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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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Cinkowski C, Yefimova M, Suffoletto B. Development of the geriatric risk assessment in the ED (GRAED) tool to predict decline after emergency department (ED) visit. J Am Geriatr Soc 2024; 72:1536-1538. [PMID: 38241203 DOI: 10.1111/jgs.18745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 12/03/2023] [Accepted: 12/11/2023] [Indexed: 01/21/2024]
Affiliation(s)
| | - Maria Yefimova
- Center for Nursing Excellence and Innovation, UCSF Health, San Francisco, California, USA
- Department of Physiological Nursing, UCSF School of Nursing, San Francisco, California, USA
| | - Brian Suffoletto
- Department of Emergency Medicine, Stanford University, Stanford, California, USA
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Espejo T, Wagner N, Riedel HB, Karakoumis J, Geigy N, Nickel CH, Bingisser R. Prognostic value of cognitive impairment, assessed by the Clock Drawing Test, in emergency department patients presenting with non-specific complaints. Eur J Intern Med 2024:S0953-6205(24)00122-5. [PMID: 38604939 DOI: 10.1016/j.ejim.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/20/2024] [Accepted: 03/12/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Cognitive impairment (CI) is common among older patients presenting to the emergency department (ED). The failure to recognize CI at ED presentation constitutes a high risk of additional morbidity, mortality, and functional decline. The Clock Drawing Test (CDT) is a well-established cognitive screening test. AIM In patients presenting to the ED with non-specific complaints (NSCs), we aimed to investigate the usability of the CDT and its prognostic value regarding length of hospital stay (LOS) and mortality. METHOD Secondary analysis of the Basel Non-specific Complaints (BANC) trial, a prospective delayed type cross-sectional study with a 30-day follow-up. In three EDs, patients presenting with NSCs were enrolled. The CDT was administered at enrollment. RESULTS In the 1,278 patients enrolled, median age was 81 [74, 87] years and 782 were female (61.19%). A valid CDT was obtained in 737 (57.7%) patients. In patients without a valid CDT median LOS was higher (29 [9, 49] days vs. 22 [9, 45] days), and 30-day mortality was significantly higher than in patients with a valid CDT (n = 45 (8.32%) vs. n = 39 (5.29%)). Of all valid CDTs, 154 clocks (20.9%) were classified as normal, 55 (7.5%) as mildly deficient, 297 (40.3%) as moderately deficient, and 231 (31.3%) as severely deficient. Mortality and LOS increased along with the CDT deficits (p = 0.012 for 30-day mortality; p < 0.001 for LOS). CONCLUSION The early identification of patients with CI may lead to improved patient management and resource allocation. The CDT could be used as a risk stratification tool for older ED patients presenting with NSCs, as it is a predictor for 30-day mortality and LOS.
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Affiliation(s)
- Tanguy Espejo
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, Basel CH-4031, Switzerland
| | | | - Henk B Riedel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, Basel CH-4031, Switzerland
| | | | - Nicolas Geigy
- Emergency Department, Kantonsspital Baselland, Liestal, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, Basel CH-4031, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, Basel CH-4031, Switzerland.
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Proehl JA, Barnason S, Kaiser J, Bradford JY, Gilmore L, Horigan AE, MacPherson-Dias R, Slivinski A, Van Dusen K, Vanhoy MA, Bishop-Royse J, Delao AM. ENA Clinical Practice Guideline Synopsis: Screening Older Adults for Cognitive Impairment. J Emerg Nurs 2024; 50:17-21. [PMID: 38212096 DOI: 10.1016/j.jen.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 09/06/2023] [Indexed: 01/13/2024]
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Mei X, Liu YH, Han YQ, Zheng CY. Risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium in elderly patients. World J Psychiatry 2023; 13:973-984. [PMID: 38186721 PMCID: PMC10768493 DOI: 10.5498/wjp.v13.i12.973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/14/2023] [Accepted: 10/30/2023] [Indexed: 12/19/2023] Open
Abstract
Delirium is an acute reversible neuropsychiatric syndrome caused by multiple factors. It is associated with many adverse clinical outcomes including cognitive impairment, functional decline, prolonged hospitalization, and increased nursing service. The prevalence of delirium was high in department of cardiology, geriatric, and intensive care unit of hospital. With the increase in the aged population, further increases in delirium seem likely. However, it remains poorly recognized in the clinical practice. This article comprehensively discusses the latest research perspectives on the epidemiological data, risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium, including specific measures to manage delirium in clinical real-world situations. This article helps readers improve their knowledge and understanding of delirium and helps clinicians quickly identify and implement timely therapeutic measures to address various delirium subtypes that occur in the clinical settings to ensure patients are treated as aggressively as possible.
