been identified. Workstream 1 will comprise three phases: (1) a systematic review identifying the format, methods, and content of existing digital delirium education interventions for health profession students, and their effect on knowledge, self-efficacy, and behavioural change; (2) focus groups with health profession students to determine awareness and experiences of delirium care; and (3) a Delphi survey informed by findings from the systematic review, focus groups, and input from the research team and expert reference group to identify resource priorities. Workstream 2 will involve the co-design of the digital resource through workshops (n = 4) with key stakeholders, including health profession students, professionals, and individuals with lived experience of delirium. Lastly, Workstream 3 will involve a mixed methods evaluation of the digital resource. Outcomes include changes to delirium knowledge and self-efficacy towards delirium care, and health profession students experience of using the resource.

DISCUSSION

Given the dearth of interdisciplinary educational resources on delirium for health profession students, a co-designed, interprofessional, digital education resource will be well-positioned to shape undergraduate delirium education. This research may enhance delirium education and the self-efficacy of future health professionals in providing delirium care, thereby improving practice and patients' experiences and outcomes.

TRIAL REGISTRATION

Not applicable.

A Toolkit for Delirium Identification and Promoting Partnerships Between Carers and Nurses: A Pilot Pre-Post Feasibility Study

BACKGROUND

Delirium is frightening for people experiencing it and their carers, and it is the most common hospital-acquired complication worldwide. Delirium is associated with higher rates of morbidity, mortality, residential care home admission, dementia, and carer stress and burden, yet strategies to embed the prevention and management of delirium as part of standard hospital care remain challenging. Carers are well placed to recognize subtle changes indicative of delirium, and partner with nurses in the prevention and management of delirium.

OBJECTIVE

To evaluate a Prevention & Early Delirium Identification Carer Toolkit (PREDICT), to support partnerships between carers and nurses to prevent and manage delirium.

DESIGN

A pre-post-test intervention and observation study.

MAIN MEASURES

Changes in carer knowledge of delirium; beliefs about their role in partnering with nurses and intended and actual use of PREDICT; carer burden and psychological distress. Secondary measures were rates of delirium.

PARTICIPANTS

Participants were carers of Indigenous patients aged 45 years and older and non-Indigenous patients aged 65 years and older.

INTERVENTION

Nurses implemented PREDICT, with a view to provide carers with information about delirium and strategies to address caregiving stress and burden.

KEY RESULTS

Participants included 25 carers (43% response rate) (n = 17, 68% female) aged 29-88 (M = 65, SD = 17.7 years). Carer delirium knowledge increased significantly from pre-to-post intervention (p =  < .001; CI 2.07-4.73). Carers' intent and actual use of PREDICT was (n = 18, 72%; and n = 17, 68%). Carer burden and psychological distress did not significantly change. The incidence of delirium in the intervention ward although not significant, decreased, indicating opportunity for scaling up.

CONCLUSION

The prevention and management of delirium are imperative for safe and quality care for patients, carers, and staff. Further comprehensive and in-depth research is required to better understand underlying mechanisms of change and explore facets of nursing practice influenced by this innovative approach.

Development and validation of a delirium care critical-thinking scale for intensive care unit nurses: A mixed-method study

AIM AND OBJECTIVES

To develop a Delirium Care Critical-Thinking Scale for nurses caring for patients in the intensive care unit and examine the scale's psychometric properties.

BACKGROUND

There is a tool to evaluate nurses' critical thinking skills to determine nursing competency when delirium care is required.

DESIGN

This cross-sectional, mixed-methods study.

METHODS

The Delphi method was applied for collection and analysis of data during conceptualization and item generation of the tool (Phase I). Item analysis, assessment of validity and reliability of the scale (Phase II) involved 318 nurses recruited by convenience sampling from nine adult intensive care units in medicine and surgery at one medical centre. Confirmatory factor analysis assessed construct validity. Internal consistency and 2-week test-retest stability measured reliability. A Critical Thinking Disposition Inventory Scale examined concurrent validity.

RESULTS

After three rounds, the Delphi method resulted in 31 scale items. Item analysis demonstrated construct reliability ranged from 9.23 to 16.18. Confirmatory factor analysis eliminated one item and extracted five factors: applying knowledge, confirming the problem and accuracy of information, reasoning logically, choosing appropriate strategies and remaining open-minded. Average variance extracted values of all factors indicated good convergent validity. Cronbach's α for internal consistency was .96 with good test-retest reliability. The correlation coefficient for concurrent validity was .301.

