Validation of the Sour Seven Questionnaire for screening delirium in hospitalized seniors by informal caregivers and untrained nurses

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.

Partnering with carers in the management of delirium in general acute care settings: An integrative review

OBJECTIVES

Delirium is a common, preventable condition. However, delirium is poorly recognised and often missed because symptoms are misinterpreted, and risk factors overlooked by health-care professionals. Carers usually have intimate knowledge about the person they care for. Therefore, they are well placed within care teams to implement delirium prevention strategies, identify symptoms and support the early diagnosis of delirium. The aim of this integrative review was to synthesise findings from the published research reporting on partnering with carers in the management of delirium in general acute care settings.

METHODS

Five databases (Medline-EBSCO, PubMed, PsycINFO, ProQuest, CINAHL and SCOPUS) were searched to identify primary research regarding partnering with carers in the management of delirium in acute care settings, and results were synthesised. PRISMA guidelines were adhered to, and quality appraisal was conducted using the Mixed Methods Appraisal Tool.

RESULTS

All seven studies reported that partnering with carers was a viable strategy in the management of delirium to maximise outcomes for people at risk of or experiencing delirium and that increasing carers' knowledge of delirium was key. The synthesis of findings also identified two themes: Increasing knowledge and Effective partnerships.

CONCLUSIONS

A collaborative approach to increasing carers' and nurses' knowledge about the management of delirium, coupled with education on how to develop therapeutic nurse-carer relationships, is important for ongoing effective partnerships in the management of delirium. Good communication supported effective partnerships, which enabled both nurses and carers the opportunity to express their needs and concerns and negotiate collaborative involvement in the management of delirium.

Recognition of Delirium Superimposed on Dementia: Is There an Ideal Tool?

Delirium in persons with dementia (DSD) is a common occurrence. Over the past three decades, several tools have been developed and validated to diagnose delirium, yet there is still a shortage of tools recommended in persons with dementia and there is a lack of sufficient research on the accuracy of performance of such tools in this growing population. The purpose of this article is to (1) conduct a clinical review of the detection of DSD across settings of care by formal health care professionals and informal family members and care partners; (2) identify barriers and facilitators to detection and highlight delirium tools that have been tested in person with dementia; and (3) make recommendations for future research, practice, and policy. Given this review, an "ideal" tool for DSD would point to tools being brief, easy to integrate into the EMR, and accurate with at least 90% accuracy given the poor outcomes associated with delirium and DSD. Knowing the baseline and communication between family members and healthcare professionals should be a top priority for education, research, and health systems policy. More work is needed in better understanding DSD and optimizing and standardizing feature assessment, especially the acute change feature at the bedside for DSD.

Perspectives from designated family caregivers of critically ill adult patients during the COVID-19 pandemic: A qualitative interview study

Background

Family visitation in intensive care units (ICU) has been impacted by the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic. While studies report on perceptions of families completely restricted from ICUs, little is known about the burden experienced by designated family caregivers allowed to visit their critically ill loved one. This study sought the perspectives of family caregivers of critically ill patients on the impact of one-person designated visitor policies mandated in ICUs during the COVID-19 pandemic.

Methods

Throughout the study period a restricted visitation policy was mandated capturing the first (April 2020) and second (December 2020) waves of the pandemic that allowed one designated family caregiver (i.e., spouses or adult children) per patient to visit the ICU. Designated family caregivers of critically ill patients admitted to ICU September 2020 to November 2020 took part in individual 60-minute, semi-structured interviews at 6-months after discharge from the index ICU admission. Themes from family interviews were summarized with representative quotations.

Results

Key themes identified following thematic analysis from six participants included: one visitor rule, patient advocate role, information needs, emotional distress, strategies for coping with challenges, practicing empathy, and appreciation of growth.

Conclusion

Designated family caregivers of critically ill patients admitted to ICU during the COVID-19 pandemic perceived a complex and highly stressful experience. Support from ICU family liaisons and psychologists may help ameliorate the impact.

