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Botero Urrea M, González MC, Villa García MM, Alviz Núñez M, Velásquez-Tirado JD, Ocampo MV, Trzepacz PT, Franco JG. Validation of the delirium diagnostic tool-provisional (DDT-Pro) in geriatric medical inpatients with diagnostic permutations of the 3Ds with and without delirium. J Psychosom Res 2024; 185:111880. [PMID: 39126891 DOI: 10.1016/j.jpsychores.2024.111880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 07/25/2024] [Accepted: 08/05/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVE Validations of brief delirium tools have not included analysis of psychiatric disorders comorbidities or control groups. We validated the Delirium Diagnostic Tool-Provisional (DDT-Pro) in 422 geriatric inpatients with high incidence of depression and/or dementia. METHODS Cross-sectional study using two delirium reference standards, DSM-5-TR and Delirium Rating Scale-Revised-98 (DRS-R98). We assessed concurrent and construct DDT-Pro validity too. RESULTS There were 117 (27.7%) delirium cases using DDT-Pro, 104 (24.6%) per DSM-5-TR and 93 (22.0%) per DRS-R98; 133 patients (31.5%) had depression and 105 (24.9%) dementia, some comorbid with delirium. DDT-Pro accuracy (AUC under ROC curve) ranges were 88.3-95.9% vs DSM-5-TR and 92.7-95.0% vs DRS-R98 for whole sample and four diagnostic groups, without statistical differences. DDT-Pro ≤6 had the most balanced sensitivity-specificity for delirium diagnosis against both DSM-5-TR and DRS-R98 with similar specificity but higher sensitivity for DRS-R98 than DSM-5-TR delirium, with the highest values in patients with depression and dementia (≥92% sensitivity, ≥81% specificity). Positive and negative likelihood ratios support diagnostic strength. Concurrent validity was high reflected by significant correlations (p < 0.001) of DDT-Pro total and item scores with DRS-R98 and Delirium Frontal Index scores, highest in groups with comorbid depression and/or dementia. The DDT-Pro represented a single construct for delirium demonstrated by one factor with high item loadings and high internal consistency reliability of its items. CONCLUSIONS The DDT-Pro demonstrated strong performance metrics in general hospital elderly inpatients with preexisting depression and/or dementia, which is unique among brief delirium tools. Its optimized cutoff score was the same as in other populations.
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Affiliation(s)
- María Botero Urrea
- Liaison Psychiatry Research Group (GIPE), Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia..
| | - Maria Carolina González
- Liaison Psychiatry Research Group (GIPE), Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia..
| | - María Margarita Villa García
- Liaison Psychiatry Research Group (GIPE), Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Marcela Alviz Núñez
- Liaison Psychiatry Research Group (GIPE), Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Juan D Velásquez-Tirado
- Liaison Psychiatry Research Group (GIPE), Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia..
| | - María V Ocampo
- Liaison Psychiatry Research Group (GIPE), Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia..
| | - Paula T Trzepacz
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - José G Franco
- Liaison Psychiatry Research Group (GIPE), Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia..
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Carpenter CR, Lee S, Kennedy M, Arendts G, Schnitker L, Eagles D, Mooijaart S, Fowler S, Doering M, LaMantia MA, Han JH, Liu SW. Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments. Acad Emerg Med 2024. [PMID: 38757369 DOI: 10.1111/acem.14935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening. METHODS We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds. RESULTS Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%. CONCLUSIONS The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.
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Affiliation(s)
| | - Sangil Lee
- University of Iowa, Iowa City, Iowa, USA
| | - Maura Kennedy
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Glenn Arendts
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Linda Schnitker
- Bolton Clarke Research Institute, Bolton Clarke School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | | | - Simon Mooijaart
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, The Netherlands
| | - Susan Fowler
- University of Connecticut Health Sciences, Farmington, Connecticut, USA
| | - Michelle Doering
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | | | - Jin H Han
- Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Soler-Sanchis A, Martínez-Arnau FM, Sánchez-Frutos J, Pérez-Ros P. The 4AT scale for rapid detection of delirium in emergency department triage. Front Med (Lausanne) 2024; 11:1345983. [PMID: 38808143 PMCID: PMC11130506 DOI: 10.3389/fmed.2024.1345983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 05/02/2024] [Indexed: 05/30/2024] Open
Abstract
Aims To assess the diagnostic accuracy and time impact of the 4AT scale in emergency department triage. Methods A Prospective diagnostic accuracy study was carried out. People aged ≥65 years presenting to the emergency department from 1 November 2021 to 30 June 2022 were included. Nurses opportunistically screened eligible patients using the 4AT scale during triage according to the Manchester Triage System Francesc de Borja Hospital emergency department, Gandía (Spain). Accuracy was compared with medical diagnosis of delirium. Time (seconds) spent in triage with and without screening was assessed. Results The study included 370 patients (55.1% men, mean age 81.8 years), of whom 58.4% (n = 216) were screened. A final diagnosis of delirium was made in 41.4% of those screened. The most frequently used presentational flow charts and discriminators were 'behaving strangely' (15%) and 'rapid onset' (33.3%). The highest accuracy was obtained for a score of 3 points or more (sensitivity 85.1%; specificity 66.9%; positive predictive value 52.8%; negative predictive value 71.7%). No significant differences were found in the time spent in triage according to the performance of screening. Conclusion A score of 3 points or more on the 4AT scale enables rapid detection of delirium in emergency department triage, without consuming more time than conventional triage.
