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Arnold E, Finucane AM, Taylor S, Spiller JA, O'Rourke S, Spenceley J, Carduff E, Tieges Z, MacLullich AM. The 4AT, a rapid delirium detection tool for use in hospice inpatient units: Findings from a validation study. Palliat Med 2024; 38:535-545. [PMID: 38767241 DOI: 10.1177/02692163241242648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Delirium is a serious neuropsychiatric syndrome with adverse outcomes, which is common but often undiagnosed in terminally ill people. The 4 'A's test or 4AT (www.the4AT.com), a brief delirium detection tool, is widely used in general settings, but validation studies in terminally ill people are lacking. AIM To determine the diagnostic accuracy of the 4AT in detecting delirium in terminally ill people, who are hospice inpatients. DESIGN A diagnostic test accuracy study in which participants underwent the 4AT and a reference standard based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The reference standard was informed by Delirium Rating Scale Revised-98 and tests assessing arousal and attention. Assessments were conducted in random order by pairs of independent raters, blinded to the results of the other assessment. SETTING/PARTICIPANTS Two hospice inpatient units in Scotland, UK. Participants were 148 hospice inpatients aged ⩾18 years. RESULTS A total of 137 participants completed both assessments. Three participants had an indeterminate reference standard diagnosis and were excluded, yielding a final sample of 134. Mean age was 70.3 (SD = 10.6) years. About 33% (44/134) had reference standard delirium. The 4AT had a sensitivity of 89% (95% CI 79%-98%) and a specificity of 94% (95% CI 90%-99%). The area under the receiver operating characteristic curve was 0.97 (95% CI 0.94-1). CONCLUSION The results of this validation study support use of the 4AT as a delirium detection tool in hospice inpatients, and add to the literature evaluating methods of delirium detection in palliative care settings. TRIAL REGISTRY ISCRTN 97417474.
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Affiliation(s)
| | - Anne M Finucane
- Marie Curie Hospice Edinburgh, Edinburgh, UK
- Clinical Psychology, University of Edinburgh, Edinburgh, UK
| | | | | | | | | | | | - Zoë Tieges
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Computing, School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Scotland, UK
| | - Alasdair Mj MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
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Sigaard JVA, Henneberg NC, Schacksen CS, Kronborg SH, Petrini L, Kidholm K, Birgisdóttir UR, Spindler H, Dinesen B. A Digital Platform (Telepalliation) for Patients in Palliative Care and Their Relatives: Protocol for a Multimethod Randomized Controlled Trial. JMIR Res Protoc 2024; 13:e49946. [PMID: 38564264 PMCID: PMC11022132 DOI: 10.2196/49946] [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: 06/14/2023] [Revised: 10/29/2023] [Accepted: 01/25/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND The World Health Organization defines end-of-life palliative care as "prevention and relief of suffering, by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual." Over 20 million people worldwide are in need of palliative care. In Denmark, palliative care is given at a general and a specialist level. The general level comprises health care professionals (HCPs) who do not perform palliative care full-time. The specialist level comprises specialized palliative care (SPC), where HCPs perform palliative care full-time. In total, 20%-30% of patients who need palliative care are referred to SPC. Challenges with SPC include a short time span from referral to end of life, patients who are very ill and may therefore find it hard to travel to an outpatient clinic, and the SPC unit having a relatively small staff. The need for SPC is expected to rise, as the number of patients dying from terminal diseases is increasing. Telehealth has been successfully implemented in different home care settings, including palliative care. OBJECTIVE The aim of the study is to present the research design of the clinical testing of a telepalliation program by the use of a digital platform for patients in palliative care and their relatives. METHODS The telepalliation program will be conducted as a multimethod randomized controlled trial. The intervention group will follow the telepalliation program, while the control group will follow the traditional standard of care program for palliative care. The primary outcome of the study is increased quality of life. Secondary outcomes include enhanced sense of security; reduced experience of pain; satisfactory experiences of patients and relatives with the TelePal platform and degree of satisfaction in being a part of the program; experiences with the use of the TelePal platform on the part of HCPs and the professionals' experiences of being a part of the program; the use of a cross-sector communication platform and the telepalliation program by patients, relatives, and HCPs; and the projected lower cost of health care services. These outcomes will be assessed using questionnaires, data generated by digital technologies, and semistructured interviews. RESULTS The collection of data began in May 2021 and will be completed in August 2024. The results of the study will be published in peer-reviewed journals and presented at international conferences. Results from the telepalliation program are expected to be published by fall 2024. CONCLUSIONS The expected outcomes of the study are increased quality of life and increased sense of security. We also expect that the study will have a clinical impact on future telepalliation for those patients who are referred to a palliative team. TRIAL REGISTRATION ClinicalTrials.gov NCT04995848; https://clinicaltrials.gov/study/NCT04995848. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/49946.
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Affiliation(s)
- Jarl Voss Andersen Sigaard
- Hospital of Southwest Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark
- Laboratory for Welfare Technology-Digital Health & Rehabilitation, ExerciseTech, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Nanna Celina Henneberg
- Laboratory for Welfare Technology-Digital Health & Rehabilitation, ExerciseTech, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Cathrine Skov Schacksen
- Laboratory for Welfare Technology-Digital Health & Rehabilitation, ExerciseTech, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Sissel Højsted Kronborg
- Laboratory for Welfare Technology-Digital Health & Rehabilitation, ExerciseTech, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Laura Petrini
- Center for Neuroplasticity and Pain, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Kristian Kidholm
- Centre for Innovative Medical Technology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Una Rósa Birgisdóttir
- Laboratory for Welfare Technology-Digital Health & Rehabilitation, ExerciseTech, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Helle Spindler
- Department of Psychology and Behavioural Scienses, Aarhus University, Aarhus, Denmark
| | - Birthe Dinesen
- Laboratory for Welfare Technology-Digital Health & Rehabilitation, ExerciseTech, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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Hauer K, Dutzi I, Werner C, Bauer J, Ullrich P. Delirium Prevention in Early Rehabilitation During Acute Hospitalization and Implementation of Programs Specifically Tailored to Older Patients with Cognitive Impairment: A Scoping Review with Meta-Analysis. J Alzheimers Dis 2024; 97:3-29. [PMID: 38073387 DOI: 10.3233/jad-230644] [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] [Indexed: 01/09/2024]
Abstract
BACKGROUND No systematic review on delirium prevention within early, hospital-based rehabilitation on implementation of approaches specifically tailored for patients with cognitive impairment (PwCI), such as Alzheimer's disease or vascular dementia, has been published despite the high relevance of specific medical care in this vulnerable population. OBJECTIVE To document design and effectiveness of delirium prevention programs by early rehabilitation during acute, hospital-based medical care and implementation of programs specifically tailored to PwCI. METHODS In a three-step approach, we first identified published systematic reviews of hospital-based, early rehabilitation interventions for older persons (>65 years) in relevant databases. In a second step, we screened each single trial of included reviews according to predefined inclusion criteria. In a third step, we analyzed studies with focus on delirium prevention. RESULTS Among n = 25 studies identified, almost all intervention programs did not specifically target cognitive impairment (CI). Interventions were heterogeneous (modules: n = 2-19); almost all study samples were mixed/unspecified for cognitive status with more affected patients excluded. Only one study exclusively included delirium patients, and only one included CI patients. Results of random effect meta-analysis showed significant effects of generic programs to reduce delirium incidence during hospitalization by 41% (p < 0.001, odds ratio, 95% confidence interval: 0.59 [0.49, 0.71] with modest heterogeneity (I2: 30%). CONCLUSIONS Study results document a lack of implementation for delirium prevention programs specifically tailored to PwCI by early, hospital-based rehabilitation. Specifying existing rehab concepts or augmenting them by CI-specific modules may help to develop, optimize, and implement innovative delirium prevention in PwCI in acute medical care.
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Affiliation(s)
- Klaus Hauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
- Robert Bosch Gesellschaft für Medizinische Forschung mbH, Stuttgart, Germany
| | - Ilona Dutzi
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Christian Werner
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen Bauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Phoebe Ullrich
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
- Department of Thoracic Oncology, Thoraxklinik Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
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4
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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.