The 12 Ds of geriatric medical-psychiatry: A new format for geriatric case presentation

Background: We present a new format for geriatric case presentation called the 12 Ds of Geriatric Medical-Psychiatry that facilitates an integrated discussion of both the physical and mental health issues that pertain to any geriatric patient. The format can be used to replace or to complement traditional medical model case presentation and can also be used as a teaching aid to provide the parameters for a holistic view of the geriatric patient. Methods: We developed the 12 Ds of Geriatric Medical-Psychiatry for case presentation by modifying the SBAR (situation, background, assessment, recommendations) with 12 clinical considerations that apply to any geriatric patient. Following implementation of the 12 Ds of Geriatric Medical-Psychiatry case presentation in our integrated team of geriatric medicine and psychiatry healthcare providers, we successfully used the 12 Ds model to present more than 180 patients and found the model easy to use and well received by learners and colleagues. Conclusion: The 12 Ds of Geriatric Medical-Psychiatry provides a comprehensive format to discuss the pertinent issues facing geriatric patients. When used in an SBAR format, it appears to be an efficient means for integrated case presentation and/or can be used as a tool for teaching and understanding a holistic view of complex geriatric cases.

Delirium diagnosis without a gold standard: Evaluating diagnostic accuracy of combined delirium assessment tools

Background

Fluctuating course of delirium and complexities of ICU care mean delirium symptoms are hard to identify or commonly confused with other disorders. Delirium is difficult to diagnose, and clinicians and researchers may combine assessments from multiple tools. We evaluated diagnostic accuracy of different combinations of delirium assessments performed in each enrolled patient.

Methods

Data were obtained from a previously conducted cross-sectional study. Eligible adult patients who remained admitted to ICU for >24 hours with at least one family member present were consecutively enrolled as patient-family dyads. Clinical delirium assessments (Intensive Care Delirium Screening Checklist [ICSDC] and Confusion Assessment Method-ICU [CAM-ICU]) were completed twice daily by bedside nurse or trained research assistant, respectively. Family delirium assessments (Family Confusion Assessment Method and Sour Seven) were completed once daily by family members. We pooled all delirium assessment tools in a single two-class latent model and pairwise (i.e., combined, clinical or family assessments) Bayesian analyses.

Results

Seventy-three patient-family dyads were included. Among clinical delirium assessments, the ICDSC had lower sensitivity (0.72; 95% Bayesian Credible [BC] interval 0.54–0.92) and higher specificity (0.90; 95%BC, 0.82–0.97) using Bayesian analyses compared to pooled latent class analysis and CAM-ICU had higher sensitivity (0.90; 95%BC, 0.70–1.00) and higher specificity (0.94; 95%BC, 0.80–1.00). Among family delirium assessments, the Family Confusion Assessment Method had higher sensitivity (0.83; 95%BC, 0.71–0.92) and higher specificity (0.93; 95%BC, 0.84–0.98) using Bayesian analyses compared to pooled latent class analysis and the Sour Seven had higher specificity (0.85; 95%BC, 0.67–0.99) but lower sensitivity (0.64; 95%BC 0.47–0.82).

Conclusions

Results from delirium assessment tools are often combined owing to imperfect reference standards for delirium measurement. Pairwise Bayesian analyses that explicitly accounted for each tool’s (performed within same patient) prior sensitivity and specificity indicate that two combined clinical or two combined family delirium assessment tools have fair diagnostic accuracy.

Detecting delirium in nursing home residents using the Informant Assessment of Geriatric Delirium (I-AGeD): a validation pilot study

Aim

The aims of this study were to record the prevalence of delirium in residents with the DSM-5, to investigate the feasibility of the I-AGeD in a Swiss nursing home and to compare the results of the I-AGeD with the DSM-5 criteria as the reference standard.

Findings

This study shows that the I-AGeD is suitable for detecting delirium in nursing home residents with a sensitivity of 60% and a specificity of 94%.

Message

The I-AGeD is a simple, brief and feasible assessment tool for the detection of delirium in nursing home residents.

Purpose

Early delirium detection in nursing home residents is vital to prevent adverse outcomes. Despite the potential of structured delirium screening tools to enhance delirium detection, they are rarely used in nursing homes. To promote delirium screening tools in nursing homes, they should be easy to integrate into the daily routine of care workers. The I-AGeD, was developed as a simple and easily understandable tool to detect delirium in older adults. The aims of this study were to record the prevalence of delirium, to investigate the feasibility of the I-AGeD, and to compare these results with the DSM-5 as the reference standard.

