A multicomponent intervention to prevent delirium in hospitalized older patients

BACKGROUND

Since in hospitalized older patients delirium is associated with poor outcomes, we evaluated the effectiveness of a multicomponent strategy for the prevention of delirium.

METHODS

We studied 852 patients 70 years of age or older who had been admitted to the general-medicine service at a teaching hospital. Patients from one intervention unit and two usual-care units were enrolled by means of a prospective matching strategy. The intervention consisted of standardized protocols for the management of six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Delirium, the primary outcome, was assessed daily until discharge.

RESULTS

Delirium developed in 9.9 percent of the intervention group as compared with 15.0 percent of the usual-care group, (matched odds ratio, 0.60; 95 percent confidence interval, 0.39 to 0.92). The total number of days with delirium (105 vs. 161, P=0.02) and the total number of episodes (62 vs. 90, P=0.03) were significantly lower in the intervention group. However, the severity of delirium and recurrence rates were not significantly different. The overall rate of adherence to the intervention was 87 percent, and the total number of targeted risk factors per patient was significantly reduced. Intervention was associated with significant improvement in the degree of cognitive impairment among patients with cognitive impairment at admission and a reduction in the rate of use of sleep medications among all patients. Among the other risk factors per patient there were trends toward improvement in immobility, visual impairment, and hearing impairment.

CONCLUSIONS

The risk-factor intervention strategy that we studied resulted in significant reductions in the number and duration of episodes of delirium in hospitalized older patients. The intervention had no significant effect on the severity of delirium or on recurrence rates; this finding suggests that primary prevention of delirium is probably the most effective treatment strategy.

Reducing delirium after hip fracture: a randomized trial

OBJECTIVES

Delirium (or acute confusional state) affects 35% to 65% of patients after hip-fracture repair, and has been independently associated with poor functional recovery. We performed a randomized trial in an orthopedic surgery service at an academic hospital to determine whether proactive geriatrics consultation can reduce delirium after hip fracture.

DESIGN

Prospective, randomized, blinded.

SETTING

Inpatient academic tertiary medical center.

PARTICIPANTS

126 consenting patients 65 and older (mean age 79 +/- 8 years, 79% women) admitted emergently for surgical repair of hip fracture.

MEASUREMENTS

Detailed assessment through interviews with patients and designated proxies and review of medical records was performed at enrollment to ascertain prefracture status. Subjects were then randomized to proactive geriatrics consultation, which began preoperatively or within 24 hours of surgery, or "usual care." A geriatrician made daily visits for the duration of the hospitalization and made targeted recommendations based on a structured protocol. To ascertain study outcomes, all subjects underwent daily, blinded interviews for the duration of their hospitalization, including the Mini-Mental State Examination (MMSE), the Delirium Symptom Interview (DSI), and the Memorial Delirium Assessment Scale (MDAS). Delirium was diagnosed using the Confusion Assessment Method (CAM) algorithm.

RESULTS

The 62 patients randomized to geriatrics consultation were not significantly different (P>.1) from the 64 usual-care patients in terms of age, gender, prefracture dementia, comorbidity, type of hip fracture, or type of surgical repair. Sixty-one percent of geriatrics consultation patients were seen preoperatively and all were seen within 24 hours postoperatively. A mean of 10 recommendations were made throughout the duration of the hospitalization, with 77% adherence by the orthopedics team. Delirium occurred in 20 /62 (32%) intervention patients, versus 32 / 64 (50%) usual-care patients (P =.04), representing a relative risk of 0.64 (95% confidence interval (CI) = 0.37-0.98) for the consultation group. One case of delirium was prevented for every 5.6 patients in the geriatrics consultation group. There was an even greater reduction in cases of severe delirium, occurring in 7/ 60 (12%) of intervention patients and 18 / 62 (29%) of usual-care patients, with a relative risk of 0.40 (95% CI = 0.18-0.89). Despite this reduction in delirium, length of stay did not significantly differ between intervention and usual-care groups (median +/- interquartile range = 5 +/- 2 days in both groups), likely because protocols and pathways predetermined length of stay. In subgroup analyses, geriatrics consultation was most effective in reducing delirium in patients without prefracture dementia or activities of daily living (ADL) functional impairment.