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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.
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5
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Matsuda Y, Tanimukai H, Inoue S, Hirayama T, Kanno Y, Kitaura Y, Inada S, Sugano K, Yoshimura M, Harashima S, Wada S, Hasegawa T, Okamoto Y, Dotani C, Takeuchi M, Kako J, Sadahiro R, Kishi Y, Uchida M, Ogawa A, Inagaki M, Okuyama T. A revision of JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements. Jpn J Clin Oncol 2023; 53:808-822. [PMID: 37190819 DOI: 10.1093/jjco/hyad042] [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: 02/02/2023] [Accepted: 04/26/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE The Japanese Psycho-Oncology Society and the Japanese Association of Supportive Care in Cancer have recently revised the clinical practice guidelines for delirium in adult cancer patients. This article reports the process of developing the revised guidelines and summarizes the recommendations made. METHODS The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multi-disciplinary members, created three new clinical questions: non-pharmacological intervention and antipsychotics for the prevention of delirium and trazodone for the management of delirium. In addition, systematic reviews of nine existing clinical questions have been updated. Two independent reviewers reviewed the proposed articles. The certainty of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development, and Evaluation system. The modified Delphi method was used to validate the recommended statements. RESULTS This article provides a compendium of the recommendations along with their rationales, as well as a short summary. CONCLUSIONS These revised guidelines will be useful for the prevention, assessment and management of delirium in adult cancer patients in Japan.
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Affiliation(s)
- Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Hitoshi Tanimukai
- Faculty of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichiro Inoue
- Department of Neuropsychiatry, Okayama University Hospital, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Takatoshi Hirayama
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yusuke Kanno
- Department of Home Health and Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Kitaura
- Department of Psychiatry, Panasonic Health Insurance Organization Matsushita Memorial Hospital, Moriguchi, Japan
| | - Shuji Inada
- Department of Psychosomatic Medicine, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Koji Sugano
- Division of Respiratory Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Masafumi Yoshimura
- Department of Occupational Therapy, Faculty of Rehabilitation, Kansai Medical University, Hirakata, Japan
| | - Saki Harashima
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Saho Wada
- Department of Neuropsychiatry, Nippon Medical School Tamanagayama Hospital, Tokyo, Japan
| | - Takaaki Hasegawa
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Yoshiaki Okamoto
- Department of pharmacy, Ashiya Municipal Hospital, Ashiya, Japan
| | - Chikako Dotani
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Mari Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Jun Kako
- College of Nursing Art and Science, University of Hyogo, Akashi, Japan
| | - Ryoichi Sadahiro
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuhiro Kishi
- Department of Psychiatry, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Megumi Uchida
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Asao Ogawa
- Division of Psycho-Oncology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Japan
| | - Masatoshi Inagaki
- Department of Psychiatry, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Toru Okuyama
- Department of Psychiatry/Palliative Care Center, Nagoya City University West Medical Center, Nagoya, Japan
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Martínez-Arnau FM, Puchades-García A, Pérez-Ros P. Accuracy of Delirium Screening Tools in Older People with Cancer-A Systematic Review. Cancers (Basel) 2023; 15:2807. [PMID: 37345143 DOI: 10.3390/cancers15102807] [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: 04/09/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND The increase in life expectancy worldwide has led to a larger population of older people, which in turn entails a rising prevalence of cancer. One of the main complications of cancer is delirium, especially in advanced stages. OBJECTIVE To determine which delirium screening instrument is the most accurate in older people with cancer. METHODS A systematic review was designed. A literature search was performed in MEDLINE, EBSCO and SCOPUS; additional records were identified by handsearching. Selection criteria were studies involving people with cancer and a mean sample age of 60 years or older, assessing delirium, and reporting the metric properties of the assessment instrument. Studies with post-surgical patients and substance abuse delirium were excluded. RESULTS From 2001 to 2021, 14 eligible studies evaluated 13 different assessment tools, reporting an incidence of delirium ranging from 14.3% to 68.3%. The Delirium Observation Screening Scale (DOSS) showed the best metric properties, followed by the Nursing Delirium Screening Scale (NuDESC), Confusion Assessment Method (CAM) and Memorial Delirium Assessment Scale (MDAS). Only two studies were considered to be at low risk of bias using the QUADAS-2 Tool. No study exclusively examined this population group. CONCLUSIONS Screening tools for delirium are heterogeneous for older people with cancer, and there is a need to analyze metric properties exclusively in the older population. Registered on PROSPERO ID: CRD42022303530.
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Affiliation(s)
- Francisco Miguel Martínez-Arnau
- Department of Physiotherapy, Universitat de València, Gascó Oliag 5, 46010 Valencia, Spain
- Frailty and Cognitive Impairment Research Group (FROG), Universitat de València, Menendez Pelayo s/n, 46010 Valencia, Spain
| | - Andrea Puchades-García
- Department of Nursing, Faculty of Nursing and Podiatry, Universitat de València, Menendez Pelayo s/n, 46010 Valencia, Spain
| | - Pilar Pérez-Ros
- Frailty and Cognitive Impairment Research Group (FROG), Universitat de València, Menendez Pelayo s/n, 46010 Valencia, Spain
- Department of Nursing, Faculty of Nursing and Podiatry, Universitat de València, Menendez Pelayo s/n, 46010 Valencia, Spain
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You W, Fan XY, Lei C, Nie CC, Chen Y, Wang XL. Melatonin intervention to prevent delirium in hospitalized patients: A meta-analysis. World J Clin Cases 2022; 10:3773-3786. [PMID: 35647160 PMCID: PMC9100708 DOI: 10.12998/wjcc.v10.i12.3773] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/01/2021] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Evaluation of the effectiveness of melatonin is necessary to prevent the development of delirium in hospitalized patients. Melatonin (N-acetyl-5-methoxytryptamine) is a hormone produced by the pineal gland of the brain from the amino acid tryptophan. Synthetic melatonin supplements have been used for various medical conditions, especially sleep-related diseases, and have proved to be successful.
AIM To determine the effect of melatonin on the prevention of delirium in hospitalized patients.
METHODS A literature search of the CNKI, Wanfang Database, VIP Database, China Biomedical Literature Database, PubMed, Embase, Cochrane Library, Web of Science, and other databases was conducted. The CNKI, Wanfang Database, VIP Database (VIP), and China Biomedical Literature Database were searched for Chinese studies, and PubMed, Embase, Cochrane Library, Web of Science and other databases were searched for international studies. It will be established in June 2021 in a randomized controlled trial (RCT) whether melatonin treatment for 6 mo prevents delirium in hospitalized patients. Literature screening, quality review, and data extraction were carried out using the Cochrane Manual 5.1.0 systematic evaluation method, and Stata 15.0 software and Review Manager 5.3 were used for meta-analysis and processing.
RESULTS A total of 18 new RCT articles and 18 experimental subjects were identified. The results of the meta-analysis showed that following the occurrence of delirium, melatonin reduced the incidence of delirium in patients (RR = 0.69, 95%CI: 0.60-0.80), which is of significance, but heterogeneity was significant I2 = 62%. Subgroup analysis was performed to examine the source of heterogeneity, and it was found that different patient types were the source of heterogeneity; the research on subgroup analysis was of high quality and homogeneous. To determine the reliability and robustness of the research results, a sensitivity analysis was carried out. The results showed that after excluding individual studies one by one, the effect size was still within 95%CI, which strengthened the reliability of the original meta-analysis results. Melatonin has a significant preventive effect on delirium in hospitalized medical patients [RR = 0.60, 95%CI: 0.47-0.76), P < 0.001].
CONCLUSION Melatonin can reduce the rate of delirium in medical patients, and the role of melatonin in reducing the incidence of delirium in surgical patients and critical care unit patients requires further study.