Methods

This is a cross-sectional prospective single-center pilot study. Seven registered nurses assessed the participants with the I-AGeD. The research assistant conducted delirium assessments based on the DSM-5 criteria, to identify delirium symptoms for the same participants. The feasibility test was verified using a five-point Likert scale ranging from very easy to very difficult.

Results

85 nursing home residents participated in the study. A delirium prevalence of 5.9% was found. The sensitivity was 60% and specificity 94% at a cut point of ≥ 4 to indicate delirium. The feasibility test showed that the 10 items of the I-AGeD were easy or very easy to answer.

Conclusion

The I-AGeD showed an acceptable performance to assess delirium in nursing home residents. Additionally, it was found feasible and due to its brevity the I-AGeD could easily be integrated into the routine of daily care in nursing homes.

The impact of patient delirium in the intensive care unit: patterns of anxiety symptoms in family caregivers

BACKGROUND

The purpose of this study was to examine the association of patient delirium in the intensive care unit (ICU) with patterns of anxiety symptoms in family caregivers when delirium was determined by clinical assessment and family-administered delirium detection.

METHODS

In this cross-sectional study, consecutive adult patients anticipated to remain in the ICU for longer than 24 h were eligible for participation given at least one present family caregiver (e.g., spouse, friend) provided informed consent (to be enrolled as a dyad) and were eligible for delirium detection (i.e., Richmond Agitation-Sedation Scale score ≥ - 3). Generalized Anxiety Disorder-7 (GAD-7) was used to assess self-reported symptoms of anxiety. Clinical assessment (Confusion Assessment Method for ICU, CAM-ICU) and family-administered delirium detection (Sour Seven) were completed once daily for up to five days.

RESULTS

We included 147 family caregivers; the mean age was 54.3 years (standard deviation [SD] 14.3 years) and 74% (n = 129) were female. Fifty (34% [95% confidence interval [CI] 26.4-42.2]) caregivers experienced clinically significant symptoms of anxiety (median GAD-7 score 16.0 [interquartile range 6]). The most prevalent symptoms of anxiety were "Feeling nervous, anxious or on edge" (96.0% [95%CI 85.2-99.0]); "Not being able to stop or control worrying" (88.0% [95%CI 75.6-94.5]; "Worrying too much about different things" and "Feeling afraid as if something awful might happen" (84.0% [95%CI 71.0-91.8], for both). Family caregivers of critically ill adults with delirium were significantly more likely to report "Worrying too much about different things" more than half of the time (CAM-ICU, Odds Ratio [OR] 2.27 [95%CI 1.04-4.91]; Sour Seven, OR 2.28 [95%CI 1.00-5.23]).

CONCLUSIONS

Family caregivers of critically ill adults with delirium frequently experience clinically significant anxiety and are significantly more likely to report frequently worrying too much about different things. Future work is needed to develop mental health interventions for the diversity of anxiety symptoms experienced by family members of critically ill patients.

TRIAL REGISTRATION

This study is registered on ClinicalTrials.gov ( https://clinicaltrials.gov/ct2/show/NCT03379129 ).

Delirium and long term cognition in critically ill patients

Delirium, a form of acute brain dysfunction, is very common in the critically ill adult patient population. Although its pathophysiology is poorly understood, multiple factors associated with delirium have been identified, many of which are coincident with critical illness. To date, no drug or non-drug treatments have been shown to improve outcomes in patients with delirium. Clinical trials have provided a limited understanding of the contributions of multiple triggers and processes of intensive care unit (ICU) acquired delirium, making identification of therapies difficult. Delirium is independently associated with poor long term outcomes, including persistent cognitive impairment. A longer duration of delirium is associated with worse long term cognition after adjustment for age, education, pre-existing cognitive function, severity of illness, and exposure to sedatives. Interestingly, differences in prevalence are seen between ICU survivor populations, with survivors of acute respiratory distress syndrome experiencing higher rates of cognitive impairment at early follow-up compared with mixed ICU survivor populations. Although cognitive performance improves over time for some ICU survivors, impairment is persistent in others. Studies have so far been unable to identify patients at higher risk of long term cognitive impairment; this is an active area of scientific investigation.

