Improving delirium care through early intervention: from bench to bedside to boardroom

The effects of environmental interventions for delirium in critically ill surgical patients

BACKGROUND

Delirium occurs at high rates among patients in intensive care units and increases the risk of morbidity and mortality. The purpose of this study was to investigate the effects of environmental interventions on delirium.

METHODS

This prospective cohort study enrolled 192 patients admitted to the surgical intensive care unit (SICU) during the pre-intervention (June 2013 to October 2013) and post-intervention (June 2014 to October 2014) periods. Environmental interventions involved a cognitive assessment, an orientation, and a comfortable environment including proper sleep conditions. The primary outcomes were the prevalence, duration, and onset of delirium.

RESULTS

There were no statistically significant differences in incidence rate, time of delirium onset, general characteristics, and mortality between the pre-intervention and post-intervention groups. The durations of delirium were 14.4±19.1 and 7.7±7.3 days in the pre-intervention and post-intervention groups, respectively, a significant reduction (P=0.027). The lengths of SICU stay were 20.0±22.9 and 12.6±8.7 days for the pre-intervention and post-intervention groups, respectively, also a significant reduction (P=0.030).

CONCLUSIONS

The implementation of an environmental intervention program reduced the duration of delirium and length of stay in the SICU for critically ill surgical patients.

The Confusion Assessment Method in action: Implementation of a protocol to increase delirium screening and diagnosis

The use of the Confusion Assessment Method (CAM) for delirium assessment in real-life can be inconsistent. We examined the impact of a protocol on delirium screening and detection in hospitalized older adults using the CAM. We analyzed data from 32,338 admissions to a quaternary hospital between 2018 and 2022. We assessed the percentage of admissions screened for delirium, adherence to daily screening, positive screening, and overlap with ICD-10 coding. The percentage of admissions screened for delirium increased from 74% in 2018 to 98.7% in 2022. Adherence to daily screening was achieved in 24.5% of admissions, and the percentage of positive screenings fluctuated between 8.4% and 11.5%. Among the admissions with a delirium-related ICD-10 code, 32% had a positive screening, 62% were negative, and 6% remained unscreened. While implementing a protocol increased the proportion of admissions screened for delirium, adherence to daily screening and consistency of positive delirium screenings remain areas for improvement.

Delirium occurrence in older Irish adults admitted to an acute medical hospital: a prospective cohort study

OBJECTIVES

Delirium, which is associated with adverse health outcomes, is poorly detected in hospital settings. This study aimed to determine delirium occurrence among older medical inpatients and to capture associated risk factors.

METHODS

This prospective cohort study was performed at an Irish University Hospital. Medical inpatients 70 years and over were included. Baseline assessments within 72 hours of admission included delirium status and severity as determined by the Revised Delirium Rating Scale (DRS-R-98), cognition, physical illness severity and physical functioning. Pre-existing cognitive impairment was determined with Short Informant Questionnaire on Cognitive Decline (IQCODE). Serial assessment of delirium status, cognition and the physical illness severity were undertaken every 3 (±1) days during participants' hospital admission.

RESULTS

Of 198 study participants, 92 (46.5%) were women and mean age was 80.6 years (s.d. 6.81; range 70-97). Using DRS-R-98, 17.7% (n = 35) had delirium on admission and 11.6% (n = 23) had new-onset delirium during admission. In regression analysis, older age, impaired cognition and lower functional ability at admission were associated with a significant likelihood of delirium.

CONCLUSIONS

In this study, almost one-third of older medical inpatients in an acute hospital had delirium during admission. Findings that increasing age, impaired cognition and lower functional ability at admission were associated with increased delirium risk suggest target groups for enhanced delirium detection and prevention strategies. This may improve clinical outcomes.

Comparison of verbal and computerised months backwards tests in a hospitalized older population

BACKGROUND

Delirium is extremely prevalent, yet underdiagnosed, in older patients and is associated with prolonged length of hospital stay and higher mortality rates. Impaired attention is the cardinal deficit in delirium and is a required feature in diagnostic criteria. The verbal months backwards test (MBT) is the most sensitive bedside test of attention, however, hospital staff occasionally have difficulty with its administration and interpretation. We hypothesise that the MBT on an electronic tablet may be easier and more consistent to use for both experienced and unexperienced medical professionals and, if the diagnostic efficacy was similar, aid delirium diagnosis.

AIM

We aim to investigate the correlation of the verbal MBT with a computerised MBT application.

METHODS

Participants recruited (age > 65, n = 75) were allocated to different cohorts (Dementia and Delirium (DMDL), Dementia (DM), Delirium (DL), No Neurocognitive Disorder (NNCD)) and were administered both the verbal and electronic versions.

RESULTS

Correlation between measurements were: overall Spearman's rho = 0.772 (p < 0.0001); DMDL rho = 0.666 (p < 0.0001); DL rho = 0.778 (p = 0.039); DM rho = 0.378 (p = 0.203); NNCD rho = 0.143 (p = 0.559).

DISCUSSION

Overall, and for the delirious subset, statistically significant agreement was present. Poor inter-test correlation existed in the groups without delirium (DM, NNCD).

CONCLUSIONS

The MBTc correlates well with the MBTv in patients who are clinically suspected to have delirium but has poor correlation in patients without delirium. Visuospatial cognition and psychomotor deficits in a dementia cohort and mechanical factors (such as tremor, poor fingernail hygiene and visual impairment) in a group with no neurocognitive disorder may limit the utility of the MBTc in a hospitalised older population.

Mental disorders, psychopharmacological treatments, and mortality in 2150 COVID-19 Spanish inpatients

OBJECTIVE

To determine how mental disorders and psychopharmacological treatments before and during COVID-19 hospital admissions are related to mortality.

METHODS

Subjects included in the study were all adult patients with a diagnosis of COVID-19, confirmed clinically and by PCR, who were admitted to a tertiary university hospital in Badalona (Spain) between March 1 and November 17, 2020. Data were extracted anonymously from computerized clinical records.