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Affiliation(s)
- Wei You
- Emergency Department Intensive Care Unit, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Xiao-Yu Fan
- Department of General Surgery, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Cheng Lei
- School of Public Health and Management, Chongqing Medical University, Chongqing 400000, Chongqing, China
| | - Chen-Cong Nie
- Department of Nursing, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Yao Chen
- Emergency Department Intensive Care Unit, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Xue-Lian Wang
- Emergency Department Intensive Care Unit, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
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8
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Brefka S, Eschweiler GW, Dallmeier D, Denkinger M, Leinert C. Comparison of delirium detection tools in acute care : A rapid review. Z Gerontol Geriatr 2022; 55:105-115. [PMID: 35029755 PMCID: PMC8921069 DOI: 10.1007/s00391-021-02003-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/06/2021] [Indexed: 11/28/2022]
Abstract
Background Delirium is a frequent psychopathological syndrome in geriatric patients. It is sometimes the only symptom of acute illness and bears a high risk for complications. Therefore, feasible assessments are needed for delirium detection. Objective and methods Rapid review of available delirium assessments based on a current Medline search and cross-reference check with a special focus on those implemented in acute care hospital settings. Results A total of 75 delirium detection tools were identified. Many focused on inattention as well as acute onset and/or fluctuating course of cognitive changes as key features for delirium. A range of assessments are based on the confusion assessment method (CAM) that has been adapted for various clinical settings. The need for a collateral history, time resources and staff training are major challenges in delirium assessment. Latest tests address these through a two-step approach, such as the ultrabrief (UB) CAM or by optional assessment of temporal aspects of cognitive changes (4 As test, 4AT). Most delirium screening assessments are validated for patient interviews, some are suitable for monitoring delirium symptoms over time or diagnosing delirium based on collateral history only. Conclusion Besides the CAM the 4AT has become well-established in acute care because of its good psychometric properties and practicability. There are several other instruments extending and improving the possibilities of delirium detection in different clinical settings. Supplementary Information The online version of this article (10.1007/s00391-021-02003-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Simone Brefka
- Institute for Geriatric Research, Ulm University, Ulm, Germany. .,Geriatric Center Ulm/Alb Donau, Ulm, Germany. .,Agaplesion Bethesda Hospital Ulm, Zollernring 26, 89073, Ulm, Germany.
| | - Gerhard Wilhelm Eschweiler
- Geriatric Center, University Hospital Tuebingen, Tuebingen, Germany.,University Hospital for Psychiatry and Psychotherapy Tuebingen, Tuebingen, Germany
| | - Dhayana Dallmeier
- Geriatric Center Ulm/Alb Donau, Ulm, Germany.,Agaplesion Bethesda Hospital Ulm, Zollernring 26, 89073, Ulm, Germany.,Dept. of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Michael Denkinger
- Institute for Geriatric Research, Ulm University, Ulm, Germany.,Geriatric Center Ulm/Alb Donau, Ulm, Germany.,Agaplesion Bethesda Hospital Ulm, Zollernring 26, 89073, Ulm, Germany
| | - Christoph Leinert
- Institute for Geriatric Research, Ulm University, Ulm, Germany.,Geriatric Center Ulm/Alb Donau, Ulm, Germany.,Agaplesion Bethesda Hospital Ulm, Zollernring 26, 89073, Ulm, Germany
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9
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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.
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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
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Yang EJ, Hahm BJ, Shim EJ. Screening and Assessment Tools for Measuring Delirium in Patients with Cancer in Hospice and Palliative Care: A Systematic Review. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2021; 24:214-225. [PMID: 37674643 PMCID: PMC10180070 DOI: 10.14475/jhpc.2021.24.4.214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/08/2021] [Accepted: 10/14/2021] [Indexed: 09/08/2023]
Abstract
Purpose This study reviewed screening and assessment tools that are used to measure delirium in patients with cancer in hospice and palliative care settings and examined their psychometric properties. Methods Four databases were searched for studies using related search terms (delirium, tools, palliative care, cancer, and others). The inclusion criteria were a) studies that included screening/assessment tools for measuring delirium in cancer patients receiving hospice/palliative care, and b) studies published in English or Korean. The exclusion criteria were a) studies that were conducted in an intensive care setting, and b) case studies, qualitative studies, systematic reviews, or meta-analyses. Results Out of the 81 studies identified, only 10 examined the psychometric properties of tools for measuring delirium, and 8 tools were ultimately identified. The psychometric properties of the Memorial Delirium Assessment Scale (MDAS) were the most frequently examined (n=5), and the MDAS showed good reliability, concurrent validity, and diagnostic accuracy. The Delirium Rating Scale had good reliability and diagnostic accuracy. The Delirium Rating Scale-Revised 98 also showed good reliability and structural validity, but its diagnostic performance was not examined in hospice/palliative care settings. The Nursing Delirium Screening Scale showed relatively low diagnostic accuracy. Conclusion The MDAS showed evidence of being a valid assessment tool for assessing delirium in patients with cancer in palliative care. Few studies examined the diagnostic performance of delirium tools. Therefore, further studies are needed to examine the diagnostic performance of screening/assessment tools for the optimal detection of delirium in patients with cancer in hospice/palliative care.
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Affiliation(s)
- Eun Jung Yang
- Department of Psychology, Pusan National University, Busan, Korea
| | - Bong-Jin Hahm
- Department of Psychiatry and Behavioral Sciences, Seoul National University College of Medicine, Seoul, Korea
| | - Eun-Jung Shim
- Department of Psychology, Pusan National University, Busan, Korea
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11
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Bramati P, Bruera E. Delirium in Palliative Care. Cancers (Basel) 2021; 13:cancers13235893. [PMID: 34885002 PMCID: PMC8656500 DOI: 10.3390/cancers13235893] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 11/18/2022] Open
Abstract
Simple Summary Delirium is a generalized cerebral dysfunction that occurs frequently near the end of life. In palliative care, delirium is frequently a sign of impending death; it is distressing for patients, families, and caregivers; and the goals of management, assessment, and treatment are controversial. We provide an update on these topics mainly focusing on patients with cancer. Abstract Delirium, a widespread neuropsychiatric disorder in patients with terminal diseases, is associated with increased morbidity and mortality, profoundly impacting patients, their families, and caregivers. Although frequently missed, the effective recognition of delirium demands attention and commitment. Reversibility is frequently not achievable. Non-pharmacological and pharmacological interventions are commonly used but largely unproven. Palliative sedation, although controversial, should be considered for refractory delirium. Psychological assistance should be available to patients and their families at all times.
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Arnold E, Finucane AM, Spiller JA, Tieges Z, MacLullich AM. Validation of the 4AT tool for delirium assessment in specialist palliative care settings: protocol of a prospective diagnostic test accuracy study [version 1; peer review: 2 approved]. AMRC OPEN RESEARCH 2021; 3:16. [PMID: 35966135 PMCID: PMC7613285 DOI: 10.12688/amrcopenres.12973.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Delirium is a serious and distressing neuropsychiatric condition, which is prevalent across all palliative care settings. Hypoactive delirium is particularly common, but difficult to recognize, partly due to overlapping symptoms with depression and dementia. Delirium screening tools can lead to earlier identification and hence better management of patients. The 4AT (4 'A's Test) is a brief tool for delirium detection, designed for use in clinical practice. It has been validated in 17 studies in over 3,700 patients. The test is currently used in specialist palliative care units, but has not been validated in this setting. The aim of the study is to determine the diagnostic accuracy of the 4AT for delirium detection against a reference standard, in hospice inpatients. METHODS 240 participants will be recruited from the inpatient units of two hospices in Scotland. If a patient lacks capacity to consent, agreement will be sought from a legal proxy. Each participant will complete the 4AT and a reference standard assessment based on the diagnostic delirium criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This will be supplemented by tests of cognition and attention, including reverse days of the week, counting down from 20 to 1, Vigilance 'A', the Observational Scale for Level of Arousal, the modified Richmond Agitation Sedation Scale and the Delirium Rating Scale-Revised-98. The assessments will be conducted in a randomized order by two independent clinicians, who will be blinded to the results until both are complete. Primary outcomes will be the sensitivity and specificity of the 4AT in detecting delirium. DISCUSSION The findings will inform clinical practice regarding delirium assessment in palliative care settings. TRIAL REGISTRATION ISRCTN ISRCTN97417474 (21/02/2020).