Improving Delirium Care in Hospitalized Older Adults: Impact of Education on Hospital Aides as Sitters

As one of several hospital team members involved in the management of care for older adults with delirium, hospital aides (HAs) are often relied on to provide direct patient care in the role of a sitter. Yet, many HAs have not received training about delirium, its associated behaviors, or appropriate interventions. As a consequence, there are gaps in quality of care for older adults with delirium and potential missed opportunities for HA sitters to contribute to the interdisciplinary team (IDT) care of these patients. In the current study, a quality improvement project at an urban hospital provided an educational session on delirium to HAs. Accuracy of HA delirium knowledge, delirium behavior recognition, and delivery of care to patients with delirium significantly increased across three postintervention measures (p = <0.001 to 0.016). HAs also reported increased confidence in caring for patients with delirium and in their perceived role on the IDT. [Journal of Gerontological Nursing, 47(6), 20-26.].

Partnering With Family Members to Detect Delirium in Critically Ill Patients

OBJECTIVES

To evaluate the diagnostic accuracy of family-administered tools to detect delirium in critically ill patients.

DESIGN

Diagnostic accuracy study.

SETTING

Large, tertiary care academic hospital in a single-payer health system.

PATIENTS

Consecutive, eligible patients with at least one family member present (dyads) and a Richmond Agitation-Sedation Scale greater than or equal to -3, no primary direct brain injury, the ability to provide informed consent (both patient and family member), the ability to communicate with research staff, and anticipated to remain admitted in the ICU for at least a further 24 hours to complete all assessments at least once.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Family-administered delirium assessments (Family Confusion Assessment Method and Sour Seven) were completed once daily. A board-certified neuropsychiatrist and team of ICU research nurses conducted the reference standard assessments of delirium (based on Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition, criteria) once daily for a maximum of 5 days. The mean age of the 147 included patients was 56.1 years (SD, 16.2 yr), 61% of whom were male. Family members (n = 147) were most commonly spouses (n = 71, 48.3%) of patients. The area under the receiver operating characteristic curve on the Family Confusion Assessment Method was 65.0% (95% CI, 60.0-70.0%), 71.0% (95% CI, 66.0-76.0%) for possible delirium (cutpoint of 4) on the Sour Seven and 67.0% (95% CI, 62.0-72.0%) for delirium (cutpoint of 9) on the Sour Seven. These area under the receiver operating characteristic curves were lower than the Intensive Care Delirium Screening Checklist (standard of care) and Confusion Assessment Method for ICU. Combining the Family Confusion Assessment Method or Sour Seven with the Intensive Care Delirium Screening Checklist or Confusion Assessment Method for ICU resulted in area under the receiver operating characteristic curves that were not significantly better, or worse for some combinations, than the Intensive Care Delirium Screening Checklist or Confusion Assessment Method for ICU alone. Adding the Family Confusion Assessment Method and Sour Seven to the Intensive Care Delirium Screening Checklist and Confusion Assessment Method for ICU improved sensitivity at the expense of specificity.

CONCLUSIONS

Family-administered delirium detection is feasible and has fair, but lower diagnostic accuracy than clinical assessments using the Intensive Care Delirium Screening Checklist and Confusion Assessment Method for ICU. Family proxy assessments are essential for determining baseline cognitive function. Engaging and empowering families of critically ill patients warrant further study.

Associations between caregiver-detected delirium and symptoms of depression and anxiety in family caregivers of critically ill patients: a cross-sectional study

BACKGROUND

Witnessing delirium can be distressing for family caregivers (i.e., relatives or friends) of critically ill patients. This study aimed to evaluate associations between caregiver-detected delirium in critically ill patients and depression and anxiety symptoms in their family caregivers.

METHODS

Consecutive adult patient-caregiver dyads were enrolled from a 28-bed medical-surgical intensive care unit. Patient delirium was screened for daily by family caregivers using the Sour Seven instrument. Family caregivers completed the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) instruments daily to assess their own depression and anxiety symptoms. Response feature analysis was used to handle repeated measures. Descriptive statistics and regression analyses were completed.