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Affiliation(s)
- Xi Mei
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
| | - Yue-Hong Liu
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
| | - Ya-Qing Han
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
| | - Cheng-Ying Zheng
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, 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: 0] [Impact Index Per Article: 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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Jordano JO, Vasilevskis EE, Duggan MC, Welch SA, Schnelle JF, Simmons SF, Ely EW, Han JH. Effect of physical and occupational therapy on delirium duration in older emergency department patients who are hospitalized. J Am Coll Emerg Physicians Open 2023; 4:e12857. [PMID: 36776211 PMCID: PMC9902677 DOI: 10.1002/emp2.12857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/22/2022] [Accepted: 11/03/2022] [Indexed: 02/10/2023] Open
Abstract
Objective Delirium in older emergency department (ED) adults is associated with poorer long-term physical function and cognition. We sought to evaluate if the time to and intensity of physical and/or occupational therapy (PT/OT) are associated with the duration of ED delirium into hospitalization (ED delirium duration). Methods This is a secondary analysis of a prospective cohort study conducted from March 2012 to November 2014 at an urban, academic, tertiary care hospital. Patients aged ≥65 years presenting to the ED and who received PT/OT during their hospitalization were included. Days from enrollment to the first PT/OT session and PT/OT duration relative to hospital length of stay (PT/OT intensity) were abstracted from the medical record. ED delirium duration was defined as the duration of delirium detected in the ED using the Brief Confusion Assessment Method. Data were analyzed using a proportional odds logistic regression adjusted for multiple variables. Adjusted odds ratios (ORs) were calculated with 95% confidence intervals (95%CI). Results The median log PT/OT intensity was 0.5% (interquartile range [IQR]: 0.3%, 0.9%) and was associated with shorter delirium duration (adjusted OR, 0.39; 95% CI, 0.21-0.73). The median time to the first PT/OT session was 2 days (IQR: 1, 3 days) and was not associated with delirium duration (adjusted OR, 1.02; 95% CI, 0.82-1.27). Conclusion In older hospitalized adults, higher PT/OT intensity may be a useful intervention to shorten delirium duration. Time to first PT/OT session was not associated with delirium duration but was initiated a full 2 days after the ED presentation.
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Affiliation(s)
| | - Eduard E. Vasilevskis
- Department of Medicine, Section of Hospital MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA,Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA
| | - Maria C. Duggan
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA,Department of Medicine, Division of Geriatric MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Sarah A. Welch
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA,Department of Physical Medicine and RehabilitationVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - John F. Schnelle
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA,Department of Medicine, Division of Geriatric MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Sandra F. Simmons
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA,Department of Medicine, Division of Geriatric MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - E. Wesley Ely
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) CenterDivision of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jin H. Han
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA,Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
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Delirium and its association with short-term outcomes in younger and older patients with acute heart failure. PLoS One 2022; 17:e0270889. [PMID: 35881580 PMCID: PMC9321444 DOI: 10.1371/journal.pone.0270889] [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: 11/22/2021] [Accepted: 06/18/2022] [Indexed: 11/19/2022] Open
Abstract
Younger patients (18 to 65 years old) are often excluded from delirium outcome studies. We sought to determine if delirium was associated with short-term adverse outcomes in a diverse cohort of younger and older patients with acute heart failure (AHF). We conducted a multi-center prospective cohort study that included adult emergency department patients with confirmed AHF. Delirium was ascertained using the Brief Confusion Assessment Method (bCAM). The primary outcome was a composite outcome of 30-day all-cause death, 30-day all-cause rehospitalization, and prolonged index hospital length of stay. Multivariable logistic regression was performed, adjusting for demographics, cognitive impairment without delirium, and HF risk factors. Older age (≥ 65 years old)*delirium interaction was also incorporated into the model. Odds ratios (OR) with their 95% confidence intervals (95%CI) were reported. A total of 1044 patients with AHF were enrolled; 617 AHF patients were < 65 years old and 427 AHF patients were ≥ 65 years old, and 47 (7.6%) and 40 (9.4%) patients were delirious at enrollment, respectively. Delirium was significantly associated with the composite outcome (adjusted OR = 1.64, 95%CI: 1.02 to 2.64). The older age*delirium interaction p-value was 0.47. In conclusion, delirium was common in both younger and older patients with AHF and was associated with poorer short-term outcomes in both cohorts. Younger patients with acute heart failure should be included in future delirium outcome studies.
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Validation and Recalibration of Modified Mayo Delirium Prediction (MDP) Tool in a Hospitalized Cohort. J Acad Consult Liaison Psychiatry 2022; 63:521-528. [PMID: 35660677 DOI: 10.1016/j.jaclp.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 05/18/2022] [Accepted: 05/28/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Delirium prediction can augment and optimize care of older adults. Mayo delirium prediction (MDP) tool is a robust tool, developed from a large retrospective data set. MDP tool predicts delirium risk for hospitalized older adults, within 24 hours of hospital admission, based on risk factor information available from electronic health record. We intend to validate the prediction performance of this tool and optimize the tool for clinical use. DESIGN Observational cohort study SETTINGS: Mayo Clinic Hospitals, Rochester, MN PARTICIPANTS: All Hospitalized older adults (age >50 years) from December 2019 to June 2020. Patients with an admitting diagnosis of substance use disorder were excluded. INTERVENTION Original MDP tool was modified to adjust for the fall risk variable as a binary variable that will facilitate broader applicability across different fall risk tools. The modified MDP tool was validated in the retrospective derivation and validation data set which yielded similar prediction capability (AUROC = 0.85, 0.83 respectively). MEASUREMENTS Diagnosis of delirium was captured by flowsheet diagnosis of delirium documented by nursing staff in medical record. Predictive variable data were collected daily. RESULTS 8055 patients were included in the study (median age 71 years). The modified MDP tool delirium prediction compared to delirium occurrence was 4% in the low-risk group, 17.8% in the medium-risk group, and 45.3% in the high-risk group (AUROC of 0.80). Recalibration of the tool was attempted to further optimize the tool that resulted in both simplification and increased performance (AUROC 0.82). The simplified tool was able to predict delirium in hospitalized patients admitted to both medical and surgical services. CONCLUSIONS Validation of modified MDP tool revealed good prediction capabilities. Recalibration resulted in simplification with increased performance of the tool in both medical and surgical hospitalized patients.