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Affiliation(s)
- Angela Soler-Sanchis
- Department of Nursing, Universitat de València, Valencia, Spain
- Hospital Francesc de Borja, Generalitat Valenciana, Gandia, Valencia, Spain
| | - Francisco Miguel Martínez-Arnau
- Department of Nursing, Universitat de València, Valencia, Spain
- Department of Physiotherapy, Universitat de València, Valencia, Spain
| | | | - Pilar Pérez-Ros
- Department of Nursing, Universitat de València, Valencia, Spain
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Swarbrick C, Poulton T, Martin P, Partridge J, Moppett IK. Study protocol for a national observational cohort investigating frailty, delirium and multimorbidity in older surgical patients: the third Sprint National Anaesthesia Project (SNAP 3). BMJ Open 2023; 13:e076803. [PMID: 38135325 DOI: 10.1136/bmjopen-2023-076803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023] Open
Abstract
INTRODUCTION Older surgical patients are more likely to be living with frailty and multimorbidity and experience postoperative complications. The management of these conditions in the perioperative pathway is evolving. In order to support objective decision-making for patients, services and national guidance, accurate, contemporary data are needed to describe the impact and associations between frailty, multimorbidity and healthcare processes with patient and service-level outcomes. METHODS AND ANALYSIS The study is comprised of an observational cohort study of approximately 7500 patients; an organisational survey of perioperative services and a clinician survey of the unplanned, medical workload generated from older surgical patients. The cohort will consist of patients who are 60 years and older, undergoing a surgical procedure during a 5-day recruitment period in participating UK hospitals. Participants will be assessed for baseline frailty and multimorbidity; postoperative morbidity including delirium; and quality of life. Data linkage will provide additional details about individuals, their admission and mortality.The study's primary outcome is length of stay, other outcome measures include incidence of postoperative morbidity and delirium; readmission, mortality and quality of life. The cohort's incidence of frailty, multimorbidity and delirium will be estimated using 95% CIs. Their relationships with outcome measures will be examined using unadjusted and adjusted multilevel regression analyses. Choice of covariates in the adjusted models will be prespecified, based on directed acyclic graphs.A parallel study is planned to take place in Australia in 2022. ETHICS AND DISSEMINATION The study has received approval from the Scotland A Research Ethics Committee and Wales Research Ethics Committee 7.This work hopes to influence the development of services and guidelines. We will publish our findings in peer-reviewed journals and provide summary documents to our participants, sites, healthcare policy-makers and the public. TRIAL REGISTRATION NUMBER ISRCTN67043129.
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Affiliation(s)
- Claire Swarbrick
- Anaesthesia & Critical Care, University of Nottingham, Nottingham, UK
- Anaesthesia, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Tom Poulton
- Anaesthesia, Perioperative Medicine, and Pain Medicine, Victorian Comprehensive Cancer Centre, University of Melbourne, Parkville, Victoria, Australia
- Critical Care, University College London, London, UK
| | - Peter Martin
- Applied Health Research, University College London, London, UK
| | - Judith Partridge
- Division of Health and Social Care Research, King's College London, London, UK
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Iain Keith Moppett
- Anaesthesia & Critical Care, University of Nottingham, Nottingham, UK
- Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Damanti S, Cilla M, Vitali G, Tiraferri V, Pomaranzi C, De Rubertis G, De Lorenzo R, Di Lucca G, Scotti R, Messina E, Dell’Acqua R, Guffanti M, Cinque P, Castagna A, Rovere-Querini P, Tresoldi M. Exploring the Association between Delirium and Malnutrition in COVID-19 Survivors: A Geriatric Perspective. Nutrients 2023; 15:4727. [PMID: 38004121 PMCID: PMC10674410 DOI: 10.3390/nu15224727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Older individuals face an elevated risk of developing geriatric syndromes when confronted with acute stressors like COVID-19. We assessed the connection between in-hospital delirium, malnutrition, and frailty in a cohort of COVID-19 survivors. Patients aged ≥65, hospitalized in a tertiary hospital in Milan for SARS-CoV-2 pneumonia, were enrolled and screened for in-hospital delirium with the 4 'A's Test (4AT) performed twice daily (morning and evening) during hospital stay. Malnutrition was assessed with the malnutrition universal screening tool (MUST) at hospital admission and with the mini-nutritional assessment short-form (MNA-SF) one month after hospital discharge. Frailty was computed with the frailty index one month after hospital discharge. Fifty patients (median age 78.5, 56% male) were enrolled. At hospital admission, 10% were malnourished. The 13 patients (26%) who developed delirium were frailer (7 vs. 4), experienced a higher in-hospital mortality (5 vs. 3), and were more malnourished one month after discharge (3 of the 4 patients with delirium vs. 6 of the 28 patients without delirium who presented at follow up). The 4AT scores correlated with the MNA-SF scores (r = -0.55, p = 0.006) and frailty (r = 0.35, p = 0.001). Frailty also correlated with MUST (r = 0.3, p = 0.04), MNA-SF (r = -0.42, p = 0.02), and hospitalization length (r = 0.44, p = 0.001). Delirium, malnutrition, and frailty are correlated in COVID-19 survivors. Screening for these geriatric syndromes should be incorporated in routine clinical practice.
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Affiliation(s)
- Sarah Damanti
- Vita Salute University, 20100 Milan, Italy; (V.T.); (C.P.); (G.D.R.); (R.D.L.); (A.C.); (P.R.-Q.)
- General Medicine and Continuity of Care Unit, IRCCS San Raffaele Hospital, 20132 Milan, Italy;
| | - Marta Cilla
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Giordano Vitali
- General Medicine and Continuity of Care Unit, IRCCS San Raffaele Hospital, 20132 Milan, Italy;
| | - Valeria Tiraferri
- Vita Salute University, 20100 Milan, Italy; (V.T.); (C.P.); (G.D.R.); (R.D.L.); (A.C.); (P.R.-Q.)
| | - Chiara Pomaranzi
- Vita Salute University, 20100 Milan, Italy; (V.T.); (C.P.); (G.D.R.); (R.D.L.); (A.C.); (P.R.-Q.)
| | - Giulia De Rubertis
- Vita Salute University, 20100 Milan, Italy; (V.T.); (C.P.); (G.D.R.); (R.D.L.); (A.C.); (P.R.-Q.)
| | - Rebecca De Lorenzo
- Vita Salute University, 20100 Milan, Italy; (V.T.); (C.P.); (G.D.R.); (R.D.L.); (A.C.); (P.R.-Q.)
| | - Giuseppe Di Lucca
- Unit of General Medicine and Advanced Care, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (G.D.L.); (R.S.); (M.T.)
| | - Raffaella Scotti
- Unit of General Medicine and Advanced Care, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (G.D.L.); (R.S.); (M.T.)
| | - Emanuela Messina
- Infectious Diseases Unit, San Raffaele Scientific Institute, 20132 Milan, Italy; (E.M.); (M.G.); (P.C.)
| | - Raffaele Dell’Acqua
- Infectious Diseases Unit, San Raffaele Scientific Institute, 20132 Milan, Italy; (E.M.); (M.G.); (P.C.)
| | - Monica Guffanti
- Infectious Diseases Unit, San Raffaele Scientific Institute, 20132 Milan, Italy; (E.M.); (M.G.); (P.C.)
| | - Paola Cinque
- Infectious Diseases Unit, San Raffaele Scientific Institute, 20132 Milan, Italy; (E.M.); (M.G.); (P.C.)
| | - Antonella Castagna
- Vita Salute University, 20100 Milan, Italy; (V.T.); (C.P.); (G.D.R.); (R.D.L.); (A.C.); (P.R.-Q.)