CONCLUSIONS

Proactive geriatrics consultation was successfully implemented with good adherence after hip-fracture repair. Geriatrics consultation reduced delirium by over one-third, and reduced severe delirium by over one-half. Our trial provides strong preliminary evidence that proactive geriatrics consultation may play an important role in the acute hospital management of hip-fracture patients.

Delirium and Its Motoric Subtypes: A Study of 614 Critically Ill Patients

OBJECTIVES

To describe the motoric subtypes of delirium in critically ill patients and compare patients aged 65 and older with a younger cohort.

DESIGN

Prospective cohort study.

SETTING

The medical intensive care unit (MICU) of a tertiary care academic medical center.

PARTICIPANTS

Six hundred fourteen MICU patients admitted during a process improvement initiative to monitor levels of sedation and delirium.

MEASUREMENTS

MICU nursing staff assessed delirium and level of consciousness in all MICU patients at least once per 12-hour shift using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale. Delirium episodes were categorized as hypoactive, hyperactive, and mixed type.

RESULTS

Delirium was detected in 112 of 156 (71.8%) subjects aged 65 and older and 263 of 458 (57.4%) subjects younger than 65. Mixed type was most common (54.9%), followed by hypoactive delirium (43.5%) and purely hyperactive delirium (1.6%). Patients aged 65 and older experienced hypoactive delirium at a greater rate than younger patients (41.0% vs 21.6%, P<.001) and never experienced hyperactive delirium. Older age was strongly and independently associated with hypoactive delirium (adjusted odds ratio=3.0, 95% confidence interval=1.7-5.3), compared with no delirium in a model that adjusted for other important determinants of delirium including severity of illness, sedative medication use, and ventilation status.

CONCLUSION

Older age is a strong predictor of hypoactive delirium in MICU patients, and this motoric subtype of delirium may be missed in the absence of active monitoring.

Fast, systematic, and continuous delirium assessment in hospitalized patients: the nursing delirium screening scale

Because no rigorously validated, simple yet accurate continuous delirium assessment instrument exists, we developed the Nursing Delirium Screening Scale (Nu-DESC). The Nu-DESC is an observational five-item scale that can be completed quickly. To test the validity of the Nu-DESC, 146 consecutive hospitalized patients from a prospective cohort study were continuously assessed for delirium symptoms by bedside nurses using the Nu-DESC. Psychometric properties of Nu-DESC screening were established using 59 blinded Confusion Assessment Method (CAM) ratings made by research nurses and psychiatrists. DSM-IV criteria and the Memorial Delirium Assessment Scale (MDAS) were rated along with CAM assessments. Analysis of these data showed that the Nu-DESC is psychometrically valid and has a sensitivity and specificity of 85.7% and 86.8%, respectively. These values are comparable to those of the MDAS, a longer instrument. Nu-DESC and DSM-IV sensitivities were similar. The Nu-DESC appears to be well-suited for widespread clinical use in busy oncology inpatient settings and shows promise as a research instrument.

An empirical study of delirium subtypes

Using a structured instrument, 325 elderly patients admitted to a general hospital for an acute medical problem were evaluated daily in order to detect symptoms of delirium. Patients were scored for 'hyperactive' or 'hypoactive' symptoms, and then the 125 patients with DSM-III delirium were rated as 'hyperactive type' (15%), 'hypoactive type' (19%), 'mixed type' (52%), or 'neither' (14%). There were no statistically significant differences between the groups with respect to age, sex, place of residence, or presence of dementia. These definitions of subtypes should be studied further.

A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients

OBJECTIVES

To develop and test the effect of a nurse-led interdisciplinary intervention program for delirium on the incidence and course (severity and duration) of delirium, cognitive functioning, functional rehabilitation, mortality, and length of stay in older hip-fracture patients.

DESIGN

Longitudinal prospective before/after design (sequential design).

SETTING

The emergency room and two traumatological units of an academic medical center located in an urban area in Belgium.

PARTICIPANTS

60 patients in an intervention cohort (81.7% females, median age = 82, interquartile range (IQR) = 13) and another 60 patients in a usual care/nonintervention cohort (80% females, median age = 80, IQR = 12).