RESULTS

2,150 subjects were included, 57% males, mean age 61 years. History of mental disorders was registered in 957 (45%). Throughout admission, de novo diagnosis of mood or anxiety, stress, or adjustment disorder was made in 12% of patients without previous history. Delirium was diagnosed in 10% of cases. 1011 patients (47%) received a psychotropic prescription during admission (36% benzodiazepines, 22% antidepressants, and 21% antipsychotics). Mortality rate was 17%. Delirium during admission and history of mood disorder were independently associated with higher mortality risk (hazard ratios, 1.39 and 1.52 respectively), while previous year's treatments with anxiolytics/hypnotics and antidepressants were independently associated with lower mortality risk (hazard ratios, 0.47 and 0.43, respectively).

CONCLUSION

Mental symptoms are very common in patients hospitalized for COVID-19 infection. Detecting, diagnosing, and treating them is key to determining the prognosis of the disease and functional recovery.

A systematic review and meta-analysis of the accuracy of the clock drawing test (CDT) in the identification of delirium in older hospitalised patients

Objective: Delirium is a common neurocognitive syndrome among hospitalised older adults. The clock drawing test (CDT) is a relatively simple bedside test of cognitive function. This systematic review and meta-analysis examine the accuracy of the CDT in identifying delirium in hospitalised older adults.Methods: PRISMA guidelines were used to report the identified studies. Pubmed, SCOPUS, and Ovid and EBSCO platforms (including MEDLINE ®, PsycINFO, PsycEXTRA, EMCARE, CINAHL and EMBASE databases) were searched. Studies were assessed for methodological quality using the Downs and Black Tool. Data were extracted regarding the number of delirious/not delirious, number with normal and abnormal CDT, age, and MMSE scores, and information regarding CDT scoring, criteria for diagnosis of delirium and setting of the study. Analysis was carried out with the "Mada" and "Metatron" packages of R software.Results: Fifteen studies were examined. The number of participants was 2199, of whom 597 (27.15%) were diagnosed with delirium. The overall sensitivity of CDT in the absence of any formal cognitive test was 0.76 (0.58-0.87) with specificity of 0.70 (0.51-0.83). When the MMSE was taken into account, the specificity and sensitivity reduced to 0.51. Diagnostic criteria for delirium, scoring method of CDT, age of participants and setting significantly (p < 0.05) affect the sensitivity and specificity of the CDT.Conclusion: Although, the CDT is generally considered to be a simple and easy to administer screening tool for cognitive impairment in older hospitalised adults, when a more formal cognitive test is used its sensitivity and specificity to detect delirium is low.

Comparison of novel tools with traditional cognitive tests in detecting delirium in elderly medical patients

BACKGROUND

Efficient detection of delirium and comorbid delirium-dementia is a key diagnostic challenge. Development of new, efficient delirium-focused methods of cognitive assessment is a key challenge for improved detection of neurocognitive disorders in everyday clinical practice.

AIM

To compare the accuracy of two novel bedside tests of attention, vigilance and visuospatial function with conventional bedside cognitive tests in identifying delirium in older hospitalized patients.

METHODS

180 consecutive elderly medical inpatients (mean age 79.6 ± 7.2; 51% female) referred to a psychiatry for later life consultation-liaison service with delirium, dementia, comorbid delirium-dementia and cognitively intact controls. Participants were assessed cross-sectionally with conventional bedside cognitive tests [WORLD, Months Backward test (MBT), Spatial span, Vigilance A and B, Clock Drawing test and Interlocking Pentagons test] and two novel cognitive tests [Lighthouse test, Letter and Shape Drawing test (LSD)-4].

RESULTS

Neurocognitive diagnoses were delirium (n = 44), dementia (n = 30), comorbid delirium-dementia (n = 60) and no neurocognitive disorder (n = 46). All conventional tests had sensitivity of > 70% for delirium, with best overall accuracy for the Vigilance-B (78.3%), Vigilance-A (77.8%) and MBT (76.7%) tests. The sustained attention component of the Lighthouse test was the most distinguishing of delirium (sensitivity 84.6%; overall accuracy 75.6%). The LSD-4 had sensitivity of 74.0% and overall accuracy 74.4% for delirium identification. Combining tests allowed for enhanced sensitivity (> 90%) and overall accuracy (≥ 75%) with the highest overall accuracy for the combination of MBT-Vigilance A and the combined Vigilance A and B tests (both 78.3%). When analyses were repeated for those with dementia, there were similar findings with the MBT-Vigilance A the most accurate overall combination (80.0%). Combining the Lighthouse-SA with the LSD-4, a fail in either test had sensitivity for delirium of 91.4 with overall accuracy of 74.4%.

CONCLUSION

Bedside tests of attention, vigilance and visuospatial ability can help to distinguish neurocognitive disorders, including delirium, from other presentations. The Lighthouse test and the LSD-4 are novel tests with high accuracy for detecting delirium.

Exploiting Machine Learning Algorithms and Methods for the Prediction of Agitated Delirium After Cardiac Surgery: Models Development and Validation Study

Background

Delirium is a temporary mental disorder that occasionally affects patients undergoing surgery, especially cardiac surgery. It is strongly associated with major adverse events, which in turn leads to increased cost and poor outcomes (eg, need for nursing home due to cognitive impairment, stroke, and death). The ability to foresee patients at risk of delirium will guide the timely initiation of multimodal preventive interventions, which will aid in reducing the burden and negative consequences associated with delirium. Several studies have focused on the prediction of delirium. However, the number of studies in cardiac surgical patients that have used machine learning methods is very limited.

Objective

This study aimed to explore the application of several machine learning predictive models that can pre-emptively predict delirium in patients undergoing cardiac surgery and compare their performance.

Methods

We investigated a number of machine learning methods to develop models that can predict delirium after cardiac surgery. A clinical dataset comprising over 5000 actual patients who underwent cardiac surgery in a single center was used to develop the models using logistic regression, artificial neural networks (ANN), support vector machines (SVM), Bayesian belief networks (BBN), naïve Bayesian, random forest, and decision trees.