- Infectious Diseases Unit, San Raffaele Scientific Institute, 20132 Milan, Italy; (E.M.); (M.G.); (P.C.)
| | - Patrizia Rovere-Querini
- Vita Salute University, 20100 Milan, Italy; (V.T.); (C.P.); (G.D.R.); (R.D.L.); (A.C.); (P.R.-Q.)
- General Medicine and Continuity of Care Unit, IRCCS San Raffaele Hospital, 20132 Milan, Italy;
- Division of Immunology, Transplantation & Infectious Diseases, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Moreno Tresoldi
- Unit of General Medicine and Advanced Care, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (G.D.L.); (R.S.); (M.T.)
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Pouw MA, Calf AH, Georg RR, de Rooij SE, Ter Maaten JC, van Munster BC. Diagnostic accuracy of the Dutch version of the 4AT for delirium detection in a mixed patient population and setting. Aging Clin Exp Res 2023:10.1007/s40520-023-02447-2. [PMID: 37285074 PMCID: PMC10363057 DOI: 10.1007/s40520-023-02447-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/17/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Delirium is an acute disturbance in attention, awareness and cognition. Immediate detection in older adults is recommended because delirium is associated with adverse outcomes. The 4 'A's Test (4AT) is a short screening instrument for delirium. The aim of this study is to evaluate diagnostic accuracy of the Dutch version of the screening tool 4AT for delirium detection in different settings. METHODS Prospective observational study conducted in two hospitals in patients aged ≥ 65 years in geriatric wards and the Emergency Department (ED). Each participant underwent two assessments; the index test 4AT, followed by the reference standard for delirium performed by a geriatric care specialist. The reference standard delirium is according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. RESULTS A total of 71 geriatric inpatients and 49 older ED patients were included. The prevalence of delirium was 11.6% in the acute geriatric ward and 6.1% in the ED. The sensitivity and specificity of the 4AT in the acute geriatric ward were 0.88 and 0.69, respectively. In the ED, the sensitivity and specificity were 0.67 and 0.83, respectively. The area under the receiver operating characteristic curve was 0.80 for the acute geriatric ward setting and 0.74 for the ED setting. CONCLUSION The Dutch version of the 4AT is a reliable screening tool for delirium detection in both acute geriatric wards and ED. Due to its brevity and practicality (i.e., no special training is required to administer the tool), it is useful in clinical practice.
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Affiliation(s)
- Maaike A Pouw
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Agneta H Calf
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Rita R Georg
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Sophia E de Rooij
- Amstelland Hospital, Laan van de Helende Meesters 8, 1186 AM, Amstelveen, The Netherlands
| | - Jan C Ter Maaten
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Barbara C van Munster
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
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Liu Y, Li Z, Li Y, Ge N, Yue J. Detecting delirium: a systematic review of ultrabrief identification instruments for hospital patients. Front Psychol 2023; 14:1166392. [PMID: 37251016 PMCID: PMC10214704 DOI: 10.3389/fpsyg.2023.1166392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/21/2023] [Indexed: 05/31/2023] Open
Abstract
Objective Early identification of delirium, which often occurs in older patients, can effectively reduce adverse prognoses. One way to increase the detection rate of delirium is to use an effective ultrabrief instrument for higher-frequency screening. The purpose of this review is to evaluate the diagnostic accuracy of ultrabrief screening tools for delirium. Methods The Cochrane Library, PubMed and EMBASE were searched from January 1, 1974, to November 31, 2022. We assessed the measurement properties of screening instruments using the consensus-based standards for selecting health measurement instruments (COSMIN) checklist and evaluated the risk bias of the included studies using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. The diagnostic test accuracy of instruments for delirium was reported using sensitivity, specificity, positive likelihood ratio (PLR) and negative likelihood ratio (NLR). Result Of the 4,914 items identified, 26 met the eligibility criteria, resulting in 5 different delirium identification tools. The overall study quality assessed by the QUADAS-2 tool was moderate to good. Of the five screening tools, two instruments had sensitivity ≥80% and specificities ≥80%: 4AT and UB-2. The most comprehensive is the 4AT scale, which has a sensitivity of 0.80 [95% confidence interval (CI):0.68, 0.88] and a specificity of 0.89 (95%CI: 0.83, 0.93) and contains 4 items. UB-2 has a sensitivity of 0.88 (95%CI: 0.72, 0.96) and a specificity of 0.64 (95%CI: 0.56, 0.70). Conclusion UB-2 and MOTYB had excellent sensitivity for delirium screening at an early stage. In terms of sensitivity and intentionality, the 4AT is the best recommended scale.
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Affiliation(s)
- Yadong Liu
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
| | - Zhenzhen Li
- Health Management Center, General Practice Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Sichuan, China
| | - Ying Li
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
| | - Ning Ge
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
| | - Jirong Yue
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
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Ma R, Zhao J, Li C, Qin Y, Yan J, Wang Y, Yu Z, Zhang Y, Zhao Y, Huang B, Sun S, Ning X. Diagnostic accuracy of the 3-minute diagnostic interview for confusion assessment method-defined delirium in delirium detection: a systematic review and meta-analysis. Age Ageing 2023; 52:afad074. [PMID: 37211364 DOI: 10.1093/ageing/afad074] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Indexed: 05/23/2023] Open
Abstract
BACKGROUND Delirium is a common complication clinically and is associated with the poor outcomes, yet it is frequently unrecognised and readily disregarded. Although the 3-minute diagnostic interview for confusion assessment method-defined delirium (3D-CAM) has been used in a variety of care settings, a comprehensive evaluation of its accuracy in all available care settings has not been performed. OBJECTIVE This study aimed to evaluate the diagnostic test accuracy of the 3D-CAM in delirium detection through a systematic review and meta-analysis. METHODS We systematically searched PubMed, EMBASE, the Cochrane Library, Web of Science, CINAHL (EBSCO) and ClinicalTrials.gov published from inception to 10 July 2022. The quality assessment of the diagnostic accuracy studies-2 tool was applied to evaluate methodological quality. A bivariate random effects model was used to pool sensitivity and specificity. RESULTS Seven studies with 1,350 participants and 2,499 assessments were included, which were carried out in general medical wards, intensive care units, internal medical wards, surgical wards, recovery rooms and post-anaesthesia care units. The prevalence of delirium ranged from 9.1% to 25%. The pooled sensitivity and specificity were 0.92 (95% confidence interval [CI] 0.87-0.95) and 0.95 (95% CI 0.92-0.97), respectively. The pooled positive likelihood ratio was 18.6 (95% CI 12.2-28.2), the negative likelihood ratio was 0.09 (95% CI 0.06-0.14) and the diagnostic odds ratio was 211 (95% CI 128-349). Moreover, the area under the curve was 0.97 (95% CI 0.95-0.98). CONCLUSIONS The 3D-CAM has good diagnostic accuracy for delirium detection in different care settings. Further analyses illustrated that it had comparable diagnostic accuracy in older adults and patients with dementia or known baseline cognitive impairment. In conclusion, the 3D-CAM is recommended for clinical delirium detection.