INTERVENTION

(1) Education of nursing staff, (2) systematic cognitive screening, (3) consultative services by a delirium resource nurse, a geriatric nurse specialist, or a psychogeriatrician, and (4) use of a scheduled pain protocol.

MEASUREMENTS

All patients were monitored for signs of delirium, as measured by the Confusion Assessment Method (CAM). Severity of delirium was assessed using a variant of the CAM. Cognitive and functional status were measured by the Mini-Mental State Examination (MMSE) (including subscales of memory, linguistic ability, concentration, and psychomotor executive skills) and the Katz Index of activities of daily living (ADLs), respectively.

RESULTS

Although there was no significant effect on the incidence of delirium (23.3% in the control vs 20.0% in the intervention cohort; P =.82), duration of delirium was shorter (P =.03) and severity of delirium was less (P =.0049) in the intervention cohort. Further, clinically higher cognitive functioning was observed for the delirious patients in the intervention cohort compared with the nonintervention cohort. Additionally, a trend toward decreased length of stay postoperatively was noted for the delirious patients in the intervention cohort. Despite these positive intervention effects, no effect on ADL rehabilitation was found. Results for risk of mortality were inconclusive.

CONCLUSIONS

This study demonstrated the beneficial effects of an intervention program focusing on early recognition and treatment of delirium in older hip-fracture patients and confirms the reversibility of the syndrome in view of the delirium's duration and severity.

Unrecognized delirium in ED geriatric patients

To determine the sensitivity of an emergency physician's conventional evaluation compared with the validated Confusion Assessment Method (CAM) regarding the recognition of acute confusional states (delirium) in elderly Emergency Department (ED) patients, a cohort of 385 patients presenting to an urban teaching hospital ED was systematically assembled. Patients had to be conscious, able to speak and older than 64 years of age. After the ED physician had examined the patient and test results had been obtained, a series of geriatric assessment results, including one for the likely presence of delirium, was made available to the ED physician; however, no result was specifically highlighted. All patients were assessed by an attending ED physician in the customary fashion. In addition, a study nurse interviewed patients using the CAM and followed patient outcomes for three months. The ED record for all patients with delirium or "probable" delirium, as determined by the CAM, were reviewed for physician diagnosis and disposition to determine how often delirium had been recognized by the emergency physician. Thirty-eight of the 385 patients screened (10%) met criteria for delirium or "probable" delirium; ED charts were complete for 35 of these, which constituted the study sample. The ED diagnosis included delirium or an acceptable synonym in 6 (17%) of these patients. In the 21 patients (62%) admitted to the hospital, the most common ED diagnosis was infection "rule out sepsis" (n = 7). Six of 13 patients discharged (46%) were diagnosed as "status post fall" without evidence of significant injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Motor subtypes of postoperative delirium in older adults

HYPOTHESIS

Increased knowledge about motor subtypes of delirium may aid clinicians in the management of postoperative geriatric patients.

DESIGN

Prospective cohort study defining preoperative risk factors, outcomes, and adverse events related to motor subtypes of postoperative delirium.

SETTING

Referral medical center.

PATIENTS

Persons 50 years and older with planned postoperative intensive care unit (ICU) admission following an elective operation were recruited.

MAIN OUTCOME MEASURES

Before surgery, a standardized frailty assessment was performed. After surgery, delirium and its motor subtypes were measured using the validated tools of the Confusion Assessment Method-ICU and the Richmond Agitation-Sedation Scale. Statistical analysis included the univariate t and χ(2) tests and analysis of variance with post hoc analysis.

RESULTS

Delirium occurred in 43.0% (74 of 172) of patients, representing 67.6% (50 of 74) hypoactive, 31.1% (23 of 74) mixed, and 1.4% (1 of 74) hyperactive motor subtypes. Compared with those having mixed delirium, patients having hypoactive delirium were older (mean [SD] age, 71 [9] vs 65 [9] years) and more anemic (mean [SD] hematocrit, 36% [8%] vs 41% [6%]) (P = .002 for both). Patients with hypoactive delirium had higher 6-month mortality (32.0% [16 of 50] vs 8.7% [2 of 23], P = .04). Delirium-related adverse events occurred in 24.3% (18 of 74) of patients with delirium; inadvertent tube or line removals occurred more frequently in the mixed group (P = .006), and sacral skin breakdown was more common in the hypoactive group (P = .002).

