Computerized tool and interdisciplinary care for older patients with delirium in the emergency department: a novel model in Taiwan

AIMS

A computerized tool and interdisciplinary care were implemented to develop a novel model for older patients with delirium in the emergency department (ED).

METHODS

We developed a computerized tool using a delirium triage screen and brief confusion assessment in the hospital information system, performed education for the healthcare providers, and developed a continuous care protocol. Comparisons for outcomes between pre- and post-intervention periods were performed.

RESULTS

Compared with the pre-intervention period, patients in the post-intervention period had shorter hospitalization stay, lower expenditure of hospitalization, more likely to return home, lower ED revisits of ≤ 3 days, re-hospitalization of ≤ 14 days, and mortality of ≤ 1 month. All mentioned differences were not statistically significant.

CONCLUSIONS

A novel model was successfully developed for delirium management in older patients in the ED. Outcome differences were not significant; however, the result is promising, which gives us an important reference in the future.

Ascertainment of Delirium Status Using Natural Language Processing From Electronic Health Records

BACKGROUND

Delirium is underdiagnosed in clinical practice and is not routinely coded for billing. Manual chart review can be used to identify the occurrence of delirium; however, it is labor-intensive and impractical for large-scale studies. Natural language processing (NLP) has the capability to process raw text in electronic health records (EHRs) and determine the meaning of the information. We developed and validated NLP algorithms to automatically identify the occurrence of delirium from EHRs.

METHODS

This study used a randomly selected cohort from the population-based Mayo Clinic Biobank (N = 300, age ≥65). We adopted the standardized evidence-based framework confusion assessment method (CAM) to develop and evaluate NLP algorithms to identify the occurrence of delirium using clinical notes in EHRs. Two NLP algorithms were developed based on CAM criteria: one based on the original CAM (NLP-CAM; delirium vs no delirium) and another based on our modified CAM (NLP-mCAM; definite, possible, and no delirium). The sensitivity, specificity, and accuracy were used for concordance in delirium status between NLP algorithms and manual chart review as the gold standard. The prevalence of delirium cases was examined using International Classification of Diseases, 9th Revision (ICD-9), NLP-CAM, and NLP-mCAM.

RESULTS

NLP-CAM demonstrated a sensitivity, specificity, and accuracy of 0.919, 1.000, and 0.967, respectively. NLP-mCAM demonstrated sensitivity, specificity, and accuracy of 0.827, 0.913, and 0.827, respectively. The prevalence analysis of delirium showed that the NLP-CAM algorithm identified 12 651 (9.4%) delirium patients, the NLP-mCAM algorithm identified 20 611 (15.3%) definite delirium cases, and 10 762 (8.0%) possible cases.

CONCLUSIONS

NLP algorithms based on the standardized evidence-based CAM framework demonstrated high performance in delineating delirium status in an expeditious and cost-effective manner.

Comparison of delirium detection tools in acute care : A rapid review

Background

Delirium is a frequent psychopathological syndrome in geriatric patients. It is sometimes the only symptom of acute illness and bears a high risk for complications. Therefore, feasible assessments are needed for delirium detection.

Objective and methods

Rapid review of available delirium assessments based on a current Medline search and cross-reference check with a special focus on those implemented in acute care hospital settings.

Results

A total of 75 delirium detection tools were identified. Many focused on inattention as well as acute onset and/or fluctuating course of cognitive changes as key features for delirium. A range of assessments are based on the confusion assessment method (CAM) that has been adapted for various clinical settings. The need for a collateral history, time resources and staff training are major challenges in delirium assessment. Latest tests address these through a two-step approach, such as the ultrabrief (UB) CAM or by optional assessment of temporal aspects of cognitive changes (4 As test, 4AT). Most delirium screening assessments are validated for patient interviews, some are suitable for monitoring delirium symptoms over time or diagnosing delirium based on collateral history only.

Conclusion

Besides the CAM the 4AT has become well-established in acute care because of its good psychometric properties and practicability. There are several other instruments extending and improving the possibilities of delirium detection in different clinical settings.

Supplementary Information

The online version of this article (10.1007/s00391-021-02003-5) contains supplementary material, which is available to authorized users.

Postoperative delirium following total joint arthroplasties in a multi-ethnic population - A prospective observational study

BACKGROUND

Postoperative delirium (POD) is a cause of poorer patient outcomes following total joint arthroplasties (TJA). However, it often goes undiagnosed. Although various risk factors have been documented, study heterogeneity leads to poor understanding within a South East Asian population. This study aims to evaluate POD within this demographic and elucidate its risk factors.

METHODS

This was a single-centre prospective observational study comprising 462 patients. Inclusion criteria was patients 65-90 years old undergoing elective TJA. Exclusion criteria was patients unable to personally provide consent for TJA. Preoperative, intraoperative, and postoperative data was recorded to analyse treatment pathway factors. Patients were assessed for POD twice daily for 3 days after TJA using the Confusion Assessment Method (CAM).