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Affiliation(s)
- Rui Ma
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jin Zhao
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Cui Li
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yunlong Qin
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jipeng Yan
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yuwei Wang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zixian Yu
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yumeng Zhang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yueru Zhao
- Medicine School of Xi'an Jiaotong University, Xi'an, China
| | - Boyong Huang
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiaoxuan Ning
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Lozano-Vicario L, Zambom-Ferraresi F, Zambom-Ferraresi F, de la Casa-Marín A, Ollo-Martínez I, Sáez de Asteasu ML, Cedeño-Veloz BA, Fernández-Irigoyen J, Santamaría E, Romero-Ortuno R, Izquierdo M, Martínez-Velilla N. Effectiveness of a multicomponent exercise training program for the management of delirium in hospitalized older adults using near-infrared spectroscopy as a biomarker of brain perfusion: Study protocol for a randomized controlled trial. Front Aging Neurosci 2022; 14:1013631. [PMID: 36589545 PMCID: PMC9797855 DOI: 10.3389/fnagi.2022.1013631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
Delirium is an important cause of morbidity and mortality in older adults admitted to hospital. Multicomponent interventions targeting delirium risk factors, including physical exercise and mobilization, have been shown to reduce delirium incidence by 30-40% in acute care settings. However, little is known about its role in the evolution of delirium, once established. This study is a randomized clinical trial conducted in the Acute Geriatric Unit of Hospital Universitario de Navarra (Pamplona, Spain). Hospitalized patients with delirium who meet the inclusion criteria will be randomly assigned to the intervention or the control group. The intervention will consist of a multicomponent exercise training program, which will be composed of supervised progressive resistance and strength exercise over 3 consecutive days. Functional Near-Infrared Spectroscopy (NIRS) will be used for assessing cerebral and muscle tissue blood flow. The objective is to assess the effectiveness of this intervention in modifying the following primary outcomes: duration and severity of delirium and functional status. This study will contribute to determine the effectiveness of physical exercise in the management of delirium. It will be the first study to evaluate the impact of a multicomponent intervention based on physical exercise in the evolution of delirium. Clinical trial registration ClinicalTrials.gov. identifier: NCT05442892 (date of registration June 26, 2022).
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Affiliation(s)
- Lucía Lozano-Vicario
- Department of Geriatric Medicine, Hospital Universitario de Navarra (HUN), Pamplona, Spain
| | - Fabiola Zambom-Ferraresi
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdisNa), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | - Fabricio Zambom-Ferraresi
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdisNa), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | - Antón de la Casa-Marín
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdisNa), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | - Iranzu Ollo-Martínez
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdisNa), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | - Mikel L. Sáez de Asteasu
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdisNa), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | | | - Joaquín Fernández-Irigoyen
- Clinical Neuroproteomics Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdisNa), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | - Enrique Santamaría
- Clinical Neuroproteomics Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdisNa), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | | | - Mikel Izquierdo
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdisNa), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | - Nicolás Martínez-Velilla
- Department of Geriatric Medicine, Hospital Universitario de Navarra (HUN), Pamplona, Spain
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdisNa), Universidad Pública de Navarra (UPNA), Pamplona, Spain
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Muacevic A, Adler JR, Paul S, Abbas MS, Nassar ST, Tasha T, Desai A, Bajgain A, Ali A, Mohammed L. Urinary Tract Infection Induced Delirium in Elderly Patients: A Systematic Review. Cureus 2022; 14:e32321. [PMID: 36632270 PMCID: PMC9827929 DOI: 10.7759/cureus.32321] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/08/2022] [Indexed: 12/13/2022] Open
Abstract
Urinary tract infection (UTI) is common in older adults, mainly due to several age-related risk factors. Symptoms of UTI are atypical in the elderly population, like hypotension, tachycardia, urinary incontinence, poor appetite, drowsiness, frequent falls, and delirium. UTI manifests more commonly and specifically for this age group as delirium or confusion in the absence of a fever. This systematic review aims to highlight the relationship between UTI and delirium in the elderly population by understanding the pathologies individually and collectively. A systematic review is conducted by searching PubMed with regular keywords and major Medical Subject Heading (MeSH) keywords, Science Direct, and Google Scholar. The inclusion criteria consisted of studies based on male and female human populations above the age of 65 in the English language, available in full text published between 2017 and 2022. However, the exclusion criteria were animal studies, clinical trials, literature published before 2017, and papers published in any other language except English. A total of 106 articles were identified, and nine final studies were selected after a quality assessment, following which a valid relationship between delirium and UTI was identified in this systematic review.
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11
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The Use of Psychotropic Medication in Pediatric Oncology for Acute Psychological and Psychiatric Problems: Balancing Risks and Benefits. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121878. [PMID: 36553324 PMCID: PMC9777172 DOI: 10.3390/children9121878] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022]
Abstract
Severe acute behavioral and emotional problems represent one of the most serious treatment-related adverse effects for children and adolescents who have cancer. The critical and severe nature of these symptoms often makes necessary the use of psychotropic drugs. A working group composed of experts in multiple disciplines had the task of creating an agreement regarding a management plan for severe acute behavioral and emotional problems (SABEPs) in children and adolescents treated for cancer. To obtain global information on the use of psychotropic drugs in pediatric oncology, the working group first developed and mailed a 15-item questionnaire to many Italian pediatric oncology centers. Overall, an evident lack of knowledge and education regarding the use of psychotropic medications for the treatment of SABEPs was found. Thus, by referring to an adapted version of the Delphi method of consensus and standard methods for the elaboration of clinical questions (PICOs), the working group elaborated evidence-based recommendations for psychotropic drugs in the pediatric oncology setting. Furthermore, based on a thorough multivariate analysis of needs and difficulties, a comprehensive management flow was developed to optimize therapeutic interventions, which allows more accurate and efficient matching of the acute needs of patients while guiding treatment options.