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Tieges Z, Maclullich AMJ, Anand A, Brookes C, Cassarino M, O’connor M, Ryan D, Saller T, Arora RC, Chang Y, Agarwal K, Taffet G, Quinn T, Shenkin SD, Galvin R. Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis. Age Ageing 2021; 50:733-743. [PMID: 33951145 PMCID: PMC8099016 DOI: 10.1093/ageing/afaa224] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 'A's Test (4AT) is a short (<2 minutes) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection. METHODS We searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials, from 2011 (year of 4AT release on the website www.the4AT.com) until 21 December 2019. Inclusion criteria were: older adults (≥65 years); diagnostic accuracy study of the 4AT index test when compared to delirium reference standard (standard diagnostic criteria or validated tool). Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model. RESULTS Seventeen studies (3,702 observations) were included. Settings were acute medicine, surgery, a care home and the emergency department. Three studies assessed performance of the 4AT in stroke. The overall prevalence of delirium was 24.2% (95% CI 17.8-32.1%; range 10.5-61.9%). The pooled sensitivity was 0.88 (95% CI 0.80-0.93) and the pooled specificity was 0.88 (95% CI 0.82-0.92). Excluding the stroke studies, the pooled sensitivity was 0.86 (95% CI 0.77-0.92) and the pooled specificity was 0.89 (95% CI 0.83-0.93). The methodological quality of studies varied but was moderate to good overall. CONCLUSIONS The 4AT shows good diagnostic test accuracy for delirium in the 17 available studies. These findings support its use in routine clinical practice in delirium detection. PROSPERO REGISTRATION NUMBER CRD42019133702.
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Affiliation(s)
- Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, UK
| | - Alasdair M J Maclullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Atul Anand
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland, UK
| | - Claire Brookes
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Marica Cassarino
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Margaret O’connor
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Damien Ryan
- Retrieval, Emergency and Disaster Medicine Research and Development Unit (REDSPoT), Emergency Department, University Hospital Limerick, Limerick, Ireland
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Rakesh C Arora
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Yue Chang
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kathryn Agarwal
- Section of Geriatrics, Baylor College of Medicine, Houston, TX, USA
- Houston Methodist Hospital, Houston, TX, USA
| | - George Taffet
- Section of Geriatrics, Baylor College of Medicine, Houston, TX, USA
- Houston Methodist Hospital, Houston, TX, USA
| | - Terence Quinn
- Institute of Cardiovascular Medicine, University of Glasgow, Glasgow, Scotland, UK
| | - Susan D Shenkin
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
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Risk factors for delirium among hospitalized patients in Zambia. PLoS One 2021; 16:e0249097. [PMID: 33831010 PMCID: PMC8031188 DOI: 10.1371/journal.pone.0249097] [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: 11/05/2020] [Accepted: 03/08/2021] [Indexed: 11/19/2022] Open
Abstract
Objective To identify risk factors for delirium among hospitalized patients in Zambia. Methods We conducted a prospective cohort study at the University Teaching Hospital in Lusaka, Zambia, from October 2017 to April 2018. We report associations of exposures including sociodemographic and clinical factors with delirium over the first three days of hospital admission, assessed using a modified Brief Confusion Assessment Method (bCAM). Findings 749 patients were included for analysis (mean age, 42.9 years; 64.8% men; 47.3% with HIV). In individual regression analyses of potential delirium risk factors adjusted for age, sex and education, factors significantly associated with delirium included being divorced/widowed (OR 1.64, 95% CI 1.09–2.47), lowest tercile income (OR 1.58, 95% CI 1.04–2.40), informal employment (OR 1.97, 95% CI 1.25–3.15), untreated HIV infection (OR 2.18, 95% CI 1.21–4.06), unknown HIV status (OR 2.90, 95% CI 1.47–6.16), history of stroke (OR 2.70, 95% CI 1.15–7.19), depression/anxiety (OR 1.52, 95% CI 1.08–2.14), alcohol overuse (OR 1.96, 95% CI 1.39–2.79), sedatives ordered on admission (OR 3.77, 95% CI 1.70–9.54), severity of illness (OR 2.00, 95% CI 1.82–2.22), neurological (OR 7.66, 95% CI 4.90–12.24) and pulmonary-system admission diagnoses (OR 1.91, 95% CI 1.29–2.85), and sepsis (OR 2.44, 95% CI 1.51–4.08). After combining significant risk factors into a multivariable regression analysis, severity of illness, history of stroke, and being divorced/widowed remained predictive of delirium (p<0.05). Conclusion Among hospitalized adults at a national referral hospital in Zambia, severity of illness, history of stroke, and being divorced/widowed were independently predictive of delirium. Extension of this work will inform future efforts to prevent, detect, and manage delirium in low- and middle-income countries.
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Abstract
Geriatric emergency medicine has emerged as a subspecialty of emergency medicine over the past 25 years. This emergence has seen the development of increases in training opportunities, care delivery strategies, collaborative best practice guidelines, and formal geriatric emergency department accreditation. This multidisciplinary field remains ripe for continued development in the coming decades as the aging US population parallels a call from patients, health care providers, and health systems to improve the delivery of high-value care. This article educates emergency medicine practitioners and highlights high-value care practice trends to inform and prioritize decision-making for this unique patient population.