Results

Only 507 out of 5584 patients (11.4%) developed delirium. We addressed the underlying class imbalance, using random undersampling, in the training dataset. The final prediction performance was validated on a separate test dataset. Owing to the target class imbalance, several measures were used to evaluate algorithm’s performance for the delirium class on the test dataset. Out of the selected algorithms, the SVM algorithm had the best F1 score for positive cases, kappa, and positive predictive value (40.2%, 29.3%, and 29.7%, respectively) with a P=.01, .03, .02, respectively. The ANN had the best receiver-operator area-under the curve (78.2%; P=.03). The BBN had the best precision-recall area-under the curve for detecting positive cases (30.4%; P=.03).

Conclusions

Although delirium is inherently complex, preventive measures to mitigate its negative effect can be applied proactively if patients at risk are prospectively identified. Our results highlight 2 important points: (1) addressing class imbalance on the training dataset will augment machine learning model’s performance in identifying patients likely to develop postoperative delirium, and (2) as the prediction of postoperative delirium is difficult because it is multifactorial and has complex pathophysiology, applying machine learning methods (complex or simple) may improve the prediction by revealing hidden patterns, which will lead to cost reduction by prevention of complications and will optimize patients’ outcomes.

Impact of an educational workshop upon psychiatrists' attitudes towards delirium care

OBJECTIVES

Improving knowledge about delirium care is a key target for health care. We describe the implementation of a four-part workshop focusing upon key aspects of delirium care.

METHODS

Attitudes towards and understanding of delirium diagnosis and management amongst psychiatrists were surveyed before and immediately after an educational workshop.

RESULTS

There were 62 participants. Pre-workshop, delirium was rated highly relevant to psychiatry. Overall level of confidence in diagnosis was modest, with the behavioural and psychological symptoms of dementia considered the most challenging differential diagnosis. Only nine participants (15%) correctly identified DSM-5 delirium criteria. Preferred assessment of attention varied with six different approaches endorsed. Confidence was higher for managing hyperactive compared with hypoactive delirium (p&lt;0.001). Pharmacotherapy was more frequently endorsed for hyperactive compared with hypoactive presentations, with haloperidol the most popular agent (p&lt;0.001). A total of 41 (66%) participants completed post-workshop assessments. Post-workshop, there were significant increases to the perceived relevance of delirium (p = 0.003), confidence in overall diagnosis (p&lt;0.001) accuracy of awareness of DSM-5 criteria (p&lt;0.001), and confidence in treating different presentations (p&lt;0.001). The Months Backward Test was the preferred bedside test of attention (38/40 respondents).

CONCLUSIONS

This interactive educational intervention impacted positively upon knowledge and attitudes amongst psychiatrists towards key aspects of delirium care. Further investigation can examine the impact upon longer term knowledge and behaviour.

Debate article: Antipsychotic medications are clinically useful for the treatment of delirium

Prescribing of antipsychotic medications for patients with delirium remains controversial. Concerns exist that these vulnerable and frail patients may be prescribed antipsychotics inappropriately as a substitute for non-pharmacological approaches when identifiable causes are not found or they challenge ward processes. Moreover, recent evidence suggests that antipsychotics may cause more harm than good in the palliative care patient group with delirium. On the other hand, guidelines in the United Kingdom and the Netherlands support prescribing of antipsychotics in certain circumstances, and a large European survey has revealed that antipsychotics tend to be prescribed first line for hyperactive delirium. Never before, therefore, is there a greater need to examine whether indeed these medications are clinically useful for the treatment of delirium. With this in mind, evidence-based arguments for and against prescribing antipsychotics for the treatment of delirium are presented in this debate article. The paper concludes with a moderation piece to help guide clinical practice.

Underdiagnosis of delirium in the elderly in acute care hospital settings: lessons not learned

BACKGROUND

Delirium is a common and poorly diagnosed cause of behavioral change in elderly. This study aimed to estimate the prevalence, diagnostic accuracy and factors associated with the onset of delirium in the elderly admitted to an urgency unit.

METHODS

Cross-sectional study including clinically stable subjects aged ≥60 years between April and June of 2014. Diagnosis of delirium based on the Confusion Assessment Method (CAM, gold standard) was compared to the subjective assessment made by physicians on duty as recorded in the medical chart. Association of sociodemographic, psychological/behavioural, and clinical variables with delirium was assessed using multivariate analysis.

RESULTS

A sample of 110 participants with a mean age of 72.7 ± 8.3 years was studied. Of these, 56.4% were men and 28.2% had a diagnosis of delirium on CAM. Significant associations were observed between delirium and male gender (P-value = 0.019), poor or very poor self-perception of health (P-value = 0.033), previous diagnosis of dementia (P-value = 0.001), previous history of stroke (P-value = 0.014), and acute bacterial infection (P-value = 0.008). Physician diagnosis had a sensitivity of 35.5%, specificity of 100%, and accuracy of 81.8% to detect delirium. Rate of misdiagnosis was 64.5%.

CONCLUSION

Delirium was underdiagnosed in this urgent care hospital setting.

Attention, vigilance, and visuospatial function in hospitalized elderly medical patients: relationship to delirium syndromal status and motor subtype profile

ABSTRACTBackground:The early and effective detection of neurocognitive disorders poses a key diagnostic challenge. We examined performance on common cognitive bedside tests according to differing delirium syndromal status and clinical (motor) subtypes in hospitalized elderly medical inpatients.

METHODS

A battery of nine bedside cognitive tests was performed on elderly medical inpatients with DSM-IV delirium, subsyndromal delirium (SSD), and no delirium (ND). Patients with delirium were compared according to clinical (motor) subtypes.