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12
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Ghosh M, Hamer O, Hill J. Diagnostic test accuracy of assessment tools for detecting delirium in patients with acute stroke: commentary of a systematic review. BRITISH JOURNAL OF NEUROSCIENCE NURSING 2022; 18:S18-S21. [PMID: 38812978 PMCID: PMC7616030 DOI: 10.12968/bjnn.2022.18.sup5.s18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Delirium is a common presentation after acute stroke. Post-stroke delirium is related to poor recovery, higher rates of mortality, falls, and longer hospital stays. Delirium can lead to challenging behaviour such as anger, aggression, and confusion. As such, it is important to identify delirium promptly for early management and to reduce the negative impact on post-stroke recovery and outcomes. An important aspect of identifying delirium depends on the use of efficient, easy to use and validated assessment tools. A wide range of tools are available, although it is not known how accurately they can identify post-stroke delirium. This article critically appraises a systematic review which identified delirium screening tools for patients with acute stroke, and summarised their accuracy.
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Affiliation(s)
| | - Oliver Hamer
- University of Central Lancashire (UCLan), Preston, UK
| | - James Hill
- University of Central Lancashire (UCLan), Preston, UK
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13
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Zhang H, Lei H, Pang J. Diagnostic performance of radiomics in adrenal masses: A systematic review and meta-analysis. Front Oncol 2022; 12:975183. [PMID: 36119492 PMCID: PMC9478189 DOI: 10.3389/fonc.2022.975183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/17/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives(1) To assess the methodological quality and risk of bias of radiomics studies investigating the diagnostic performance in adrenal masses and (2) to determine the potential diagnostic value of radiomics in adrenal tumors by quantitative analysis.MethodsPubMed, Embase, Web of Science, and Cochrane Library databases were searched for eligible literature. Methodological quality and risk of bias in the included studies were assessed by the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) and Radiomics Quality Score (RQS). The diagnostic performance was evaluated by pooled sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curve (AUC). Spearman’s correlation coefficient and subgroup analysis were used to investigate the cause of heterogeneity. Publication bias was examined using the Deeks’ funnel plot.ResultsTwenty-eight studies investigating the diagnostic performance of radiomics in adrenal tumors were identified, with a total of 3579 samples. The average RQS was 5.11 (14.2% of total) with an acceptable inter-rater agreement (ICC 0.94, 95% CI 0.93–0.95). The risk of bias was moderate according to the result of QUADAS-2. Nine studies investigating the use of CT-based radiomics in differentiating malignant from benign adrenal tumors were included in the quantitative analysis. The pooled sensitivity, specificity, DOR and AUC with 95% confidence intervals were 0.80 (0.68-0.88), 0.83 (0.73-0.90), 19.06 (7.87-46.19) and 0.88 (0.85–0.91), respectively. There was significant heterogeneity among the included studies but no threshold effect in the meta-analysis. The result of subgroup analysis demonstrated that radiomics based on unenhanced and contrast-enhanced CT possessed higher diagnostic performance, and second-order or higher-order features could enhance the diagnostic sensitivity but also increase the false positive rate. No significant difference in diagnostic ability was observed between studies with machine learning and those without.ConclusionsThe methodological quality and risk of bias of studies investigating the diagnostic performance of radiomics in adrenal tumors should be further improved in the future. CT-based radiomics has the potential benefits in differentiating malignant from benign adrenal tumors. The heterogeneity between the included studies was a major limitation to obtaining more accurate conclusions.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/ CRD 42022331999 .
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Beretta M, Uggeri S, Santucci C, Cattaneo M, Ermolli D, Gerosa C, Ornaghi M, Roccasalva A, Santambrogio P, Varrassi G, Corli O. Early Diagnosis of Delirium in Palliative Care Patients Decreases Mortality and Necessity of Palliative Sedation: Results of a Prospective Observational Study. Cureus 2022; 14:e25706. [PMID: 35812586 PMCID: PMC9260701 DOI: 10.7759/cureus.25706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/05/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction: Delirium in end-of-life patients is reported to be between 13% and 42% and up to 80% in the terminal phase. It is a serious clinical situation, often a cause of death due to the frequent ineffectiveness of treatments. This study aimed to assess whether and how much precocity of diagnosis, hitherto little considered, could affect the outcomes and prognosis of delirium in palliative care settings. Methods: Patients consecutively admitted to a palliative care unit (PCU) between October 2018 and December 2019, cared for both in hospice and home programs, were analyzed. All patients were subjected to a careful procedure aimed at recognizing the onset of delirium. The first step was the detection of prodromal "sentinel" symptoms related to incoming delirium. PCU staff and family members/caregivers were trained to observe the patients and immediately identify the appearance of even one symptom. The final diagnosis was performed with the 4AT (4 A’s test). Patients were then included in the categories of "early" or "slow" diagnosis (cut-off: four hours) depending on the time between sentinel symptom observation and the final diagnosis of delirium. Results: Among 503 admitted patients, 95 developed delirium. Confusion was the most frequent sentinel symptom (49.5%). The early diagnosis was more frequent in hospice than in home care (p-value<0.0001). Delirium was positively resolved in 43 patients, of which 25 with an early diagnosis (p-value=0.038). Time to resolution was shorter in the case of early diagnosis (7.1 vs. 13.7 hours in hospice patients; p-value=0.018). Palliative sedation was performed on 25 patients, but only 8 of them had an early diagnosis. Conclusion: Time of diagnosis was important in determining the clinical outcomes of patients in charge of PCU who experienced delirium. The early diagnosis reduced both mortality and the necessity of palliative sedation.
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Nurse-Driven Assessment, Prevention, and Management of Delirium on an Acute Inpatient Neurology Unit. J Nurs Care Qual 2022; 37:334-341. [PMID: 35486389 DOI: 10.1097/ncq.0000000000000628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Delirium commonly affects hospitalized patients and is associated with increased hospital length of stay, discharge to skilled care, cost, morbidity, and mortality. LOCAL PROBLEM At our organization, there was no formal delirium assessment performed by the nursing staff outside of the intensive care unit. METHODS Assessment of nurses' knowledge about delirium, a nurse-driven delirium screening protocol, and patient education were implemented on an adult inpatient neurology unit. Knowledge change, protocol implementation, and patient-level outcomes were assessed. INTERVENTIONS Staff nurse delirium education and a nurse-driven delirium screening protocol were implemented. RESULTS No change in nursing knowledge occurred pre/postintervention. Falls, falls with injury, and restraint and sitter usage decreased. Changes in length of stay varied over the intervention period. The trend to discharge to home increased, while the trend to discharge to skilled nursing care decreased. CONCLUSIONS Formal delirium screening protocols may add organizational value by positively impacting patient outcomes.