CONCLUSION

The new Delirium Care Critical-Thinking Scale for intensive care nurses was demonstrated to be a reliable and valid tool for evaluating their ability to assess patients with delirium.

RELEVANCE TO CLINICAL PRACTICE

This new scale could be used to assess outcomes of education interventions and the effectiveness of nursing care quality involving patients with delirium in intensive and critical care units.

REPORTING METHOD

The COSMIN checklist was used as the reporting guideline for this study.

PATIENT OR PUBLIC CONTRIBUTION

None.

Effect of a prophylactic dressing for sacral pressure injuries in non-critically ill patients after general surgery: A randomized controlled trial

BACKGROUND

Hospital-acquired pressure injuries are strongly associated with surgeries performed under general anesthesia.

AIMS

The aim of this study was to evaluate the effects of using a prophylactic multi-layer soft silicone foam dressing in non-critically ill patients with a Braden Scale score of ≤18 after undergoing routine surgery without sacral pressure injuries.

METHODS

This randomized controlled trial included 156 patients who were admitted for surgery under general anesthesia in a tertiary general hospital. The patients were divided into a control group and an intervention group. A 5-layer soft silicone foam dressing was applied to the sacrum of patients in the intervention group immediately after surgery. For the control group, standard pressure injury prevention activities were performed alongside standard care without preventive dressings.

RESULTS

There were no significant differences in general and clinical characteristics between the two groups; however, the incidence of pressure injury and blanching erythema was higher in the control group, showing a significant difference from the experimental group. Factors influencing the development of pressure injuries and blanching erythema through multivariate regression analysis were prophylactic dressing application and Braden Scale score at the time of admission. A statistically significant difference was noted in survival time from pressure injury between both groups.

LINKING EVIDENCE TO ACTION

The incidence of pressure injuries and blanching erythema was lower when the prophylactic dressing was applied with standard protocol for general ward patients after surgery. Accurate evaluation of the patient's skin condition and pressure injury risk assessment before surgery are important. Progressive prophylactic dressings to prevent pressure injuries are effective, and tailored nursing interventions based on accurate assessment of patient's skin condition and risk factors are essential for maintaining skin integrity.

Validation of Two Screening Tools for Detecting Delirium in Older Patients in the Post-Anaesthetic Care Unit: A Diagnostic Test Accuracy Study

(1) Background: Delirium is a common complication among surgical patients after major surgery, but it is often underdiagnosed in the post-anaesthetic care unit (PACU). Valid and reliable tools are required for improving diagnoses of delirium. The objective of this study was to evaluate the diagnostic test accuracy of the Three-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM) and the 4A's Test (4AT) as screening tools for detection of delirium in older people in the PACU. (2) Methods: A prospective diagnostic test accuracy study was conducted in the PACU and surgical wards of a university-affiliated tertiary care hospital in Victoria, Australia. A consecutive prospective cohort of elective and emergency patients (aged 65 years or older) admitted to the PACU were recruited between July 2021 and December 2021 following a surgical procedure performed under general anaesthesia and expected to stay in the hospital for at least 24 h following surgery. The outcome measures were sensitivity, specificity positive predictive value and negative predictive value for 3D-CAM and 4AT. (3) Results: A total of 271 patients were recruited: 16.2% (44/271) had definite delirium. For a diagnosis of definite delirium, the 3D-CAM (area under curve (AUC) = 0.96) had a sensitivity of 100% (95% CI 92.0 to 100.0) in the PACU and during the first 5 days post-operatively. Specificity ranged from 93% (95% CI 87.8 to 95.2) to 91% (95% CI 85.9 to 95.2) in the PACU and during the first 5 days post-operatively. The 4AT (AUC = 0.92) had a sensitivity of 93% (95% CI 81.7 to 98.6) in the PACU and during the first 5 days post-operatively, and specificity ranged from 89% (95% CI 84.6 to 93.1) to 87% (95%CI 80.9 to 91.8) in the PACU and during the first 5 days post-operatively. (4) Conclusions: The 3D-CAM and the 4AT are sensitive and specific screening tools that can be used to detect delirium in older people in the PACU. Screening with either tool could have an important clinical impact by improving the accuracy of delirium detection in the PACU and hence preventing adverse outcomes associated with delirium.