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Zhang Q, Li S, Chen M, Yang Q, Cao X, Ge L, Di B. Delirium screening tools in the emergency department: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24779. [PMID: 33663094 PMCID: PMC7909163 DOI: 10.1097/md.0000000000024779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Delirium is a common type of acute brain dysfunction among emergency department (ED) patients. The prevalence of delirium in the ED is up to 40%. Although screening instruments used to identify delirium have been developed, it is unclear which tool is the most accurate in the ED. To address this challenging, we systematically examine the accuracy of delirium screening tools used to assess the ED patients. METHODS This study has been registered at the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY), and the registration number is INPLASY202110041. We will search the PubMed, EMBASE, PsycINFO, and the Cochrane Library. Studies involving patients which compared diagnostic instruments with the criteria in Diagnostic and Statistical Manual of Mental Disorders (DSM) as a reference standard will be included. We will use STATA 15.1 and MetaDiSC to make careful analysis of the results. The quality of included studies will be assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 scale. RESULTS In this study, the accuracy of different screening methods among ED patients is assessed by a high-quality synthesis. The number of tools available for screening delirium in the ED, the information of studies including the countries, the study design, the sample size and the characteristic of studies, the quality of the studies and the results of meta-analysis. The systematic review and meta-analysis will be published in a peer-reviewed journal. CONCLUSION According to the conclusion of the systematic review, evidence will be provided to judge which screening method is the best for the ED patients. The results will bring better understanding of screening methods in the ED and highlight gaps for future research.
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Affiliation(s)
| | - Sheng Li
- The First People's Hospital of Lanzhou City
| | - Meixi Chen
- The First Clinical Medical College, Lanzhou University
| | | | - Xiao Cao
- School of Nursing, Lanzhou University
| | - Long Ge
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University
| | - Baoshan Di
- The First Hospital, Lanzhou University, Lanzhou, China
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14
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Bridwell RE, April MD, Long B. Is the 4AT Score Accurate in Identifying Delirium in Older Adults? Ann Emerg Med 2021; 77:628-630. [PMID: 33612281 DOI: 10.1016/j.annemergmed.2020.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Rachel E Bridwell
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX
| | - Michael D April
- Department of Military Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Brit Long
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX
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15
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Banerdt JK, Mateyo K, Wang L, Lindsell CJ, Riviello ED, Saylor D, Heimburger DC, Ely EW. Delirium as a predictor of mortality and disability among hospitalized patients in Zambia. PLoS One 2021; 16:e0246330. [PMID: 33571227 PMCID: PMC7877643 DOI: 10.1371/journal.pone.0246330] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/18/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To study the epidemiology and outcomes of delirium among hospitalized patients in Zambia. METHODS We conducted a prospective cohort study at the University Teaching Hospital in Lusaka, Zambia, from October 2017 to April 2018. The primary exposure was delirium duration over the initial 3 days of hospitalization, assessed daily using the Brief Confusion Assessment Method. The primary outcome was 6-month mortality. Secondary outcomes included 6-month disability, evaluated using the World Health Organization Disability Assessment Schedule 2.0. FINDINGS 711 adults were included (median age, 39 years; 461 men; 459 medical, 252 surgical; 323 with HIV). Delirium prevalence was 48.5% (95% CI, 44.8%-52.3%). 6-month mortality was higher for delirious participants (44.6% [39.3%-50.1%]) versus non-delirious participants (20.0% [15.4%-25.2%]; P < .001). After adjusting for covariates, delirium duration independently predicted 6-month mortality and disability with a significant dose-response association between number of days with delirium and odds of worse clinical outcome. Compared to no delirium, presence of 1, 2 or 3 days of delirium resulted in odds ratios for 6-month mortality of 1.43 (95% CI, 0.73-2.80), 2.20 (1.07-4.51), and 3.92 (2.24-6.87), respectively (P < .001). Odds of 6-month disability were 1.20 (0.70-2.05), 1.73 (0.95-3.17), and 2.80 (1.78-4.43), respectively (P < .001). CONCLUSION Among hospitalized medical and surgical patients in Zambia, delirium prevalence was high and delirium duration independently predicted mortality and disability at 6 months. This work lays the foundation for prevention, detection, and management of delirium in low-income countries. Long-term follow up of outcomes of critical illness in resource-limited settings appears feasible using the WHO Disability Assessment Schedule.
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Affiliation(s)
- Justin K. Banerdt
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
| | - Kondwelani Mateyo
- University of Zambia School of Medicine, Lusaka, Zambia
- University Teaching Hospital, Lusaka, Zambia
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Christopher J. Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Elisabeth D. Riviello
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Deanna Saylor
- University of Zambia School of Medicine, Lusaka, Zambia
- University Teaching Hospital, Lusaka, Zambia
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Douglas C. Heimburger
- University of Zambia School of Medicine, Lusaka, Zambia
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee, United States of America
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16
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Calf AH, Pouw MA, van Munster BC, Burgerhof JGM, de Rooij SE, Smidt N. Screening instruments for cognitive impairment in older patients in the Emergency Department: a systematic review and meta-analysis. Age Ageing 2021; 50:105-112. [PMID: 33009909 PMCID: PMC7793600 DOI: 10.1093/ageing/afaa183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Indexed: 11/16/2022] Open
Abstract
Background cognitive impairment is highly prevalent among older patients attending the Emergency Department (ED) and is associated with adverse outcomes. Methods we conducted a systematic review and meta-analysis to evaluate the diagnostic accuracy of cognitive screening instruments to rule out cognitive impairment in older patients in the ED. A comprehensive literature search was performed in MEDLINE, EMBASE, CINAHL and CENTRAL. A risk of bias assessment using QUADAS-2 was performed. Results 23 articles, examining 18 different index tests were included. Only seven index tests could be included in the meta-analysis. For ruling out cognitive impairment irrespective of aetiology, Ottawa 3 Day Year (O3DY) (pooled sensitivity 0.90; (95% CI) 0.71–0.97) had the highest sensitivity. Fourteen articles focused on screening for cognitive impairment specifically caused by delirium. For ruling out delirium, the 4 A’s Test (4AT) showed highest sensitivity (pooled sensitivity 0.87, 95% confidence interval (95% CI) 0.74–0.94). Conclusions high clinical and methodological heterogeneity was found between included studies. Therefore, it is a challenge to recommend one diagnostic test for use as a screening instrument for cognitive impairment in the ED. The 4AT and O3DY seem most promising for ruling out cognitive impairment in older patients attending the ED. The review protocol was registered in PROSPERO (CRD42018082509).