RESULTS

One hundred forty-seven patient-caregiver dyads were enrolled. Clinically significant symptoms of depression and anxiety occurred in 27% and 35% of family caregivers, respectively. Caregiver-detected delirium occurred in 65% of patients, and was not associated with clinically significant caregiver depression (Odds Ratio [OR] 1.4, 95% Confidence Interval [95%CI] 0.6-3.1) or anxiety (OR 1.2, 95%CI 0.6-2.6) symptoms. When stratified by Sour Seven scores, scores 1-3 and 4-9 were associated with increased symptoms of anxiety (OR 3.1, 95%CI 1.3-7.0) and depression (OR 2.6, 95%CI 1.1-6.1) in family caregivers. Caregiver-detected delirium score was associated with severity of family caregiver anxiety symptoms (coefficient 0.2, 95%CI 0.1-0.4), but not depression symptoms (coefficient 0.2, 95%CI -0.0-0.3).

CONCLUSIONS

Caregiver-detected patient delirium was associated with increased depression and anxiety symptoms in family caregivers of critically ill patients. Further randomized research is required to confirm these associations.

Patients, family members and providers perceive family-administered delirium detection tools in the adult ICU as feasible and of value to patient care and family member coping: a qualitative focus group study

PURPOSE

While studies report on perceptions of family participation in delirium prevention, little is known about the use of family-administered delirium detection tools in the care of critically ill patients. This study sought the perspectives of patients, their family members, and healthcare providers on the use of family-administered delirium detection tools to detect delirium in critically ill patients and barriers and facilitators to using family-administered delirium detection tools in patient care.

METHODS

In this qualitative study, critical care providers (five physicians, six registered nurses) and participants from the Family ICU Delirium Detection Study (seven past patients and family members) took part in four focus groups at one hospital in Calgary, Alberta.

RESULTS

Key themes identified following thematic analysis from 18 participants included: 1) perceptions of acceptability of family-administered delirium detection (e.g., family feels valued, intensive care unit (ICU) care team may not use a family member's results, intensification of work load), 2) considerations regarding feasibility (e.g., insufficient knowledge, healthcare team buy-in), and 3) overarching strategies to support implementation into routine patient care (e.g., value of family-administered delirium detection for patients and families is well understood in the clinical context, regular communication between the family and ICU providers, an electronic version of the tool).

CONCLUSIONS

Patients, family members and healthcare providers who participated in the focus groups perceived family participation in delirium detection and the use of family-administered delirium detection tools at the bedside as feasible and of value to patient care and family member coping.

TRIAL REGISTRATION

www.ClinicalTrials.gov (NCT03379129); registered 15 December 2017.

Effectiveness of an intensive care unit family education intervention on delirium knowledge: a pre-test post-test quasi-experimental study

PURPOSE

To create, validate, and refine an intensive care unit (ICU) delirium education intervention to prepare family members to partner with the ICU care team to detect delirium symptoms and prevent and manage delirium using nonpharmacological strategies.

METHODS

In this pre-test post-test quasi-experimental study, consecutive eligible family members of critically ill patients admitted to an ICU completed an ICU Family Education Delirium intervention in two parts: 1) six-minute video on ICU delirium (risk factors, prevention/management, symptoms, communication with the ICU care team), and 2) two case vignettes to practice detecting delirium using family-administered delirium detection questionnaires (Family Confusion Assessment Method [FAM-CAM] and Sour Seven). Family members' delirium knowledge was measured before, immediately after, and two weeks following the intervention using the Caregiver ICU Delirium Knowledge Questionnaire (CIDKQ).

RESULTS

Of 99 family members recruited over eight months, 81 (82%) completed the intervention and 63 (63/81, 78%) completed all follow-up questionnaires. Family members' delirium knowledge improved significantly following the intervention (pre-CIDKQ, 14; 95% confidence interval [CI], 13 to 15; post-CIDKQ, 17; 95% CI, 16 to 17; P < 0.001) and was retained two weeks after the intervention (CIDKQ 16; 95% CI, 16 to 17; P < 0.001). This included increased knowledge regarding delirium risk factors (e.g., medication, mechanical ventilation), prevention/management (e.g., orientation, day/night routine), and symptoms of delirium. More family members correctly detected delirium symptoms in case vignettes using the Sour Seven (92%) compared with the FAM-CAM (78%).

CONCLUSIONS

A video-based ICU delirium education intervention is effective in educating family members about prevention, detection, and management of delirium.