Evaluation of the association of anticholinergic burden and delirium in older hospitalised patients - A cohort study comparing 19 anticholinergic burden scales

AIMS

A recent review identified 19 anticholinergic burden scales (ABSs) but no study has yet compared the impact of all 19 ABSs on delirium. We evaluated whether a high anticholinergic burden as classified by each ABS is associated with incident delirium.

METHOD

We performed a retrospective cohort study in a Swiss tertiary teaching hospital using data from 2015-2018. Included were patients aged ≥65, hospitalised ≥48 hours with no stay >24 hours in intensive care. Delirium was defined twofold: (i) ICD-10 or CAM and (ii) ICD-10 or CAM or DOSS. Patients' cumulative anticholinergic burden score, calculated within 24 hours after admission, was classified using a binary (<3: low, ≥3: high burden) and a categorical approach (0: no, 0.5-3: low, ≥3: high burden). Association was analysed using multivariable logistic regression.

RESULTS

Over 25 000 patients (mean age 77.9 ± 7.6 years) were included. Of these, (i) 864 (3.3%) and (ii) 2770 (11.0%) developed delirium. Depending on the evaluated ABS, 4-63% of the patients were exposed to at least one anticholinergic drug. Out of 19 ABSs, (i) 14 and (ii) 16 showed a significant association with the outcomes. A patient with a high anticholinergic burden score had odds ratios (ORs) of 1.21 (95% confidence interval [CI]: 1.03-1.42) to 2.63 (95% CI: 2.28-3.03) for incident delirium compared to those with low or no burden.

CONCLUSION

A high anticholinergic burden within 24 hours after admission was significantly associated with incident delirium. Although prospective studies need to confirm these results, discontinuing or substituting drugs with a score of ≥3 at admission might be a targeted intervention to reduce incident delirium.

Positive scores on the 4AT delirium assessment tool at hospital admission are linked to mortality, length of stay and home time: two-centre study of 82,770 emergency admissions

BACKGROUND

Studies investigating outcomes of delirium using large-scale routine data are rare. We performed a two-centre study using the 4 'A's Test (4AT) delirium detection tool to analyse relationships between delirium and 30-day mortality, length of stay and home time (days at home in the year following admission).

METHODS

The 4AT was performed as part of usual care. Data from emergency admissions in patients ≥65 years in Lothian, UK (n = 43,946) and Salford, UK (n = 38,824) over a period of $\sim$3 years were analysed using logistic regression models adjusted for age and sex.

RESULTS

4AT completion rates were 77% in Lothian and 49% in Salford. 4AT scores indicating delirium (≥4/12) were present in 18% of patients in Lothian, and 25% of patients in Salford. Thirty-day mortality with 4AT ≥4 was 5.5-fold greater than the 4AT 0/12 group in Lothian (adjusted odds ratio (aOR) 5.53, 95% confidence interval [CI] 4.99-6.13) and 3.4-fold greater in Salford (aOR 3.39, 95% CI 2.98-3.87). Length of stay was more than double in patients with 4AT scores of 1-3/12 (indicating cognitive impairment) or ≥ 4/12 compared with 4AT 0/12. Median home time at 1 year was reduced by 112 days (Lothian) and 61 days (Salford) in the 4AT ≥4 group (P < 0.001).

CONCLUSIONS

Scores on the 4AT used at scale in practice are strongly linked with 30-day mortality, length of hospital stay and home time. The findings highlight the need for better understanding of why delirium is linked with poor outcomes and also the need to improve delirium detection and treatment.

Postoperative delirium screening tools for post-anaesthetic adult patients in non-intensive care units: A systematic review and meta-analysis

AIMS AND OBJECTIVES

To identify the most accurate postoperative delirium screening tools for detecting postoperative delirium among patients who underwent general anaesthesia surgery in general wards.

BACKGROUND

The lack of detection of postoperative delirium can negatively affect the patient's condition, along with their postoperative treatment and rehabilitation, and it can prolong their hospitalisation, persists cognitive dysfunction and increases mortality. Screening for postoperative delirium in hospitalised patients as nursing assessment is routine clinical practice for early detection.

DESIGN

A systematic review and meta-analysis.

METHODS

MEDLINE, Embase, CINAHL, KoreaMed and Cochrane electronic databases were searched using the key words delirium, postoperative, assessment or screening, and adult for articles published up to April 2020, with no limit on the year of publishing. Only prospective cohort studies reporting sensitivity and specificity values were included. We followed the recommendations of the Cochrane Handbook of Diagnostic Test Accuracy Reviews and the PRISMA checklist. The Quality Assessment of the Diagnostic Accuracy Studies-2 tool was used for data extraction and quality assessment, while a bivariate random-effects meta-analysis model was used for pooling and comparing diagnostic accuracy and providing a summary of evidence.

RESULTS

Six delirium assessment tools were evaluated from nine papers including 3088 patients. Due to the limited number of papers, the meta-analysis included the Confusion Assessment Method (CAM) and its variants, Delirium Detection Score (DDS) and Nurses' Delirium Screening Checklist (NuDESC). Overall, NuDESC demonstrated higher sensitivity than CAM or DDS, while all showed high specificity (0.90 or greater).

CONCLUSION

This review suggested that NuDESC can be employed as an accurate screening tool with high specificity for assessing postoperative delirium during routine checkups. However, it is necessary to consider suitable cut-off values, which is the reference point, in accordance with the clinical setting and the patients' condition.

RELEVANCE TO CLINICAL PRACTICE

NuDESC reported the best evidence of diagnostic accuracy, and we recommend clinical nurses to employ this easy-to-use and validated tool for daily screening of postoperative delirium in general wards to facilitate its early detection and the accurate estimation of its prevalence.

Delirium awareness day: a portuguese perspective

Delirium is a syndrome characterized by impairment of awareness and inattention, that represents a change from the patient's baseline cognitive functioning. It is triggered by an underlying medical condition, reaching a prevalence of 24.7% in geriatric wards. However, undiagnosed delirium remains a reality among inpatient individuals, with an estimated frequency of 24.1%. The inappropriate knowledge of diagnostic criteria and standard screening tools was pointed out as a relevant contributing factor to this paradigm.

Liaison Psychiatry Services guarantee psychiatric approach and treatment to patients attending general hospitals. Considering that older adult patient care requires a well-trained and skilled team, the Centro Hospitalar e Universitário de Coimbra has a Geriatric Psychiatry Liaison Service, where delirium is one of the prevailing clinical conditions assessed by this team. The International Delirium Awareness Day is going to be worldwide celebrated on the 11th of March. Given that delirium has been consistently associated with the economic burden and adverse outcomes this symbolic day works as a huge opportunity to raise insight into the preventive strategies that could be implemented among healthcare professionals, patients, and caregivers. Within the Portuguese National Health System there is a need to build a set of systematic epidemiological data about delirium prevalence and incidence in the different settings and it would be essential the employment of a multicomponent intervention package delivered by a multidisciplinary team trained and competent in delirium prevention into routine care.

Delirium: A Marker of Vulnerability in Older People

Delirium is an acute neuropsychiatric syndrome and one of the most common presenting symptoms of acute medical illnesses in older people. Delirium can be triggered by a single cause, but in most cases, it is multifactorial as it depends on the interaction between predisposing and precipitating factors. Delirium is highly prevalent in older patients across various settings of care and correlates with an increased risk of adverse clinical outcomes. Several pathophysiological mechanisms may contribute to its onset, including neurotransmitter imbalance, neuroinflammation, altered brain metabolism, and impaired neuronal network connectivity. Several screening and diagnostic tools for delirium exist, but they are unfortunately underutilized. Additionally, the diagnosis of delirium superimposed on dementia poses a formidable challenge – especially if dementia is severe. Non-pharmacological approaches for the prevention and multidomain interventions for the treatment of delirium are recommended, given that there is currently no robust evidence of drugs that can prevent or resolve delirium. This article aims to review the current understanding about delirium in older people. To achieve this goal, we will describe the epidemiology and outcomes of the syndrome, the pathophysiological mechanisms that are supposed to be involved, the most commonly used tools for screening and diagnosis, and prevention strategies and treatments recommended. This review is intended as a brief guide for clinicians in hospital wards to improve their knowledge and practice. At the end of the article, we propose an approach to improve the quality of care provided to older patients throughout a systematic detection of delirium.

Delirium researchers' perspectives of the challenges in delirium biomarker research: A qualitative study

Background

Despite the prevalence and impact of delirium, its pathophysiology remains unclear. In order to advance this field of research, robust scientific methodology is required, yet quality of reporting in this field of research has been highly inconsistent. Delirium biomarker research poses several challenges, none of which have been documented in the literature before. The aim of this study was to explore the perspectives of delirium researchers about key methodological issues in delirium biomarker research.

Methods

Following a Delphi study with delirium experts resulting in 60 recommendations for reporting delirium biomarker studies, semi-structured interviews with international delirium researchers were conducted. Interviews were audio-taped and transcribed verbatim, followed by thematic analysis of the qualitative data.