RESULTS

A total of 198 patients (mean age 79.14 ± 8.26) were assessed with full syndromal delirium (FSD: n = 110), SSD (n = 45), and ND (n = 43). Delirium status was not associated with differences in terms of gender distribution, age, or overall medication use. Dementia burden increased with greater delirium status. Overall, the ability to meaningfully engage with the tests varied from 59% for the Vigilance B test to 85% for Spatial Span Forward test and was lowest in patients with FSD, where engagement ranged from 32% for the Vigilance B test to 77% for the Spatial Span Forwards test. The ND group was distinguished from SSD group for the Months of the year backwards, Vigilance B, global VSP, Clock Drawing test, and Interlocking Pentagons test. The SSD group was distinguished from the FSD group by Vigilance A, Spatial Span Forward, and Spatial Span Backwards. Regarding differences among motor subtypes in terms of percentage engagement and performance, the No subtype group had higher ratings across all tests. Delirious patients with no subtype had significantly lower scores on the DRS-R98 than for the other three subtype categories.

CONCLUSIONS

Simple bedside tests of attention, vigilance, and visuospatial ability are useful in distinguishing neurocognitive disorders, including SSD from other presentations.

Palliative and end-of-life care research in Scotland 2006-2015: a systematic scoping review

Background

The Scottish Government set out its 5-year vision to improve palliative care in its Strategic Framework for Action 2016–2021. This includes a commitment to strengthening research and evidence based knowledge exchange across Scotland. A comprehensive scoping review of Scottish palliative care research was considered an important first step. The aim of the review was to quantify and map palliative care research in Scotland over the ten-year period preceding the new strategy (2006–15).

Methods

A systematic scoping review was undertaken. Palliative care research involving at least one co-author from a Scottish institution was eligible for inclusion. Five databases were searched with relevant MeSH terms and keywords; additional papers authored by members of the Scottish Palliative and End of Life Care Research Forum were added.

Results

In total, 1919 papers were screened, 496 underwent full text review and 308 were retained in the final set. 73% were descriptive studies and 10% were interventions or feasibility studies. The top three areas of research focus were services and settings; experiences and/or needs; and physical symptoms. 58 papers were concerned with palliative care for people with conditions other than cancer – nearly one fifth of all papers published. Few studies focused on ehealth, health economics, out-of-hours and public health. Nearly half of all papers described unfunded research or did not acknowledge a funder (46%).

Conclusions

There was a steady increase in Scottish palliative care research during the decade under review. Research output was strong compared with that reported in an earlier Scottish review (1990–2005) and a similar review of Irish palliative care research (2002–2012). A large amount of descriptive evidence exists on living and dying with chronic progressive illness in Scotland; intervention studies now need to be prioritised. Areas highlighted for future research include palliative interventions for people with non-malignant illness and multi-morbidity; physical and psychological symptom assessment and management; interventions to support carers; and bereavement support. Knowledge exchange activities are required to disseminate research findings to research users and a follow-up review to examine future research progress is recommended.

Electronic supplementary material

The online version of this article (10.1186/s12904-017-0266-0) contains supplementary material, which is available to authorized users.

Five short screening tests in the detection of prevalent delirium: diagnostic accuracy and performance in different neurocognitive subgroups

BACKGROUND

Delirium is prevalent and serious, yet remains under-recognised. Systematic screening could improve detection; however, consensus is lacking as to the best approach. Our aim was to assess the diagnostic accuracy of five simple cognitive tests in delirium screening: six-item cognitive impairment test (6-CIT), clock-drawing test, spatial span forwards, months of the year backwards (MOTYB) and intersecting pentagons (IPT).

METHODS

A cross-sectional study was conducted. Within 36 h of admission, older medical patients were assessed for delirium using the Revised Delirium Rating Scale. They also underwent testing using the five cognitive tests outlined above. Sensitivity, specificity, positive and negative predictive values (PPV; NPV) were calculated for each method. Where appropriate, area under the receiver operating characteristic curve (AUC) was also calculated.

RESULTS

Four hundred seventy patients were included, and 184 had delirium. Of the tests scored on a scale, the 6-CIT had the highest AUC (0.876), the optimum cut-off for delirium screening being 8/9 (sensitivity 89.9%, specificity 62.7%, NPV 91.2%, PPV 59.2%). The MOTYB, scored in a binary fashion, also performed well (sensitivity 84.6%, specificity 58.4%, NPV 87.4%, PPV 52.8). On discriminant analysis, 6-CIT was the only test to discriminate between patients with delirium and those with dementia (without delirium), Wilks' Lambda = 0.748, p < 0.001.

CONCLUSION

The 6-CIT measures attention, temporal orientation and short-term memory and shows promise as a delirium screening test. This study suggests that it may also have potential in distinguishing the cognitive impairment of delirium from that of dementia in older patients. Copyright © 2016 John Wiley & Sons, Ltd.

Sleep-wake cycle disturbances in elderly acute general medical inpatients: Longitudinal relationship to delirium and dementia

INTRODUCTION

Sleep disturbances in elderly medical inpatients are common, but their relationship to delirium and dementia has not been studied.

METHODS

Sleep and delirium status were assessed daily for a week in 145 consecutive newly admitted elderly acute general hospital patients using the Delirium Rating Scale-Revised-98 (DRS-R98), Diagnostic and Statistical Manual 5, and Richards-Campbell Sleep Quality Scale measures. The longitudinal relationship between DRS-R98 and Richards-Campbell Sleep Quality Scale sleep scores and delirium, also with dementia as a covariate, was evaluated using generalized estimating equation logistic regression.

RESULTS

The cohort was divided into delirium only, dementia only, comorbid delirium-dementia, and no-delirium/no-dementia subgroups. Mean age of total group was 80 ± 6.3, 48% were female, and 31 (21%) had dementia, 29 had delirium at admission (20%), and 27 (18.5%) experienced incident delirium. Mild sleep disturbance (DRS-R98 sleep item score ≥1) occurred for at least 1 day in all groups, whereas moderate sleep disturbance (score ≥2) occurred in significantly more of the prevalent delirium-only (81%; n = 17) cases than incident delirium-only (46%; n = 13) cases (P < .001). There were more cases with DRS-R98 sleep item scores ≥2 (P < .001) in the delirium-only group compared with the other subgroups. Severity of sleep-wake cycle disturbance over time was significantly associated with Diagnostic and Statistical Manual 5 delirium status but not with age, sex, or dementia (P < .001).