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Affiliation(s)
- Elizabeth Arnold
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, Scotland, EH10 7DR, UK
| | - Anne M. Finucane
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, Scotland, EH10 7DR, UK
| | - Juliet A. Spiller
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, Scotland, EH10 7DR, UK
| | - Zoë Tieges
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland, EH16 4SA, UK
| | - Alasdair M.J. MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland, EH16 4SA, UK
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13
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Watt CL, Scott M, Webber C, Sikora L, Bush SH, Kabir M, Boland JW, Woodhouse R, Sands MB, Lawlor PG. Delirium screening tools validated in the context of palliative care: A systematic review. Palliat Med 2021; 35:683-696. [PMID: 33588640 DOI: 10.1177/0269216321994730] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Delirium is a distressing neuropsychiatric disorder affecting patients in palliative care. Although many delirium screening tools exist, their utility, and validation within palliative care settings has not undergone systematic review. AIM To systematically review studies that validate delirium screening tools conducted in palliative care settings. DESIGN Systematic review with narrative synthesis (PROSPERO ID: CRD42019125481). A risk of bias assessment via Quality Assessment Tool for Diagnostic Accuracy Studies-2 was performed. DATA SOURCES Five electronic databases were systematically searched (January 1, 1982-May 3, 2020). Quantitative studies validating a screening tool in adult palliative care patient populations were included. Studies involving alcohol withdrawal, critical or perioperative care were excluded. RESULTS Dual-reviewer screening of 3749 unique titles and abstracts identified 95 studies for full-text review and of these, 17 studies of 14 screening tools were included (n = 3496 patients). Data analyses revealed substantial heterogeneity in patient demographics and variability in screening and diagnostic practices that limited generalizability between study populations and care settings. A risk of bias assessment revealed methodological and reporting deficits, with only 3/17 studies at low risk of bias. CONCLUSIONS The processes of selecting a delirium screening tool and determining optimal screening practices in palliative care are complex. One tool is unlikely to fit the needs of the entire palliative care population across all palliative care settings. Further research should be directed at evaluating and/or adapting screening tools and practices to fit the needs of specific palliative care settings and populations.
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Affiliation(s)
- Christine L Watt
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Mary Scott
- Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lindsey Sikora
- University of Ottawa, Health Sciences Library, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Rebecca Woodhouse
- Hull York Medical School and Department of Health Sciences, University of York, York, UK
| | - Megan B Sands
- University of New South Wales Prince of Wales Clinical School, Randwick, NSW, Australia
| | - Peter G Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Sands MB, Sharma S, Carpenter L, Hartshorn A, Lee JT, Lujic S, Congdon ME, Buchanan AM, Agar M, Vardy JL. "SQiD, the Single Question in Delirium; can a single question help clinicians to detect delirium in hospitalised cancer patients?" running heading Single Question in Delirium" (Bcan-D-20-01665). BMC Cancer 2021; 21:75. [PMID: 33461523 PMCID: PMC7814717 DOI: 10.1186/s12885-020-07504-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/07/2020] [Indexed: 12/01/2022] Open
Abstract
Aim A serious syndrome for cancer in-patients, delirium risk increases with age and medical acuity. Screening tools exist but detection is frequently delayed or missed. We test the ‘Single Question in Delirium’ (SQiD), in comparison to psychiatrist clinical interview. Methods Inpatients in two comprehensive cancer centres were prospectively screened. Clinical staff asked informants to respond to the SQiD: “Do you feel that [patient’s name] has been more confused lately?”. The primary endpoint was negative predictive value (NPV) of the SQiD versus psychiatrist diagnosis (Diagnostic and Statistics Manual criteria). Secondary endpoints included: NPV of the Confusion Assessment Method (CAM), sensitivity, specificity and Cohen’s Kappa coefficient. Results Between May 2012 and July 2015, the SQiD plus CAM was applied to 122 patients; 73 had the SQiD and psychiatrist interview. Median age was 65 yrs. (interquartile range 54–74), 46% were female; median length of hospital stay was 12 days (5–18 days). Major cancer types were lung (19%), gastric or other upper GI (15%) and breast (14%). 70% of participants had stage 4 cancer. Diagnostic values were similar between the SQiD (NPV = 74, 95% CI 67–81; kappa = 0.32) and CAM (NPV = 72, 95% CI 67–77, kappa = 0.32), compared with psychiatrist interview. Overall the CAM identified only a small number of delirious cases but all were true positives. The specificity of the SQiD was 87% (74–95) The SQiD had higher sensitivity than CAM (44% [95% CI 41–80] vs 26% [10–48]). Conclusion The SQiD, administered by bedside clinical staff, was feasible and its psychometric properties are now better understood. The SQiD can contribute to delirium detection and clinical care for hospitalised cancer patients. Supplementary information Supplementary information accompanies this paper at 10.1186/s12885-020-07504-x.
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Affiliation(s)
- Megan B Sands
- University of New South Wales, Prince of Wales Clinical School, Sydney, NSW, Australia. .,Department of Palliative and Supportive Care, Nelune Comprehensive Cancer Centre, Prince of Wales Hospital and Community Health Service, Randwick, NSW, 2031, Australia.
| | - Swapnil Sharma
- University of New South Wales, Prince of Wales Clinical School, Sydney, NSW, Australia
| | - Lindsay Carpenter
- University of New South Wales, Prince of Wales Clinical School, Sydney, NSW, Australia.,Psychological Medicine Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrew Hartshorn
- Concord Cancer Centre, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Jessica T Lee
- Concord Cancer Centre, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Sanja Lujic
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Megan E Congdon
- University of New South Wales, Prince of Wales Clinical School, Sydney, NSW, Australia
| | | | - Meera Agar
- Centre of Cardiovascular and Chronic Care, University of Technology Sydney Faculty of Health, Ultimo, Australia
| | - Janette L Vardy
- Concord Cancer Centre, Concord Repatriation General Hospital, Sydney, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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15
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Lawlor PG, McNamara-Kilian MT, MacDonald AR, Momoli F, Tierney S, Lacaze-Masmonteil N, Dasgupta M, Agar M, Pereira JL, Currow DC, Bush SH. Melatonin to prevent delirium in patients with advanced cancer: a double blind, parallel, randomized, controlled, feasibility trial. Palliat Care 2020; 19:163. [PMID: 33087111 PMCID: PMC7579814 DOI: 10.1186/s12904-020-00669-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/07/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Delirium is highly problematic in palliative care (PC). Preliminary data indicate a potential role for melatonin to prevent delirium, but no randomized controlled trials (RCTs) are reported in PC. METHODS Patients aged ≥18 years, with advanced cancer, admitted to an inpatient Palliative Care Unit (PCU), having a Palliative Performance Scale rating ≥ 30%, and for whom consent was obtained, were included in the study. Patients with delirium on admission were excluded. The main study objectives were to assess the feasibility issues of conducting a double-blind RCT of exogenous melatonin to prevent delirium in PC: recruitment, retention, procedural acceptability, appropriateness of outcome measures, and preliminary efficacy and safety data. Study participants were randomized in a double-blind, parallel designed study to receive daily melatonin 3 mg or placebo orally at 21:00 over 28 days or less if incident delirium, death, discharge or withdrawal occurred earlier. Delirium was diagnosed using the Confusion Assessment Method. Efficacy endpoints in the melatonin and placebo groups were compared using time-to-event analysis: days from study entry to onset of incident delirium. RESULTS Over 16 months, 60/616 (9.7%; 95% CI: 7.5-12.4%) screened subjects were enrolled. The respective melatonin (n = 30) vs placebo (n = 30) outcomes were: incident delirium in 11/30 (36.7%; 95%CI: 19.9-56.1%) vs 10/30 (33%; 95% CI: 17.3-52.8%); early discharge (6 vs 5); withdrawal (6 vs 3); death (0 vs 1); and 7 (23%) vs 11 (37%) reached the 28-day end point. The 25th percentile time-to-event were 9 and 18 days (log rank, χ2 = 0.62, p = 0.43) in melatonin and placebo groups, respectively. No serious trial medication-related adverse effects occurred and the core study procedures were acceptable. Compared to those who remained delirium-free during their study participation, those who developed delirium (n = 21) had poorer functional (p = 0.036) and cognitive performance (p = 0.013), and in particular, poorer attentional capacity (p = 0.003) at study entry. CONCLUSIONS A larger double-blind RCT is feasible, but both subject accrual and withdrawal rates signal a need for multisite collaboration. The apparent trend for shorter time to incident delirium in the melatonin group bodes for careful monitoring in a larger trial. TRIAL REGISTRATION Registered on July 21st 2014 with ClinicalTrials.gov : NCT02200172 .