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Abstract
Delirium remains a challenging clinical problem in hospitalized older adults, especially for postoperative patients. This complication, with a high risk of postoperative mortality and an increased length of stay, frequently occurs in older adult patients. This brief narrative paper aims to review the recent literature regarding delirium and its most recent update. We also offer physicians a brief and essential clinical practice guide to managing this acute and common disease.
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17
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Kim S, Choi E, Jung Y, Jang I. Postoperative delirium screening tools for post-anaesthetic adult patients in non-intensive care units: A systematic review and meta-analysis. J Clin Nurs 2021; 32:1691-1704. [PMID: 34881476 DOI: 10.1111/jocn.16157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/31/2021] [Accepted: 11/19/2021] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To identify the most accurate postoperative delirium screening tools for detecting postoperative delirium among patients who underwent general anaesthesia surgery in general wards. BACKGROUND The lack of detection of postoperative delirium can negatively affect the patient's condition, along with their postoperative treatment and rehabilitation, and it can prolong their hospitalisation, persists cognitive dysfunction and increases mortality. Screening for postoperative delirium in hospitalised patients as nursing assessment is routine clinical practice for early detection. DESIGN A systematic review and meta-analysis. METHODS MEDLINE, Embase, CINAHL, KoreaMed and Cochrane electronic databases were searched using the key words delirium, postoperative, assessment or screening, and adult for articles published up to April 2020, with no limit on the year of publishing. Only prospective cohort studies reporting sensitivity and specificity values were included. We followed the recommendations of the Cochrane Handbook of Diagnostic Test Accuracy Reviews and the PRISMA checklist. The Quality Assessment of the Diagnostic Accuracy Studies-2 tool was used for data extraction and quality assessment, while a bivariate random-effects meta-analysis model was used for pooling and comparing diagnostic accuracy and providing a summary of evidence. RESULTS Six delirium assessment tools were evaluated from nine papers including 3088 patients. Due to the limited number of papers, the meta-analysis included the Confusion Assessment Method (CAM) and its variants, Delirium Detection Score (DDS) and Nurses' Delirium Screening Checklist (NuDESC). Overall, NuDESC demonstrated higher sensitivity than CAM or DDS, while all showed high specificity (0.90 or greater). CONCLUSION This review suggested that NuDESC can be employed as an accurate screening tool with high specificity for assessing postoperative delirium during routine checkups. However, it is necessary to consider suitable cut-off values, which is the reference point, in accordance with the clinical setting and the patients' condition. RELEVANCE TO CLINICAL PRACTICE NuDESC reported the best evidence of diagnostic accuracy, and we recommend clinical nurses to employ this easy-to-use and validated tool for daily screening of postoperative delirium in general wards to facilitate its early detection and the accurate estimation of its prevalence.
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Affiliation(s)
- Sujeong Kim
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Eunju Choi
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Youngsun Jung
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Insil Jang
- Department of Nursing, Chung-Ang University, Seoul, Korea
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O Riordan J, Kane PM, Noble H, Smyth A. Advance care planning and health literacy in older dialysis patients: qualitative interview study. BMJ Support Palliat Care 2021:bmjspcare-2021-003273. [PMID: 34782344 DOI: 10.1136/bmjspcare-2021-003273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/25/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Low health literacy among older adults is associated with limited engagement in end-of-life care planning, higher hospitalisation rates and increased mortality. Frequently, older dialysis patients derive no survival benefit from dialysis and their quality of life often deteriorates further on dialysis. Older dialysis patients' values and wishes are frequently unknown during key healthcare decision making and many endure medically intensive end-of-life scenarios. The objectives of this study were to explore older dialysis patients' understanding of haemodialysis, to explore their engagement in end-of-life care planning and to explore their satisfaction with life on haemodialysis. METHODS 15 older dialysis patients participated in qualitative semistructured interviews in two haemodialysis units in Ireland. Thematic saturation was reached. Thematic analysis, applied inductively, was used to distill the data. RESULTS Themes identified included disempowerment among participants reflected limited health literacy, poor advance care planning compromised participant well-being, haemodialysis compromised participants' core values. CONCLUSION Health literacy levels among older dialysis patients are poor, patient empowerment is limited and their participation in shared decision making and advance care planning is suboptimal. Consequently, healthcare decision making, including haemodialysis, may jeopardise patients' core values. Improving health literacy through enhanced patient education and improved communication skills training for clinicians is necessary to promote patient participation in shared decision making. Clinician training to facilitate discussion of patients' values and wishes will help guide clinicians and patients towards healthcare decisions most concordant with patients' core values. This approach will optimise the circumstances for patient-centred care.
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Affiliation(s)
- Julien O Riordan
- Palliative Medicine, IPU, Galway Hospice Foundation, Renmore, Ireland
- School of Medicine, National University of Ireland Galway School of Medicine, Galway, Ireland
| | - P M Kane
- Community Palliative Care Services, Laois, Longford, Westmeath, Mullingar General Hospital, Mullingar, Ireland
- Palliative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Helen Noble
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Andrew Smyth
- Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
- Nephrology, Galway University Hospitals, Galway, Ireland
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Johansson YA, Tsevis T, Nasic S, Gillsjö C, Johansson L, Bogdanovic N, Kenne Sarenmalm E. Diagnostic accuracy and clinical applicability of the Swedish version of the 4AT assessment test for delirium detection, in a mixed patient population and setting. BMC Geriatr 2021; 21:568. [PMID: 34663229 PMCID: PMC8522056 DOI: 10.1186/s12877-021-02493-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delirium is common in older hospitalized patients. It has serious consequences e.g., poor health outcomes, mortality and increased costs. Despite that, many cases are undetected. Early detection of delirium is important in improving outcomes and use of assessment tools improves detection rates. The 4AT is a brief screening tool for delirium detection, which has not previously been translated into Swedish. The study aim was to evaluate diagnostic accuracy and clinical applicability of a Swedish version of the screening tool 4AT for delirium detection. METHOD This diagnostic test accuracy study used a quantitative and a qualitative approach and evaluated the patients' and the health care professionals' experiences of the tool. Study included 200 patients ≥65 years from a university hospital and a county hospital in two Swedish regions. Medical specialties were geriatric stroke/neurology, geriatric multimorbidity, severe cognitive impairment, orthopaedic, and urology. The translated 4AT was tested against the reference standard DSM-IV-TR criteria, based on the Organic Brain Syndrome scale and patient records. The 4AT was assessed simultaneously and independently by two assessors. Additionally, data was collected through patient record reviews, and questions about applicability to the patients (n = 200) and the assessors (n = 37). Statistical analyses, and qualitative content analyses were conducted. RESULTS By reference standard 18% had delirium, and by 4AT 19%. The overall percent agreement was 88%, AUROC 0.808, sensitivity 0.70 (95% CI 0.51-0.84) and specificity 0.92 (95% CI 0.87-0.96). In the ward for severe cognitive impairment (n = 63) the 4AT was less sensitive and less specific. In the other wards (n = 132) sensitivity was 0.77 (95% CI 0.50-0.93), specificity 0.93 (95% CI 0.87-0.97), and AUROC 0.848. Interrater reliability (Kappa) was 0.918, p = < 0.001 (n = 144). The 4AT was well tolerated by patients, easy to use for health care professionals, and took a few minutes to conduct. CONCLUSION The Swedish version of 4AT is an accurate and applicable tool to use in clinical practice for detecting delirium in hospitalized patients across different medical specialities, and to use by different professionals and levels of seniority. To improve patient outcomes, we recommend the 4AT to be incorporated in clinical practice in health care settings in Sweden.