CONCLUSIONS

Observer-rated more severe sleep-wake cycle disturbances are highly associated with delirium irrespective of dementia status, consistent with being a core feature of delirium. Monitoring for altered sleep-wake cycle patterns may be a simple way to improve delirium detection.

Risk factors for incident delirium in an acute general medical setting: a retrospective case-control study

AIMS AND OBJECTIVES

To determine predisposing and precipitating risk factors for incident delirium in medical patients during an acute hospital admission.

BACKGROUND

Incident delirium is the most common complication of hospital admission for older patients. Up to 30% of hospitalised medical patients experience incident delirium. Determining risk factors for delirium is important for identifying patients who are most susceptible to incident delirium.

DESIGN

Retrospective case-control study with two controls per case.

METHODS

An audit tool was used to review medical records of patients admitted to acute medical units for data regarding potential risk factors for delirium. Data were collected between August 2013 and March 2014 at three hospital sites of a healthcare organisation in Melbourne, Australia. Cases were 161 patients admitted to an acute medical ward and diagnosed with incident delirium between 1 January 2012 and 31 December 2013. Controls were 321 patients sampled from the acute medical population admitted within the same time range, stratified for admission location and who did not develop incident delirium during hospitalisation.

RESULTS

Identified using logistic regression modelling, predisposing risk factors for incident delirium were dementia, cognitive impairment, functional impairment, previous delirium and fracture on admission. Precipitating risk factors for incident delirium were use of an indwelling catheter, adding more than three medications during admission and having an abnormal sodium level during admission.

CONCLUSIONS

Multiple risk factors for incident delirium exist; patients with a history of delirium, dementia and cognitive impairment are at greatest risk of developing delirium during hospitalisation.

RELEVANCE TO CLINICAL PRACTICE

Nurses and other healthcare professionals should be aware of patients who have one or more risk factors for incident delirium. Knowledge of risk factors for delirium has the potential to increase the recognition and understanding of patients who are vulnerable to delirium. Early recognition and prevention of delirium can contribute to improved patients safety and reduction in harm.

Attention, vigilance and visuospatial function in hospitalized elderly medical patients: Relationship to neurocognitive diagnosis

OBJECTIVE

Efficient detection of neurocognitive disorders is a key diagnostic challenge. We explored how simple bedside tests of attention, vigilance and visuospatial function might assist in identifying delirium in hospitalized patients.

METHODS

Performance on a battery of bedside cognitive tests was compared in elderly medical inpatients with DSM-IV delirium, dementia, comorbid delirium-dementia, and no neurocognitive disorder.

RESULTS

193 patients [mean age 79.9±7.3; 97 male] were assessed with delirium (n=45), dementia (n=33), comorbid delirium-dementia (n=65) and no neurocognitive disorder (NNCD) (n=50). The ability to meaningfully engage with the tests varied from 84% (Spatial Span Forwards) to 57% (Vigilance B test), and was especially problematic among the comorbid delirium-dementia group. The NNCD was distinguished from the delirium groups for most tests, and from the dementia group for the Vigilance B test and the Clock Drawing Test. The dementia group differed from delirium groups in respect of the Months Backward Test, Vigilance A and B tests, Global assessment of visuospatial ability and the Interlocking Pentagons Test. Overall, patients with delirium were best identified by three tests - the Months Backward Test, Vigilance A test and the Global Assessment of visuospatial function with failure to correctly complete any two of these predicting delirium status in 80% of cases.

CONCLUSION

Simple bedside tests of attention, vigilance and visuospatial ability can help to distinguish neurocognitive disorders, including delirium, from other presentations. There is a need to develop more accurate methods specifically designed to assess patients with neurocognitive disorder who are unable to engage with conventional tests.

The utility of the clock drawing test in detection of delirium in elderly hospitalised patients

OBJECTIVES

Delirium is common neuropsychiatric condition among elderly inpatients. The clock drawing test (CDT) has been used widely as bedside screening tool in assessing cognitive impairment in elderly people. Previous studies which evaluate its usefulness in delirium reported conflicting results. The objective of this study was to evaluate the utility of CDT to detect delirium in elderly medical patients.

METHOD

Prospective, observational, longitudinal study. All acute medical admissions 70 years of age and above were approached within 72 hours of admission for recruitment. Patients eligible for inclusion were assessed four times, twice weekly during admission. Assessment included Confusion Assessment Method (CAM), Delirium Rating Scale (DRS-98R), Montreal Cognitive Assessment (MoCA), Acute Physiology and Chronic Health Evaluation II (APACHE) II, and CDT. Data was analysed using a linear mixed effect model.

RESULTS

Three hundred and twenty-three assessments with the CDT were performed on 200 subjects (50% male, mean age 81.13; standard deviation: 6.45). The overall rate of delirium (CAM+) during hospitalisation was 23%. There was a significant negative correlation between the CDT and DRS-R98 scores (Pearson correlation r = -0.618, p < 0.001), CDT and CAM (Spearman's rho = -0.402, p < 0.001) and CDT and total MoCA score (Pearson's r = 0.767, p < 0.001). However, when the data were analysed longitudinally controlling for all the factors, we found that cognitive function and age were significant factors associated with CDT scores (p < .0001): neither the presence nor the severity of delirium had an additional significant effect on the CDT.

CONCLUSION

CDT score reflects cognitive impairment, independently of the presence or severity of delirium. The CDT is not a suitable test for delirium in hospitalised elderly patients.

Concordance between the delirium motor subtyping scale (DMSS) and the abbreviated version (DMSS-4) over longitudinal assessment in elderly medical inpatients

BACKGROUND

Delirium is a common neuropsychiatric syndrome that includes clinical subtypes identified by the Delirium Motor Subtyping Scale (DMSS). We explored the concordance between the DMSS and an abbreviated 4-item version in elderly medical inpatients.

METHODS

Elderly general medical admissions (n = 145) were assessed for delirium using the Revised Delirium Rating scale (DRS-R98). Clinical subtype was assessed with the DMSS (which includes the four items included in the DMSS-4). Motor subtypes were generated for all patient assessments using both versions of the scale. The concordance of the original and abbreviated DMSS was examined.