CONCLUSIONS

Motor subtypes of delirium alert clinicians to differing prognosis and adverse event profiles in postoperative geriatric patients. Hypoactive delirium is the most common motor subtype and is associated with worse prognosis (6-month mortality, 1 in 3 patients). Knowledge of differing adverse event profiles can modify clinicians' management of older patients with postoperative delirium.

Clinical significance of delirium subtypes in older people

OBJECTIVE

to examine the relative frequency and outcome of clinical subtypes of delirium in older hospital patients.

DESIGN

prospective observational study.

SETTING

acute geriatric unit in a teaching hospital.

SUBJECTS

94 patients with delirium from a prospective study of 225 admissions.

MEASUREMENTS

clinical subtypes of delirium were determined according to predefined criteria. Characteristics examined in these subgroups included illness severity on admission, prior cognitive impairment, mortality, duration of hospital stay and hospital-acquired complications.

RESULTS

of the 94 patients, 20 (21%) had a hyperactive delirium, 27 (29%) had a hypoactive delirium, 40 (43%) had a mixed hypoactive-hyperactive psychomotor pattern and seven (7%) had no psychomotor disturbance. There were significant differences between the four groups in illness severity (P < 0.05), length of hospital stay (P < 0.005) and frequency of falls (P < 0.05). Patients with hypoactive delirium were sicker on admission, had the longest hospital stay and were most likely to develop pressure sores. Patients with hyperactive delirium were most likely to fall in hospital. There were no differences in aetiological factors between the groups.

CONCLUSION

outcomes of hospitalization differ in different clinical subtypes of delirium.

Relationship between symptoms and motoric subtype of delirium

For 46 patients with delirium who were consecutive referrals to a consultation-liaison psychiatry service, the authors describe the relationships between symptoms, as rated on the Delirium Rating Scale, and delirium motoric subtypes, as defined by Liptzin and Levkoff's criteria. Most cases were of the mixed subtype (46%), 24% were hypoactive, and 30% were hyperactive. Overall scores differed significantly among motoric subtype groups, being highest in the hyperactive, lowest in the hypoactive, and intermediate in the mixed. On item scores, the hypoactive group scored lower than the hyperactive group for delusions, mood lability, sleep-wake cycle disturbances, and variability of symptoms, but lower than the mixed group only for mood lability. The results suggest that delirium presents as motoric subtypes that differ according to symptom profile and severity of delirium. These subtypes may differ in their underlying pathophysiologies, responsiveness to therapeutic interventions, and outcome.

Phenomenological subtypes of delirium in older persons: patterns, prevalence, and prognosis

BACKGROUND

Delirium is an acute confusional state that is common, preventable, and life-threatening.

OBJECTIVE

The authors investigated the phenomenology of delirium severity as measured with the Memorial Delirium Assessment Scale among 441 older patients (age 65 and older) admitted with delirium in post-acute care.

METHODS

Using latent class analysis, they identified four classes of psychomotor-severity subtypes of delirium: 1) hypoactive/mild; 2) hypoactive/severe; 3) mixed, with hyperactive features/severe; and 4) normal/mild.

RESULTS

Among those with dementia (N=166), the hypoactive/mild class was associated with a higher risk of mortality. Among those without dementia (N=275), greater severity was associated with mortality, regardless of psychomotor features, when compared with the normal/mild class.

CONCLUSION

The data suggest that instruments measuring delirium severity and psychomotor features provide important prognostic information and should be integrated into the assessment of delirium.

The delirium subtypes: A review of prevalence, phenomenology, pathophysiology, and treatment response

Delirium is a highly prevalent disease in the elderly and postoperative, cancer, and AIDS patients. However it is often misdiagnosed and mistreated. This may be partly due to the inconsistencies of the diagnosis itself. Delirium is best defined currently by an association of cognitive impairment and arousal disturbance. Three subtypes (hyperactive, hypoactive, mixed) receive a definition in the literature, but those definitions may vary from author to author according to the importance they give either to the motoric presentation of the delirium or to the arousal disturbance. Our aim is to point out the inconsistencies we found in the literature, but also to identify different paths that have been explored to solve them, that is, the suggestion to emphasize the arousal disturbances in defining the subtypes instead of the motoric presentations, which seem to be more fluctuating, and because of the fluctuating course of the disease to extend the observation over a period of time, which may improve the accuracy of the diagnosis. This is not without importance from a clinical standpoint. Subtypes of delirium may be explained by different pathophysiologic mechanisms, which remain partly unexplained, and may respond to specific treatments. There is a trend to isolate core symptoms (disorientation, cognitive deficits, sleep–wake cycle disturbance, disorganized thinking, and language abnormalities) so as to distinguish them from secondary symptoms that may be correlated with the different etiologies. Our contribution is also to challenge, with new data, the accepted belief that psychotic features are quite rare in the hypoactive type of delirium. We demonstrate that delusions and perceptual disturbances, although less frequent, are present in more than half of the patients with hypoactive delirium. The psychotic features are clearly correlated with a highly prevalent rate of patients', spouses', and caregivers' distress. The mixed subtype of delirium seems to have the worst prognosis, the hyperactive showing the best prognosis. The treatment of the agitated delirious patient is also more consensual. Haloperidol remains the gold standard in the treatment of delirium regardless of the clinical presentation, but the literature provides several alternatives that may prove more specific and have less adverse effects (atypical antipsychotics, psychostimulants, anesthetics).

Sedative and Analgesic Medications: Risk Factors for Delirium and Sleep Disturbances in the Critically Ill

Sedatives and analgesics are routinely used in critically ill patients, although they have the potential for side effects, such as delirium and sleep architecture disruption. Although it should be emphasized that these medications are extremely important in providing patient comfort, health care professionals must also strive to achieve the right balance of sedative and analgesic administration through greater focus on reducing unnecessary or overzealous use. Ongoing clinical trials should help us to understand whether altering the delivery strategy, via daily sedation interruption, or protocolized target-based sedation or changing sedation paradigms to target different central nervous system receptors can affect cognitive outcomes and sleep preservation in our critically ill patients.

Recognizing delirium superimposed on dementia: assessing nurses' knowledge using case vignettes

Delirium is a serious and prevalent problem that occurs in many hospitalized older adults. Delirium superimposed on dementia (DSD) occurs when a delirium occurs concurrently with a pre-existing dementia. DSD is typically underrecognized by medical and nursing staff. The current study measured nursing identification of DSD using standardized case vignettes, and the Mary Starke Harper Aging Knowledge Exam (MSHAKE). Results revealed that the nurses in this study had a high level of general geropsychiatric nursing knowledge as measured by the MSHAKE, yet had difficulty recognizing DSD compared to dementia alone and delirium alone. Only 21% were able to correctly identify the hypoactive form of DSD, and 41% correctly identified hypoactive delirium alone in the case vignettes. Interventions and educational programs designed to increase nursing awareness of DSD symptoms could help to decrease this gap in nursing knowledge.

Detection of delirium in the intensive care unit: comparison of confusion assessment method for the intensive care unit with confusion assessment method ratings

OBJECTIVES

To compare the Confusion Assessment Method (CAM) and CAM for the Intensive Care Unit (CAM-ICU) methods for detecting delirium in alert, nonintubated older ICU patients.

DESIGN

Comparison study.

SETTING

Fourteen-bed medical ICU of an 800-bed university teaching hospital.

PARTICIPANTS

Twenty-two patients aged 65 and older admitted to the ICU.

MEASUREMENTS

Two blinded, trained clinician-researchers who had undergone interrater reliability testing interviewed patients separately, usually within 10 minutes of each other (up to 120 minutes). Each researcher examined patients for the four key CAM criteria: acuteness, inattention, disorganized thinking, and altered level of consciousness. One researcher used the CAM method with the Mini-Mental State Examination and Digit Span; the other researcher used the CAM-ICU method with nonverbal cognitive and attention tasks.

RESULTS

Rates of delirium were 68% according to CAM and 50% according CAM-ICU. Comparing the two methods, agreement was 82%, with a kappa of 0.64. Using the CAM as the reference standard, the CAM-ICU had a sensitivity of 73% (95% confidence interval (CI)=60-86) and specificity of 100% (95% CI=56-100). There were four false-negative ratings using the CAM-ICU. Reasons for disparate results were that the CAM used more-detailed cognitive testing that detected more deficits (3 patients) and the time elapsed (90 minutes) between ratings in one patient with markedly fluctuating symptoms.

CONCLUSION

CAM and CAM-ICU agreement was moderately high. Although the CAM-ICU is recommended for ICU patients because of its brevity and ease of use, the standard CAM method may detect more subtle cases of delirium in nonintubated, verbal ICU patients.

The delirium index, a measure of the severity of delirium: new findings on reliability, validity, and responsiveness

OBJECTIVES

To assess the reliability, validity, and responsiveness of an instrument for measuring the severity of delirium, the Delirium Index (DI).

DESIGN

Prospective cohort study, with repeated patient assessments at multiple points in the hospital, at 8 weeks after discharge, and at 6 and 12 months after admission.

SETTING

The medical services of a primary acute-care hospital.

PARTICIPANTS

Medical admissions aged 65 and older: 165 with delirium and dementia, 57 with delirium only, 55 with dementia only, and 41 with neither.

MEASUREMENTS

Severity of delirium symptoms was measured using the DI. Delirium was diagnosed using the Confusion Assessment Method. Other measures included the Mini-Mental State Examination, Informant Questionnaire on Cognitive Decline in the Elderly, Barthel Index (BI), premorbid instrumental activities of daily living, Charlson Comorbidity Index, Clinical Severity of Illness scale (CSI), and the Acute Physiology Score (APS).

RESULTS

The intraclass correlation coefficient of interrater reliability was 0.98. Two measures of fluctuation were significantly higher in patients with delirium than in those without delirium. At baseline, the DI was correlated with the BI, APS, and CSI in delirious patients with (correlation coefficient (r)=-0.43, 0.17, and 0.36, respectively) or without (r=-0.44, 0.39, 0.22, respectively) dementia. At 8 weeks, in delirious patients with and without dementia, internal responsiveness as measured by effect sizes was -0.60 and -0.74, respectively, and the standardized response mean for both groups was -0.64. Low to good levels of external responsiveness were found.

CONCLUSION

The DI appears to be a reliable, valid, and responsive measure of the severity of delirium, in patients with delirium, with or without dementia.

The misdiagnosis of delirium

The authors examined the ability of nonpsychiatric house staff to accurately diagnose delirium at the time of consultation. Of 221 consultations over a 5-year period, 46% were misdiagnosed by the house staff. House staff on the general medicine wards and the nonintensive care unit environment did significantly better than those on the surgical wards and intensive care units. Age, gender, and race of the patient did not overall influence incorrect diagnoses; however, when a misdiagnosis occurred, women were more often given a diagnosis of a depressive disorder, whereas men were more often given a "no diagnosis" label. Finally, the consultees improved over an academic year in accurately identifying women as delirious, whereas no such learning curve existed for men.

The natural history of delirium in older hospitalized patients: a syndrome of heterogeneity

OBJECTIVES

To determine the presentation, course and duration of delirium in hospitalized older people.

DESIGN

Observational cohort study.

SETTING

Inpatient surgical and medical wards at a university hospital.

PARTICIPANTS

432 people over the age of 65.

MEASUREMENTS

All participants were screened daily for confusion and, in those who were confused, delirium was ascertained using the Diagnostic and Statistical Manual of Mental Disorders (DSM) III-R criteria. Those who were found to be delirious were followed daily while in hospital for evidence of delirium. The Delirium Rating Scale (DRS) was used to describe the clinical characteristics of delirium.

RESULTS

About 15% of subjects had delirium. Sixty-nine percent of delirious subjects had delirium on a single day. The DRS total was higher on the first day of delirium for those with delirium on multiple days than those with delirium on a single day (P = 0.03). Among those with delirium on multiple days, there were no patterns of change over time in specific DRS items.

CONCLUSIONS

Delirium in hospitalized older people is common and has a varied presentation and time course. Clinicians and researchers need to consider this great heterogeneity when caring for patients and when studying delirium.

Survival prediction for terminally ill cancer patients: revision of the palliative prognostic score with incorporation of delirium

PURPOSE

An existing and validated palliative prognostic (PaP) score predicts survival in terminally ill cancer patients based on dyspnea, anorexia, Karnofsky performance status score, clinical prediction of survival, total WBC, and lymphocyte percentage. The PaP score assigns patients to three different risk groups according to a 30-day survival probability--group A, >70%; group B, 30%-70%; group C, <30%. The impact of delirium is known but was not incorporated into the PaP score.

MATERIALS AND METHODS

Our aim was to incorporate information on delirium into the PaP score based on a retrospective series of 361 terminally ill cancer patients. We followed the approach of "validation by calibration," proposed by van Houwelingen and later adapted by Miceli for achieving score revision with inclusion of a new variable. The discriminating performance of the scores was estimated using the K statistic.

RESULTS

The prognostic contribution of delirium was confirmed as statistically significant (p < .001) and the variable was accordingly incorporated into the PaP score (D-PaP score). Following this revision, 30-day survival estimates in groups A, B, and C were 83%, 50%, and 9% for the D-PaP score and 87%, 51%, and 16% for the PaP score, respectively. The overall performance of the D-PaP score was better than that of the PaP score.

CONCLUSION

The revision of the PaP score was carried out by modifying the cutoff values used for prognostic grouping without, however, affecting the partial scores of the original tool. The performance of the D-PaP score was better than that of the PaP score and its key feature of simplicity was maintained.

The measurement of delirium: review of scales

This review describes the characteristics and evaluates the psychometric qualities (process of testing and the results) of thirteen delirium instruments. Delirium instruments differ in goal (diagnosis, screening symptoms severity), type of data on which the rating is based (observation, interview or test of patients), the rater qualities required, the number of items and the rating time needed. Most instruments are based on the Diagnostic Statistical Manual criteria and measure signs and symptoms as described by these criteria. Reliability of delirium instruments shows good to excellent results. Validity of the delirium instruments is overall fair to good. Differences exist, however, in the degree to which reliability and validity were tested and the quality of the testing procedures. Most instruments are not further developed and tested after the initial study. Conclusion of this review is that most delirium instruments show promising results but need further testing. Testing is needed in different samples and on a broader range of aspects with regard to reliability and validity. Much emphasis should be given to the procedures used in future studies. Ease of use is an aspect of testing that is so far not taken into account, however, is important for use of instruments in clinical practice. A minority of instruments can be seen as "ready to use" instruments meaning well tested in more than one sample with good results. For screening high-risk, elderly hospitalized patients, the NEECHAM Confusion Scale and the Delirium Observation Screening Scale are recommended. The Confusion Assessment Method is the best diagnostic tool and the Delirium Rating Scale shows best results in screening symptom severity. For ICU patients the CAM-ICU is recommended. The MDAS is well tested in cancer patients. Nurses, however, have not yet tested the DRS and MDAS in practice.

Is delirium different when it occurs in dementia? A study using the delirium rating scale

The authors studied 61 geropsychiatric patients with delirium from a cohort of 843 consecutive admissions to a geriatric clinical research unit. A central study goal was to assess how the presence of dementia affected the presentation of delirium. Eighteen delirious (D) and 43 delirious-demented (D-D) patients were compared on the Delirium Rating Scale (DRS), Mini-Mental State Examination (MMSE), Brief Psychiatric Rating Scale (BPRS), and EEG. D-D patients had lower MMSE scores, but no differences were found in total DRS or BPRS scores or in EEG grade. DRS items were similar in the two groups except that D-D had more cognitive impairment than D. An exploratory principal components analysis of DRS items identified two core factors. The authors conclude that the presentation of delirium in the setting of concurrent dementia is very similar to delirium without dementia, with subtle differences probably attributable to dementia.