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Affiliation(s)
- Yvonne A Johansson
- Skaraborg Hospital, Skövde, Sweden. .,The Research School of Health and Welfare, Aging Research Network-Jönköping (ARN-J), Jönköping University, Jönköping, Sweden.
| | - Theofanis Tsevis
- Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden.,Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Salmir Nasic
- Skaraborg Hospital, Skövde, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Catharina Gillsjö
- School of Health Sciences, University of Skövde, Skövde, Sweden.,College of Nursing, University of Rhode Island, Kingston, RI, USA
| | - Linda Johansson
- Institute of Gerontology, Aging Research Network-Jönköping (ARN-J), School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Nenad Bogdanovic
- Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden.,Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Elisabeth Kenne Sarenmalm
- Skaraborg Hospital, Skövde, Sweden.,School of Health Sciences, University of Skövde, Skövde, Sweden.,Institute of Health and Care Science, Sahlgrenska Academy, Centre for Person-Centred Care Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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20
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O Riordan J, Kane PM, Noble H, Smyth A. Advance care planning in older dialysis patients: health care literacy qualitative study. BMJ Support Palliat Care 2021:bmjspcare-2021-003398. [PMID: 34635544 DOI: 10.1136/bmjspcare-2021-003398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Low health literacy among older adults is associated with limited engagement in end-of-life care plans, more hospitalisations and excess mortality. Frequently, older patients derive no survival benefit from dialysis and quality of life often deteriorates with dialysis. Older dialysis patients' values and wishes are often unknown during key healthcare decision-making and many endure medically intensive end-of-life interventions . The objectives of this study were to examine older dialysis patients' understanding of haemodialysis, their engagement in end-of-life care planning and their satisfaction with life on haemodialysis. METHODS 15 older dialysis patients participated in qualitative semi-structured interviews in two haemodialysis units . Thematic saturation was reached. Thematic analysis, applied inductively, distilled the data. RESULTS Themes identified included disempowerment which reflected limited health literacy, poor advance care planning compromised well-being and haemodialysis compromised their core values. CONCLUSION Health literacy among older dialysis patients appeared poor, patient empowerment was limited and participation in shared decision-making and advance care planning suboptimal. Consequently, complex healthcare decision-making, including haemodialysis may jeopardise patients' core values. These findings have significant implications for the validity of the informed consent process prior to dialysis initiation. Improved health literacy through enhanced patient education and better communication skills for clinicians are necessary to promote patient participation in shared decision-making. Clinician training to facilitate discussion of patients' values and wishes will help guide clinicians and patients towards healthcare decisions most concordant with individual core values. This will optimise patient-centred care.
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Affiliation(s)
- Julien O Riordan
- Palliative Medicine, IPU, Galway Hospice Foundation, Renmore, Ireland
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - P M Kane
- Community Palliative Care Services, Palliative Medicine, Specialist Community Palliative Care Services, Laois, Ireland
- Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Helen Noble
- Queen's University Belfast School of Nursing and Midwifery, Belfast, UK
| | - Andrew Smyth
- Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
- Nephrology, Galway University Hospital, Galway, Ireland
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Corli O, Santucci C, Uggeri S, Bosetti C, Cattaneo M, Ermolli D, Varrassi G, Myrcik D, Paladini A, Rekatsina M, Gerosa C, Ornaghi M, Roccasalva A, Santambrogio P, Beretta M. Factors for Timely Identification of Possible Occurrence of Delirium in Palliative Care: A Prospective Observational Study. Adv Ther 2021; 38:4289-4303. [PMID: 34228345 PMCID: PMC8342371 DOI: 10.1007/s12325-021-01814-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/01/2021] [Indexed: 12/19/2022]
Abstract
Delirium occurs in 50–80% of end-of-life patients but is often misdiagnosed. Identification of clinical factors potentially associated with delirium onset can lead to a correct early diagnosis. To this aim, we conducted a prospective cohort study on patients from an Italian palliative care unit (PCU) admitted in 2018–2019. We evaluated the presence of several clinical factors at patient admission and compared their presence in patients who developed delirium and in those who did not develop it during follow-up. Among 503 enrolled patients, after a median follow-up time of 16 days (interquartile range 6–40 days), 95 (18.9%) developed delirium. Hazard ratios (HR) and corresponding 95% confidence intervals were computed using Cox proportional hazard models. In univariate analyses, factors significantly more frequent in patients with delirium were care in hospice, compromised performance status, kidney disease, fever, renal failure, hypoxia, dehydration, drowsiness, poor well-being, breathlessness, and “around the clock” therapy with psychoactive drugs, particularly haloperidol. In multivariate analyses, setting of care (HR 2.28 for hospice versus home care, 95% CI 1.45–3.60; p < 0.001), presence of breathlessness (HR 1.71, 95% CI 1.03–2.83, p = 0.037), and administration of psychoactive drugs, particularly haloperidol (HR 2.17 for haloperidol, 95% CI 1.11–4.22 and 1.53 for other drugs, 95% CI 0.94–2.48; p = 0.048) were significantly associated with the risk of developing delirium. The study indicates that some clinical factors are associated with the probability of delirium onset. Their evaluation in PC patients could help healthcare professionals to identify the development of delirium in those patients in a timely manner.