A study protocol for a randomized controlled trial of family-partnered delirium prevention, detection, and management in critically ill adults: the ACTIVATE study

Background

Delirium is very common in critically ill patients admitted to the intensive care unit (ICU) and results in negative long-term outcomes. Family members are also at risk of long-term complications, including depression and anxiety. Family members are frequently at the bedside and want to be engaged; they know the patient best and may notice subtle changes prior to the care team. By engaging family members in delirium care, we may be able to improve both patient and family outcomes by identifying delirium sooner and capacitating family members in care.

Methods

The primary aim of this study is to determine the effect of family-administered delirium prevention, detection, and management in critically ill patients on family member symptoms of depression and anxiety, compared to usual care. One-hundred and ninety-eight patient-family dyads will be recruited from four medical-surgical ICUs in Calgary, Canada. Dyads will be randomized 1:1 to the intervention or control group. The intervention consists of family-partnered delirium prevention, detection, and management, while the control group will receive usual care. Delirium, depression, and anxiety will be measured using validated tools, and participants will be followed for 1- and 3-months post-ICU discharge. All analyses will be intention-to-treat and adjusted for pre-identified covariates. Ethical approval has been granted by the University of Calgary Conjoint Health Research Ethics Board (REB19–1000) and the trial registered. The protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist.

Discussion

Critically ill patients are frequently unable to participate in their own care, and partnering with their family members is particularly important for improving experiences and outcomes of care for both patients and families.

Trial registration

Registered September 23, 2019 on Clinicaltrials.gov NCT04099472.

Family Identification of Delirium in the Emergency Department in Patients With and Without Dementia: Validity of the Family Confusion Assessment Method (FAM-CAM)

OBJECTIVE

To examine the ability of the family-rated Family Confusion Assessment Method (FAM-CAM) to identify delirium in the emergency department (ED) among patients with and without dementia, as compared to the reference-standard Confusion Assessment Method (CAM).

DESIGN

Validation study.

SETTING

Urban academic ED.

PARTICIPANTS

Dyads of ED patients, aged 70 years and older, and their family caregivers (N = 108 dyads).

MEASUREMENTS

A trained reference standard interviewer performed a cognitive screen, delirium symptom assessment, and scored the CAM. The caregiver self-administered the FAM-CAM. Dementia was assessed using the Informant Questionnaire on Cognitive Decline in the Elderly and the medical record. For concurrent validity, performance of the FAM-CAM was compared to the CAM. For predictive validity, clinical outcomes (ED visits, hospitalization, and mortality) over 6 months were compared in FAM-CAM positive and negative patients, controlling for age, sex, comorbidity, and cognitive status.

RESULTS

Among the 108 patients, 30 (28%) were CAM positive for delirium and 58 (54%) presented with dementia. The FAM-CAM had a specificity of 83% and a negative predictive value of 83%. Most false negatives (n = 9 of 13, 69%) were due to caregivers not identifying the inattention criteria for delirium on the FAM-CAM. In patients with dementia, sensitivity was higher than in patients without (61% vs 43%). In adjusted models, a hospitalization in the following 6 months was more than three times as likely in FAM-CAM positive compared to negative patients (odds ratio = 3.4; 95% confidence interval = 1.2-9.3).

CONCLUSIONS

Among patients with and without dementia, the FAM-CAM shows qualities that are important in the ED setting for identification of delirium. Using the FAM-CAM as part of a systematic screening strategy for the ED, in which families' assessments could supplement healthcare professionals' assessments, is promising. J Am Geriatr Soc 68:983-990, 2020.

Delirium in hospitalized older adults

Delirium is a common and underdiagnosed problem in hospitalized older adults. It is associated with an increased risk of poor cognitive and functional outcomes, institutionalization, and death. Timely diagnosis of delirium and non-pharmacological prevention and management strategies can improve patient outcomes. The Confusion Assessment Method (CAM) is the most widely used clinical assessment tool for the diagnosis of delirium. Multiple variations of the CAM have been developed for ease of administration and for the unique needs of specific patient populations, including the 3-min diagnostic CAM (3D CAM), CAM-Intensive Care Unit (CAM-ICU), Delirium Triage Screen (DTS)/Brief CAM (b-CAM), 4AT tool, and ultrabrief delirium assessment. Strong evidence supports the effectiveness of nonpharmacologic strategies as the primary intervention for the prevention of delirium. Multicomponent delirium prevention strategies can reduce the incidence of delirium by 40%. Investigation of underlying medical precipitants and optimization of non-pharmacological interventions are first line in the management of delirium. Despite a lack of evidence supporting use of antipsychotics, low dose antipsychotics remain second line for off-label treatment of distressing psychoses and/or agitated behaviors that are refractory to non-pharmacological behavioral interventions and pose an imminent risk of harm to self or others. Any antipsychotic prescription for delirium should be accompanied by an appropriate taper plan. Follow up with primary care providers on discharge from hospital for ongoing screening of cognitive impairment is important.