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Affiliation(s)
- Agneta H Calf
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
| | - Maaike A Pouw
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
- Department of Internal Medicine, Martini Hospital, Groningen, The Netherlands
| | - Barbara C van Munster
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
- Department of Geriatrics, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Johannes G M Burgerhof
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sophia E de Rooij
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
- Medical Spectrum Twente, Medical School Twente, Enschede, The Netherlands
| | - Nynke Smidt
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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17
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Carpenter CR, Hammouda N, Linton EA, Doering M, Ohuabunwa UK, Ko KJ, Hung WW, Shah MN, Lindquist LA, Biese K, Wei D, Hoy L, Nerbonne L, Hwang U, Dresden SM. Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement. Acad Emerg Med 2021; 28:19-35. [PMID: 33135274 DOI: 10.1111/acem.14166] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions. METHODS GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci. RESULTS In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research. CONCLUSIONS Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.
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Affiliation(s)
- Christopher R. Carpenter
- From the Department of Emergency Medicine Washington University in St. Louis School of MedicineEmergency Care Research Core St. Louis MIUSA
| | - Nada Hammouda
- the Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
| | - Elizabeth A. Linton
- the Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
- the Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MDUSA
| | - Michelle Doering
- the Becker Medical Library Washington University in St. Louis School of Medicine St. Louis MOUSA
| | - Ugochi K. Ohuabunwa
- the Division of General Medicine and Geriatrics Emory University School of Medicine Atlanta GAUSA
| | - Kelly J. Ko
- Clinical Research West Health Institute La Jolla CAUSA
| | - William W. Hung
- James J. Peters VA Medical Center Bronx NYUSA
- and the Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
| | - Manish N. Shah
- the BerbeeWalsh Department of Emergency Medicine University of Wisconsin–Madison Madison WIUSA
| | - Lee A. Lindquist
- the Department of Medicine Northwestern University Feinberg School of Medicine Chicago ILUSA
| | - Kevin Biese
- the Departments of Emergency Medicine and Internal Medicine University of North Carolina at Chapel Hill Chapel Hill NCUSA
| | - Daniel Wei
- the BerbeeWalsh Department of Emergency Medicine University of Wisconsin–Madison Madison WIUSA
| | | | | | - Ula Hwang
- the Department of Emergency Medicine Yale School of Medicine New Haven CTUSA
| | - Scott M. Dresden
- and the Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL USA
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18
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Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, Slooter AJC, Ely EW. Delirium. Nat Rev Dis Primers 2020; 6:90. [PMID: 33184265 PMCID: PMC9012267 DOI: 10.1038/s41572-020-00223-4] [Citation(s) in RCA: 394] [Impact Index Per Article: 98.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 02/06/2023]
Abstract
Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.
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Affiliation(s)
- Jo Ellen Wilson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Psychiatry and Behavioral Sciences, Division of General Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew F Mart
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Republic of Ireland
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy D Girard
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN, USA
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19
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Abstract
Delirium is a common and underdiagnosed problem in hospitalized older adults. It is associated with an increased risk of poor cognitive and functional outcomes, institutionalization, and death. Timely diagnosis of delirium and non-pharmacological prevention and management strategies can improve patient outcomes. The Confusion Assessment Method (CAM) is the most widely used clinical assessment tool for the diagnosis of delirium. Multiple variations of the CAM have been developed for ease of administration and for the unique needs of specific patient populations, including the 3-min diagnostic CAM (3D CAM), CAM-Intensive Care Unit (CAM-ICU), Delirium Triage Screen (DTS)/Brief CAM (b-CAM), 4AT tool, and ultrabrief delirium assessment. Strong evidence supports the effectiveness of nonpharmacologic strategies as the primary intervention for the prevention of delirium. Multicomponent delirium prevention strategies can reduce the incidence of delirium by 40%. Investigation of underlying medical precipitants and optimization of non-pharmacological interventions are first line in the management of delirium. Despite a lack of evidence supporting use of antipsychotics, low dose antipsychotics remain second line for off-label treatment of distressing psychoses and/or agitated behaviors that are refractory to non-pharmacological behavioral interventions and pose an imminent risk of harm to self or others. Any antipsychotic prescription for delirium should be accompanied by an appropriate taper plan. Follow up with primary care providers on discharge from hospital for ongoing screening of cognitive impairment is important.