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Affiliation(s)
- Peter G. Lawlor
- grid.28046.380000 0001 2182 2255Division of Palliative Care, Department of Medicine, University of Ottawa, 43 Bruyère Street, Ottawa, ON K1N 5C8 Canada ,grid.418792.10000 0000 9064 3333Bruyère Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Ottawa Hospital Research Institute, Ottawa, Canada ,grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
| | | | | | - Franco Momoli
- grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, London, Canada
| | - Sallyanne Tierney
- grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
| | | | - Monidipa Dasgupta
- grid.39381.300000 0004 1936 8884Department of Geriatric Medicine, Department of Medicine, University of Western Ontario, London, Canada
| | - Meera Agar
- Centre of Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Hamilton, Canada
| | - Jose L. Pereira
- grid.25073.330000 0004 1936 8227Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Canada
| | - David C. Currow
- Centre of Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Hamilton, Canada
| | - Shirley H. Bush
- grid.28046.380000 0001 2182 2255Division of Palliative Care, Department of Medicine, University of Ottawa, 43 Bruyère Street, Ottawa, ON K1N 5C8 Canada ,grid.418792.10000 0000 9064 3333Bruyère Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Ottawa Hospital Research Institute, Ottawa, Canada ,grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
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16
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Luo A, Muraida S, Pinchotti D, Richardson E, Ye E, Hollingsworth B, Win A, Myers O, Langsjoen J, Valles E, Zolyomi A, Quinn DK. Bispectral Index Monitoring With Density Spectral Array for Delirium Detection. J Acad Consult Liaison Psychiatry 2020; 62:318-329. [PMID: 33223218 DOI: 10.1016/j.psym.2020.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/26/2020] [Accepted: 08/27/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Delirium in hospitalized patients often goes undetected. Cerebral state monitors, which measure limited-channel electroencephalography, have shown potential for improving delirium detection. OBJECTIVE The aim of this study was to compare an FDA-approved cerebral state monitor, bispectral index monitoring with density spectral array (DSA), for delirium identification with clinical screening methods. METHODS Hospitalized patients receiving psychiatric consultation were assessed for delirium using the 3-minute Diagnostic Interview for Confusion Assessment Method (3D-CAM) and underwent bispectral index monitor + DSA monitoring. Visual inspection of frequency band power of the DSA was performed by 2 trained independent raters. Average hue values were calculated for each frequency band using image analysis software as the device did not allow for extraction of raw electroencephalography data. Delirious versus nondelirious group averages, sensitivity, specificity, and area under the curve were calculated for significant DSA variables and the 3D-CAM. RESULTS In an initial cohort of 43 patients, visual ratings of the DSA were not associated with delirium (P > 0.1). In a larger cohort of 123 subjects, multiple band hue ratios were associated with delirium, although none survived correction for multiple comparisons. In a subgroup of 74 non-neurological patients, low theta/low delta ratio was significantly associated with delirium (P = 0.001) (sensitivity/specificity/area under the curve: 83%/70%/0.757; 3D-CAM: 67%/77%/0.717; paired-sample area under the curve difference: -0.040, P = 0.68). In 21 patients with dementia, low theta power demonstrated significantly greater sensitivity/specificity/area under the curve of 83%/78%/0.824, whereas 3D-CAM achieved 50%/78%/0.639 (P = 0.04). CONCLUSION Bispectral index monitor + DSA was similar to 3D-CAM for detecting delirium in hospitalized patients with and without neurological disorders, and was significantly more accurate in patients with dementia. More studies are needed to validate the use of cerebral state monitors for quantitative delirium detection.
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Affiliation(s)
- Alice Luo
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, 87131.
| | - Susan Muraida
- Department of Family and Community Medicine, University of New Mexico, Albuquerque, NM, 87131
| | - Dana Pinchotti
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, 87131
| | - Elizabeth Richardson
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, 87131
| | - Enstin Ye
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, 87131
| | | | - Alexander Win
- Department of Psychology, University of New Mexico, Albuquerque, NM, 87131
| | - Orrin Myers
- Department of Family and Community Medicine, University of New Mexico, Albuquerque, NM, 87131
| | - Jens Langsjoen
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, 87106
| | - Emiliano Valles
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, 87131
| | - Arpad Zolyomi
- Department of Anesthesiology, University of New Mexico, Albuquerque, NM, 87106
| | - Davin K Quinn
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, 87131
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Clinical characteristics and treatment of delirium in palliative care settings. MEMO-MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2020. [DOI: 10.1007/s12254-020-00641-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
SummaryDelirium is commonly seen in palliative care. It usually develops over a short period of time and is characterized by a disturbance of attention and awareness. As delirium is associated with increased mortality, prevention and early identification of this severe neurocognitive disorder is of high clinical relevance. This paper provides a brief overview of risk factors, preventive measures, current screening and diagnostic procedures, as well as nonpharmacological and pharmacological treatment options of delirium in the palliative care setting.
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Use of the brief Confusion Assessment Method in a veteran palliative care population: A pilot validation study. Palliat Support Care 2020; 17:569-573. [PMID: 30887938 DOI: 10.1017/s1478951518001050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Many patients with advanced serious illness or at the end of life experience delirium, a potentially reversible form of acute brain dysfunction, which may impair ability to participate in medical decision-making and to engage with their loved ones. Screening for delirium provides an opportunity to address modifiable causes. Unfortunately, delirium remains underrecognized. The main objective of this pilot was to validate the brief Confusion Assessment Method (bCAM), a two-minute delirium-screening tool, in a veteran palliative care sample. METHOD This was a pilot prospective, observational study that included hospitalized patients evaluated by the palliative care service at a single Veterans' Administration Medical Center. The bCAM was compared against the reference standard, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Both assessments were blinded and conducted within 30 minutes of each other. RESULT We enrolled 36 patients who were a median of 67 years (interquartile range 63-73). The primary reasons for admission to the hospital were sepsis or severe infection (33%), severe cardiac disease (including heart failure, cardiogenic shock, and myocardial infarction) (17%), or gastrointestinal/liver disease (17%). The bCAM performed well against the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, for detecting delirium, with a sensitivity (95% confidence interval) of 0.80 (0.4, 0.96) and specificity of 0.87 (0.67, 0.96). SIGNIFICANCE OF RESULTS Delirium was present in 27% of patients enrolled and never recognized by the palliative care service in routine clinical care. The bCAM provided good sensitivity and specificity in a pilot of palliative care patients, providing a method for nonpsychiatrically trained personnel to detect delirium.
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Abstract
Delirium is a prevalent acute neurocognitive condition in patients with progressive life-limiting illness. Delirium remains underdetected; a systematic approach to screening is essential. Delirium at the end of life requires a comprehensive assessment. Consider the potential for reversibility, illness trajectory, patient preference, and goals of care before proceeding with investigations and interventions. Management should be interdisciplinary, and nonpharmacologic therapy is fundamental. For patients with refractory and severe agitation or perceptual disturbance, judicious use of medication may also be required. Carers and family should be seen as partners in care and be involved in shared decision making about care.
