1
|
Zarour S, Weiss Y, Kiselevich Y, Iacubovici L, Karol D, Shaylor R, Davydov T, Matot I, Cohen B. The association between midazolam premedication and postoperative delirium - a retrospective cohort study. J Clin Anesth 2024; 92:111113. [PMID: 37280146 DOI: 10.1016/j.jclinane.2023.111113] [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: 11/04/2022] [Revised: 02/17/2023] [Accepted: 03/17/2023] [Indexed: 06/08/2023]
Abstract
STUDY OBJECTIVE To evaluate the association between midazolam premedication and postoperative delirium in a large retrospective cohort of patients ≥70 years. DESIGN Retrospective cohort study. SETTING A single tertiary academic medical center. PATIENTS Patients ≥70 years having elective non-cardiac surgery under general anesthesia from 2020 to 2021. INTERVENTIONS Midazolam premedication, defined as intravenous midazolam administration prior to induction of general anesthesia. MEASUREMENTS The primary outcome, postoperative delirium, was a collapsed composite outcome including at least one of the following: a positive 4A's test during post-anesthesia care unit stay and/or the initial 2 postoperative days; physician or nursing records reporting new-onset confusion as captured by the CHART-DEL instrument; or a positive 3D-CAM test. The association between midazolam premedication and postoperative delirium was assessed using multivariable logistic regression, adjusting for potential confounding variables. As secondary analysis, we investigated the association between midazolam premedication and a composite of other postoperative complications. Several sensitivity analyses were performed using similar regression models. MAIN RESULTS In total, 1973 patients were analyzed (median age 75 years, 47% women, 50% ASA score ≥ 3, 32% high risk surgery). The overall incidence of postoperative delirium was 15.3% (302/1973). Midazolam premedication was administered to 782 (40%) patients (median [IQR] dose 2 [1,2] mg). After adjustment for potential confounding variables, midazolam premedication was not associated with increased odds of postoperative delirium, with adjusted odds ratio of 1.09 (95% confidence interval 0.82-1.45; P = 0.538). Midazolam premedication was also not associated with the composite of other postoperative complications. Furthermore, no association was found between midazolam premedication and postoperative delirium in any of the sensitivity analyses preformed. CONCLUSIONS Our results suggest that low doses of midazolam can be safely used to pre-medicate elective surgical patients 70 years or older before non-cardiac surgery, without significant effect on the risk of developing postoperative delirium.
Collapse
Affiliation(s)
- Shiri Zarour
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Yotam Weiss
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Yossef Kiselevich
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Liat Iacubovici
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Karol
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Ruth Shaylor
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Tamara Davydov
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Idit Matot
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Barak Cohen
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel; Outcomes Research Consortium, Cleveland, OH, United States of America.
| |
Collapse
|
2
|
Demirtakan T, Cakmak F, Ipekci A, Akdeniz YS, Biberoglu S, Ikızceli I, Ozkan S. Clinical assessment and short-term mortality prediction of older adults with altered mental status using RASS and 4AT tools. Am J Emerg Med 2024; 75:14-21. [PMID: 37897915 DOI: 10.1016/j.ajem.2023.10.022] [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: 11/02/2022] [Revised: 10/07/2023] [Accepted: 10/08/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Altered mental status (AMS) in older adults is a common reason for admission to emergency departments (EDs) and usually results from delirium, stupor, or coma. It is important to proficiently identify underlying factors and anticipate clinical outcomes for those patients. AIM The primary objective of this study was to reveal and compare the clinical outcomes and etiologic factors of older patients with delirium, stupor, and coma. The secondary objective was to identify the 30-day mortality risk for those patients. METHOD The study was conducted as prospective and observational research. We included patients aged 65 years and older who presented with new-onset neurological and cognitive symptoms or worsening in baseline mental status. Patients who presented no change in their baseline mental status within 48 h and those who needed urgent interventions were excluded. Selected patients were assessed using RASS and 4AT tools and classified into three groups: stupor/coma, delirium, and no stupor/coma or delirium (no-SCD). Appropriate statistical tests were applied to compare these 3 groups. The 30-day mortality risks were identified by Cox survival analysis and Kaplan-Meier curve. RESULTS A total of 236 patients were eligible for the study. Based on their RASS and 4AT test scores: 56 (23.7%), 94 (40.6%), and 86 (36.4%) patients formed the stupor/coma, delirium and no-SCD groups, respectively. There was no statistical difference in the three groups for gender, mean age, and medical comorbidities. Neurological (34.7%), infectious (19.4%), and respiratory (19.0%) diseases were the leading factors for AMS. Post-hoc tests showed that CCI scores of the delirium (6, IQR = 3) and stupor/coma (7, IQR = 3) groups were not significantly different. The 30-day mortality rates of stupor/coma, delirium, and no-SCD groups were 42.%, 15.9%, and 12.8%, respectively (p < 0.005). The hazard ratio of the stupor/coma group was 2.79 (CI: 95%, 1.36-5.47, p = 0.005). CONCLUSION AMS remains a significant clinical challenge in EDs. Using the RASS and 4AT tests provides benefits and advantages for emergency medicine physicians. Neurological, infectious, and respiratory diseases can lead to life-threatening mental deterioration. Our study revealed that long-term mortality predictor CCI scores were quite similar among patients with delirium, stupor, or coma. However, the short-term mortality was significantly increased in the stupor/coma patients and they had 2.8 times higher 30-day mortality risk than others.
Collapse
Affiliation(s)
- Turker Demirtakan
- Emergency Department, University of Health Science, Kanuni Sultan Süleyman Research and Training Hospital, Istanbul, Turkey.
| | - Fatih Cakmak
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Afsin Ipekci
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Yonca Senem Akdeniz
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Serap Biberoglu
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Ibrahim Ikızceli
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Seda Ozkan
- Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| |
Collapse
|
3
|
O'Brien A, Hopkins J, Boardman G, Stanley G, Daly P, Martin L, Wood F. A retrospective, cross-sectional analysis of delirium in burn injury compared to other surgical specialities. Burns 2023; 49:1676-1687. [PMID: 37821275 DOI: 10.1016/j.burns.2023.05.008] [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: 08/03/2022] [Revised: 04/12/2023] [Accepted: 05/06/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Delirium is an acute cerebral disorder characterised by a disturbance in cognition, attention, and awareness. Often, it's undiagnosed and associated with increased morbidity and mortality. For burn patients, the reported prevalence ranges from 16% to 39%, with a multifactorial aetiology, increasing when intensive care is required. A direct comparison of delirium between surgical specialities has not been made. AIM 1. To audit the use of the 4AT for those who become delirious during their stay. 2. Assess the proportion of patients diagnosed with delirium during hospitalisation by surgical specialities. 3. Identification of the factors associated with delirium in surgical patients. METHODS Investigators at a single centre conducted a two-phase study. An initial retrospective audit of delirious patients under burns, general, and orthopaedic specialities over 16months, as defined by ICD-10 coding, identified compliance screening with the 4 A's Test. This informed the design of a retrospective, observational cohort study to compare factors associated with delirium and statistical comparison between four specialities to identify delirium-associated factor, where an analysis corrects for age. RESULTS 37% of patients with an ICD-10 code indicating delirium had a 4AT test completed. Speciality, number of operations, LOS, ICU hours, age, and discharge destination were all statistically significant independent variables. When all other variables were equal, burns had the highest predicted probability of delirium diagnosis. CONCLUSIONS Further analysis to identify and diagnose across the specialties is required. From a patient viewpoint, their LOS, ICU hours, and operations are increased for patients coded as delirious compared to non-delirious across the specialities. On a hospital level, the mean difference in cost for a delirious compared to a non-delirious patient is AU$9317. Despite the low incidence of delirium amongst the observed specialities, burns patients were most likely to develop delirium when demographic and clinical profiles were the same, and were more likely to develop delirium at a younger age and if in ICU.
Collapse
Affiliation(s)
- Aoife O'Brien
- Burns Service of Western Australia, Fiona Stanley Hospital, Western Australia, Australia.
| | - Jane Hopkins
- Service 4, Fiona Stanley Fremantle Hospitals Group, Western Australia, Australia
| | - Glenn Boardman
- Research Support and Development Unit, Fiona Stanley Hospital, Western Australia, Australia
| | - Guy Stanley
- Burns Service of Western Australia, Fiona Stanley Hospital, Western Australia, Australia; Burn Injury Research Unit, University of Western Australia, Crawley, Western Australia, Australia
| | - Patrick Daly
- Burns Service of Western Australia, Fiona Stanley Hospital, Western Australia, Australia
| | - Lisa Martin
- Burn Injury Research Unit, University of Western Australia, Crawley, Western Australia, Australia
| | - Fiona Wood
- Burns Service of Western Australia, Fiona Stanley Hospital, Western Australia, Australia; Burn Injury Research Unit, University of Western Australia, Crawley, Western Australia, Australia
| |
Collapse
|
4
|
Likhvantsev VV, Landoni G, Berikashvili LB, Ermokhina NV, Yadgarov MY, Kotani Y, Kadantseva KK, Makarevich DM, Grechko AV. Effects of early postoperative neurocognitive disorders on clinically relevant outcomes: a meta-analysis. Korean J Anesthesiol 2023; 76:490-500. [PMID: 37232073 PMCID: PMC10562076 DOI: 10.4097/kja.23126] [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: 02/19/2023] [Revised: 05/18/2023] [Accepted: 05/25/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Early postoperative neurocognitive disorders (ePND), include both emergence delirium, which is defined as very early onset postoperative delirium, and emergence agitation, defined as motor arousal. Although research on anesthesia emergence is limited, ePND are likely associated with unfavorable outcomes. This meta-analysis assessed the effect of ePND on clinically relevant outcomes. METHODS A systematic search of studies published between 2002 and 2022 on MEDLINE, PubMed, Google Scholar, and the Cochrane Library was performed. Studies that included adults with emergence agitation and/or delirium and reported at least one of the following outcomes: mortality, postoperative delirium, length of post-anesthesia care unit stay, or length of hospital stay were included. The internal validity, risk of bias, and certainty of the evidence were assessed. RESULTS A total of 16,028 patients from 21 prospective observational studies and one case-control retrospective study were included in this meta-analysis. The occurrence rate of ePND was 13% (data excluding the case-control study). The mortality rate was 2.4% in patients with ePND vs. 1.2% in the normal emergence group (risk ratio [RR]: 2.6, P = 0.01, very low quality of evidence). Postoperative delirium occurred in 29% of patients with ePND and 4.5% of patients with normal emergence (RR: 9.5, P < 0.001, I2 = 93%). Patients with ePND had a prolonged length of post-anesthesia care unit stay (P = 0.004) and length of hospital stay (P < 0.001). CONCLUSIONS This meta-analysis suggests that ePND are associated with twice the risk of mortality and a 9-fold increased risk of postoperative delirium.