Feasibility and acceptability of family administration of delirium detection tools in the intensive care unit: a patient-oriented pilot study

BACKGROUND

Family-administered delirium detection tools may serve as valuable diagnostic adjuncts because family caregivers may be better able than providers to detect changes in patient cognition and behaviour from pre-illness levels of functioning. The aim of this pilot study was to assess the feasibility and acceptability of family-administered tools to detect delirium in critically ill patients.

METHODS

In this single-centre pilot tool validation study conducted in August and September 2017, eligible family caregivers used the Family Confusion Assessment Method (FAM-CAM) and the Sour Seven questionnaire to detect delirium during the patient's intensive care unit (ICU) stay. We calculated descriptive statistics for all study variables. Patients and family caregivers were involved as research partners throughout the study. A patient-orient research approach was taken, engaging patients and family caregivers as full partners.

RESULTS

Of 141 patients admitted to the ICU, 75 were eligible, of whom 53 were approached; 21 patients (40%), 23/38 family caregivers (60%) and 17/38 dyads (i.e., patient and family caregiver enrolled together) (45%) consented to participate. The most common reason for nonenrolment was refusal by the family, who commonly reported feeling overwhelmed. The completion rate for the FAM-CAM and Sour Seven questionnaire was 74% (17/23). Among 13 dyads, family caregivers detected delirium in 5 patients (38%) using the FAM-CAM, and delirium or possible delirium in 8 patients (62%) using the Sour Seven questionnaire, whereas trained research assistants detected delirium in 8 patients (62%) using the Confusion Assessment Method for the Intensive Care Unit 7 and the Richmond Agitation-Sedation Scale (κ coefficient for agreement between the former and the FAM-CAM and Sour Seven questionnaire 0.62 and 0.85, respectively).

INTERPRETATION

Administration of the FAM-CAM and Sour Seven questionnaire by family caregivers to detect delirium in the ICU is feasible and acceptable, although, as with most family engagement strategies, it was not desired by all. Results from this pilot study support a definitive study with a larger sample to enable calculation of inferential statistics, but additional recruitment strategies are necessary to improve the response rate. Trial registration: Clinicaltrials.gov, no. NCT03379129.

Choosing the Right Delirium Assessment Tool

Delirium is an increasing concern with current combined annual costs for the United States and Europe of approximately $350 billion. Although standardized definitions and diagnostic criteria exist, more than 80% of delirium in the acute care setting is overlooked or misdiagnosed. Delays in identification result in increases in severity and mortality and a reduction in quality of life. Selecting an assessment tool is the first step toward improving recognition.

Validation of the Stanford Proxy Test for Delirium (S-PTD) among critical and noncritical patients

BACKGROUND

The Stanford Proxy Test for Delirium (S-PTD) is a tool developed to be completed by nurses at the end of their shift. It was designed to use the knowledge acquired during a full shift of nurse-patient interaction. The objective of our study was to validate the S-PTD among a mixed sample of patients in both the intensive care unit (ICU) and non-ICU settings.

METHODS

A cross-sectional study was conducted in an ICU and three general medical wards in a tertiary care hospital. Patients were independently and blindly assessed for delirium by (1) the patients' primary nurses using the S-PTD at the end of their shift, and (2) a Consultation liaison psychiatrist who conducted a neuropsychiatric evaluation based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

RESULTS

A total 288 patients were included in current analysis. Using the S-PTD, delirium was identified in 72 (25.0%), while an expert neuropsychiatric examination, based on DSM-5 identified delirium in 75 (26.0%) patients. This study demonstrated that the S-PTD has very strong discriminative ability (area under the curve= 0.946, p<0.001). An S-PTD cut-off score ≥3 was associated with an 82.7% sensitivity, an 95.3% specificity, an 86.1% positive predictive value, a 94.0% negative predictive value, and a 92.0% overall diagnostic accuracy. These results were similar in both ICU and general ward patients.