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Affiliation(s)
- Katie M Rieck
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sandeep Pagali
- Division of Hospital Internal Medicine, and Division of Geriatrics and Gerontology, Mayo Clinic, Rochester, MN, USA
| | - Donna M Miller
- Division of Hospital Internal Medicine, and Division of Geriatrics and Gerontology, Mayo Clinic, Rochester, MN, USA
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20
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McNeil JB, Hughes CG, Girard T, Ware LB, Ely EW, Chandrasekhar R, Han JH. Plasma biomarkers of inflammation, coagulation, and brain injury as predictors of delirium duration in older hospitalized patients. PLoS One 2019; 14:e0226412. [PMID: 31856187 PMCID: PMC6922408 DOI: 10.1371/journal.pone.0226412] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 11/26/2019] [Indexed: 12/21/2022] Open
Abstract
Background Delirium's pathophysiology is poorly understood. We sought to determine if plasma biomarkers of inflammation, coagulation, endothelial activation, and blood brain barrier (BBB) injury were associated with emergency department (ED) delirium duration. Methods We enrolled hospitalized patients who were 65 years or older from the ED. Plasma biomarkers of inflammation (interleukin-6 [IL-6], IL-8, soluble tumor necrosis factor receptor I [sTNFRI]), coagulation (Protein C), endothelial activation (plasminogen activating inhibitor-1 [PAI-1]), and BBB injury (S100B) at were measured using blood obtained at enrollment. The dependent variable was ED delirium duration which was determined by the Brief Confusion Assessment Method assessed in the ED and hospitalization. Proportional odds logistic regression analyses were performed adjusted for relevant confounders and allowing for interaction by baseline dementia status. Results A total of 156 patients were enrolled. IL-6 (POR = 1.59, 95%CI: 1.09–2.32) and PAI-1 (POR = 2.96, 95%CI: 1.48 to 6.85) were independently associated with more prominent ED delirium duration in subjects without dementia only. No significant associations between IL-8, Protein C, sTNRFI, and S100B and ED delirium duration were observed. Conclusions Plasma Biomarkers of systemic inflammation and endothelial activation are associated with ED delirium duration in older ED patients without dementia.
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Affiliation(s)
- J. Brennan McNeil
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Christopher G. Hughes
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Timothy Girard
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Veteran Affairs Geriatric Research, Education, and Clinical Center (GRECC), Nashville, Tennessee, United States of America
| | - Rameela Chandrasekhar
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Jin H. Han
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Veteran Affairs Geriatric Research, Education, and Clinical Center (GRECC), Nashville, Tennessee, United States of America
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
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21
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Noel CB, Cirbus JR, Han JH. Emergency Department Interventions and Their Effect on Delirium's Natural Course: The Folly May be in the Foley. J Emerg Trauma Shock 2019; 12:280-285. [PMID: 31798243 PMCID: PMC6883498 DOI: 10.4103/jets.jets_137_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 06/27/2019] [Indexed: 11/04/2022] Open
Abstract
Background Delirium frequently affects older emergency department (ED) patients and has been associated with accelerated cognitive and functional decline, increased length of stay (LOS), and higher in- and out-of-hospital mortality. Objectives Care provided in the ED may have downstream effects on delirium duration during hospitalization. This study aimed to identify the modifiable factors of ED care associated with delirium duration in patients admitted to the hospital through the ED. Materials and Methods This prospective cohort study enrolled ED patients who were 65 years and older and admitted to the hospital. Delirium was determined in the ED and during the first 7 days of hospitalization using the modified Brief Confusion Assessment Method. All delirious patients and a random selection (17%) of nondelirious patients were also enrolled. ED LOS, opioid administration, benzodiazepine administration, anticholinergic medication administration, and bladder catheter placement were obtained by medical record review. Multivariable proportional odds logistic regression was performed to determine if each of the factors was associated with delirium duration after adjusting for age, dementia, baseline function, comorbidity burden, severity of illness, nursing home residence, and central nervous system insult. Results A total of 228 patients were enrolled. ED bladder catheter placement was significantly associated (adjusted proportional odds ratio = 3.1, 95% confidence interval: 1.3 to 7.4) with increased delirium duration after adjusting for confounders. ED LOS, opioid administration, benzodiazepine administration, and anticholinergic burden, however, were not. Conclusions ED bladder catheter placement was significantly associated with delirium duration and may present an opportunity for intervention.