A comparison of the CAM-ICU and the NEECHAM Confusion Scale in intensive care delirium assessment: an observational study in non-intubated patients

BACKGROUND

Several reports indicate a high incidence of intensive care delirium. To develop strategies to prevent this complication, validated instruments are needed. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is widely used. A binary result diagnoses delirium. The Neelon and Champagne (NEECHAM) Confusion Scale recently has been validated for use in the ICU and has a numeric assessment. This scale allows the patients to be classified in four categories: non-delirious, at risk, confused, and delirious. In this study, we investigated the results of the NEECHAM scale in comparison with the CAM-ICU.

METHODS

A consecutive sample of 172 non-intubated patients in a mixed ICU was assessed after a stay in the ICU for at least 24 hours. All adult patients with a Glasgow Coma Scale score of greater than 9 were included. A nurse researcher simultaneously assessed both scales once daily in the morning. A total of 599 paired observations were made.

RESULTS

The CAM-ICU showed a 19.8% incidence of delirium. The NEECHAM scale detected incidence rates of 20.3% for delirious, 24.4% for confused, 29.7% for at risk, and 25.6% for normal patients. The majority of the positive CAM-ICU patients were detected by the NEECHAM scale. The sensitivity of the NEECHAM scale was 87% and the specificity was 95%. The positive predictive value and the negative predictive value were 79% and 97%, respectively. The diagnostic capability in cardiac surgery patients proved to be lower than in other patients.

CONCLUSION

In non-intubated patients, the NEECHAM scale identified most cases of delirium which were detected by the CAM-ICU. Additional confused patients were identified in the categorical approach of the scale. The NEECHAM scale proved to be a valuable screening tool compared with the CAM-ICU in the early detection of intensive care delirium by nurses.

Survival prediction of terminally ill cancer patients by clinical symptoms: development of a simple indicator

BACKGROUND

Although accurate prediction of survival is essential for palliative care, no clinical tools have been established.

METHODS

Performance status and clinical symptoms were prospectively assessed on two independent series of terminally ill cancer patients (training set, n = 150; testing set, n = 95). On the training set, the cases were divided into two groups with or without a risk factor for shorter than 3 and 6 weeks survival, according to the way the classification achieved acceptable predictive value. The validity of this classification for survival prediction was examined on the test samples.

RESULTS

The cases with performance status 10 or 20, dyspnea at rest or delirium were classified in the group with a predicted survival of shorter than 3 weeks. The cases with performance status 10 or 20, edema, dyspnea at rest or delirium were classified in the group with a predicted survival of shorter than 6 weeks. On the training set, this classification predicted 3 and 6 weeks survival with sensitivity 75 and 76% and specificity 84 and 78%, respectively. On the test populations, whether patients survived for 3 and 6 weeks or not was predicted with sensitivity 85 and 79% and specificity 84 and 72%, respectively.

CONCLUSION

Whether or not patients live for 3 and 6 weeks can be acceptably predicted by this simple classification.

Using DSM-III criteria to diagnose delirium in elderly general medical patients

Studies of delirium in general medical populations have used criteria for delirium different from current DSM-III or DSM-IIIR criteria of the American Psychiatric Association, or have used DSM-III or DSM-IIIR criteria without operationalizing the components of these criteria. Therefore this prospective study was conducted to establish an approach to operationalizing DSM-III criteria and to determine the incidence and prevalence of delirium. Two hundred thirty-five consecutive subjects age 70 and over admitted to general medicine underwent daily standardized screening. Patients with low scores on screening tests or clinical evidence suggestive of any psychiatric disorder and controls were seen by a psychiatrist, who determined whether delirium was present by applying explicit operational definitions to each component of the DSM-III criteria for delirium. We conclude that the syndrome of delirium as defined by the American Psychiatric Association is prevalent on admission among elderly on general medical services, but the number of cases developing in the hospital is much less than often stated in the literature.

Clinical subtypes of delirium in the elderly

Psychomotor disturbance is common in delirium, with some patients being restless and hyperactive and others lethargic and hypoalert. Although patients with hyperactive delirium may be recognised more readily, hypoactive and mixed forms of delirium are more common on general hospital wards. Recent evidence suggests that hyperactive delirium has a better prognosis than other subtypes. It remains uncertain whether this reflects fundamental differences in the pathophysiology of different subtypes.