Results

Fifteen participants were interviewed between August and November 2019. Most were male (n = 12; 75%), clinician researchers (n = 13; 86%), and had more than ten years’ experience in conducting delirium research (n = 9; 60%). Analysis revealed two major themes and ten sub-themes, outlining key considerations to advance the field of delirium biomarker research. The major themes were: 1) Practical and scientific challenges of delirium biomarker research: stagnation versus driving improved methods and reporting; and 2) Valuing delirium research through investment and collaboration.

Conclusion

Findings identified a range of factors that contribute to the practical and ethical challenges of conducting delirium biomarker research, which have not previously been explicitly acknowledged or reported. A clear vision for collaborative efforts to enhance research quality for improved impact was also presented by the delirium researchers. This work complements the preceding Delphi and together these studies provide an in-depth understanding of what is needed in the field to inform and improve methods and reporting of delirium biomarker research.

Evaluation of a delirium awareness podcast for undergraduate nursing students in Northern Ireland: a pre-/post-test study

BACKGROUND

Delirium is a common disorder affecting several people in primary, secondary, and tertiary settings. The condition is frequently under-diagnosed leading to long-lasting physical and cognitive impairment or premature death. Despite this, there has been limited research on the impact of innovative approaches to delirium education amongst undergraduate nursing students. The aim of this study was to evaluate the effect of a delirium awareness podcast on undergraduate nursing student knowledge and confidence related to the condition in Northern Ireland.

METHODS

The intervention was a 60-min delirium awareness podcast, available throughout May 2020, to a convenience sample of year one undergraduate nursing students (n = 320) completing a BSc Honours Nursing degree programme in a Northern Ireland University. The podcast focused on how nursing students could effectively recognise, manage, and prevent delirium. Participants had a period of 4 weeks to listen to the podcast and complete the pre and post questionnaires. The questionnaires were comprised of a 35-item true-false Delirium Knowledge Questionnaire (DKQ), a 3-item questionnaire about professional confidence and a 7-item questionnaire evaluating the use of podcasting as an approach to promote knowledge and confidence about delirium. Data were analysed using paired t-tests and descriptive statistics.

RESULTS

Students improved across all three core areas in the post-test questionnaire, demonstrating improvements in knowledge about symptoms of delirium (7.78% increase), causes and risk factors of delirium (13.34% increase) and management of delirium (12.81% increase). In relation to perceived confidence, students reported a 46.50% increase in confidence related to recognition of delirium, a 48.32% increase in relation to delirium management and a 50.71% increase their ability to communicate about delirium. Both questionnaires were statistically significant (P < 0.001). The final questionnaire illustrated that nursing students positively evaluated the use of podcast for promoting their knowledge and confidence about delirium and 96.32% of nursing students believed that the podcast met their learning needs about delirium.

CONCLUSIONS

A 60-min podcast on delirium improved first year student nurse knowledge about delirium. Nursing students also expressed that this approach to delirium education was effective in their learning about the condition.

Diagnostic Test Accuracy of the 4AT for Delirium Detection: A Systematic Review and Meta-Analysis

Under-recognition of delirium is an international problem. For the early detection of delirium, a feasible and valid screening tool for healthcare professionals is needed. This study aimed to present a scientific reason for using the 4 'A's Test (4AT) through a systematic review and meta-analysis of studies on the diagnostic test accuracy. We systematically searched articles in the EMBASE, MEDLINE, CINAHL, and PsycINFO databases and selected relevant articles on the basis of the predefined inclusion criteria. The quality of the included articles was evaluated using the Quality Assessment of the Diagnostic Accuracy Studies-2 tool. We estimated the pooled values of diagnostic test accuracy by employing the bivariate model and the hierarchical summary receiver operating characteristic (HSROC) model in data synthesis. A total of 3729 patients of 13 studies were included in the analysis. The pooled estimates of sensitivity and specificity of the 4AT were 81.5% (95% confidence interval: 70.7%, 89.0%) and 87.5% (79.5%, 92.7%), respectively. Given the 4AT's evidence of accuracy and practicality, we suggest healthcare professionals to utilize this tool for routine screening of delirium. However, for detecting delirium in the dementia population, further work is required to evaluate the 4AT with other cut-off points or scoring methods in order for it to be more sensitive and specific.