RESULTS

The agreement between the DMSS and DMSS-4 was high, both at initial and subsequent assessments (κ range 0.75-0.91). Intraclass Correlation Coefficient (ICC) for all three raters for the DMSS was high (0.70) and for DMSS-4 was moderate (0.59). Analysis of the agreement between raters for individual DMSS items found higher concordance in respect of hypoactive features compared to hyperactive.

CONCLUSIONS

The DMSS-4 allows for rapid assessment of clinical subtype in delirium and has high concordance with the longer and well-validated DMSS, including over longitudinal assessment. There is good inter-rater reliability between medical and nursing staff. More consistent clinical subtyping can facilitate better delirium management and more focused research effort.

Creative Music Therapy in an Acute Care Setting for Older Patients with Delirium and Dementia

BACKGROUND/AIMS

The acute hospital ward can be unfamiliar and stressful for older patients with impaired cognition, rendering them prone to agitation and resistive to care. Extant literature shows that music therapy can enhance engagement and mood, thereby ameliorating agitated behaviours. This pilot study evaluates the impact of a creative music therapy (CMT) programme on mood and engagement in older patients with delirium and/or dementia (PtDD) in an acute care setting. We hypothesize that CMT improves engagement and pleasure in these patients.

METHODS

Twenty-five PtDD (age 86.5 ± 5.7 years, MMSE 6/30 ± 5.4) were observed for 90 min (30 min before, 30 min during, and 30 min after music therapy) on 3 consecutive days: day 1 (control condition without music) and days 2 and 3 (with CMT). Music interventions included music improvisation such as spontaneous music making and playing familiar songs of patient's choice. The main outcome measures were mood and engagement assessed with the Menorah Park Engagement Scale (MPES) and Observed Emotion Rating Scale (OERS).

RESULTS

Wilcoxon signed-rank test showed a statistically significant positive change in constructive and passive engagement (Z = 3.383, p = 0.01) in MPES and pleasure and general alertness (Z = 3.188,p = 0.01) in OERS during CMT. The average pleasure ratings of days 2 and 3 were higher than those of day 1 (Z = 2.466, p = 0.014). Negative engagement (Z = 2.582, p = 0.01) and affect (Z = 2.004, p = 0.045) were both lower during CMT compared to no music.

CONCLUSION

These results suggest that CMT holds much promise to improve mood and engagement of PtDD in an acute hospital setting. CMT can also be scheduled into the patients' daily routines or incorporated into other areas of care to increase patient compliance and cooperation.

A Prospective Comparison of Informant-based and Performance-based Dementia Screening Tools to Predict In-Hospital Delirium

Dementia is an important risk factor for delirium, but the optimal strategy for incorporating cognitive impairment into delirium risk assessment at the time of hospital admission is unknown. We compared 2 informant-based screening tools for dementia and mild cognitive impairment [AD8 and D=(MC)] to the Mini Mental State Examination (MMSE) and Mini-cog in predicting hospital-acquired delirium. This prospective cohort study at an academic medical center consisted of 162 medical inpatients over age 50 years without delirium upon admission. Each participant was evaluated using the MMSE, Mini-cog, AD8, and D=(MC) upon admission and was assessed daily for delirium. An MMSE≤24 carried a 5.5 [95% confidence intervals (CI), 2.7-11.1] relative risk for delirium, whereas cognitive impairment detected by the Mini-cog, D=(MC), or AD8 carried a 2-fold risk. Adding the D=(MC) to the MMSE increased the sensitivity for predicting delirium from 52% (range, 32% to 73%) for the MMSE alone to 65% (range, 46% to 85%) if either test was positive. If both were positive, specificity was maximized at 97% (range, 94% to 100%), but sensitivity was 17% (range, 2% to 33%). The MMSE and Mini-cog identify a large proportion of patients at risk for hospital-acquired delirium, but the combination of performance-based and an informant-based screens may maximize specificity and sensitivity.

Delirium diagnosis, screening and management

Purpose of review

Our review focuses on recent developments across many settings regarding the diagnosis, screening and management of delirium, so as to inform these aspects in the context of palliative and supportive care.

Recent findings

Delirium diagnostic criteria have been updated in the long-awaited Diagnostic Statistical Manual of Mental Disorders, fifth edition. Studies suggest that poor recognition of delirium relates to its clinical characteristics, inadequate interprofessional communication and lack of systematic screening. Validation studies are published for cognitive and observational tools to screen for delirium. Formal guidelines for delirium screening and management have been rigorously developed for intensive care, and may serve as a model for other settings. Given that palliative sedation is often required for the management of refractory delirium at the end of life, a version of the Richmond Agitation-Sedation Scale, modified for palliative care, has undergone preliminary validation.

Summary

Although formal systematic delirium screening with brief but sensitive tools is strongly advocated for patients in palliative and supportive care, it requires critical evaluation in terms of clinical outcomes, including patient comfort. Randomized controlled trials are needed to inform the development of guidelines for the management of delirium in this setting.

Prevention of post-operative delirium in older patients with cancer undergoing surgery

Prevention has been shown to be the most effective strategy for minimizing the occurrence of delirium as well as delirium-associated complications.(5) Therefore prevention of delirium in older adults undergoing surgery is a top research priority given the extent of the problem in this patient population. In this review, we will describe the POD syndrome, previously identified risk factors that predict POD in surgical cancer patients, long-term outcomes of POD and both non-pharmacologic and pharmacologic therapies aimed at preventing POD.

Concordance between DSM-IV and DSM-5 criteria for delirium diagnosis in a pooled database of 768 prospectively evaluated patients using the delirium rating scale-revised-98

BACKGROUND

The Diagnostic and Statistical Manual fifth edition (DSM-5) provides new criteria for delirium diagnosis. We examined delirium diagnosis using these new criteria compared with the Diagnostic and Statistical Manual fourth edition (DSM-IV) in a large dataset of patients assessed for delirium and related presentations.