Collapse
Affiliation(s)
- Valery V Likhvantsev
- Department of Clinical Trials, V. Negovsky Reanimatology Research Institute, Moscow, Russia
- Department of Anesthesiology and Resuscitation, First Moscow State Medical University, Moscow, Russia
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Levan B Berikashvili
- Department of Clinical Trials, V. Negovsky Reanimatology Research Institute, Moscow, Russia
- Department of Anesthesiology and Resuscitation, Vladimirsky Moscow Regional Research and Clinical Institute, Moscow, Russia
| | - Nadezhda V Ermokhina
- Department of Clinical Trials, V. Negovsky Reanimatology Research Institute, Moscow, Russia
| | - Mikhail Ya Yadgarov
- Department of Clinical Trials, V. Negovsky Reanimatology Research Institute, Moscow, Russia
| | - Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Kristina K Kadantseva
- Department of Clinical Trials, V. Negovsky Reanimatology Research Institute, Moscow, Russia
- Department of Anesthesiology and Resuscitation, A. Loginov Moscow Clinical Scientific Center, Moscow, Russia
| | - Dmitry M Makarevich
- Department of Anesthesiology and Resuscitation, V. Demikhov Municipal Hospital №68, Moscow, Russia
| | - Andrey V Grechko
- Department of Intensive Care Medicine, Federal Research and Clinical Center of Reanimatology and Rehabilitology, Moscow, Russia
| |
Collapse
|
5
|
Aldwikat RK, Manias E, Holmes AC, Tomlinson E, Nicholson P. Associations of postoperative delirium with activities of daily living in older people after major surgery: A prospective cohort study. J Clin Nurs 2023; 32:7578-7588. [PMID: 37341067 DOI: 10.1111/jocn.16801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 05/01/2023] [Accepted: 05/30/2023] [Indexed: 06/22/2023]
Abstract
AIMS To assess the association of postoperative delirium developed in the post-anaesthetic care unit (PACU) with older patients' ability to perform activities of daily living (ADL) during the first five postoperative days. BACKGROUND Previous studies have focused on the association between postoperative delirium and long-term function decline, however the association between postoperative delirium and the ability to perform ADL, particularly in the immediate postoperative period, needs further investigation. DESIGN A prospective cohort study. METHODS A total of 271 older patients who underwent elective or emergency surgery at a tertiary care hospital in Victoria, Australia, participated in the study. Data were collected between July 2021 and December 2021. Delirium was assessed using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The Katz Index of Independence in Activities of Daily Living (KATZ ADL) scale was used to measure ADL. ADL was assessed preoperatively and daily during the first five postoperative days. The STROBE checklist was used to report this study. RESULTS Results showed that 44 (16.2%) patients developed new episode of delirium. Postoperative delirium was independently associated with decline in ADL (RR = 2.83, 95% CI = 2.71-2.97; p < 0.001). CONCLUSIONS Postoperative delirium was associated with a decline in ADL among older people during the first five postoperative days. Screening for delirium in the PACU is essential to identify delirium during the early stages of postoperative period and implement a timely comprehensive plan. RELEVANCE TO CLINICAL PRACTICE Delirium assessment of older patients in the PACU, and for at least the first five postoperative days, is strongly recommended. We also recommend engagement of patients in a focused physical and cognitive daily activity plan, particularly for older patients undergoing major surgery. PATIENT OR PUBLIC CONTRIBUTION Patients and nurses helped in data collection at a tertiary care hospital.
Collapse
Affiliation(s)
- Rami K Aldwikat
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research, Faculty of Health, Deakin University, Geelong, Victoria, Australia
- School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
- Operating Theatre, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Elizabeth Manias
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research, Faculty of Health, Deakin University, Geelong, Victoria, Australia
- School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
- Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Alex C Holmes
- Department of Psychiatry, The University of Melbourne, Parkville, Victoria, Australia
- Department of Mental Health, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Emily Tomlinson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research, Faculty of Health, Deakin University, Geelong, Victoria, Australia
- Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Patricia Nicholson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research, Faculty of Health, Deakin University, Geelong, Victoria, Australia
- Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| |
Collapse
|
6
|
Lin CJ, Su IC, Huang SW, Chen PY, Traynor V, Chang HCR, Liu IH, Lai YS, Lee HC, Rolls K, Chiu HY. Delirium assessment tools among hospitalized older adults: A systematic review and metaanalysis of diagnostic accuracy. Ageing Res Rev 2023; 90:102025. [PMID: 37527704 DOI: 10.1016/j.arr.2023.102025] [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: 02/17/2023] [Revised: 06/08/2023] [Accepted: 07/28/2023] [Indexed: 08/03/2023]
Abstract
Delirium is a common neuropsychiatric syndrome that is often overlooked in clinical settings. The most accurate instrument for screening delirium has not been established. This study aimed to compare the diagnostic accuracy of the 4 'A's Test (4AT), Nursing Delirium Screening Scale (Nu-DESC), and Confusion Assessment Method (CAM) in detecting delirium among older adults in clinical settings. These assessment tools feature concise item sets and straightforward administration procedures. Five electronic databases were systematically searched from their inception to September 7, 2022. Studies evaluating the sensitivity and specificity of the 4AT, Nu-DESC, and CAM against the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases as the reference standard were included. Bivariate random effects model was used to summarize the sensitivity and specificity results. A total of 38 studies involving 7378 patients were included. The 4AT, Nu-DESC, and CAM had comparable sensitivity in detecting delirium (0.76, 0.78, and 0.80, respectively). However, the specificity of the CAM was higher than that of the 4AT (0.98 vs 0.89, P = .01) and Nu-DESC 0.99 vs 0.90, P = .003). Diagnostic accuracy was moderated by the percentage of women, acute care setting, sample size, and assessors. The three tools exhibit comparable sensitivity, and the CAM has the highest specificity. Based on the feasibility of the tools, nurses and clinical staffs could employ the Nu-DESC and the 4AT on screening out positive delirium cases and integrate these tools into daily practice. Further investigations are warranted to verify our findings.
Collapse
Affiliation(s)
- Chia-Jou Lin
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - I-Chang Su
- Department of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Neurosurgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Sheng-Wen Huang
- Division of Neurosurgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Pin-Yuan Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan
| | - Victoria Traynor
- Illawarra Health and Medical Research Institute, Northfields Ave, Wollongong, NSW 2522, Australia; School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Hui-Chen Rita Chang
- School of Nursing and Midwifery, Western Sydney University, Parramatta South Campus, Australia
| | - I-Hsing Liu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Yun-Shuan Lai
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Hsin-Chien Lee
- Department of Psychiatry, Taipei Medical University Hospital, Taipei, Taiwan; Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kaye Rolls
- Illawarra Health and Medical Research Institute, Northfields Ave, Wollongong, NSW 2522, Australia; School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Hsiao-Yean Chiu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Taipei Medical University Hospital, Taipei, Taiwan.
| |
Collapse
|
7
|
McCullagh IJ, Salas B, Teodorczuk A, Callaghan M. Modifiable risk factors for post-operative delirium in older adults undergoing major non-cardiac elective surgery: a multi-centre, trainee delivered observational cohort feasibility study and trainee survey. BMC Geriatr 2023; 23:436. [PMID: 37454100 PMCID: PMC10349417 DOI: 10.1186/s12877-023-04122-7] [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: 12/09/2022] [Accepted: 06/20/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Post-operative delirium (POD) is an acute brain failure which may occur following major surgery, with serious implications for participants and caregivers. Evidence regarding optimal anaesthetic management for older participants at higher risk of POD is conflicting. We conducted a feasibility study of our protocol in 5 centres to guide sample size estimation and inform future recruitment strategies for a larger cohort study. METHODS Participants aged over 65 and scheduled for major surgery were recruited. They were assessed pre-operatively for delirium, cognitive impairment, depression, comorbidity, activity levels and alcohol use. Details of management during surgery, all medications and complications were recorded by a trainee-led research team. Participants were assessed for delirium in the immediate recovery period and then on post-operative days 1-4 using the 4 question attention test (4AT) with complications assessed at day 4 using the post-operative morbidity survey (POMS). Primary outcomes were the incident rates of POD. Secondary outcomes were number of eligible patients, recruitment rates and retention rates throughout the study, time required for data collection, preoperative risk factors assessment and daily postoperative delirium assessments. Also to assess the added value of employing the regional trainee research network (INCARNNET) to deliver the study. Specifically, what proportion of patient consent, data collection and post-operative testing is performed by anaesthesia trainees from this group, especially the success of weekend delirium assessment by trainees? A survey was completed at the end of the study by the trainees involved regarding their involvement in the study. RESULTS Ninety-five participants were recruited, of whom 93 completed the study. Overall, POD occurred in 9 patients. Of these, three were detected in recovery and six on post-op days 1-4. Median length of stay was 6 days. Recruitment rates were high in all but one site. 59 (62%) participants were consented by trainees and 189 (63%) of post op delirium assessments were performed by trainees. A total of six patients declined the study (in a follow up survey of trainees). Pre-existing cognitive impairment, depression and problem drinking were detected in 4(4.3%), 3(3.2%) and 5(5.37%) participants, respectively. Co-morbidity was common with 55(59%) in class three or four of the geriatric index of morbidity. Overall, from a total of 641 data points, levels of missing data were as follows, site A = 9.3%, B = 13.5%, C = 15.4%, D = 10.9%, E = 11.1% (data could not be completed retrospectively). CONCLUSIONS A multi-centre observational cohort study of delirium carried out by UK trainee anaesthetists is feasible. Patients are content to undergo day of surgery consent and multiple short questionnaires pre-operatively. Proposed data, especially pharmacological, should be carefully considered for their relevance to modifiable mechanisms that can lead to POD. Future research to enable prognostic modelling of POD should involve large scale cohort studies of enriched populations to capture a higher POD incidence. POD remains a common complication in older persons undergoing major surgery in the UK and studies of interventions are urgently needed. TRIAL REGISTRATION All methods were carried out in accordance with relevant guidelines and regulations. The study was retrospectively registered with ISRCTN94663125 on 07/02/2018.