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Affiliation(s)
- Meera Agar
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation) Faculty of Health, University of Technology Sydney, Building 10, Level 3, 235 Jones Street, Ultimo, New South Wales 2007, Australia.
| | - Shirley H Bush
- The Ottawa Hospital, General Campus, 501 Smyth Road, Box 206, Ottawa, ON K1H 8L6, Canada; Bruyère Research Institute, 85 Primrose Ave, Ottawa, ON K1R 6M1, Canada; Ottawa Hospital Research Institute, 053 Carling Ave, Ottawa, ON K1Y 4E9, Canada; Palliative Care, Bruyère Continuing Care, The Ottawa Hospital, 43, Bruyère Street, Ottawa, Ontario K1N 5C8, Canada
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20
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Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings. Eur Geriatr Med 2020; 11:1-32. [DOI: 10.1007/s41999-019-00278-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
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21
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Liveris A, Stein DM. Delirium in the Elderly Surgical Patient. CURRENT GERIATRICS REPORTS 2019. [DOI: 10.1007/s13670-019-00288-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Watt CL, Momoli F, Ansari MT, Sikora L, Bush SH, Hosie A, Kabir M, Rosenberg E, Kanji S, Lawlor PG. The incidence and prevalence of delirium across palliative care settings: A systematic review. Palliat Med 2019; 33:865-877. [PMID: 31184538 PMCID: PMC6691600 DOI: 10.1177/0269216319854944] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Delirium is a common and distressing neurocognitive condition that frequently affects patients in palliative care settings and is often underdiagnosed. AIM Expanding on a 2013 review, this systematic review examines the incidence and prevalence of delirium across all palliative care settings. DESIGN This systematic review and meta-analyses were prospectively registered with PROSPERO and included a risk of bias assessment. DATA SOURCES Five electronic databases were examined for primary research studies published between 1980 and 2018. Studies on adult, non-intensive care and non-postoperative populations, either receiving or eligible to receive palliative care, underwent dual reviewer screening and data extraction. Studies using standardized delirium diagnostic criteria or valid assessment tools were included. RESULTS Following initial screening of 2596 records, and full-text screening of 153 papers, 42 studies were included. Patient populations diagnosed with predominantly cancer (n = 34) and mixed diagnoses (n = 8) were represented. Delirium point prevalence estimates were 4%-12% in the community, 9%-57% across hospital palliative care consultative services, and 6%-74% in inpatient palliative care units. The prevalence of delirium prior to death across all palliative care settings (n = 8) was 42%-88%. Pooled point prevalence on admission to inpatient palliative care units was 35% (confidence interval = 0.29-0.40, n = 14). Only one study had an overall low risk of bias. Varying delirium screening and diagnostic practices were used. CONCLUSION Delirium is prevalent across all palliative care settings, with one-third of patients delirious at the time of admission to inpatient palliative care. Study heterogeneity limits meta-analyses and highlights the future need for rigorous studies.
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Affiliation(s)
- Christine L Watt
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada
| | - Franco Momoli
- 3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,4 Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,5 School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mohammed T Ansari
- 5 School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lindsey Sikora
- 6 Health Sciences Library, University of Ottawa, Ottawa, ON, Canada
| | - Shirley H Bush
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | - Annmarie Hosie
- 8 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | - Erin Rosenberg
- 9 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,10 Department of Critical Care, The Ottawa Hospital, Ottawa, ON, Canada
| | - Salmaan Kanji
- 3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,11 Department of Pharmacy, The Ottawa Hospital, Ottawa, ON, Canada.,12 Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter G Lawlor
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
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Shenkin SD, Fox C, Godfrey M, Siddiqi N, Goodacre S, Young J, Anand A, Gray A, Hanley J, MacRaild A, Steven J, Black PL, Tieges Z, Boyd J, Stephen J, Weir CJ, MacLullich AMJ. Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method. BMC Med 2019; 17:138. [PMID: 31337404 PMCID: PMC6651960 DOI: 10.1186/s12916-019-1367-9] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/13/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 'A's Test (4AT, www.the4AT.com ) is a short delirium assessment tool designed for routine use without special training. The primary objective was to assess the accuracy of the 4AT for delirium detection. The secondary objective was to compare the 4AT with another commonly used delirium assessment tool, the Confusion Assessment Method (CAM). METHODS This was a prospective diagnostic test accuracy study set in emergency departments or acute medical wards involving acute medical patients aged ≥ 70. All those without acutely life-threatening illness or coma were eligible. Patients underwent (1) reference standard delirium assessment based on DSM-IV criteria and (2) were randomised to either the index test (4AT, scores 0-12; prespecified score of > 3 considered positive) or the comparator (CAM; scored positive or negative), in a random order, using computer-generated pseudo-random numbers, stratified by study site, with block allocation. Reference standard and 4AT or CAM assessments were performed by pairs of independent raters blinded to the results of the other assessment. RESULTS Eight hundred forty-three individuals were randomised: 21 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome, and 785 were included in the analysis. Mean age was 81.4 (SD 6.4) years. 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT had an area under the receiver operating characteristic curve of 0.90 (95% CI 0.84-0.96). The 4AT had a sensitivity of 76% (95% CI 61-87%) and a specificity of 94% (95% CI 92-97%). The CAM had a sensitivity of 40% (95% CI 26-57%) and a specificity of 100% (95% CI 98-100%). CONCLUSIONS The 4AT is a short, pragmatic tool which can help improving detection rates of delirium in routine clinical care. TRIAL REGISTRATION International standard randomised controlled trial number (ISRCTN) 53388093 . Date applied 30/05/2014; date assigned 02/06/2014.
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Affiliation(s)
- Susan D. Shenkin
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
| | - Christopher Fox
- Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Mary Godfrey
- Elderly Care and Rehabilitation and Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, Hull York Medical School, Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Young
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
| | - Atul Anand
- Cardiovascular Sciences and Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | - Alasdair Gray
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Janet Hanley
- Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly L. Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher J. Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Alasdair M. J. MacLullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Royal Infirmary of Edinburgh, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh 51, Little France Crescent, Edinburgh, EH16 4SA UK
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24
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Lawlor PG, Rutkowski NA, MacDonald AR, Ansari MT, Sikora L, Momoli F, Kanji S, Wright DK, Rosenberg E, Hosie A, Pereira JL, Meagher D, Rice J, Scott J, Bush SH. A Scoping Review to Map Empirical Evidence Regarding Key Domains and Questions in the Clinical Pathway of Delirium in Palliative Care. J Pain Symptom Manage 2019; 57:661-681.e12. [PMID: 30550832 DOI: 10.1016/j.jpainsymman.2018.12.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/03/2018] [Accepted: 12/03/2018] [Indexed: 02/03/2023]
Abstract
CONTEXT Based on the clinical care pathway of delirium in palliative care (PC), a published analytic framework (AF) formulated research questions in key domains and recommended a scoping review to identify evidence gaps. OBJECTIVES To produce a literature map for key domains of the published AF: screening, prognosis and diagnosis, management, and the health-related outcomes. METHODS A standard scoping review framework was used by an interdisciplinary study team of nurse- and physician-delirium researchers, an information specialist, and review methodologists to conduct the review. Knowledge user engagement provided context in refining 19 AF questions. A peer-reviewed search strategy identified citations in Medline, PsycINFO, Embase, and CINAHL databases between 1980 and 2018. Two reviewers independently screened records for inclusion using explicit study eligibility criteria for the population, design, delirium diagnosis, and investigational intent. RESULTS Of 104 studies reporting empirical data and meeting eligibility criteria, most were conducted in patients with cancer (73.1%) and in inpatient PC units (52%). The most frequent study design was a one or more group, nonrandomized trial or cohort (67.3%). Evidence gaps were identified: delirium risk prediction; comparative effectiveness and harms of prevention, variability in delirium management across PC settings, advanced directive and substitute decision-maker input, and transition of care location; and estimating delirium reversibility. Future rigorous primary studies are required to address these gaps and preliminary concerns regarding the quality of extant literature. CONCLUSION Substantial evidence gaps exist, providing opportunities for future research regarding the assessment, prognosis, and management of delirium in PC settings.
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Affiliation(s)
- Peter G Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | | | | | - Mohammed T Ansari
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada
| | - Franco Momoli
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - David K Wright
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Erin Rosenberg
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Department of Critical Care, Ottawa, Ontario, Canada
| | - Annmarie Hosie
- University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Jose L Pereira
- Department of Family Medicine, University of Ottawa, Ontario, Canada; Division of Palliative Medicine, McMaster University, Ontario, Canada
| | - David Meagher
- University of Limerick School of Medicine, Limerick, Ireland
| | - Jill Rice
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - John Scott
- The Ottawa Hospital, Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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25
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Bush SH, Tierney S, Lawlor PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs 2019; 77:1623-1643. [PMID: 28864877 PMCID: PMC5613058 DOI: 10.1007/s40265-017-0804-3] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.
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Affiliation(s)
- Shirley Harvey Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Bruyère Research Institute (BRI), Ottawa, ON, Canada. .,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada. .,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.
| | - Sallyanne Tierney
- Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| | - Peter Gerard Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute (BRI), Ottawa, ON, Canada.,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
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26
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Bush SH, Lawlor PG, Ryan K, Centeno C, Lucchesi M, Kanji S, Siddiqi N, Morandi A, Davis DHJ, Laurent M, Schofield N, Barallat E, Ripamonti CI. Delirium in adult cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv143-iv165. [PMID: 29992308 DOI: 10.1093/annonc/mdy147] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- S H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa
- Ottawa Hospital Research Institute, Ottawa
- Bruyère Research Institute, Ottawa
- Bruyère Continuing Care, Ottawa, Canada
| | - P G Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa
- Ottawa Hospital Research Institute, Ottawa
- Bruyère Research Institute, Ottawa
- Bruyère Continuing Care, Ottawa, Canada
| | - K Ryan
- Department of Palliative Medicine, Mater Misericordiae University Hospital, Dublin
- St Francis Hospice, Dublin
- School of Medicine, University College, Dublin, Ireland
| | - C Centeno
- Department of Palliative Medicine, University of Navarra Hospital, Pamplona
- Palliative Medicine Group, Oncology Area, Navarra Institute for Health Research IdiSNA, Pamplona
- ATLANTES Research Program, Institute for Culture and Society (ICS), University of Navarra, Pamplona, Spain
| | - M Lucchesi
- Division of Thoracic Oncology, Cardio-Thoracic Department, University Hospital of Pisa, Pisa, Italy
| | - S Kanji
- Ottawa Hospital Research Institute, Ottawa
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada
| | - N Siddiqi
- Department of Health Sciences, Hull York Medical School, University of York, York
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | - A Morandi
- Department of Rehabilitation, Aged Care Unit, Ancelle Hospital, Cremona, Italy
| | - D H J Davis
- MRC Unit for Lifelong Health and Ageing at University College London, London, UK
| | - M Laurent
- Internal Medicine and Geriatric Department, APHP, Henri-Mondor Hospital, Créteil
- University Paris Est (UPE), UPEC A-TVB DHU, CEpiA (Clinical Epidemiology and Aging) Unit EA 7376, Créteil, France
| | | | - E Barallat
- Faculty of Nursing, Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
| | - C I Ripamonti
- Department of Onco-Haematology Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
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27
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Marra A, Jackson JC, Ely EW, Graves AJ, Schnelle JF, Dittus RS, Wilson A, Han JH. Focusing on Inattention: The Diagnostic Accuracy of Brief Measures of Inattention for Detecting Delirium. J Hosp Med 2018; 13:551-557. [PMID: 29578552 PMCID: PMC6502509 DOI: 10.12788/jhm.2943] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Delirium is frequently missed in most clinical settings. Brief delirium assessments are needed. OBJECTIVE To determine the diagnostic accuracy of reciting the months of year backwards (MOTYB) from December to July (MOTYB-6) and December to January (MOTYB-12) for delirium as diagnosed by a psychiatrist and to explore the diagnostic accuracies of the following other brief attention tasks: (1) spell the word "LUNCH" backwards, (2) recite the days of the week backwards, (3) 10-letter vigilance "A" task, and (4) 5 picture recognition task. DESIGN Preplanned secondary analysis of a prospective observational study. SETTING Emergency department located within an academic, tertiary care hospital. PARTICIPANTS 234 acutely ill patients who were =65 years old. MEASUREMENTS The inattention tasks were administered by a physician. The reference standard for delirium was a comprehensive psychiatrist assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. Sensitivities and specificities were calculated. RESULTS Making any error on the MOTYB-6 task had a sensitivity of 80.0% (95% confidence interval [CI], 60.9%-91.1%) and specificity of 57.1% (95% CI, 50.4%- 63.7%). Making any error on the MOTYB-12 task had a sensitivity of 84.0% (95% CI, 65.4%-93.6%) and specificity of 51.9% (95% CI, 45.2%-58.5%). The best combination of sensitivity and specificity was reciting the days of the week backwards task; if the patient made any error, this was 84.0% (95% CI, 65.4%-93.6%) sensitive and 81.9% (95% CI, 76.1%-86.5%) specific. CONCLUSIONS MOTYB-6 and MOTYB-12 had very good sensitivities but had modest specificities for delirium, limiting their use as a standalone assessment. Reciting the days of the week backwards appeared to have the best combination of sensitivity and specificity for delirium.
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Affiliation(s)
- Annachiara Marra
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples, Federico II, Naples, Italy
| | - James C Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amy J Graves
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John F Schnelle
- Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert S Dittus
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amanda Wilson
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jin H Han
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Hausner D, Kevork N, Pope A, Hannon B, Bryson J, Lau J, Rodin G, Le LW, Zimmermann C. Factors associated with discharge disposition on an acute palliative care unit. Support Care Cancer 2018; 26:3951-3958. [PMID: 29850945 DOI: 10.1007/s00520-018-4274-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/15/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Acute palliative care units (APCUs) admit patients with cancer for symptom control, transition to community palliative care units or hospice (CPCU/H), or end-of-life care. Prognostication early in the course of admission is crucial for decision-making. We retrospectively evaluated factors associated with patients' discharge disposition on an APCU in a cancer center. METHODS We evaluated demographic, administrative, and clinical data for all patients admitted to the APCU in 2015. Clinical data included cancer diagnosis, delirium screening, and Edmonton Symptom Assessment System (ESAS) symptoms. An ESAS sub-score composed of fatigue, drowsiness, shortness of breath, and appetite (FDSA) was also investigated. Factors associated with patients' discharge disposition (home, CPCU/H, died on APCU) were identified using three-level multinomial logistic regression. RESULTS Among 280 patients, the median age was 65.5 and median length of stay was 10 days; 155 (55.4%) were admitted for symptom control, 65 (23.2%) for transition to CPCU/H, and 60 (21.4%) for terminal care. Discharge dispositions were as follows: 156 (55.7%) died, 63 (22.5%) returned home, and 61 (21.8%) were transferred to CPCU/H. On multivariable analysis, patients who died were less likely to be older (OR 0.97, p = 0.01), or to be admitted for symptom control (OR 0.06, p < 0.0001), and more likely to have a higher FDSA score 21-40 (OR 3.02, p = 0.004). Patients discharged to CPCU/H were less likely to have been admitted for symptom control (OR 0.06, p < 0.0001). CONCLUSION Age, reason for admission, and the FDSA symptom cluster on admission are variables that can inform clinicians about probable discharge disposition on an APCU.
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Affiliation(s)
- David Hausner
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada
| | - Nanor Kevork
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada
| | - Ashley Pope
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada
| | - Breffni Hannon
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada
| | - John Bryson
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada
| | - Jenny Lau
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada.,Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Princess Margaret Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Lisa W Le
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Camilla Zimmermann
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada. .,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada. .,Department of Psychiatry, University of Toronto, Toronto, Canada. .,Princess Margaret Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.