RESULTS

Mean age of the study cohort was 72 ± 5 years; 70.1% were female; and mean MMSE score preoperatively was 27.3 ± 3.3. 419 patients underwent total knee arthroplasty (TKA) and 43 patients underwent total hip arthroplasty (THA). 164 patients received general anaesthesia, and 298 patients received regional anaesthesia. Overall, 0% (0/462) of patients tested positive for POD at any postoperative timepoint. While various CAM components were met, no patients were positive for the complete requisite criteria for POD diagnosis.

CONCLUSION

We report zero incidence of POD in 462 patients who underwent elective TJA in our institution. We believe that our streamlined care process including pre-operative assessment, patient-specific anaesthesia regime as well as a strictly administered inpatient clinical care pathway with opioid-reducing strategy and early mobilization are protective factors against POD.

Postoperative Delirium in Patients After Brain Tumor Surgery

BACKGROUND

Postoperative delirium is a common surgical complication that can be associated with poorer outcome. Many patients with brain tumors experience delirium after surgery. We hypothesize that patients who experience delirium after resection of a brain tumor will have worse outcomes post surgery in terms of mortality, disposition, and length of stay compared with those without postoperative delirium. We also examine differences between nurse and physician diagnoses of delirium.

METHODS

Data from patients undergoing brain tumor resection at University of Missouri Hospital were retrospectively collected. Delirium was defined using Diagnostic and Statistical Manual-5 criteria. Patients with delirium were compared with patients without delirium using chi-squared test, Cohen Kappa value, and binomial proportion analysis at 95% confidence intervals or P < 0.05.

RESULTS

Of 500 patients having brain tumor resections, 93 (18.6%) were diagnosed with postoperative delirium. Patients with delirium had higher 30-day mortality (9.78% vs. 1.48%; P < 0.0001), required restraints more often (42.39% vs. 5.91%, P < 0.0001), had longer hospital length of stay (14.3 vs. 6.3 days; P < 0.0001), and increased skilled nursing facility disposition (57.3% vs. 26.11%; P < 0.0001) than patients without delirium. Diagnosis of delirium between nursing staff and clinicians moderately correlated (Kappa 0.5677 ± 0.0536).

CONCLUSIONS

Delirium, a common postoperative complication after brain tumor surgery, is associated with longer length of stay, increased disposition to skilled nursing facility, and increased 30-day mortality. These findings reinforce the importance of early recognition, diagnosis, and treatment of postoperative delirium in brain tumor resection patients.

Preoperative Depression and Plasma Cortisol Levels as Predictors of Delirium after Cardiac Surgery

BACKGROUND

Delirium is common in old patients who undergo cardiac surgery, and it is associated with adverse outcomes. The genesis of delirium is thought to be multi-factorial, but it is still not well understood. Symptoms of depression and elevated cortisol level have been described in some previous studies as factors associated with delirium, suggesting a shared pathophysiology.

AIMS

The objective of the present study was to determine whether preoperative depression symptoms and increased cortisol level represent risk factors for delirium after cardiac surgery.

METHODS

We performed a prospective cohort study in 183 patients aged >50 years undergoing elective cardiac surgery. The Geriatric Depression Scale (GDS) was used to assess patients for depressive symptoms before surgery. Preoperative plasma cortisol levels were available in 145 participants. Delirium was diagnosed using the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) during the first 7 days after surgery. Spearman correlation was used for correlations between GDS, Mini-Mental State Examination (MMSE), Charlson comorbidity index, and age. Binary logistic regression was used to determine whether GDS and cortisol levels predict postoperative delirium.

RESULTS

Delirium occurred in 60 patients out of 183 (32.8%) included and lasted 2.3 days (SD 1.36). GDS was correlated with age (p = 0.001) and comorbidity index (p = 0.003) and inversely correlated with MMSE score (p < 0.001). Higher preoperative GDS scores were associated with incidence of delirium in the postoperative period (p = 0.002). The association was significant after controlling for age, MMSE score, history of stroke, and Charlson comorbidity index (p = 0.045). Preoperative cortisol level was not associated with the development of postoperative delirium.

CONCLUSION

Our results suggest that a higher preoperative depression score is associated with an increased risk of postoperative delirium. On the other hand, preoperative plasma cortisol level does not seem to be a predictor of delirium after surgery. Further studies are needed to determine the potential of preoperative depression treatment to prevent postoperative delirium.

Implementation of the Confusion Assessment Method for Noncritically Ill Adult Patients

Several hospital interventions increase patient risk for developing delirium, including mechanical ventilation, monitoring devices, medication interactions, urinary catheters, interrupted sleep cycles, and use of physical restraints. Developing delirium leads to increased length of hospital stay, likelihood of requiring long-term care services after discharge, and risk of mortality following hospitalization. Longer periods of delirium worsen cognition, executive functioning, ability to complete activities of daily living, and sensorimotor functioning. Routine screening and early recognition prevent or reduce the long-term health and financial effects of delirium. The Confusion Assessment Method is a useable tool for screening noncritically ill adult patients for delirium.