METHODS

Patient data (n = 768) from six prospectively collected cohorts, clinically assessed using DSM-IV and the Delirium Rating Scale-Revised-98 (DRS-R98), were pooled. Post hoc application of DRS-R98 item scores were used to rate DSM-5 criteria. 'Strict' and 'relaxed' DSM-5 criteria to ascertain delirium were compared to rates determined by DSM-IV.

RESULTS

Using DSM-IV by clinical assessment, delirium was found in 510/768 patients (66%). Strict DSM-5 criteria categorized 158 as delirious including 155 (30%) with DSM-IV delirium, whereas relaxed DSM-5 criteria identified 466 as delirious, including 455 (89%) diagnosed by DSM-IV (P <0.001). The concordance between the different diagnostic methods was: 53% (ĸ = 0.22) between DSM-IV and the strict DSM-5, 91% (ĸ = 0.82) between the DSM-IV and relaxed DSM-5 criteria and 60% (ĸ = 0.29) between the strict versus relaxed DSM-5 criteria. Only 155 cases were identified as delirium by all three approaches. The 55 (11%) patients with DSM-IV delirium who were not rated as delirious by relaxed criteria had lower mean DRS-R98 total scores than those rated as delirious (13.7 ± 3.9 versus 23.7 ± 6.0; P <0.001). Conversely, mean DRS-R98 score (21.1 ± 6.4) for the 70% not rated as delirious by strict DSM-5 criteria was consistent with suggested cutoff scores for full syndromal delirium. Only 11 cases met DSM-5 criteria that were not deemed to have DSM-IV delirium.

CONCLUSIONS

The concordance between DSM-IV and the new DSM-5 delirium criteria varies considerably depending on the interpretation of criteria. Overly-strict adherence for some new text details in DSM-5 criteria would reduce the number of delirium cases diagnosed; however, a more 'relaxed' approach renders DSM-5 criteria comparable to DSM-IV with minimal impact on their actual application and is thus recommended.

Delirium and depression: inter-relationship and clinical overlap in elderly people

Delirium and depression are complex neuropsychiatric syndromes common in the elderly and are associated with poor health-care outcomes. Accurate diagnosis is essential to the provision of optimum health care for individuals with these conditions but is complicated by substantial clinical overlap in symptoms and comorbidities. A careful assessment of the patient's symptoms, including their context and time course, is needed for accurate diagnosis. Previous depression is common in patients with delirium and depressive illness is a recognised sequelae of delirium. The two syndromes seem to be caused by similar pathophysiological mechanisms, involving disturbances in stress and inflammatory responses, monoaminergic and melatonergic signalling, which point to new avenues for therapeutic intervention. Improved methods to assess delirium and depression in populations at high risk by virtue of their age, diminished cognitive reserve and physical frailty is a key target to achieve improved health-care outcomes in elderly individuals.

Delirium during psychiatric admission increases mortality in psychiatric patients during and after hospitalization. A nationwide study from 1995 through 2012

OBJECTIVE

Delirium is a common acute neuropsychiatric disorder caused by a variety of physical insults. It is commonly associated with a variety of serious adverse outcomes, including elevated mortality. There are few studies of delirium occurring in psychiatric patients, including its mortality. The aim was to determine the psychiatric diagnostic profile of Danish psychiatric inpatients diagnosed with delirium and to compare standardized mortality ratio (SMR) in this group with the Danish population and general psychiatric inpatients from 1995 through 2012.

METHODS

All first time ICD-10 diagnoses of delirium among psychiatric inpatients were identified in the nationwide Danish Psychiatric Central Research Register (DPCRR) from 1995 through 2012.

RESULTS

A total of 7179 persons diagnosed with delirium were identified in the DPCRR between 1995 and 2012. Of these patients 40.8% had more than one diagnosis of delirium during the period. We identified three distinct groups, based on the first delirium-diagnosis; unspecified delirium (76.9%), comorbid delirium-dementia (19.8%), and drug-related delirium (3.3%). Use of sedative-hypnotics was noted in 46% of those with drug-related delirium. The SMR of delirious psychiatric inpatients compared to all psychiatric inpatients was stable at 1.7 throughout the time period.

CONCLUSION

Delirium occurring in psychiatric inpatients is associated with elevated mortality. Sedative-hypnotic agents are commonly involved in drug-related delirium. Particular preventative effort is warranted for patients with a previous history of delirium, as we found approximately 40% with more than one episode of delirium.

Treating an established episode of delirium in palliative care: expert opinion and review of the current evidence base with recommendations for future development

CONTEXT

Delirium is a highly prevalent complication in patients in palliative care settings, especially in the end-of-life context.

OBJECTIVES

To review the current evidence base for treating episodes of delirium in palliative care settings and propose a framework for future development.

METHODS

We combined multidisciplinary input from delirium researchers and other purposely selected stakeholders at an international delirium study planning meeting. This was supplemented by a literature search of multiple databases and relevant reference lists to identify studies regarding therapeutic interventions for delirium.

RESULTS

The context of delirium management in palliative care is highly variable. The standard management of a delirium episode includes the investigation of precipitating and aggravating factors followed by symptomatic treatment with drug therapy. However, the intensity of this management depends on illness trajectory and goals of care in addition to the local availability of both investigative modalities and therapeutic interventions. Pharmacologically, haloperidol remains the practice standard by consensus for symptomatic control. Dosing schedules are derived from expert opinion and various clinical practice guidelines as evidence-based data from palliative care settings are limited. The commonly used pharmacologic interventions for delirium in this population warrant evaluation in clinical trials to examine dosing and titration regimens, different routes of administration, and safety and efficacy compared with placebo.

CONCLUSION

Delirium treatment is multidimensional and includes the identification of precipitating and aggravating factors. For symptomatic management, haloperidol remains the practice standard. Further high-quality collaborative research investigating the appropriate treatment of this complex syndrome is needed.

Delirium diagnostic and classification challenges in palliative care: subsyndromal delirium, comorbid delirium-dementia, and psychomotor subtypes

CONTEXT

Delirium often presents difficult diagnostic and classification challenges in palliative care settings.