Collapse
Affiliation(s)
- Iain J McCullagh
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
- Newcastle University, Newcastle upon Tyne, UK.
| | - Barbara Salas
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew Teodorczuk
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Metro North Mental Health, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Medicine and Dentistry, University of Queensland, Brisbane, Australia
| | - Mark Callaghan
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| |
Collapse
|
8
|
Lam MSH, Luoma AMV, Reddy U. Acute perioperative neurological emergencies. Int Anesthesiol Clin 2023; 61:53-63. [PMID: 37249171 DOI: 10.1097/aia.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Michelle S H Lam
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Astri M V Luoma
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
| | - Ugan Reddy
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
| |
Collapse
|
9
|
Weiss Y, Zac L, Refaeli E, Ben-Yishai S, Zegerman A, Cohen B, Matot I. Preoperative Cognitive Impairment and Postoperative Delirium in Elderly Surgical Patients: A Retrospective Large Cohort Study (The CIPOD Study). Ann Surg 2023; 278:59-64. [PMID: 35913053 DOI: 10.1097/sla.0000000000005657] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To test the hypothesis that in surgical patients ≥70 years, preoperative cognitive impairment is independently associated with postoperative delirium. BACKGROUND Postoperative delirium is common among elderly surgical patients and is associated with longer hospitalization and significant morbidity. Some evidence suggest that baseline cognitive impairment is an important risk factor. Routine screening for both preoperative cognitive impairment and postoperative delirium is recommended for older surgical patients. As of 2019, we implemented such routine perioperative screening in all elective surgical patients ≥70 years. METHODS Retrospective single-center analysis of prospectively collected data between January and December 2020. All elective noncardiac surgical patients ≥70 years without pre-existing dementia were included. Postoperative delirium, defined as 4A's test score ≥4, was evaluated in the postanesthesia care unit and during the initial 2 postoperative days. Patients' electronic records were also reviewed for delirium symptoms and other adverse outcomes. RESULTS Of 1518 eligible patients, 1338 (88%) were screened preoperatively [mean (SD) age 77 (6) years], of whom 21% (n=279) had cognitive impairment (Mini-Cog score ≤2). Postoperative delirium occurred in 15% (199/1338). Patients with cognitive impairment had more postoperative delirium [30% vs. 11%, adjusted odds ratio (95% confidence interval) 3.3 (2.3-4.7)]. They also had a higher incidence of a composite of postoperative complications [20% vs. 12%, adjusted odds ratio: 1.8 (1.2-2.5)], and median 1-day longer hospital stay [median (interquartile range): 6 (3,12) vs. 5 (3,9) days]. CONCLUSIONS One-fifth of elective surgical patients ≥70 years present to surgery with preoperative cognitive impairment. These patients are at increased risk of postoperative delirium and major adverse outcomes.
Collapse
Affiliation(s)
- Yotam Weiss
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Lilach Zac
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Einat Refaeli
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Shimon Ben-Yishai
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Alexander Zegerman
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Barak Cohen
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH
| | - Idit Matot
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| |
Collapse
|
10
|
Pouw MA, Calf AH, Georg RR, de Rooij SE, Ter Maaten JC, van Munster BC. Diagnostic accuracy of the Dutch version of the 4AT for delirium detection in a mixed patient population and setting. Aging Clin Exp Res 2023:10.1007/s40520-023-02447-2. [PMID: 37285074 PMCID: PMC10363057 DOI: 10.1007/s40520-023-02447-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/17/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Delirium is an acute disturbance in attention, awareness and cognition. Immediate detection in older adults is recommended because delirium is associated with adverse outcomes. The 4 'A's Test (4AT) is a short screening instrument for delirium. The aim of this study is to evaluate diagnostic accuracy of the Dutch version of the screening tool 4AT for delirium detection in different settings. METHODS Prospective observational study conducted in two hospitals in patients aged ≥ 65 years in geriatric wards and the Emergency Department (ED). Each participant underwent two assessments; the index test 4AT, followed by the reference standard for delirium performed by a geriatric care specialist. The reference standard delirium is according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. RESULTS A total of 71 geriatric inpatients and 49 older ED patients were included. The prevalence of delirium was 11.6% in the acute geriatric ward and 6.1% in the ED. The sensitivity and specificity of the 4AT in the acute geriatric ward were 0.88 and 0.69, respectively. In the ED, the sensitivity and specificity were 0.67 and 0.83, respectively. The area under the receiver operating characteristic curve was 0.80 for the acute geriatric ward setting and 0.74 for the ED setting. CONCLUSION The Dutch version of the 4AT is a reliable screening tool for delirium detection in both acute geriatric wards and ED. Due to its brevity and practicality (i.e., no special training is required to administer the tool), it is useful in clinical practice.
Collapse
Affiliation(s)
- Maaike A Pouw
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Agneta H Calf
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Rita R Georg
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Sophia E de Rooij
- Amstelland Hospital, Laan van de Helende Meesters 8, 1186 AM, Amstelveen, The Netherlands
| | - Jan C Ter Maaten
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Barbara C van Munster
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| |
Collapse
|
11
|
Rudy M, Saller T. [Postoperative delirium in the recovery room]. DIE ANAESTHESIOLOGIE 2023:10.1007/s00101-023-01281-5. [PMID: 37233791 DOI: 10.1007/s00101-023-01281-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 02/25/2023] [Indexed: 05/27/2023]
Abstract
Postoperative delirium during emergence from anesthesia is the most frequent neuropsychiatric complication in the post-anesthesia care unit. In addition to increased medical and especially nursing care efforts, affected patients are threatened with delayed rehabilitation with a longer hospital stay and an increased mortality. It is therefore essential to identify risk factors at an early stage and to implement preventive measures; however, should a postoperative delirium occur in the post-anesthesia care unit despite the use of these preventive measures, it should be detected and treated at an early stage using suitable screening procedures. In this context, working instructions for delirium prophylaxis and standardized test procedures for detection of delirium have been shown to be useful. An additional drug treatment can be indicated when all nonpharmacological options have been exhausted.
Collapse
Affiliation(s)
- Margret Rudy
- Klinik für Anaesthesiologie, LMU Klinikum, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland.
| | - Thomas Saller
- Klinik für Anaesthesiologie, LMU Klinikum, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland
| |
Collapse
|
12
|
Liu Y, Li Z, Li Y, Ge N, Yue J. Detecting delirium: a systematic review of ultrabrief identification instruments for hospital patients. Front Psychol 2023; 14:1166392. [PMID: 37251016 PMCID: PMC10214704 DOI: 10.3389/fpsyg.2023.1166392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/21/2023] [Indexed: 05/31/2023] Open
Abstract
Objective Early identification of delirium, which often occurs in older patients, can effectively reduce adverse prognoses. One way to increase the detection rate of delirium is to use an effective ultrabrief instrument for higher-frequency screening. The purpose of this review is to evaluate the diagnostic accuracy of ultrabrief screening tools for delirium. Methods The Cochrane Library, PubMed and EMBASE were searched from January 1, 1974, to November 31, 2022. We assessed the measurement properties of screening instruments using the consensus-based standards for selecting health measurement instruments (COSMIN) checklist and evaluated the risk bias of the included studies using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. The diagnostic test accuracy of instruments for delirium was reported using sensitivity, specificity, positive likelihood ratio (PLR) and negative likelihood ratio (NLR). Result Of the 4,914 items identified, 26 met the eligibility criteria, resulting in 5 different delirium identification tools. The overall study quality assessed by the QUADAS-2 tool was moderate to good. Of the five screening tools, two instruments had sensitivity ≥80% and specificities ≥80%: 4AT and UB-2. The most comprehensive is the 4AT scale, which has a sensitivity of 0.80 [95% confidence interval (CI):0.68, 0.88] and a specificity of 0.89 (95%CI: 0.83, 0.93) and contains 4 items. UB-2 has a sensitivity of 0.88 (95%CI: 0.72, 0.96) and a specificity of 0.64 (95%CI: 0.56, 0.70). Conclusion UB-2 and MOTYB had excellent sensitivity for delirium screening at an early stage. In terms of sensitivity and intentionality, the 4AT is the best recommended scale.
Collapse
Affiliation(s)
- Yadong Liu
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
| | - Zhenzhen Li
- Health Management Center, General Practice Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Sichuan, China
| | - Ying Li
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
| | - Ning Ge
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
| | - Jirong Yue
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Sichuan, China
| |
Collapse
|
13
|
Chang Y, Ragheb SM, Oravec N, Kent D, Nugent K, Cornick A, Hiebert B, Rudolph JL, MacLullich AMJ, Arora RC. Diagnostic accuracy of the "4 A's Test" delirium screening tool for the postoperative cardiac surgery ward. J Thorac Cardiovasc Surg 2023; 165:1151-1160.e8. [PMID: 34243932 DOI: 10.1016/j.jtcvs.2021.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 05/12/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Delirium is prevalent and underdetected among cardiac surgery patients on the postoperative ward. This study aimed to validate the 4 A's Test delirium screening tool and evaluate its accuracy both when used by research assistants and when subsequently implemented by nursing staff on the ward. METHODS This single-center, prospective observational study evaluated the performance of the 4 A's Test administered by research assistants (phase 1) and nursing staff (phase 2). Assessments were undertaken during the patients' first 3 postoperative days on the postcardiac surgery ward along with previous routine nurse-led Confusion Assessment Method assessments. These index tests were compared with a reference standard diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Surveys regarding delirium screening were administered to nurses pre- and postimplementation of the 4 A's Test in phase 2 of the study. RESULTS In phase 1, a total of 137 patients were enrolled, of whom 24.8% experienced delirium on the postoperative cardiac ward. The 4 A's Test had a sensitivity of 85% (95% confidence interval, 73-93) and a specificity of 90% (95% confidence interval, 85-93) compared with the reference standard. The nurse-assessed Confusion Assessment Method had a sensitivity of 23% (95% confidence interval, 13-37) and specificity of 100% (95% confidence interval, 99-100). In phase 2, nurses (n = 51) screened 179 patients for delirium using the 4 A's Test. Compared with the reference rater, the 4 A's Test had a sensitivity of 58% (95% confidence interval, 28-85) and specificity of 94% (95% confidence interval, 85-98). Postimplementation, 64% of nurses thought that the 4 A's Test improved their confidence in delirium detection, and 76% of nurses would consider routine 4 A's Test use. CONCLUSIONS The 4 A's Test demonstrated moderate sensitivity and high specificity to detect delirium in a real-world setting after cardiac surgery on the postoperative ward. A modified model of use with less frequent administration, along with increased engagement of the postoperative team, is recommended to improve early delirium detection on the cardiac surgery postoperative ward.