Evaluation of a co-produced delirium awareness programme for undergraduate nursing students in Northern Ireland: a pre-test/post-test study

BACKGROUND

Delirium is recognised internationally as a common disorder that causes acute deterioration in a person's cognitive abilities. Healthcare professionals play a key role in the early identification and management of delirium and effective education can support timely recognition and treatment. There is currently a lack of research exploring the delirium education provided to undergraduate nursing students. The aim of this study was to evaluate the effectiveness of a co-produced delirium awareness programme on undergraduate nursing students in Northern Ireland.

METHODS

The intervention was a 2-h delirium workshop, delivered in April 2019, to a convenience sample of year one undergraduate nursing students (n = 206) completing a BSc Honours Nursing degree programme in a Northern Ireland University. The workshop focused on four core elements: defining delirium, reflecting on practice, recognition of delirium and management of delirium. Participants completed a 35-item true-false Delirium Knowledge Questionnaire (DKQ) at baseline and post intervention using Socrative, a cloud-based student response system. In addition, students also completed a short questionnaire at baseline and post-workshop, designed by the authors, to ascertain perceived confidence about caring for people with delirium. Data were analysed using paired t-tests and descriptive statistics.

RESULTS

In the DKQ, Scores were normally distributed around the mean at baseline (71.89%) and post intervention (81.89%). Students improved across all three core areas in the post-test questionnaire, demonstrating improvements in knowledge about symptoms of delirium (7.32% increase), causes and risk factors of delirium (17.91% increase) and management of delirium (5.72% increase). In relation to perceived confidence, students reported a 60.20% increase in confidence related to recognition of delirium, a 49.51% increase in relation to delirium management and a 45.04% increase their ability to communicate about delirium. Both questionnaires were statistically significant (P < 0.01).

CONCLUSIONS

A 2-h workshop on delirium improved first year student nurse knowledge about delirium. Nursing students expressed that this approach to delirium education enabled collective thinking about how knowledge could be transferred into individual practises. Students also stated that learning incorporating the voice of the person who has experienced delirium, was an effective and powerful way to deliver education.

[Prevalence of cognitive impairments in acute nursing care-Analysis and comparison of routine data]

Hintergrund

Aufgrund des demografischen Wandels ist von einer zunehmenden Prävalenz stationärer Patienten mit kognitiven Beeinträchtigungen auszugehen. Für eine bestmögliche Versorgung gilt es, diese Patientengruppe mit einem routinemäßigen Verfahren frühzeitig zu erkennen.

Methode

Die aktuelle Studie untersuchte die Prävalenzrate von kognitiven Beeinträchtigungen bei stationären Patienten >65 Jahre, die mit dem Mini-Mental-Status-Test (MMST) während der pflegerischen Aufnahme untersucht wurden. Anhand der Screeningquote wurde die Bereitschaft von Pflegekräften, den MMST als Routineinstrument zu verwenden, überprüft. Die Quote wurde zudem mit der Anzahl der kodierten F‑Diagnosen der ICD-10-GM verglichen. Diese retrospektive Studie wurde vom Oktober 2018 bis März 2019 an einer Universitätsklinik durchgeführt.

Ergebnisse

Von 7311 stationären Patienten >65 Jahre wurden 11,7 % gescreent. Die Prävalenz kognitiver Beeinträchtigungen betrug 20,7 % und war höher als die Prävalenzrate von Demenz und Delir aufgrund medizinischer Diagnosen (p < 0,001). Mit 11,7 % ist die Bereitschaft des Pflegepersonals, den MMST zur Einschätzung kognitiver Beeinträchtigungen während der Patientenaufnahmen einzusetzen, gering.

Diskussion

Die höhere Prävalenz bestätigt die Notwendigkeit, Patienten mit kognitiven Störungen zu erkennen. Die geringe Bereitschaft, den MMST anzuwenden, legt jedoch nahe, dass zum einen ein kürzeres Instrument verwendet und zum anderen Pflegenden mehr Informationen zu kognitiv beeinträchtigten Patienten vermittelt werden sollten.

Capacity issues at the front door

Decision-making capacity is often overestimated by clinicians. An average of one third of patients lack capacity to make complex decisions and clinicians should be alert to such a possibility. Cognitive impairment, acute infection, intoxication and other common medical and psychiatric problems can impair patients' capacity. The Mental Capacity Act 2005 has to be applied when treating patients who lack capacity. The main decision maker for a proposed treatment or investigation is responsible for assessing capacity. However, all clinicians have to consider and assess capacity, and act in a patient's best interests if he/she lacks capacity.