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Huang G, Wei X, Tang H, Bai F, Lin X, Xue D. A systematic review and meta-analysis of diagnostic performance and physicians' perceptions of artificial intelligence (AI)-assisted CT diagnostic technology for the classification of pulmonary nodules. J Thorac Dis 2021; 13:4797-4811. [PMID: 34527320 PMCID: PMC8411165 DOI: 10.21037/jtd-21-810] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/09/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Lung cancer was the second most commonly diagnosed cancer and the leading cause of cancer death in 2020. Although artificial intelligence (AI)-assisted diagnostic technologies have shown promise and has been used in clinical practice in recent years, no products related to AI-assisted CT diagnostic technologies for the classification of pulmonary nodules have been approved by the National Medical Products Administration in China. The objective of this article was to systematically review the diagnostic performance of AI-assisted CT diagnostic technology for the classification of pulmonary nodules as benign or malignant and to analyze physicians' perceptions of this technology in China. METHODS All relevant studies from 6 literature databases were searched and screened according to the inclusion and exclusion criteria. Data were extracted and the study quality was assessed by two reviewers. The study heterogeneity and publication bias were estimated. A questionnaire survey on the perceptions of physicians was conducted in 9 public tertiary hospitals in China. A meta-analysis, meta-regression and univariate logistic model were used in the systematic review and to explore the association of physicians' perceptions with their rate of support for the clinical application of the technology. RESULTS Twenty-seven studies with 5,727 pulmonary nodules were finally included in the meta-analysis. We found that the quality of the included studies was generally acceptable and that the pooled sensitivity and specificity of AI-assisted CT diagnostic technology for the classification of pulmonary nodules as benign or malignant were 0.90 and 0.89, respectively. The pooled diagnostic odds ratio (DOR) was 70.33. The majority of the surveyed physicians in China perceived "reduced workload for radiologists" and "improved diagnostic efficiency" as the important benefits of this technology. In addition, diagnostic accuracy (including misdiagnosis) and practical experience were significantly associated with whether physicians supported its clinical application. CONCLUSIONS In the context of lung cancer diagnosis, AI-assisted CT diagnostic technology for the classification of pulmonary nodules as benign or malignant has good diagnostic performance, but its specificity needs to be improved.
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Affiliation(s)
- Guo Huang
- NHC Key Laboratory of Health Technology Assessment (Fudan University), Department of Hospital Management, School of Public Health, Fudan University, Shanghai, China
| | - Xuefeng Wei
- Health Commission of Gansu Province, Lanzhou, China
| | - Huiqin Tang
- Health Commission of Hubei Province, Wuhan, China
| | - Fei Bai
- National Center for Medical Service Administration, Beijing, China
| | - Xia Lin
- National Center for Medical Service Administration, Beijing, China
| | - Di Xue
- NHC Key Laboratory of Health Technology Assessment (Fudan University), Department of Hospital Management, School of Public Health, Fudan University, Shanghai, China
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Bellelli G, Brathwaite JS, Mazzola P. Delirium: A Marker of Vulnerability in Older People. Front Aging Neurosci 2021; 13:626127. [PMID: 33994990 PMCID: PMC8119654 DOI: 10.3389/fnagi.2021.626127] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 04/06/2021] [Indexed: 12/11/2022] Open
Abstract
Delirium is an acute neuropsychiatric syndrome and one of the most common presenting symptoms of acute medical illnesses in older people. Delirium can be triggered by a single cause, but in most cases, it is multifactorial as it depends on the interaction between predisposing and precipitating factors. Delirium is highly prevalent in older patients across various settings of care and correlates with an increased risk of adverse clinical outcomes. Several pathophysiological mechanisms may contribute to its onset, including neurotransmitter imbalance, neuroinflammation, altered brain metabolism, and impaired neuronal network connectivity. Several screening and diagnostic tools for delirium exist, but they are unfortunately underutilized. Additionally, the diagnosis of delirium superimposed on dementia poses a formidable challenge - especially if dementia is severe. Non-pharmacological approaches for the prevention and multidomain interventions for the treatment of delirium are recommended, given that there is currently no robust evidence of drugs that can prevent or resolve delirium. This article aims to review the current understanding about delirium in older people. To achieve this goal, we will describe the epidemiology and outcomes of the syndrome, the pathophysiological mechanisms that are supposed to be involved, the most commonly used tools for screening and diagnosis, and prevention strategies and treatments recommended. This review is intended as a brief guide for clinicians in hospital wards to improve their knowledge and practice. At the end of the article, we propose an approach to improve the quality of care provided to older patients throughout a systematic detection of delirium.
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Affiliation(s)
- Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
| | | | - Paolo Mazzola
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
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Jeong E, Park J, Chang SO. Development and Evaluation of Clinical Practice Guideline for Delirium in Long-Term Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E8255. [PMID: 33182243 PMCID: PMC7664888 DOI: 10.3390/ijerph17218255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/14/2022]
Abstract
Delirium is highly prevalent and leads to several bad outcomes for older long-term care (LTC) residents. For a more successful translation of delirium knowledge, Clinical Practice Guidelines (CPGs) tailored to LTC should be developed and applied based on the understanding of the barriers to implementation. This study was conducted to develop a CPG for delirium in LTC and to determine the barriers perceived by healthcare professionals related to the implementation of the CPG. We followed a structured, evidence- and theory-based procedure during the development process. After a systematic search, quality appraisal, and selection for eligible up-to-date CPGs for delirium, the recommendations applicable to the LTC were drafted, evaluated, and confirmed by an external group of experts. To evaluate the barriers to guideline uptake from the users' perspectives, semi-structured interviews were conducted which resulted in four major themes: (1) a lack of resources, (2) a tendency to follow mindlines rather than guidelines, (3) passive attitudes, and (4) misunderstanding delirium care in LTC. To minimize adverse prognoses through prompt delirium care, the implementation of a CPG with an approach that comprehensively considers various barriers at the system, practice, healthcare professional, and patients/family levels is necessary.
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Affiliation(s)
- Eunhye Jeong
- College of Nursing, Korea University, Seoul 02841, Korea; (E.J.); (J.P.)
| | - Jinkyung Park
- College of Nursing, Korea University, Seoul 02841, Korea; (E.J.); (J.P.)
| | - Sung Ok Chang
- College of Nursing, Korea University, Seoul 02841, Korea; (E.J.); (J.P.)
- Transdisciplinary Major in Learning Health Systems, Graduate School, Korea University, Seoul 02841, Korea
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