Collapse
Affiliation(s)
- Yue Chang
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sandra M Ragheb
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nebojsa Oravec
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Kent
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Kristina Nugent
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Alexandra Cornick
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Brett Hiebert
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - James L Rudolph
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, and Brown University, Providence, RI
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada.
| |
Collapse
|
14
|
Diagnostic accuracy of the 4AT for delirium: A systematic review and meta-analysis. Asian J Psychiatr 2023; 80:103374. [PMID: 36584541 DOI: 10.1016/j.ajp.2022.103374] [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: 01/15/2022] [Revised: 09/13/2022] [Accepted: 10/29/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Despite common, serious, costly, and often fatal conditions affecting up to 50 % of older patients, delirium is often unrecognized and overlooked. We examine the accuracy of the 4AT for detecting older patients with delirium. METHODS We performed a systematic search of PubMed, Web of Science, PsycINFO, and EMBASE databases from inception to April 2020 and updated to January 2022. Four independently reviewers extracted study data and assessed the methodological quality using the revised quality assessment of diagnostic accuracy studies tool (QUADAS-2). Pooled estimates of sensitivity and specificity were generated using a bivariate random effects model. All statistical analyses were performed with STATA version 15.1 and Meta-DiSc version 1.4 software. RESULTS Eleven studies with 2789 participants were included. The pooled sensitivity and specificity were 0.87 (95 % CI: 0.81-0.91) and 0.87 (95 % CI: 0.79-0.92), respectively, and the positive and negative likelihood ratios were 6.66 (95 % CI: 4.12-10.74) and 0.15 (95 % CI: 0.10-0.23), respectively. Deeks' test indicated no significant publication bias (t = 0.83, P = 0.43). Univariable meta-regression showed that patient selection and flow and timing significantly influenced the pooled sensitivity (P < 0.05), settings significantly influenced the pooled specificity (P < 0.05). CONCLUSION Our meta-analysis demonstrates that 4AT is a sensitive and specific screening tool for delirium in older patients. Its brevity and simplicity support its use in routine clinical practice, particularly in time-poor settings. Clinicians should come to a conclusion based largely on the 4AT findings in conjunction with clinical judgment.
Collapse
|
15
|
Saller T, Hubig L, Seibold H, Schroeder Z, Wang B, Groene P, Perneczky R, von Dossow V, Hinske LC. Association between post-operative delirium and use of volatile anesthetics in the elderly: A real-world big data approach. J Clin Anesth 2022; 83:110957. [PMID: 36084424 DOI: 10.1016/j.jclinane.2022.110957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE Early post-operative delirium is a common perioperative complication in the post anesthesia care unit. To date it is unknown if a specific anesthetic regime can affect the incidence of delirium after surgery. Our objective was to examine the effect of volatile anesthetics on post-operative delirium. DESIGN Single Center Observational Study. SETTING Post Anesthesia Care Units at a German tertiary medical center. PATIENTS 30,075 patients receiving general anesthesia for surgery. MEASUREMENTS Delirium was assessed with the Nursing Delirium Screening Scale at the end of the recovery period. Subgroup-specific effects of volatile anesthetics on post-operative delirium were estimated using generalized-linear-model trees with inverse probability of treatment weighting. We further assessed the age-specific effect of volatiles using logistic regression models. MAIN RESULTS Out of 30,075 records, 956 patients (3.2%) developed delirium in the post anesthesia care unit. On average, patients who developed delirium were older than patients without delirium. We found volatile anesthetics to increase the risk (Odds exp. (B) for delirium in the elderly 1.8-fold compared to total intravenous anesthesia. Odds increases with unplanned surgery 3.0-fold. In the very old (87 years or older), the increase in delirium is 6.2-fold. This result was confirmed with internal validation and in a logistic regression model. CONCLUSIONS Our exploratory study indicates that early postoperative delirium is associated with the use of volatile anesthetics especially in the sub-cohort of patients aged 75 years and above. Further studies should include both volatile and intravenous anesthetics to find the ideal anesthetic in elderly patients.
Collapse
Affiliation(s)
- Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; Scientific Commission on Gerontoanaesthesiology, German Association for Anaesthesiology and Intensive Care Medicine, Roritzer Str. 19, 90419 Nuremberg, Germany.
| | - Lena Hubig
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Heidi Seibold
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Zoé Schroeder
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Baocheng Wang
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Philipp Groene
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Robert Perneczky
- Department of Psychiatry, University Hospital, LMU Munich, Nussbaumstr. 7, 80336 Munich, Germany; German Center for Neurodegenerative Disorders (DZNE), Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Feodor-Lynen-Strasse 17, 81377 Munich, Germany; Ageing Epidemiology Research Unit, School of Public Health, Imperial College London, Level 2 Faculty Building South Kensington Campus, London SW7 2AZ, UK; Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, 385A Glossop Road, Sheffield S10 2HQ, UK
| | - Vera von Dossow
- Scientific Commission on Gerontoanaesthesiology, German Association for Anaesthesiology and Intensive Care Medicine, Roritzer Str. 19, 90419 Nuremberg, Germany; Institute for Anesthesiology, Heart and Diabetes Center NRW, Ruhr University of Bochum, Georgstr. 11, 32545 Bad Oeynhausen, Germany
| | - Ludwig C Hinske
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; Professorship for Data Management und Clinical Decision Support, Faculty of Medicine, Augsburg University, University Hospital, Stenglinstr. 2, 86156 Augsburg, Germany
| |
Collapse
|
16
|
Aldwikat RK, Manias E, Holmes A, Tomlinson E, Nicholson P. Validation of Two Screening Tools for Detecting Delirium in Older Patients in the Post-Anaesthetic Care Unit: A Diagnostic Test Accuracy Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16020. [PMID: 36498093 PMCID: PMC9738308 DOI: 10.3390/ijerph192316020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 06/17/2023]
Abstract
(1) Background: Delirium is a common complication among surgical patients after major surgery, but it is often underdiagnosed in the post-anaesthetic care unit (PACU). Valid and reliable tools are required for improving diagnoses of delirium. The objective of this study was to evaluate the diagnostic test accuracy of the Three-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM) and the 4A's Test (4AT) as screening tools for detection of delirium in older people in the PACU. (2) Methods: A prospective diagnostic test accuracy study was conducted in the PACU and surgical wards of a university-affiliated tertiary care hospital in Victoria, Australia. A consecutive prospective cohort of elective and emergency patients (aged 65 years or older) admitted to the PACU were recruited between July 2021 and December 2021 following a surgical procedure performed under general anaesthesia and expected to stay in the hospital for at least 24 h following surgery. The outcome measures were sensitivity, specificity positive predictive value and negative predictive value for 3D-CAM and 4AT. (3) Results: A total of 271 patients were recruited: 16.2% (44/271) had definite delirium. For a diagnosis of definite delirium, the 3D-CAM (area under curve (AUC) = 0.96) had a sensitivity of 100% (95% CI 92.0 to 100.0) in the PACU and during the first 5 days post-operatively. Specificity ranged from 93% (95% CI 87.8 to 95.2) to 91% (95% CI 85.9 to 95.2) in the PACU and during the first 5 days post-operatively. The 4AT (AUC = 0.92) had a sensitivity of 93% (95% CI 81.7 to 98.6) in the PACU and during the first 5 days post-operatively, and specificity ranged from 89% (95% CI 84.6 to 93.1) to 87% (95%CI 80.9 to 91.8) in the PACU and during the first 5 days post-operatively. (4) Conclusions: The 3D-CAM and the 4AT are sensitive and specific screening tools that can be used to detect delirium in older people in the PACU. Screening with either tool could have an important clinical impact by improving the accuracy of delirium detection in the PACU and hence preventing adverse outcomes associated with delirium.
Collapse
Affiliation(s)
- Rami K. Aldwikat
- School of Nursing and Midwifery, Deakin University, Geelong, VIC 3220, Australia
- Centre for Quality and Patient Safety Research, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia
- Operating Theatre, The Royal Melbourne Hospital, Parkville, VIC 3050, Australia
| | - Elizabeth Manias
- School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC 3800, Australia
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Alex. Holmes
- Department of Psychiatry, The University of Melbourne, Parkville, VIC 3010, Australia
- Department of Mental Health, The Royal Melbourne Hospital, Parkville, VIC 3050, Australia
| | - Emily Tomlinson
- School of Nursing and Midwifery, Deakin University, Geelong, VIC 3220, Australia
- Centre for Quality and Patient Safety Research, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia
- Institute for Health Transformation, Deakin University, Geelong, VIC 3220, Australia
| | - Patricia Nicholson
- School of Nursing and Midwifery, Deakin University, Geelong, VIC 3220, Australia
- Centre for Quality and Patient Safety Research, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia
- Institute for Health Transformation, Deakin University, Geelong, VIC 3220, Australia
| |
Collapse
|
17
|
Prevalence of Emergence Delirium and Associated Factors among Older Patients Who Underwent Elective Surgery: A Multicenter Observational Study. Anesthesiol Res Pract 2022; 2022:2711310. [PMID: 36119120 PMCID: PMC9481404 DOI: 10.1155/2022/2711310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 08/27/2022] [Indexed: 11/30/2022] Open
Abstract
Background Emergence delirium is a common and serious postoperative complication in older surgical patients. It occurs at any time in the perioperative period, during or immediately following emergence from general anesthesia. Unfortunately, it is highly associated with postoperative complications such as a decrease in functional capacity, prolonged hospital stay, an increase in health care costs, and morbidity and mortality. The goal of this study was to determine the prevalence of emergence delirium and associated factors among older patients who underwent elective surgery in the teaching hospitals of Ethiopia at the postanesthesia care unit in 2021. Methods A multicenter prospective observational study was conducted at the postanesthetic care unit in the four teaching hospitals of Ethiopia. Older surgical patients admitted to the postanesthesia care unit who underwent elective surgery in the four teaching hospitals of Ethiopia were selected by using simple random sampling. Pretested structured questionnaire was used to collect data. Data were entered into EpiData (version 4.6) and exported to the SPSS (version 25.0). Binary logistic regression was used to identify factors independently associated with the emergence delirium. Results Out of 384 older patients included in the study, the prevalence of emergence delirium was 27.6%. Preoperative low hemoglobin levels (AOR: 2.0, 95% CI; 1.77–3.46), opioid (AOR: 8.0, 95% CI; 3.22–27.8), anticholinergic premedications (AOR: 8.5, 95% CI; 6.85–17.35), and postoperative pain (AOR: 3.10, 95 CI; 2.07–9.84) at PACU were independently associated with emergence delirium. Conclusion The prevalence of emergence delirium was high among older patients who underwent elective surgery. Opioid and anticholinergic premedication, low preoperative hemoglobin, and the presence of postoperative pain were independently associated with the emergence delirium. Adequate preoperative optimization and postoperative analgesia may reduce the prevalence of emergence delirium.