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Affiliation(s)
- Christopher B Noel
- Department of Medicine, Division of Critical Care Medicine, Cooper University Hospital, Camden, New Jersey, USA
| | - Jamie R Cirbus
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee, USA.,Center for Quality Aging, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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22
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Han JH, Chen A, Vasilevskis EE, Schnelle JF, Ely EW, Chandrasekhar R, Morrison RD, Ryan TP, Daniels JS, Sutherland JJ, Simmons SF. Supratherapeutic Psychotropic Drug Levels in the Emergency Department and Their Association with Delirium Duration: A Preliminary Study. J Am Geriatr Soc 2019; 67:2387-2392. [PMID: 31503339 DOI: 10.1111/jgs.16156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/03/2019] [Accepted: 07/05/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Polypharmacy is associated with delirium, but the mechanisms for this connection are unclear. Our goal was to determine the frequency of supratherapeutic psychotropic drug levels (SPDLs) in older hospitalized patients and if it is associated with the duration of emergency department (ED) delirium. DESIGN Secondary analysis of a prospective cohort study. SETTING Tertiary care academic medical center. PARTICIPANTS ED patients 65 years or older who were admitted to the hospital. MEASUREMENTS Delirium was assessed in the ED and during the first 7 days of hospitalization using the modified Brief Confusion Assessment Method. Drug concentrations were determined in serum samples collected at enrollment via a novel platform based on liquid chromatography-tandem mass spectrometry capable of identifying and quantitating 78 clinically approved medications including opioids, benzodiazepines, antidepressants, antipsychotics, and amphetamines. Patients with serum psychotropic drug concentrations above established reference ranges were considered supratherapeutic and have a SPDL. We performed proportional odds logistic regression to determine if SPDLs were associated with ED delirium duration adjusted for confounders. Medical record review was performed to determine if the doses of medications associated with SPDLs were adjusted at hospital discharge. RESULTS A total of 158 patients were enrolled; of these, 66 were delirious in the ED. SPDLs were present in 11 (17%) of the delirious and 4 (4%) of the non-delirious ED patients. SPDLs were significantly associated with longer ED delirium duration (adjusted proportional odds ratio = 6.0; 95% confidence interval = 2.1-17.3) after adjusting for confounders. Of the 15 medications associated with SPDLs, 9 (60%) were prescribed at the same or higher doses at the time of hospital discharge. CONCLUSION SPDLs significantly increased the odds of prolonged ED delirium episodes. Approximately half of the medications associated with SPDLs were continued after hospital discharge at the same or higher doses. J Am Geriatr Soc 67:2387-2392, 2019.
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Affiliation(s)
- Jin H Han
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee.,Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alex Chen
- Department of Emergency Medicine, Division of Medical Toxicology and Precision Medicine, University of Arizona College of Medicine, Phoenix, Arizona
| | - Eduard E Vasilevskis
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee.,Department of Medicine, Division of General Internal Medicine and Public Health, Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John F Schnelle
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee.,Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E Wesley Ely
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee.,Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rameela Chandrasekhar
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | | | - Sandra F Simmons
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee.,Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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Delirium etiology subtypes and their effect on six-month function and cognition in older emergency department patients. Int Psychogeriatr 2019; 31:267-276. [PMID: 30021661 DOI: 10.1017/s1041610218000777] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED ABSTRACTBackground:Delirium is heterogeneous and can vary by etiology. OBJECTIVES We sought to determine how delirium subtyped by etiology affected six-month function and cognition. DESIGN Prospective cohort study. SETTING Tertiary care, academic medical center. PARTICIPANTS A total of 228 hospitalized patients > 65 years old were admitted from the emergency department (ED). MEASUREMENTS The modified Brief Confusion Assessment Method was used to determine delirium in the ED. Delirium etiology was determined by three trained physician reviewers using a Delirium Etiology checklist. Pre-illness and six-month function and cognition were determined using the Older American Resources and Services Activities of Daily Living (OARS ADL) questionnaire and the short-form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Multiple linear regression was performed to determine if delirium etiology subtypes were associated with six-month function and cognition adjusted for baseline OARS ADL and IQCODE. Two-factor interactions were incorporated to determine pre-illness function or cognition-modified relationships between delirium subtypes and six-month function and cognition. RESULTS In patients with poorer pre-illness function only, delirium secondary to metabolic disturbance (β coefficient = -2.9 points, 95%CI: -0.3 to -5.6) and organ dysfunction (β coefficient = -4.3 points, 95%CI: -7.2 to -1.4) was significantly associated with poorer six-month function. In patients with intact cognition only, delirium secondary to central nervous system insults was significantly associated with poorer cognition (β coefficient = 0.69, 95%CI: 0.19 to 1.20). CONCLUSIONS Delirium is heterogeneous and different etiologies may have different prognostic implications. Furthermore, the effect of these delirium etiologies on outcome may be dependent on the patient's pre-illness functional status and cognition.
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Delirium's Arousal Subtypes and Their Relationship with 6-Month Functional Status and Cognition. PSYCHOSOMATICS 2018; 60:27-36. [PMID: 29929733 DOI: 10.1016/j.psym.2018.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/01/2018] [Accepted: 05/01/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE We sought to determine how delirium subtyped by arousal affected 6-month function and cognition in acutely ill older patients. METHODS This was secondary analysis of a prospective cohort study which enrolled hospitalized patients ≥65 years old. Delirium and arousal were ascertained daily in the emergency department and the first 7 days of hospitalization using the modified Brief Confusion Assessment Method and Richmond Agitation Sedation Scale, respectively. For each day, patients were categorized as having no delirium, delirium with normal arousal, delirium with decreased arousal, or delirium with increased arousal. Preillness and 6-month functional status were determined using the Older American Resources and Services activities of daily living scale which ranges from 0 (completely dependent) to 28 (completely independent). Preillness and 6-month cognition were determined using the Informant Questionnaire on Cognitive Decline in the Elderly which ranges from 1 (markedly improved cognition) to 5 (severe cognitive impairment). Multiple linear regression was performed adjusted for preillness Older American Resources and Services activities of daily living and Informant Questionnaire on Cognitive Decline in the Elderly and other relevant confounders. RESULTS In 228 older patients, delirium with normal arousal was the only subtype independently associated with poorer 6-month function and cognition. For every day spent in this subtype, the 6-month Older American Resources and Services activities of daily living decreased by 0.84 points (95% confidence interval: -1.59 to -0.09) and the patient's 6-month Informant Questionnaire on Cognitive Decline in the Elderly significantly increased by 0.14 points (95% confidence interval: 0.06-0.23). CONCLUSIONS Delirium with normal arousal, as opposed to delirium with decreased or increased arousal, was the only arousal subtype significantly associated with worsening 6-month function and cognition. Subtyping delirium by arousal may have important prognostic value.