CONCLUSION

The S-PTD has excellent sensitivity and specificity in detecting delirium in both ICU and ward patients, even when compared with the gold-standard, a DSM-based neuropsychiatric examination.

[Cognitive decline in geriatric oncology: Trends, evaluation and treatment]

Cancer prevalence increases with aging. Prevalent or incident neurocognitive disorders are frequent in geriatric oncology. Cognitive decline associated with cancer increases the risk of under or over-cancer treatment and makes therapeutic decisions complex. In this context, we present tools to optimize cognitive impairment screening, identification of underlying mechanisms and specific treatments. Geriatric specialists intervention can help global care, social services utilization and patient's orientation when ambulatory cares become difficult.

Validation of Caregiver-Centered Delirium Detection Tools: A Systematic Review

OBJECTIVES

To summarize the validity of caregiver-centered delirium detection tools in hospitalized adults and assess associated patient and caregiver outcomes.

DESIGN

Systematic review.

SETTING

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus from inception to May 15, 2017.

PARTICIPANTS

Hospitalized adults.

INTERVENTION

Caregiver-centered delirium detection tools.

MEASUREMENTS

We drafted a protocol from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two reviewers independently completed abstract and full-text review, data extraction, and quality assessment. We summarized findings using descriptive statistics including mean, median, standard deviation, range, frequencies (percentages), and Cohen's kappa. Studies that reported on the validity of caregiver-centered delirium detection tools or associated patient and caregiver outcomes and were cohort or cross-sectional in design were included.

RESULTS

We reviewed 6,056 titles and abstracts, included 6 articles, and identified 6 caregiver-centered tools. All tools were designed to be administered in several minutes or less and had 11 items or fewer. Three tools were caregiver administered (completed independently by caregivers): Family Confusion Assessment Method (FAM-CAM), Informant Assessment of Geriatric Delirium (I-AGeD), and Sour Seven. Three tools were caregiver informed (administered by a healthcare professional using caregiver input): Single Question in Delirium (SQiD), Single Screening Question Delirium (SSQ-Delirium), and Stressful Caregiving Response to Experiences of Dying. Caregiver-administered tools had better psychometric properties (FAM-CAM sensitivity 75%, 95% confidence interval (CI)=35-95%, specificity 91%, 95% CI=74-97%; Sour Seven positive predictive value 89.5%, negative predictive value 90%) than caregiver-informed tools (SQiD: sensitivity 80%, 95% CI=28.4-99.5%; specificity 71%, 95% CI=41.9-91.6%; SSQ-Delirium sensitivity 79.6%, specificity 56.1%).

CONCLUSION

Delirium detection is essential for appropriate delirium management. Caregiver-centered delirium detection tools show promise in improving delirium detection and associated patient and caregiver outcomes. Comparative studies using larger sample sizes and multiple centers are required to determine validity and reliability characteristics.

Polypharmacy in palliative care-COPD and multimorbidity : A case report

This is the case report of an 80-year-old woman with advanced chronic obstructive pulmonary disease (COPD), multimorbidity and frailty. Despite regular critical re-evaluation of on-going medication, a significant reduction of prescribed medication was not achieved up until the patient's terminal phase, and this may have contributed to several episodes of delirium. It was particularly difficult to reduce the number of prescribed drugs due to cardiovascular, endocrinologic, orthopaedic, neurologic, psychiatric and pulmonary comorbidities. Probable drug-drug interactions and side effects were repeatedly observed. This case report aims to describe a dilemma frequently encountered in the care of patients with progressed pulmonary disease in the context of frailty and multimorbidity.

Delirium in Older Persons: Advances in Diagnosis and Treatment

Importance

Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual's function and quality of life, as well as broad societal effects with substantial health care costs.

Objective

To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field.

Evidence Review

Search of Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011, until March 16, 2017, using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded.

Findings

Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment; 4 A's Test; and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method-Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of delirium, based on recent reviews of the evidence, recommend reserving use of antipsychotics and other sedating medications for treatment of severe agitation that poses risk to patient or staff safety or threatens interruption of essential medical therapies.

Conclusions and Relevance

Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial.