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Clout M, Turner N, Clement C, Braude P, Benger J, Gagg J, Gendall E, Holloway S, Ingram J, Kandiyali R, Lewis A, Maskell NA, Shipway D, Smith JE, Taylor J, Darweish Medniuk A, Carlton E. The RELIEF feasibility trial: topical lidocaine patches in older adults with rib fractures. Emerg Med J 2024:emermed-2024-213905. [PMID: 38760021 DOI: 10.1136/emermed-2024-213905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/29/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Lidocaine patches, applied over rib fractures, may reduce pulmonary complications in older patients. Known barriers to recruiting older patients in emergency settings necessitate a feasibility trial. We aimed to establish whether a definitive randomised controlled trial (RCT) evaluating lidocaine patches in older patients with rib fracture(s) was feasible. METHODS This was a multicentre, parallel-group, open-label, feasibility RCT in seven hospitals in England and Scotland. Patients aged ≥65 years, presenting to ED with traumatic rib fracture(s) requiring hospital admission were randomised to receive up to 3×700 mg lidocaine patches (Ralvo), first applied in ED and then once daily for 72 hours in addition to standard care, or standard care alone. Feasibility outcomes were recruitment, retention and adherence. Clinical end points (pulmonary complications, pain and frailty-specific outcomes) and patient questionnaires were collected to determine feasibility of data collection and inform health economic scoping. Interviews and focus groups with trial participants and clinicians/research staff explored the understanding and acceptability of trial processes. RESULTS Between October 23, 2021 and October 7, 2022, 206 patients were eligible, of whom 100 (median age 83 years; IQR 74-88) were randomised; 48 to lidocaine patches and 52 to standard care. Pulmonary complications at 30 days were determined in 86% of participants and 83% of expected 30-day questionnaires were returned. Pulmonary complications occurred in 48% of the lidocaine group and 59% in standard care. Pain and some frailty-specific outcomes were not feasible to collect. Staff reported challenges in patient compliance, unfamiliarity with research measures and overwhelming the patients with research procedures. CONCLUSION Recruitment of older patients with rib fracture(s) in an emergency setting for the evaluation of lidocaine patches is feasible. Refinement of data collection, with a focus on the collection of pain, frailty-specific outcomes and intervention delivery are needed before progression to a definitive trial. TRIAL REGISTRATION NUMBER ISRCTN14813929.
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Affiliation(s)
- Madeleine Clout
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Nicholas Turner
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Philip Braude
- CLARITY (Collaborative Ageing Research), North Bristol NHS Trust, Westbury on Trym, UK
| | - Jonathan Benger
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
| | - James Gagg
- Department of Emergency Medicine, Somerset NHS Foundation Trust, Taunton, UK
| | - Emma Gendall
- Research and Innovation, Southmead Hospital, Bristol, UK
| | - Simon Holloway
- Pharmacy Clinical Trials and Research, Southmead Hospital, Bristol, UK
| | - Jenny Ingram
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Amanda Lewis
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - David Shipway
- Department of Medicine for Older People, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jason E Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jodi Taylor
- Bristol Trials Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Edward Carlton
- Emergency Department, Southmead Hospital, Bristol, UK
- Department of Emergency Medicine, Translational Health Sciences, University of Bristol, Bristol, UK
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Geßele C, Saller T, Smolka V, Dimitriadis K, Amann U, Strobach D. Development and validation of a new drug-focused predictive risk score for postoperative delirium in orthopaedic and trauma surgery patients. BMC Geriatr 2024; 24:422. [PMID: 38741037 DOI: 10.1186/s12877-024-05005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/24/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Postoperative delirium (POD) is the most common complication following surgery in elderly patients. During pharmacist-led medication reconciliation (PhMR), a predictive risk score considering delirium risk-increasing drugs and other available risk factors could help to identify risk patients. METHODS Orthopaedic and trauma surgery patients aged ≥ 18 years with PhMR were included in a retrospective observational single-centre study 03/2022-10/2022. The study cohort was randomly split into a development and a validation cohort (6:4 ratio). POD was assessed through the 4 A's test (4AT), delirium diagnosis, and chart review. Potential risk factors available at PhMR were tested via univariable analysis. Significant variables were added to a multivariable logistic regression model. Based on the regression coefficients, a risk score for POD including delirium risk-increasing drugs (DRD score) was established. RESULTS POD occurred in 42/328 (12.8%) and 30/218 (13.8%) patients in the development and validation cohorts, respectively. Of the seven evaluated risk factors, four were ultimately tested in a multivariable logistic regression model. The final DRD score included age (66-75 years, 2 points; > 75 years, 3 points), renal impairment (eGFR < 60 ml/min/1.73m2, 1 point), anticholinergic burden (ACB-score ≥ 3, 1 point), and delirium risk-increasing drugs (n ≥ 2; 2 points). Patients with ≥ 4 points were classified as having a high risk for POD. The areas under the receiver operating characteristic curve of the risk score model were 0.89 and 0.81 for the development and the validation cohorts, respectively. CONCLUSION The DRD score is a predictive risk score assessable during PhMR and can identify patients at risk for POD. Specific preventive measures concerning drug therapy safety and non-pharmacological actions should be implemented for identified risk patients.
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Affiliation(s)
- Carolin Geßele
- Hospital Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany.
- Doctoral Program Clinical Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany.
| | - Thomas Saller
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Vera Smolka
- Department of Orthopaedics and Trauma Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Ute Amann
- Faculty of Medicine, LMU Munich, Munich, Germany
| | - Dorothea Strobach
- Hospital Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany
- Doctoral Program Clinical Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany
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Lewis A, Clout M, Benger J, Braude P, Turner N, Gagg J, Gendall E, Holloway S, Ingram J, Kandiyali R, Maskell N, Shipway D, Smith JE, Taylor J, Darweish-Medniuk A, Carlton E. The Randomised Evaluation of early topical Lidocaine patches In Elderly patients admitted to hospital with rib Fractures (RELIEF): feasibility trial protocol. NIHR Open Res 2023; 3:38. [PMID: 37881461 PMCID: PMC10593328 DOI: 10.3310/nihropenres.13438.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/27/2023]
Abstract
Background Topical lidocaine patches, applied over rib fractures, have been suggested as a non-invasive method of local anaesthetic delivery to improve respiratory function, reduce opioid consumption and consequently reduce pulmonary complications. Older patients may gain most benefit from improved analgesic regimens yet lidocaine patches are untested as an early intervention in the Emergency Department (ED). The aim of this trial is to investigate uncertainties around trial design and conduct, to establish whether a definitive randomised trial of topical lidocaine patches in older patients with rib fractures is feasible. Methods RELIEF is an open label, multicentre, parallel group, individually randomised, feasibility randomised controlled trial with economic scoping and nested qualitative study. Patients aged ≥ 65 years presenting to the ED with traumatic rib fracture(s) requiring admission will be randomised 1:1 to lidocaine patches (intervention), in addition to standard clinical management, or standard clinical management alone. Lidocaine patches will be applied immediately after diagnosis in ED and continued daily for 72 hours or until discharge. Feasibility outcomes will focus on recruitment, adherence and follow-up data with a total sample size of 100. Clinical outcomes, such as 30-day pulmonary complications, and resource use will be collected to understand feasibility of data collection. Qualitative interviews will explore details of the trial design, trial acceptability and recruitment processes. An evaluation of the feasibility of measuring health economics outcomes data will be completed. Discussion Interventions to improve outcomes in elderly patients with rib fractures are urgently required. This feasibility trial will test a novel early intervention which has the potential of fulfilling this unmet need. The Randomised Evaluation of early topical Lidocaine patches In Elderly patients admitted to hospital with rib Fractures (RELIEF) feasibility trial will determine whether a definitive trial is feasible. ISRCTN Registration ISRCTN14813929 (22/04/2021).
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Affiliation(s)
- Amanda Lewis
- Bristol Trials Centre (BTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Madeleine Clout
- Bristol Trials Centre (BTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Jonathan Benger
- Emergency Care, Faculty of Health and Applied Sciences, University of the West of England, Bristol, England, UK
| | - Philip Braude
- Department of Elderly Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, England, UK
| | - Nicholas Turner
- Bristol Trials Centre (BTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - James Gagg
- Department of Emergency Medicine, Musgrove Park Hospital, Taunton, England, UK
| | - Emma Gendall
- Research and Innovation, Southmead Hospital, North Bristol NHS Trust, Bristol, England, UK
| | - Simon Holloway
- Pharmacy Clinical Trials and Research, Southmead Hospital, North Bristol NHS Trust, Bristol, England, UK
| | - Jenny Ingram
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Rebecca Kandiyali
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Warwick, England, UK
| | - Nick Maskell
- Academic Respiratory Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - David Shipway
- Department of Elderly Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, England, UK
| | - Jason E Smith
- Emergency Department, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jodi Taylor
- Bristol Trials Centre (BTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Alia Darweish-Medniuk
- Department of Anaesthesia and Pain Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, England, UK
| | - Edward Carlton
- Department of Emergency Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, England, UK
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
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Fox A, Dulhunty J, Ballard E, Fraser M, Macandrew M, Taranec S, Waters R, Yang M, Yates M, Yelland C, Beattie E. The impact of a cognitive impairment support program on patients in an acute care setting: a pre-test post-test intervention study. BMC Geriatr 2023; 23:260. [PMID: 37127621 PMCID: PMC10150670 DOI: 10.1186/s12877-023-03930-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 03/24/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Patients with cognitive impairment are at greater risk of hospital acquired complications, longer hospital stays, and poor health outcomes compared to patients without cognitive impairment. The Cognitive Impairment Support Program is a multi-disciplinary approach to improve screening rates and awareness of patients with cognitive impairment and guide clinician response and communication during their hospitalisation to improve health outcomes. OBJECTIVE This study evaluated the impact of implementing the Cognitive Impairment Support Program on patient hospital acquired complications, patient reported quality of life and staff satisfaction in an outer metropolitan hospital. DESIGN A pre-test post-test design was used to collect data in two 6-month time periods between March 2020 and November 2021. PARTICIPANTS Patients aged ≥ 65 years, admitted to a participating ward for > 24 h. INTERVENTION The Cognitive Impairment Support Program consisted of four components: cognitive impairment screening, initiation of a Cognitive Impairment Care Plan, use of a Cognitive Impairment Identifier and associated staff education. MEASURES The primary outcome was hospital acquired complications experienced by patients with cognitive impairment identified using clinical coding data. Secondary outcomes were patient quality of life and a staff confidence and perceived organisational support to care for patients with cognitive impairment. RESULTS Hospital acquired complication rates did not vary significantly between the two data collection periods for patients experiencing cognitive impairment with a 0.2% (95% confidence interval: -5.7-6.1%) reduction in admissions with at least one hospital acquired complication. Patients in the post intervention period demonstrated statistically significant improvements in many items in two of the Dementia Quality of Life Measure domains: memory and everyday life. The staff survey indicated statistically significant improvement in clinical staff confidence to care for patients with cognitive impairment (p = 0.003), satisfaction with organisational support for patients (p = 0.004) and job satisfaction (p ≤ 0.001). CONCLUSION This study provides evidence that a multicomponent Cognitive Impairment Support Program had a positive impact on staff confidence and satisfaction and patient quality of life. Broader implementation with further evaluation of the multicomponent cognitive impairment intervention across a range of settings using varied patient outcomes is recommended.
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Affiliation(s)
- Amanda Fox
- Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia.
- School of Nursing, Faculty of Health, Queensland University of Technology, N Block, Victoria Park Road, Kelvin Grove, Brisbane, QLD, Australia.
- Redcliffe Hospital, Anzac Avenue, Redcliffe, Australia.
| | - Joel Dulhunty
- Redcliffe Hospital, Anzac Avenue, Redcliffe, Australia
| | - Emma Ballard
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Maria Fraser
- Redcliffe Hospital, Anzac Avenue, Redcliffe, Australia
| | - Margaret Macandrew
- Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
- School of Nursing, Faculty of Health, Queensland University of Technology, N Block, Victoria Park Road, Kelvin Grove, Brisbane, QLD, Australia
| | - Sally Taranec
- Redcliffe Hospital, Anzac Avenue, Redcliffe, Australia
| | | | - Min Yang
- School of Nursing, Faculty of Health, Queensland University of Technology, N Block, Victoria Park Road, Kelvin Grove, Brisbane, QLD, Australia
| | - Mark Yates
- Ballarat Health Services, Ballarat, Australia
| | | | - Elizabeth Beattie
- Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
- School of Nursing, Faculty of Health, Queensland University of Technology, N Block, Victoria Park Road, Kelvin Grove, Brisbane, QLD, Australia
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Crockett S, Hanna L, Singh A, Gunning S, Nicholas R, Bicknell C, Hamady M, Gable D, Sallam M, Modarai B, Abisi S, Lyons O, Gibbs R. Carbon dioxide flushing versus saline flushing of thoracic aortic stents (INTERCEPTevar): protocol for a multicentre pilot randomised controlled trial. BMJ Open 2023; 13:e067605. [PMID: 37105705 PMCID: PMC10151986 DOI: 10.1136/bmjopen-2022-067605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 02/21/2023] [Indexed: 04/29/2023] Open
Abstract
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) carries a 3%-6.1% stroke risk, including risk of 'silent' cerebral infarction (SCI). Stent-grafts are manufactured in room air and retain air. Instructions for use recommend saline flushing to 'de-air' the system prior to insertion, but substantial amounts of air are released when deploying them, potentially leading to downstream neuronal injury and SCI. Carbon dioxide (CO2) is more dense and more soluble in blood than air, without risk of bubble formation, so could be used in addition to saline to de-air stents. This pilot trial aims to assess the feasibility of a full-scale randomised controlled trial (RCT) investigating the neuroprotective benefit against SCI with the use of CO2-flushed aortic stent-grafts. METHODS AND ANALYSIS This is a multicentre pilot RCT, which is taking place in vascular centres in the UK, USA and New Zealand. Patients identified for TEVAR will be enrolled after informed written consent. 120 participants will be randomised (1:1) to TEVAR-CO2 or TEVAR-saline, stratified according to TEVAR landing zone. Participants will undergo preoperative neurocognitive tests and quality of life assessments, which will be repeated at 6 weeks, or first outpatient appointment, and 6 months. Inpatient neurological testing will be performed within 48 hours of return to level 1 care for clinical stroke or delirium. Diffusion-weighted MRI will be undertaken within 72 hours postoperatively (1-7 days) and at 6 months to look for evidence and persistence of SCI. Feasibility will be assessed via measures of recruitment and retention, informing the design of a full-scale trial. ETHICS AND DISSEMINATION The study coordination centre has obtained approval from the London Fulham Research Ethics Committee (19/LO/0836) and Southern Health and Disability Ethics Committee (NZ) and UK's Health Regulator Authority (HRA). The study has received ethical approval for recruitment in the UK (Fulham REC, 19/LO/0836), New Zealand (21/STH/192) and the USA (IRB 019-264, Ref 378630). Consent for entering into the study will be taken using standardised consent forms by the local study team, led by a local PI. The results of the trial will be submitted for publication in an open access journal. TRIAL REGISTRATION NUMBER NCT03886675.
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Affiliation(s)
- Stephen Crockett
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Lydia Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Abhinav Singh
- Neuroradiology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Stephen Gunning
- Clinical Health and Psychology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Richard Nicholas
- Neurology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Colin Bicknell
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Mohamad Hamady
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Dennis Gable
- Vascular Surgery Department, Baylor Scott & White Health, Dallas, Texas, USA
| | - Morad Sallam
- Vascular Surgery Department, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Bijan Modarai
- Vascular Surgery Department, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Said Abisi
- Vascular Surgery Department, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Oliver Lyons
- Vascular Surgery Department, Canterbury District Health Board, Christchurch, New Zealand
| | - Richard Gibbs
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
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Hou L, Zhang Q, Cao L, Chen M, Wang Q, Li Y, Li S, Ge L, Yang K. 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] [What about the content of this article? (0)] [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.
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Tieges Z, Maclullich AMJ, Anand A, Brookes C, Cassarino M, O’connor M, Ryan D, Saller T, Arora RC, Chang Y, Agarwal K, Taffet G, Quinn T, Shenkin SD, Galvin R. Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis. Age Ageing 2021; 50:733-743. [PMID: 33951145 PMCID: PMC8099016 DOI: 10.1093/ageing/afaa224] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 'A's Test (4AT) is a short (<2 minutes) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection. METHODS We searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials, from 2011 (year of 4AT release on the website www.the4AT.com) until 21 December 2019. Inclusion criteria were: older adults (≥65 years); diagnostic accuracy study of the 4AT index test when compared to delirium reference standard (standard diagnostic criteria or validated tool). Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model. RESULTS Seventeen studies (3,702 observations) were included. Settings were acute medicine, surgery, a care home and the emergency department. Three studies assessed performance of the 4AT in stroke. The overall prevalence of delirium was 24.2% (95% CI 17.8-32.1%; range 10.5-61.9%). The pooled sensitivity was 0.88 (95% CI 0.80-0.93) and the pooled specificity was 0.88 (95% CI 0.82-0.92). Excluding the stroke studies, the pooled sensitivity was 0.86 (95% CI 0.77-0.92) and the pooled specificity was 0.89 (95% CI 0.83-0.93). The methodological quality of studies varied but was moderate to good overall. CONCLUSIONS The 4AT shows good diagnostic test accuracy for delirium in the 17 available studies. These findings support its use in routine clinical practice in delirium detection. PROSPERO REGISTRATION NUMBER CRD42019133702.
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Affiliation(s)
- Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, UK
| | - Alasdair M J Maclullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Atul Anand
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland, UK
| | - Claire Brookes
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Marica Cassarino
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Margaret O’connor
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Damien Ryan
- Retrieval, Emergency and Disaster Medicine Research and Development Unit (REDSPoT), Emergency Department, University Hospital Limerick, Limerick, Ireland
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Rakesh C Arora
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Yue Chang
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kathryn Agarwal
- Section of Geriatrics, Baylor College of Medicine, Houston, TX, USA
- Houston Methodist Hospital, Houston, TX, USA
| | - George Taffet
- Section of Geriatrics, Baylor College of Medicine, Houston, TX, USA
- Houston Methodist Hospital, Houston, TX, USA
| | - Terence Quinn
- Institute of Cardiovascular Medicine, University of Glasgow, Glasgow, Scotland, UK
| | - Susan D Shenkin
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
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Jeong E, Park J, Lee J. Diagnostic Test Accuracy of the 4AT for Delirium Detection: A Systematic Review and Meta-Analysis. Int J Environ Res 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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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Affiliation(s)
- Eunhye Jeong
- College of Nursing, Korea University, Seoul 02841, Korea; (E.J.); (J.P.)
| | - Jinkyung Park
- College of Nursing, Korea University, Seoul 02841, Korea; (E.J.); (J.P.)
| | - Juneyoung Lee
- Department of Biostatistics, College of Medicine, Korea University, Seoul 02841, Korea
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