Use of the confusion assessment method in multicentre delirium trials: training and standardisation

Background

Delirium occurs commonly in older adults and is associated with adverse outcomes. Multicentre clinical trials evaluating interventions to prevent delirium are needed. The Confusion Assessment Method (CAM) is a validated instrument for delirium detection. We hypothesised it would be possible for a large feasibility study to train a large number of research assistants, with varying experience levels, to conduct CAM assessments reliably in multiple hospital sites.

Methods

A standardised training programme was followed, incorporating structured training at a central location and at study sites. CAM practice sessions on both delirious and non-delirious patients by research assistants were conducted and, thereafter, there was ongoing inter-rater reliability assessment on the CAM between research assistant pairs at study sites. The setting was eight acute care hospitals in England and Wales. Participants were research assistants working on a multicentre feasibility study of delirium prevention. The measurement used was the Confusion Assessment Method.

Results

Thirty-seven research assistants were trained in CAM assessment and 33 returned training logs. The logs showed there was 100% overall agreement between research assistant pairs on 295 CAM assessments, of which 263 (89.2%) were negative for delirium and 32 (10.8%) were positive. In the course of the feasibility study, research assistants successfully completed 5065 (89.7%) of the 5645 expected CAM assessments, with minimal missing data.

Conclusion

Using the training methods described in this study, it is possible to achieve high quality delirium assessments for large numbers of patients with little missing data across geographically dispersed sites in multicentre studies. The standardisation of multisite delirium assessments is an important contribution to research methodology, and provides a much-needed advance for the field.

Trial registration

ISRCT ISRCTN01187372. Registered 13 March 2014.

The Reliability and Validity of the Chinese Version of Confusion Assessment Method Based Scoring System for Delirium Severity (CAM-S)

Previous studies showed that the Confusion Assessment Method based delirium severity evaluation tool (CAM-S) had good reliability and validity. However, there is no Chinese version of the CAM-S. Therefore, we set out to perform a prospective investigation in older Chinese patients who had total joint replacement surgery under general anesthesia in Tenth People's Hospital in Shanghai, P.R. China. A total of 576 participants, aged 60 years or older, were screened, 179 participants were enrolled, and 125 of them were included for the final analysis. Pre-operative evaluations were conducted one day before the surgery. Postoperative evaluations were conducted twice daily from postoperative day 1 to day 3. The incidence of postoperative delirium was 24.8%. The Chinese version of CAM-S [including a Short Form (CAM-S Short Form) and a Long Form (CAM-S Long Form)] had an optimal reliability reflected by internal consistency (Cronbach's α= 0.748 and 0.839 for CAM-S Short Form and CAM-S Long Form respectively), split-halves reliability (Pearson correlation coefficient = 0.372 and 0.384 for CAM-S Short Form and CAM-S Long Form respectively), and inter-rater reliability (intra-class correlation coefficients = 0.629 and 0.945 for CAM-S Short Form and CAM-S Long Form respectively). Additionally, the Chinese version of CAM-S also showed a good discriminate validity. The domain scores of CAM-S were inversely correlated with corresponding domain scores of the MMSE. Finally, a receiver operating characteristic (ROC) analysis obtained an optimal cutoff point of 2.5 for CAM-S Short Form and 3.5 for CAM-S Long Form in recognizing delirium diagnosed by CAM. The areas under the ROC were 0.989 (95% CI 0.972 - 1.000, p < 0.001) and 0.964 (95% CI 0.946 - 0.982, p < 0.001), respectively. These data suggest that the Chinese version of CAM-S has good reliability and validity in evaluating postoperative delirium in geriatric Chinese patients and may be a useful tool to assess the severity of delirium.

Delirium assessment in hospitalized elderly patients: Italian translation and validation of the nursing delirium screening scale

BACKGROUND

Delirium has a high incidence pathology associated with negative outcomes. Although highly preventable, half the cases are not recognized. One major cause of delirium misdiagnosis is the absence of a versatile instrument to measure it.

AIMS

Our objective was to translate the nursing delirium screening scale (Nu-DESC) and evaluate its performance in Italian settings.

METHODS

This was a methodological study conducted in two sequential phases. The first was the Italian translation of Nu-DESC through a translation and back-translation process. The second aimed to test the inter-rater reliability, the sensibility and specificity of the instrument on a convenience sample of 101 hospitalized elderly people admitted to relevant wards of the San Gerardo Hospital in Monza. To evaluate the inter-rater reliability, two examiners tested Nu-DESC on 20 patients concurrently without comparison. To measure the sensibility and specificity of Nu-DESC, the confusion assessment method was used as a gold standard measure.

RESULTS

The inter-rater reliability (Cohen Kappa) was 0.87-an excellent agreement between examiners. The study of the ROC curve showed an AUC value of 0.9461 suggesting high test accuracy. Using 3 as a cut-off value, Nu-DESC showed 100 % sensibility and 76 % specificity.

DISCUSSION AND CONCLUSION

Further research is needed to test Nu-DESC on a larger sample. However, based on our results, Nu-DESC can be used in research and clinical practice in Italian settings because of its very good and similar performances to previous validation studies. The value of 3 appears to be the optimal cut-off in the Italian context.