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Han JH, Wilson A, Schnelle JF, Dittus RS, Ely EW. An evaluation of single question delirium screening tools in older emergency department patients. Am J Emerg Med 2018; 36:1249-1252. [PMID: 29699898 DOI: 10.1016/j.ajem.2018.03.060] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 03/21/2018] [Accepted: 03/21/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To determine the diagnostic performances of several single question delirium screens. To the patient we asked: "Have you had any difficulty thinking clearly lately?" To the patient's surrogate, we asked: "Is the patient at his or her baseline mental status?" and "Have you noticed the patient's mental status fluctuate throughout the course of the day?" METHODS This was a prospective observational study that enrolled English speaking patients 65 years or older. A research assistant (RA) and emergency physician (EP) independently asked the patient and surrogate the single question delirium screens. The reference standard for delirium was a consultation-liaison psychiatrist's assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria. All assessments were performed within 3 h and were all blinded to each other. RESULTS Of the 406 patients enrolled, 50 (12%) were delirious. A patient who was unable to answer the question "Have you had any difficulty thinking clearly lately?" was 99.7% (95% CI: 98.0%-99.9%) specific, but only 24.0% (95% CI: 14.3%-37.4%) sensitive for delirium when asked by the RA. The baseline mental status surrogate question was 77.1% (95% CI: 61.0%-87.9%) sensitive and 87.5% (95% CI: 82.8%-91.1%) specific for delirium when asked by the RA. The fluctuating course surrogate question was 77.1% (95% CI: 61.0%-87.9%) sensitive and 80.2% (95% CI: 74.8%-84.7%) specific. When asked by the EP, the single question delirium screens' diagnostic performances were similar. CONCLUSIONS The patient and surrogate single question delirium assessments may be useful for delirium screening in the ED.
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Affiliation(s)
- Jin H Han
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, United States; Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States.
| | - Amanda Wilson
- Department of Psychiatry, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - John F Schnelle
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, United States; Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN, United States; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, United States; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN, United States
| | - Robert S Dittus
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, United States; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN, United States
| | - E W Ely
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, United States; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN, United States
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Han JH, Vasilevskis EE, Chandrasekhar R, Liu X, Schnelle JF, Dittus RS, Ely EW. Delirium in the Emergency Department and Its Extension into Hospitalization (DELINEATE) Study: Effect on 6-month Function and Cognition. J Am Geriatr Soc 2017; 65:1333-1338. [PMID: 28263444 DOI: 10.1111/jgs.14824] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 12/15/2016] [Accepted: 12/16/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The natural course and clinical significance of delirium in the emergency department (ED) is unclear. OBJECTIVES We sought to (1) describe the extent to which delirium in the ED persists into hospitalization (ED delirium duration) and (2) determine how ED delirium duration is associated with 6-month functional status and cognition. DESIGN Prospective cohort study. SETTING Tertiary care, academic medical center. PARTICIPANTS ED patients ≥65 years old who were admitted to the hospital. MEASUREMENTS The modified Brief Confusion Assessment Method was used to ascertain delirium in the ED and hospital. Premorbid and 6-month function were determined using the Older American Resources and Services Activities of Daily Living (OARS ADL) questionnaire which ranged from 0 (completely dependent) to 28 (completely dependent). Premorbid and 6-month cognition were determined using the short form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) which ranged from 1 to 5 (severe dementia). Multiple linear regression was performed to determine if ED delirium duration was associated with 6-month function and cognition adjusted for baseline OARS ADL and IQCODE, and other confounders. RESULTS A total of 228 older ED patients were enrolled. Of the 105 patients who were delirious in the ED, 81 (77.1%) patients' delirium persisted into hospitalization. For every ED delirium duration day, the 6-month OARS ADL decreased by 0.63 points (95% CI: -1.01 to -0.24), indicating poorer function. For every ED delirium duration day, the 6-month IQCODE increased 0.06 points (95% CI: 0.01-0.10) indicating poorer cognition. CONCLUSIONS Delirium in the ED is not a transient event and frequently persists into hospitalization. Longer ED delirium duration is associated with an incremental worsening of 6-month functional and cognitive outcomes.
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Affiliation(s)
- Jin H Han
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA.,Department of Emergency Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Eduard E Vasilevskis
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA.,Division of General Internal Medicine and Public Health, Section of Hospital Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN, USA
| | - Rameela Chandrasekhar
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Xulei Liu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - John F Schnelle
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA.,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN, USA
| | - Robert S Dittus
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA.,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN, USA
| | - E Wesley Ely
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN, USA
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Lawlor PG. Cancer patients with delirium in the emergency department: A frequent and distressing problem that calls for better assessment. Cancer 2016; 122:2783-6. [DOI: 10.1002/cncr.30132] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 05/07/2016] [Accepted: 05/11/2016] [Indexed: 02/03/2023]
Affiliation(s)
- Peter G. Lawlor
- Division of Palliative Care; Department of Medicine; University of Ottawa; Ottawa Ontario Canada
- Bruyère and Ottawa Hospital Research Institutes; Ottawa Ontario Canada
- Palliative Care Unit, Bruyère Continuing Care; Ottawa Ontario Canada
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