OBJECTIVES

To review three major areas that create diagnostic and classification challenges in relation to delirium in palliative care: subsyndromal delirium (SSD), delirium in the context of comorbid dementia, and classification of psychomotor subtypes, and to identify knowledge gaps and research priorities in relation to these three areas of focus.

METHODS

We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant PubMed literature searches as the knowledge synthesis strategy in this review.

RESULTS

We identified six (SSD), 33 (dementia), and 44 (psychomotor subtypes) articles of relevance in relation to the focus of our review. Recent literature data highlight the frequency and impact of SSD, the relevance of comorbid dementia, and the propensity for a hypoactive presentation of delirium in the palliative population. The differential diagnoses to consider are wide and include pain, fatigue, mood disturbance, psychoactive medication effects, and other causes for altered consciousness.

CONCLUSION

Challenges in the diagnosis and classification of delirium in people with advanced disease are compounded by the generalized disturbance of central nervous system function that occurs in the seriously ill, often with comorbid illness, including dementia. Further research is needed to delineate the pathophysiological and clinical associations of these presentations and thus inform therapeutic strategies. The expanding aged population and growing focus on dementia care in palliative care highlight the need to conduct this research.

Clinical practice guidelines for delirium management: potential application in palliative care

CONTEXT

Delirium occurs in patients across a wide array of health care settings. The extent to which formal management guidelines exist or are adaptable to palliative care is unclear.

OBJECTIVES

This review aims to 1) source published delirium management guidelines with potential relevance to palliative care settings, 2) discuss the process of guideline development, 3) appraise their clinical utility, and 4) outline the processes of their implementation and evaluation and make recommendations for future guideline development.

METHODS

We searched PubMed (1990-2013), Scopus, U.S. National Guideline Clearinghouse, Google, and relevant reference lists to identify published guidelines for the management of delirium. This was supplemented with multidisciplinary input from delirium researchers and other relevant stakeholders at an international delirium study planning meeting.

RESULTS

There is a paucity of high-level evidence for pharmacological and non-pharmacological interventions in the management of delirium in palliative care. However, multiple delirium guidelines for clinical practice have been developed, with recommendations derived from "expert opinion" for areas where research evidence is lacking. In addition to their potential benefits, limitations of clinical guidelines warrant consideration. Guidelines should be appraised and then adapted for use in a particular setting before implementation. Further research is needed on the evaluation of guidelines, as disseminated and implemented in a clinical setting, focusing on measurable outcomes in addition to their impact on quality of care.

CONCLUSION

Delirium clinical guidelines are available but the level of evidence is limited. More robust evidence is required for future guideline development.

The descriptive epidemiology of delirium symptoms in a large population-based cohort study: results from the Medical Research Council Cognitive Function and Ageing Study (MRC CFAS)

Background

In the general population, the epidemiological relationships between delirium and adverse outcomes are not well defined. The aims of this study were to: (1) construct an algorithm for the diagnosis of delirium using the Geriatric Mental State (GMS) examination; (2) test the criterion validity of this algorithm against mortality and dementia risk; (3) report the age-specific prevalence of delirium as determined by this algorithm.

Methods

Participant and informant data in a randomly weighted subsample of the Cognitive Function and Ageing Study were taken from a standardized assessment battery. The algorithmic definition of delirium was based on the DSM-IV classification. Outcomes were: proportional hazard ratios for death; odds ratios of dementia at 2-year follow-up.

Results

Data from 2197 persons (representative of 13,004) were used, median age 77 years, 64% women. Study-defined delirium was associated with a new dementia diagnosis at two years (OR 8.82, 95% CI 2.76 to 28.2) and death (HR 1.28, 95% CI 1.03 to 1.60), even after adjustment for acute illness severity. Similar associations were seen for study-defined subsyndromal delirium. Age-specific prevalence as determined by the algorithm increased with age from 1.8% in the 65-69 year age group to 10.1% in the ≥85 age group (p < 0.01 for trend). For study-defined subsyndromal delirium, age-specific period prevalence ranged from 8.2% (65-69 years) to 36.1% (≥85 years).

Conclusions

These results demonstrate the possibility of constructing an algorithmic diagnosis for study-defined delirium using data from the GMS schedule, with predictive criterion validity for mortality and dementia risk. These are the first population-based analyses able to account prospectively for both illness severity and an earlier study diagnosis of dementia.

New horizons in the pathogenesis, assessment and management of delirium

Delirium is one of the foremost unmet medical needs in healthcare. It affects one in eight hospitalised patients and is associated with multiple adverse outcomes including increased length of stay, new institutionalisation, and considerable patient distress. Recent studies also show that delirium strongly predicts future new-onset dementia, as well as accelerating existing dementia. The importance of delirium is now increasingly being recognised, with a growing research base, new professional international organisations, increased interest from policymakers, and greater prominence of delirium in educational and audit programmes. Nevertheless, the field faces several complex research and clinical challenges. In this article we focus on selected areas of recent progress and/or uncertainty in delirium research and practice. (i) Pathogenesis: recent studies in animal models using peripheral inflammatory stimuli have begun to suggest mechanisms underlying the delirium syndrome as well as its link with dementia. A growing body of blood and cerebrospinal fluid studies in humans have implicated inflammatory and stress mediators. (ii) Prevention: delirium prevention is effective in the context of research studies, but there are several unresolved issues, including what components should be included, the role of prophylactic drugs, and the overlap with general best care for hospitalised older people. (iii) Assessment: though there are several instruments for delirium screening and assessment, detection rates remain dismal. There are no clear solutions but routine screening embedded into clinical practice, and the development of new rapid screening instruments, offer potential. (iv) Management: studies are difficult given the heterogeneity of delirium and currently expert and comprehensive clinical care remains the main recommendation. Future studies may address the role of drugs for specific elements of delirium. In summary, though facing many challenges, the field continues to make progress, with several promising lines of enquiry and an expanding base of interest among researchers, clinicians and policymakers.