Collapse
|
18
|
Sieber F, Gearhart S, Bettick D, Wang NY. Edmonton frailty scale score predicts postoperative delirium: a retrospective cohort analysis. BMC Geriatr 2022; 22:585. [PMID: 35840875 PMCID: PMC9288043 DOI: 10.1186/s12877-022-03252-8] [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: 01/14/2022] [Accepted: 06/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Frailty has been associated with postoperative delirium (POD). Studies suggest that the Fried phenotype has a stronger association with POD than the Edmonton Frailty Scale (EFS) criteria. Although phenotypic frailty is recognized as a good predictor of delirium, the EFS has higher ratings for feasibility in the surgical setting. Thus, our aim was to determine the association between EFS-assessed vulnerability and POD in an elective surgical population of older adults. A secondary aim was to determine which domains assessed by the EFS were closely associated with POD. METHODS After IRB approval was received, electronic medical records of surgical patients at our institution were downloaded from 12/1/2018 to 3/1/2020. Inclusion criteria included age ≥ 65 years, preoperative EFS assessment within 6 months of surgery, elective surgery not scheduled for intensive care unit (ICU) stay but followed by at least 1 day postoperative stay, and at least two in-hospital evaluations with the 4 A's test (arousal, attention, abbreviated mental test-4, acute change [4AT]) on the surgical ward. Vulnerability was determined by EFS score ≥ 6. Patients were stratified into two groups according to highest postoperative 4AT score: 0-3 (no POD) and ≥ 4 (POD). Odds of POD associated with EFS score ≥ 6 were evaluated by using logistic regression adjusted for potential confounders. RESULTS The dataset included 324 patients. Vulnerability was associated with higher incidence of POD (p = 0.0007, Fisher's exact). EFS ≥6 was consistently associated with POD in all bivariate models. Vulnerability predicted POD in multivariable modeling (OR = 3.5, 95% CI 1.1 to 11.5). Multivariable analysis of EFS domains revealed an overall trend in which higher scores per domain had a higher odds for POD. The strongest association occurred with presence of incontinence (OR = 3.8, 95% CI 1.2 to 11.0). CONCLUSIONS EFS criteria for vulnerability predict POD in older, non-ICU patients undergoing elective surgery.
Collapse
Affiliation(s)
- Frederick Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Susan Gearhart
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Dianne Bettick
- Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Nae-Yuh Wang
- Departments of Medicine (General Internal Medicine), Biostatistics, and Epidemiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| |
Collapse
|
19
|
Gnatta JR, Cavassana TM, Nascimento ASD, Poveda VDB. Instruments to Identify Delirium in Patients Recovering From Anesthesia: A Scoping Review. J Perianesth Nurs 2022; 37:961-965.e7. [PMID: 35760717 DOI: 10.1016/j.jopan.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/06/2021] [Accepted: 12/26/2021] [Indexed: 11/15/2022]
Abstract
PURPOSE To identify the validated instruments used for screening and detecting postoperative delirium (POD) during Post Anesthesia Recovery (PAR) period, and the incidence and associated risk factors with POD. DESIGN A scoping review. METHODS The study search occurred in May 2021 in the PubMed, Embase, Scopus, CINAHL, Web of Science and LILACS databases. Primary studies that used validated instruments for screening and detecting POD in the PAR period were included. FINDINGS A total of 38 articles were included. The most used instruments were CAM-ICU, Nu-DESC, and RASS. The instruments that screened and detected delirium earliest were the Nu-DESC and CAM-ICU. POD incidence was up to 20% in more than half of the included studies. Cardiovascular comorbidities, chronic kidney disease, low functional reserve, chronic obstructive pulmonary disease and postoperative pain were among the primary risk factors. CONCLUSION The instrumentsshowing the greatest accuracy for screening and detecting POD in the PAR period were the Nu-DESC and CAM-ICU.
Collapse
Affiliation(s)
- Juliana Rizzo Gnatta
- Medical Surgical Department, School of Nursing, University of Sao Paulo, Brazil; The Brazilian Centre of Evidence-based Healthcare: A JBI Centre of Excellence (JBI Brazil)
| | | | | | - Vanessa de Brito Poveda
- Medical Surgical Department, School of Nursing, University of Sao Paulo, Brazil; The Brazilian Centre of Evidence-based Healthcare: A JBI Centre of Excellence (JBI Brazil)
| |
Collapse
|
20
|
Delirium screening tools in the post-anaesthetic care unit: a systematic review and meta-analysis. Aging Clin Exp Res 2022; 34:1225-1235. [PMID: 34981431 DOI: 10.1007/s40520-021-02057-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 12/16/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Delirium is a serious neurocognitive disorder among surgical patients in the post-anaesthetic care unit (PACU). Despite the development of screening tools to identify delirium, it is not clear which tool is the most accurate and reliable in assessing delirium in the PACU. AIM To examine the diagnostic accuracy of delirium screening tools used in the PACU. METHODS A systematic literature search of CINAHL, MEDLINE, Embase, PsycINFO and Scopus was conducted, using MeSH terms and relevant keywords, from databases establishment to 23 April 2021. Studies were assessed for methodological quality using the Standards for Reporting of Diagnostic Accuracy Studies (STARD) tool. RESULTS A total of 1503 studies were screened from the database search, four studies met the inclusion criteria for this review. Six delirium screening tools used in the PACU were identified in the selected studies. Three studies evaluated screening tools in adult surgical patients without cognitive impairment and dementia. Two studies evaluated screening tools among patients who were scheduled for elective surgery. Review results indicated that two tools, the 4A's test (4AT; sensitivity 96%; specificity 99%) and the 3 min diagnostic interview for the Confusion Assessment Method (3D-CAM; sensitivity 100%; specificity 88%), had greatest validity and reliability as a screening tool for detecting delirium in the PACU. CONCLUSION Results indicate the 4AT and the 3D-CAM are most accurate screening tools to detect delirium in the PACU. Further research is required to validate those tools among a broader surgical population, including patients with cognitive impairment, dementia and those undergoing emergency surgical procedures.
Collapse
|
21
|
Effect of Programmed Comprehensive Nursing for Postoperative Delirium in Intensive Care Unit Patients. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:1227659. [PMID: 35600946 PMCID: PMC9117019 DOI: 10.1155/2022/1227659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/10/2022] [Accepted: 04/18/2022] [Indexed: 11/17/2022]
Abstract
Background This study is to evaluate the effect of programmed comprehensive nursing for postoperative delirium in intensive care unit (ICU) patients. Methods A total of 90 cases of ICU surgery patients admitted to our hospital from July 2019 to July 2020 were recruited and assigned via the random number table method (1 : 1) to receive either conventional nursing (control group) or programmed comprehensive nursing (experimental group). The delirium assessment method was used to record the incidence of delirium events at different time points after the intervention. Outcome measures included delirium events, the Visual Analogue Scale (VAS) scores, the Pittsburgh sleep quality index (PSQI) scores, the activities of daily living (ADL) scale scores, nursing satisfaction, and total nursing efficiency. Results Programmed comprehensive nursing was associated with significantly better nursing satisfaction, ADL scores, VAS scores, PSQI scores, and nursing efficiency than conventional nursing (all P < 0.05). Programmed comprehensive nursing resulted in a significantly lower incidence of postoperative delirium than conventional nursing (P < 0.05). Conclusion The application of programmed comprehensive nursing for postoperative delirium in ICU patients shows a promising efficiency, effectively alleviates the clinical symptoms of patients, and optimizes various clinical indicators of patients; hence, it is worthy of further application and promotion.
Collapse
|
22
|
Mossie A, Regasa T, Neme D, Awoke Z, Zemedkun A, Hailu S. Evidence-Based Guideline on Management of Postoperative Delirium in Older People for Low Resource Setting: Systematic Review Article. Int J Gen Med 2022; 15:4053-4065. [PMID: 35444455 PMCID: PMC9014957 DOI: 10.2147/ijgm.s349232] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/05/2022] [Indexed: 12/28/2022] Open
Affiliation(s)
- Addisu Mossie
- Anesthesia Department, Hawassa University, Hawassa, Ethiopia
| | - Teshome Regasa
- Anesthesia Department, Dilla University, Dilla, Ethiopia
- Correspondence: Teshome Regasa, Email
| | - Derartu Neme
- Anesthesia Department, Dilla University, Dilla, Ethiopia
| | - Zemedu Awoke
- Anesthesia Department, Dilla University, Dilla, Ethiopia
| | | | - Seyoum Hailu
- Anesthesia Department, Dilla University, Dilla, Ethiopia
| |
Collapse
|
23
|
Buckley RA, Atkins KJ, Silbert B, Scott DA, Evered L. Digital clock drawing test metrics in older patients before and after endoscopy with sedation: An exploratory analysis. Acta Anaesthesiol Scand 2022; 66:207-214. [PMID: 34811719 DOI: 10.1111/aas.14003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/25/2021] [Accepted: 11/02/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND In the postoperative period, clinically feasible instruments to monitor elderly patients' neurocognitive recovery and discharge-readiness, especially after short-stay procedures, are limited. Cognitive monitoring may be improved by a novel digital clock drawing test (dCDT). We screened for cognitive impairment with the 4 A Test (4AT) and then administered the dCDT pre and post short-stay procedure (endoscopy). The primary aim was to investigate whether the dCDT was sensitive to a change in cognitive status postendoscopy. We also investigated if preoperative cognitive status impacted postendoscopy dCDT variables. METHODS We recruited 100 patients ≥65 years presenting for endoscopy day procedures at a single metropolitan hospital. Participants were assessed after admission and immediately before discharge from the hospital. We administered the 4AT, followed by both command and copy clock conditions of the dCDT. We analysed the total drawing time (dCDT time), as well as scored the drawn clock against the established Montreal Cognitive Assessment (MoCA) criteria both before and after endoscopy. RESULTS Linear regression showed higher 4AT test scores (poorer performance) were associated with longer postoperative dCDT time (β = 5.6, p = 0.012) for the command condition after adjusting for preoperative baseline dCDT metrics, sex, age, and years of education. CONCLUSION Postoperative dCDT time-based variables slowed in those with baseline cognitive impairment detected by the 4AT, but not for those without cognitive impairment. Our results suggest the dCDT, using the command mode, may help detect cognitive impairment in patients aged >65 years after elective endoscopy.
Collapse
Affiliation(s)
- Richard A. Buckley
- University of Melbourne Melbourne Victoria Australia
- Department of Anaesthesia and Acute Pain Medicine St Vincent's Hospital Melbourne Fitzroy Victoria Australia
| | - Kelly J. Atkins
- University of Melbourne Melbourne Victoria Australia
- Department of Anaesthesia and Acute Pain Medicine St Vincent's Hospital Melbourne Fitzroy Victoria Australia
| | - Brendan Silbert
- University of Melbourne Melbourne Victoria Australia
- Department of Anaesthesia and Acute Pain Medicine St Vincent's Hospital Melbourne Fitzroy Victoria Australia
| | - David A. Scott
- University of Melbourne Melbourne Victoria Australia
- Department of Anaesthesia and Acute Pain Medicine St Vincent's Hospital Melbourne Fitzroy Victoria Australia
| | - Lisbeth Evered
- University of Melbourne Melbourne Victoria Australia
- Department of Anaesthesia and Acute Pain Medicine St Vincent's Hospital Melbourne Fitzroy Victoria Australia
- Department of Anesthesiology Weill Cornell Medicine New York New York USA
| |
Collapse
|
24
|
Kim S, Choi E, Jung Y, Jang I. Postoperative delirium screening tools for post-anaesthetic adult patients in non-intensive care units: A systematic review and meta-analysis. J Clin Nurs 2021; 32:1691-1704. [PMID: 34881476 DOI: 10.1111/jocn.16157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/31/2021] [Accepted: 11/19/2021] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To identify the most accurate postoperative delirium screening tools for detecting postoperative delirium among patients who underwent general anaesthesia surgery in general wards. BACKGROUND The lack of detection of postoperative delirium can negatively affect the patient's condition, along with their postoperative treatment and rehabilitation, and it can prolong their hospitalisation, persists cognitive dysfunction and increases mortality. Screening for postoperative delirium in hospitalised patients as nursing assessment is routine clinical practice for early detection. DESIGN A systematic review and meta-analysis. METHODS MEDLINE, Embase, CINAHL, KoreaMed and Cochrane electronic databases were searched using the key words delirium, postoperative, assessment or screening, and adult for articles published up to April 2020, with no limit on the year of publishing. Only prospective cohort studies reporting sensitivity and specificity values were included. We followed the recommendations of the Cochrane Handbook of Diagnostic Test Accuracy Reviews and the PRISMA checklist. The Quality Assessment of the Diagnostic Accuracy Studies-2 tool was used for data extraction and quality assessment, while a bivariate random-effects meta-analysis model was used for pooling and comparing diagnostic accuracy and providing a summary of evidence. RESULTS Six delirium assessment tools were evaluated from nine papers including 3088 patients. Due to the limited number of papers, the meta-analysis included the Confusion Assessment Method (CAM) and its variants, Delirium Detection Score (DDS) and Nurses' Delirium Screening Checklist (NuDESC). Overall, NuDESC demonstrated higher sensitivity than CAM or DDS, while all showed high specificity (0.90 or greater). CONCLUSION This review suggested that NuDESC can be employed as an accurate screening tool with high specificity for assessing postoperative delirium during routine checkups. However, it is necessary to consider suitable cut-off values, which is the reference point, in accordance with the clinical setting and the patients' condition. RELEVANCE TO CLINICAL PRACTICE NuDESC reported the best evidence of diagnostic accuracy, and we recommend clinical nurses to employ this easy-to-use and validated tool for daily screening of postoperative delirium in general wards to facilitate its early detection and the accurate estimation of its prevalence.
Collapse
Affiliation(s)
- Sujeong Kim
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Eunju Choi
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Youngsun Jung
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Insil Jang
- Department of Nursing, Chung-Ang University, Seoul, Korea
| |
Collapse
|
25
|
Ho MH, Choi EPH, Chiu HY, Shen Hsiao ST, Traynor V. Using the nursing delirium screening scale in assessing postoperative delirium: A meta-regression. Res Nurs Health 2021; 45:23-33. [PMID: 34730848 DOI: 10.1002/nur.22194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 09/16/2021] [Accepted: 10/21/2021] [Indexed: 11/09/2022]
Abstract
The nursing delirium screening scale (Nu-DESC) was developed for the rapid assessment of delirium, but little is known regarding the performance of the Nu-DESC in assessing postoperative delirium. The purpose of this systematic review and meta-analysis was to review and summarize the evidence of the diagnostic accuracy of the Nu-DESC in assessing postoperative delirium. The EMBASE, MEDLINE, Cochrane Library, CINAHL, and a Chinese e-Journal database were searched from the period of the inception of the Nu-DESC to June 18, 2020. Participants were adult (age ≥ 18 years) postoperative patients who received any type of surgery and any method of anesthesia. The quality assessment of diagnostic accuracy studies-2 was employed to assess the risk of bias among the selected studies, and meta-regression analyses were used to detect sources of between-study heterogeneity. Eleven studies involving 2062 postoperative patients in surgical settings were included. The Nu-DESC revealed a pooled sensitivity of 0.73 (95% confidence interval, 0.44-0.90) and a specificity of 0.93 (0.87-0.96). The area under the summary receiver operating characteristics curve was 0.94 (0.91-0.96), which also confirmed the accuracy of the Nu-DESC. Covariates, including the region of study and the standard reference used, were identified as possible sources of heterogeneity in the meta-regression. The findings of this review can update existing clinical guidelines for postoperative delirium. On the basis of its satisfactory diagnostic performance, we suggest that the Nu-DESC could be considered for nurses and allied health professionals for assessing postoperative delirium. However, because of the heterogeneity, the result of this meta-analysis should be considered with caution.
Collapse
Affiliation(s)
- Mu-Hsing Ho
- Department of Nursing, Taipei Medical University Hospital, Taipei, Taiwan.,School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Edmond Pui Hang Choi
- School of Nursing, LKS Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Hsiao-Yean Chiu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan.,Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shu-Tai Shen Hsiao
- Department of Nursing, Taipei Medical University Hospital, Taipei, Taiwan.,School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Victoria Traynor
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| |
Collapse
|
26
|
Johansson YA, Tsevis T, Nasic S, Gillsjö C, Johansson L, Bogdanovic N, Kenne Sarenmalm E. Diagnostic accuracy and clinical applicability of the Swedish version of the 4AT assessment test for delirium detection, in a mixed patient population and setting. BMC Geriatr 2021; 21:568. [PMID: 34663229 PMCID: PMC8522056 DOI: 10.1186/s12877-021-02493-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delirium is common in older hospitalized patients. It has serious consequences e.g., poor health outcomes, mortality and increased costs. Despite that, many cases are undetected. Early detection of delirium is important in improving outcomes and use of assessment tools improves detection rates. The 4AT is a brief screening tool for delirium detection, which has not previously been translated into Swedish. The study aim was to evaluate diagnostic accuracy and clinical applicability of a Swedish version of the screening tool 4AT for delirium detection. METHOD This diagnostic test accuracy study used a quantitative and a qualitative approach and evaluated the patients' and the health care professionals' experiences of the tool. Study included 200 patients ≥65 years from a university hospital and a county hospital in two Swedish regions. Medical specialties were geriatric stroke/neurology, geriatric multimorbidity, severe cognitive impairment, orthopaedic, and urology. The translated 4AT was tested against the reference standard DSM-IV-TR criteria, based on the Organic Brain Syndrome scale and patient records. The 4AT was assessed simultaneously and independently by two assessors. Additionally, data was collected through patient record reviews, and questions about applicability to the patients (n = 200) and the assessors (n = 37). Statistical analyses, and qualitative content analyses were conducted. RESULTS By reference standard 18% had delirium, and by 4AT 19%. The overall percent agreement was 88%, AUROC 0.808, sensitivity 0.70 (95% CI 0.51-0.84) and specificity 0.92 (95% CI 0.87-0.96). In the ward for severe cognitive impairment (n = 63) the 4AT was less sensitive and less specific. In the other wards (n = 132) sensitivity was 0.77 (95% CI 0.50-0.93), specificity 0.93 (95% CI 0.87-0.97), and AUROC 0.848. Interrater reliability (Kappa) was 0.918, p = < 0.001 (n = 144). The 4AT was well tolerated by patients, easy to use for health care professionals, and took a few minutes to conduct. CONCLUSION The Swedish version of 4AT is an accurate and applicable tool to use in clinical practice for detecting delirium in hospitalized patients across different medical specialities, and to use by different professionals and levels of seniority. To improve patient outcomes, we recommend the 4AT to be incorporated in clinical practice in health care settings in Sweden.
Collapse
Affiliation(s)
- Yvonne A Johansson
- Skaraborg Hospital, Skövde, Sweden. .,The Research School of Health and Welfare, Aging Research Network-Jönköping (ARN-J), Jönköping University, Jönköping, Sweden.
| | - Theofanis Tsevis
- Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden.,Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Salmir Nasic
- Skaraborg Hospital, Skövde, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Catharina Gillsjö
- School of Health Sciences, University of Skövde, Skövde, Sweden.,College of Nursing, University of Rhode Island, Kingston, RI, USA
| | - Linda Johansson
- Institute of Gerontology, Aging Research Network-Jönköping (ARN-J), School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Nenad Bogdanovic
- Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden.,Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Elisabeth Kenne Sarenmalm
- Skaraborg Hospital, Skövde, Sweden.,School of Health Sciences, University of Skövde, Skövde, Sweden.,Institute of Health and Care Science, Sahlgrenska Academy, Centre for Person-Centred Care Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
27
|
Zastrow I, Tohsche P, Loewen T, Vogt B, Feige M, Behnke M, Wolff A, Kiefmann R, Olotu C. Comparison of the '4-item assessment test' and 'nursing delirium screening scale' delirium screening tools on non-intensive care unit wards: A prospective mixed-method approach. Eur J Anaesthesiol 2021; 38:957-965. [PMID: 33606422 DOI: 10.1097/eja.0000000000001470] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In elderly patients following surgery, postoperative delirium (POD) is the most frequent complication and is associated with negative outcomes. The 2017 European Society of Anaesthesiology guideline on POD aims to improve patient care by implementing structured delirium prevention, diagnosis and treatment. However, these recommendations, especially systematic delirium screening, are still incompletely adopted in clinical practice. The aim of this study was to evaluate the feasibility and acceptance of validated delirium screening tools and to identify barriers to their implementation on nonintensive care unit wards. METHODS Screening rates, as well as practicability, acceptance and the interprofessional handling of positive results, were assessed for each group. Screening rates were calculated as a percentage of the total potential testing episodes completed (up to 15 per patient). Patients were considered eligible when aged 65 years and above. Barriers and motivating factors were assessed in a mixed method approach by utilising questionnaires and focus group discussions. INTERVENTION In a 3-month phase, a guideline-compliant screening protocol involving screening for POD three times daily for 5 days following surgery was introduced in five wards: both the 4-item assessment test (4AT) and the nursing delirium screening scale (NuDESC) were used. Before commencing the study and again after 6 weeks, medical staff of the respective wards underwent a 45 min training session. RESULTS Of a total of 3183 potential testing episodes, 999 (31.4%) were completed, with more NuDESC observational tests (43%) than 4AT bedside tests completed (20%). The 4AT was considered more difficult to integrate into daily working routines, it took longer to administer, and nurses felt uncomfortable conducting the screening (53 vs. 13%). Screening results indicating delirium were often not discussed within the team (47%), and nurses felt that often such results were not taken seriously by physicians (54%). CONCLUSION The observational NuDESC showed a higher completion rate than the bedside 4AT, although overall testing rates were low. The necessary time needed to conduct the screening, the negative reactions by patients, insufficient team communication and a lack of initiation of any therapy were identified as major barriers in the implementation of the guideline-compliant screening protocol. For all staff, further education and awareness of the importance of POD diagnosis and treatment might improve the screening rates. The NuDesc received better results concerning acceptance, practicability and introduction into daily work routine, leading to higher screening rates compared with the 4AT. The latter instrument, which was intended to be used rather selectively or when POD is suspected, might therefore not be suitable for guideline-compliant regular and repeated screening for POD.
Collapse
Affiliation(s)
- Inke Zastrow
- From the Department of Patient and Care Management (IZ, BV, MF), Department of Intensive Care Medicine (PT, AW) and Department of Anaesthesiology (TL, MB, RK, CO), Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre, Hamburg, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
[Disorientation and delirium assessment : A secondary analysis of a prospective, observational study]. Med Klin Intensivmed Notfmed 2021; 117:419-427. [PMID: 34432084 PMCID: PMC9452438 DOI: 10.1007/s00063-021-00850-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/08/2021] [Accepted: 07/03/2021] [Indexed: 10/25/2022]
Abstract
Disorientation may present as a warning sign of developing delirium. The most commonly used delirium assessment tool in Germany, the Confusion Assessment Method for Intensive Care Unit (CAM-ICU), does not rate "disorientation", since intubated patients cannot communicate verbally. However, the majority of German ICU patients are not orally intubated, so they could be examined for their orientation. This study was carried out to investigate whether the delirium feature "disorientation" in extubated patients yields diverging findings in comparison to the CAM-ICU and whether the sensitivity of the CAM-ICU may be improved when combined with the feature "disorientation" (CAM-IMC). A total of 86 paired assessments were completed in 50 extubated patients. Delirium was found in 19.8% (N = 17). The CAM-ICU had a sensitivity of 71% (95% confidence interval [CI] 44-90%) and a specificity of 100% (95-100%). Disorientation, if taken as the only delirium feature, had a sensitivity of 77% (50-93%) and a specificity of 93% (89-100%). The CAM-IMC reached a sensitivity of 88% (64-99%) and a specificity of 100% (95-100%). The receiver operating characteristics (ROC) analyses found an area under the curve (AUC) of 0.941 (95%CI 0.851-1.000) for the CAM-IMC, which was the highest compared to the other delirium tests (CAM-ICU, AUC 0.853 [0.720-0.986]; disorientation, AUC 0.868 [0.745-0.991]). This research emphasizes the importance of the feature "disorientation" for delirium assessments in patients able to verbally communicate and explains some controversial delirium ratings in daily practice. The CAM-IMC appears to be an attractive tool for delirium assessment in nonintubated patients and deserves further research.
Collapse
|
29
|
Nilsson U, Bergman L. "Never the Same" After Surgery: Postoperative Delirium and Early Postoperative Cognitive Decline. J Perianesth Nurs 2021; 36:321-322. [PMID: 34112368 DOI: 10.1016/j.jopan.2021.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Ulrica Nilsson
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden; Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
| | - Lina Bergman
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
30
|
Rose L, Burry L, Agar M, Blackwood B, Campbell NL, Clarke M, Devlin JW, Lee J, Marshall JC, Needham DM, Siddiqi N, Page V. A core outcome set for studies evaluating interventions to prevent and/or treat delirium for adults requiring an acute care hospital admission: an international key stakeholder informed consensus study. BMC Med 2021; 19:143. [PMID: 34140006 PMCID: PMC8211534 DOI: 10.1186/s12916-021-02015-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Trials of interventions to prevent or treat delirium in adults in an acute hospital setting report heterogeneous outcomes. Our objective was to develop international consensus among key stakeholders for a core outcome set (COS) for future trials of interventions to prevent and/or treat delirium in adults with an acute care hospital admission and not admitted to an intensive care unit. METHODS A rigorous COS development process was used including a systematic review, qualitative interviews, modified Delphi consensus process, and in-person consensus using nominal group technique (registration http://www.comet - initiative.org/studies/details/796 ). Participants in qualitative interviews were delirium survivors or family members. Participants in consensus methods comprised international representatives from three stakeholder groups: researchers, clinicians, and delirium survivors and family members. RESULTS Item generation identified 8 delirium-specific outcomes and 71 other outcomes from 183 studies, and 30 outcomes from 18 qualitative interviews, including 2 that were not extracted from the systematic review. De-duplication of outcomes and formal consensus processes involving 110 experts including researchers (N = 32), clinicians (N = 63), and delirium survivors and family members (N = 15) resulted in a COS comprising 6 outcomes: delirium occurrence and reoccurrence, delirium severity, delirium duration, cognition, emotional distress, and health-related quality of life. Study limitations included exclusion of non-English studies and stakeholders and small representation of delirium survivors/family at the in-person consensus meeting. CONCLUSIONS This COS, endorsed by the American and Australian Delirium Societies and European Delirium Association, is recommended for future clinical trials evaluating delirium prevention or treatment interventions in adults presenting to an acute care hospital and not admitted to an intensive care unit.
Collapse
Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, Rm 1.13, James Clerk Maxwell Building, 57 Waterloo Rd, London, SE1 8WA, UK.
| | - Lisa Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Mount Sinai Hospital, Sinai Health System, Toronto, Canada
| | - Meera Agar
- Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute of Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Noll L Campbell
- College of Pharmacy, Purdue University, West Lafayette, IN, USA
| | - Mike Clarke
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Jacques Lee
- Inaugural Research Chair in Geriatric Emergency Medicine, Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
| | - John C Marshall
- St Michael's Hospital and Li Ka Shing Research Institute, Toronto, Canada
| | - Dale M Needham
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Najma Siddiqi
- Hull York Medical School, University of York, York, UK
| | | |
Collapse
|
31
|
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.
Collapse
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
| |
Collapse
|
32
|
Evensen S, Hylen Ranhoff A, Lydersen S, Saltvedt I. The delirium screening tool 4AT in routine clinical practice: prediction of mortality, sensitivity and specificity. Eur Geriatr Med 2021; 12:793-800. [PMID: 33813725 PMCID: PMC8321971 DOI: 10.1007/s41999-021-00489-1] [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] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/17/2021] [Indexed: 11/27/2022]
Abstract
Aim Investigate if 4AT score predicts 1 year mortality and explore the sensitivity and specificity of the 4AT when applied as part of a clinical routine. Findings 4AT score is one of several clinical characteristics predicting 1 year mortality. The 4AT has reasonable sensitivity and specificity to detect delirium in a clinical routine setting. Message The 4AT seems to be a useful tool for delirium screening and may predict mortality. Purpose Delirium is common and associated with poor outcomes, partly due to underdetection. We investigated if the delirium screening tool 4 A’s test (4AT) score predicts 1 year mortality and explored the sensitivity and specificity of the 4AT when applied as part of a clinical routine. Methods Secondary analyses of a prospective study of 228 patients acutely admitted to a Medical Geriatric Ward. Physicians without formal training conducted the index test (the 4AT); a predefined cut-off ≥ 4 suggested delirium. Reference standard was delirium diagnosed by two geriatricians using the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). We calculated hazard ratios (HR) using Cox regression based on the groups 4AT = 0, 1–3, 4–7 and ≥ 8, first unadjusted, then adjusted for the covariates age, comorbidity, and personal activities of daily living. We calculated sensitivity, specificity, and the area under the receiver operating curve (AUC). Results Mean age of patients was 86.6 years, 139 (61.0%) were female, 78 (34.2%) had DSM-5 delirium; of these, 56 had 4AT-delirium. 1 year mortality was 27.6% (63 patients). Compared to 4AT score 0, the group 4AT ≥ 8 had increased 1 year mortality (HR 2.86, 95% confidence interval 1.28–6.37, p = 0.010). The effect was reduced in multiadjusted analyses (HR 1.69, 95% confidence interval 0.70–4.07, p = 0.24). Sensitivity, specificity, and AUC were 0.72, 0.84, and 0.88, respectively. Conclusions 4AT ≥ 8 indicates increased mortality, but the effect was reduced in multiadjusted analyses. 4AT had acceptable sensitivity and specificity when applied as a clinical routine.
Collapse
Affiliation(s)
- Sigurd Evensen
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491, Trondheim, Norway
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - Anette Hylen Ranhoff
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Stian Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491, Trondheim, Norway.
- Department of Geriatrics, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| |
Collapse
|
33
|
Buckley RA, Atkins KJ, Fortunato E, Silbert B, Scott DA, Evered L. A novel digital clock drawing test as a screening tool for perioperative neurocognitive disorders: A feasibility study. Acta Anaesthesiol Scand 2021; 65:473-480. [PMID: 33296501 DOI: 10.1111/aas.13756] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/26/2020] [Accepted: 11/21/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND We developed a digital clock drawing test (dCDT), an adaptation of the original pen and paper clock test, that may be advantageous over previous dCDTs in the perioperative environment. We trialed our dCDT on a tablet device in the preoperative period to determine the feasibility of administration in this setting. To assess the clinical utility of this test, we examined the relationship between the performance on the test and compared derived digital clock measures with the 4 A's Test (4AT), a delirium and cognition screening tool. METHODS We recruited a sample of 102 adults aged 65 years and over presenting for elective surgery in a single tertiary hospital. Participants completed the 4AT, followed by both command and copy clock conditions of the dCDT. We recorded time-based clock-drawing metrics, alongside clock replications scored using the Montreal Cognitive Assessment (MoCA) clock scoring criteria. RESULTS The dCDT had an acceptance rate of 99%. After controlling for demographic variables and prior tablet use, regression analyses showed higher 4AT scores were associated with greater dCDT time (seconds) for both command (β = 8.2, P = .020) and copy clocks (β = 12, P = .005) and lower MoCA-based clock scores in both command (OR = 0.19, P = .001) and copy conditions (OR = 0.14, P = .012). CONCLUSION The digital clock drawing test is feasible to administer and is highly acceptable to older adults in a preoperative setting. We demonstrated a significant association between both the dCDT time and clock score metrics, with the established 4AT. Our results provide convergent validity of the dCDT in the preoperative setting.
Collapse
Affiliation(s)
- Richard A Buckley
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
- Faculty of Medicine, School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Kelly J Atkins
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
- Faculty of Medicine, School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Erika Fortunato
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Brendan Silbert
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
- Faculty of Medicine, School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - David A Scott
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
- Faculty of Medicine, School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Lisbeth Evered
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
- Faculty of Medicine, School of Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Anesthesiology, Weill Cornell Medicine, NY, USA
| |
Collapse
|
34
|
Henao-Castaño AM, Pachón Cetina LE, Monroy Rodríguez JD. Nursing Delirium Screening Scale, a Tool for Early Detection of Delirium: Integrative Review. AQUICHAN 2020. [DOI: 10.5294/aqui.2020.20.4.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: To analyze the context and use of the Nursing Delirium Screening Scale (Nu-DESC) for early detection of delirium in adult patients, compiling the available evidence.
Method: Searching for relevant articles on databases such as Cinahl, Medline, Ovid, Scopus, and Web of Science. Inclusion criteria: Articles written in English, Spanish, and Portuguese, published between January 2013 and October 2019. Search terms: “nursing delirium screen,” “inpatient delirium screening,” and “nursing assessment.” We identified 23 articles in which the Nu-DESC was used. Two reviewers independently assessed the articles using the CASPe (Critical Appraisal Skills Program in Spanish) tool.
Results: The Nu-DESC is employed in different contexts such as the adult intensive care unit (ICU), post-anesthetic care unit (PACU), palliative care unit, and hospitalization unit. It is more frequently used in the PACU with a more sensitive threshold (≥ 1); the test showed greater sensitivity of 54.5 % (95 % CI: 32.2–75.6) and specificity of 97.1 % (95 % CI: 95.3–98.4).
Conclusion: The Nu-DESC facilitates the recognition of delirium episodes by the nursing team, makes care quicker and individualized for each patient, avoiding immediate pharmacological interventions, and coordinate interdisciplinary actions for diagnosis, especially in post-anesthetic care units.
Collapse
|
35
|
Jeong E, Park J, Lee J. Diagnostic Test Accuracy of the 4AT for Delirium Detection: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E7515. [PMID: 33076557 PMCID: PMC7602716 DOI: 10.3390/ijerph17207515] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 02/01/2023]
Abstract
Under-recognition of delirium is an international problem. For the early detection of delirium, a feasible and valid screening tool for healthcare professionals is needed. This study aimed to present a scientific reason for using the 4 'A's Test (4AT) through a systematic review and meta-analysis of studies on the diagnostic test accuracy. We systematically searched articles in the EMBASE, MEDLINE, CINAHL, and PsycINFO databases and selected relevant articles on the basis of the predefined inclusion criteria. The quality of the included articles was evaluated using the Quality Assessment of the Diagnostic Accuracy Studies-2 tool. We estimated the pooled values of diagnostic test accuracy by employing the bivariate model and the hierarchical summary receiver operating characteristic (HSROC) model in data synthesis. A total of 3729 patients of 13 studies were included in the analysis. The pooled estimates of sensitivity and specificity of the 4AT were 81.5% (95% confidence interval: 70.7%, 89.0%) and 87.5% (79.5%, 92.7%), respectively. Given the 4AT's evidence of accuracy and practicality, we suggest healthcare professionals to utilize this tool for routine screening of delirium. However, for detecting delirium in the dementia population, further work is required to evaluate the 4AT with other cut-off points or scoring methods in order for it to be more sensitive and specific.
Collapse
Affiliation(s)
- Eunhye Jeong
- College of Nursing, Korea University, Seoul 02841, Korea; (E.J.); (J.P.)
| | - Jinkyung Park
- College of Nursing, Korea University, Seoul 02841, Korea; (E.J.); (J.P.)
| | - Juneyoung Lee
- Department of Biostatistics, College of Medicine, Korea University, Seoul 02841, Korea
| |
Collapse
|
36
|
Jeong E, Park J, Lee J. Diagnostic test accuracy of the Nursing Delirium Screening Scale: A systematic review and meta‐analysis. J Adv Nurs 2020; 76:2510-2521. [DOI: 10.1111/jan.14482] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/18/2020] [Accepted: 07/06/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Eunhye Jeong
- College of Nursing Korea University Seoul Republic of Korea
| | - Jinkyung Park
- College of Nursing Korea University Seoul Republic of Korea
| | - Juneyoung Lee
- Department of Biostatistics College of Medicine Korea University Seoul Republic of Korea
| |
Collapse
|
37
|
Aldwikat RK, Manias E, Nicholson P. Incidence and risk factors for acute delirium in older patients with a hip fracture: A retrospective cohort study. Nurs Health Sci 2020; 22:958-966. [PMID: 32623791 DOI: 10.1111/nhs.12753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 12/20/2022]
Abstract
This retrospective cohort study aimed to determine the incidence, and preoperative, intraoperative, and postoperative risk factors for postoperative delirium in older patients undergoing surgical fixation of a hip fracture. Electronic medical records were examined of 260 patients who underwent a surgical fixation of a hip fracture between June 2017 and October 2018 at a university-affiliated tertiary care hospital in Victoria, Australia. Demographic, clinical, and perioperative data were examined for potential risk factors for postoperative delirium. Of the 260 patients, 63 patients (24.2%) developed delirium postoperatively. Univariate logistic regression analysis indicated that advanced age, comorbidity, cognitive impairment, dementia, American Society of Anesthesiologists score, and antipsychotic usage were significant risk factors for delirium, while doses of paracetamol, fentanyl, and diazepam showed complex associations. Multivariate logistic regression analysis determined comorbidity and cognitive impairment as independent risk factors for the development of delirium. This study demonstrates the importance of evaluation of medications prescribed in the perioperative period as modifiable risk factors, in order to identify patients at high risk of delirium and enable targeted monitoring and treatment during patients' hospitalization.
Collapse
Affiliation(s)
- Rami K Aldwikat
- School of Nursing and Midwifery, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patients Safety Research, Faculty of Health, Geelong, Victoria, Australia
| | - Patricia Nicholson
- School of Nursing and Midwifery, Centre for Quality and Patients Safety Research, Faculty of Health, Deakin University Geelong, Geelong, Victoria, Australia
| |
Collapse
|
38
|
Saller T, MacLullich AMJ, Perneczky R. The 4AT - an instrument for delirium detection for older patients in the post-anaesthesia care unit. Anaesthesia 2020; 75:410. [PMID: 32022910 DOI: 10.1111/anae.14937] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- T Saller
- Edinburgh Royal Infirmary, Edinburgh, UK
- German Center for Neurodegenerative Diseases, Munich, Germany
| | - A M J MacLullich
- Edinburgh Royal Infirmary, Edinburgh, UK
- German Center for Neurodegenerative Diseases, Munich, Germany
| | - R Perneczky
- Edinburgh Royal Infirmary, Edinburgh, UK
- German Center for Neurodegenerative Diseases, Munich, Germany
| |
Collapse
|
39
|
Abstract
As the population ages, there is a higher prevalence of both dementia and conditions that require major surgery. However, patients with dementia undergoing surgery have poorer outcomes than surgical patients without dementia. This article explores new guidance about delivering perioperative care for patients with dementia presenting for surgery. Management of patients with cognitive changes begins with developing an understanding of the classifications and pathophysiology of these disease processes, and addressing any modifiable risk factors for developing dementia, postoperative cognitive decline and postoperative delirium. Thorough preoperative assessment provides the opportunity to identify patients with and at risk of these cognitive impairments and to involve the appropriate multidisciplinary team in care planning. Once patients are identified, an individualised perioperative management plan addressing any issues surrounding capacity and consent, conduct of anaesthesia, possible polypharmacy and potential drug interactions, and postoperative pain management can improve quality of care and outcomes for these patients.
Collapse
Affiliation(s)
| | - Helen Jordan
- South East Scotland School of Anaesthesia, Edinburgh, Scotland
| | - Annemarie B Docherty
- Department of Anaesthesia and Critical Care, University of Edinburgh, Edinburgh, Scotland Conflicts of interest
| |
Collapse
|
40
|
|