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29
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O'Regan NA, Maughan K, Liddy N, Fitzgerald J, Adamis D, Molloy DW, Meagher D, Timmons S. Five short screening tests in the detection of prevalent delirium: diagnostic accuracy and performance in different neurocognitive subgroups. Int J Geriatr Psychiatry 2017; 32:1440-1449. [PMID: 27917538 DOI: 10.1002/gps.4633] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 10/18/2016] [Accepted: 10/27/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Delirium is prevalent and serious, yet remains under-recognised. Systematic screening could improve detection; however, consensus is lacking as to the best approach. Our aim was to assess the diagnostic accuracy of five simple cognitive tests in delirium screening: six-item cognitive impairment test (6-CIT), clock-drawing test, spatial span forwards, months of the year backwards (MOTYB) and intersecting pentagons (IPT). METHODS A cross-sectional study was conducted. Within 36 h of admission, older medical patients were assessed for delirium using the Revised Delirium Rating Scale. They also underwent testing using the five cognitive tests outlined above. Sensitivity, specificity, positive and negative predictive values (PPV; NPV) were calculated for each method. Where appropriate, area under the receiver operating characteristic curve (AUC) was also calculated. RESULTS Four hundred seventy patients were included, and 184 had delirium. Of the tests scored on a scale, the 6-CIT had the highest AUC (0.876), the optimum cut-off for delirium screening being 8/9 (sensitivity 89.9%, specificity 62.7%, NPV 91.2%, PPV 59.2%). The MOTYB, scored in a binary fashion, also performed well (sensitivity 84.6%, specificity 58.4%, NPV 87.4%, PPV 52.8). On discriminant analysis, 6-CIT was the only test to discriminate between patients with delirium and those with dementia (without delirium), Wilks' Lambda = 0.748, p < 0.001. CONCLUSION The 6-CIT measures attention, temporal orientation and short-term memory and shows promise as a delirium screening test. This study suggests that it may also have potential in distinguishing the cognitive impairment of delirium from that of dementia in older patients. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- N A O'Regan
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland.,Division of Geriatric Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Parkwood Institute, St. Joseph's Healthcare, London, Ontario, Canada
| | - K Maughan
- School of Applied Psychology, University College Cork, Cork, Ireland
| | - N Liddy
- School of Medicine, University College Cork, Cork, Ireland
| | - J Fitzgerald
- Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation and Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - D Adamis
- Sligo Mental Health Services, Sligo, Ireland
| | - D W Molloy
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | - D Meagher
- Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation and Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - S Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
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Bush SH, Tierney S, Lawlor PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs 2017. [PMID: 28864877 DOI: 10.1007/s40265‐017‐0804‐3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.
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Affiliation(s)
- Shirley Harvey Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Bruyère Research Institute (BRI), Ottawa, ON, Canada. .,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada. .,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.
| | - Sallyanne Tierney
- Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| | - Peter Gerard Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute (BRI), Ottawa, ON, Canada.,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
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Baird L, Spiller JA. A quality improvement approach to cognitive assessment on hospice admission: could we use the 4AT or Short CAM? BMJ Open Qual 2017; 6:e000153. [PMID: 28959786 PMCID: PMC5609350 DOI: 10.1136/bmjoq-2017-000153] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 07/30/2017] [Indexed: 11/20/2022] Open
Abstract
Background Prevalence studies show that 13%–42% of patients admitted to specialist palliative care inpatient units have delirium. Symptoms of delirium are often subtle and easily missed, or misdiagnosed as fatigue or depression, and so the use of a screening tool could improve early identification and management of delirium and lead to improved outcomes. Patients admitted to hospices are often frail and tired, therefore a quick and easy-to-use method of cognitive assessment is essential. Methods A quality improvement (QI) approach (PDSA: Plan, Do, Study, Act) was used to improve screening for delirium on admission to a hospice unit. A baseline measure was taken of the rate of performance of cognitive assessment on admission. Five PDSA cycles were then undertaken which involved implementing change and then evaluating results through auditing case notes and interviewing staff. Results The first cycle determined staff preference between two cognitive assessment methods: the Short Confusion Assessment Method and the four ‘A’s Test (4AT). Two further PDSA cycles embedded the 4AT (the preferred tool) into the admission process, establishing it as a usable tool in the hospice setting for up to 92% of admissions. A subsequent cycle showing poor sustainability prompted staff education and changes to admission documentation, resulting in an increase in cognitive assessment being performed, from 50% to 76%. Conclusion The 4AT is a usable tool in the hospice inpatient setting to assess patients’ cognitive state on admission and can easily be incorporated into the admission process. The QI approach highlighted the need to link staff awareness of their use of the screening tool with perceived improvements in the treatment of delirium, which prompted the creation and implementation of a ‘Delirium Checklist’. Some initial lack of sustainability was addressed by staff education and changes to the admission paperwork to ensure compliance with the use of the 4AT and sustained improvement in screening for cognitive impairment.
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Affiliation(s)
- Lucy Baird
- Marie Curie Hospice, Marie Curie, Edinburgh, UK
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32
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Covarrubias-Gómez A, López Collada-Estrada M. Propofol-Based Palliative Sedation to Treat Antipsychotic-Resistant Agitated Delirium. J Pain Palliat Care Pharmacother 2017; 31:190-194. [PMID: 28506099 DOI: 10.1080/15360288.2017.1315476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Delirium is a common problem in terminally ill patients that is associated with significant distress and, hence, considered a palliative care emergency. The three subtypes of delirium are hyperactive, hypoactive, and mixed, depending on the level of psychomotor activity and arousal disturbance. When agitated delirium becomes refractory in the setting of imminent dying, the agitation may be so severe that palliative sedation (PS) is required. Palliative sedation involves the administration of sedative medications with the purpose of reducing level of consciousness for patients with refractory suffering in the setting of a terminal illness. Propofol is a sedative that has a short duration of action and a very rapid onset. These characteristics make it relatively easy to titrate. Reported doses range from 50 to 70 mg per hour. The authors present a case of antipsychotic-resistant agitated delirium treated with a propofol intravenous infusion.
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van Velthuijsen EL, Zwakhalen SMG, Warnier RMJ, Mulder WJ, Verhey FRJ, Kempen GIJM. Psychometric properties and feasibility of instruments for the detection of delirium in older hospitalized patients: a systematic review. Int J Geriatr Psychiatry 2016; 31:974-89. [PMID: 26898375 DOI: 10.1002/gps.4441] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 01/06/2016] [Accepted: 01/20/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Delirium is a serious and common complication among older hospitalized patients and is a predictor of many adverse outcomes. However, up to 72% of delirium incidents are unrecognized or misdiagnosed. The aim of this systematic review is to determine the validity, reliability, and feasibility of instruments for the detection of delirium in older hospitalized patients. METHODS A systematic literature search was conducted. The inclusion criteria were a mean or median age of 65+ years, the use of the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases-10 as a reference standard, and publication in English. All included studies underwent a quality assessment (QUADAS-2). RESULTS Forty-three of the 3.790 identified studies were relevant to the review, describing 28 instruments. Quality assessment resulted in 37 studies with a positive quality assessment, describing 23 instruments. Five instruments (Delirium Observation Scale (DOS), Nursing Delirium Screening Scale (Nu-DESC), Confusion Assessment Method (CAM), CAM-Intensive Care Unit (ICU), and Delirium Rating Scale-Revised-98) were described in three or more methodologically sound studies. The Delirium Observation Screening Scale (DOS) and Nu-DESC are observational instruments with good psychometric properties, but the Nu-DESC is shorter and has been validated in more languages. The CAM, CAM-ICU, and Delirium Rating Scale-Revised-98 (DRS-R-98) are instruments with both observational and interactive components. The CAM is the most widely studied and demonstrates the best psychometric properties. CONCLUSION Timely detection of delirium might reduce the negative outcomes of delirium in the long term. The Nu-DESC and CAM appear to be the most adequate instruments for detecting delirium. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Eveline L van Velthuijsen
- CAPHRI School for Public Health and Primary Care and Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Sandra M G Zwakhalen
- CAPHRI School for Public Health and Primary Care and Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Ron M J Warnier
- CAPHRI School for Public Health and Primary Care and Department of Health Services Research, Maastricht University, Maastricht, The Netherlands.,Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wubbo J Mulder
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Frans R J Verhey
- Alzheimer Center Limburg, MHeNS School for Mental Health and NeuroScience and Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands
| | - Gertrudis I J M Kempen
- CAPHRI School for Public Health and Primary Care and Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
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Jorgensen SM, Carnahan RM, Weckmann MT. Validity of the Delirium Observation Screening Scale in Identifying Delirium in Home Hospice Patients. Am J Hosp Palliat Care 2016; 34:744-747. [PMID: 27413013 DOI: 10.1177/1049909116658468] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Delirium is common in home hospice patients and conveys significant morbidity to both patients and caregivers. The Delirium Observation Screening Scale (DOS) was developed to improve delirium recognition but has yet to be validated in the home hospice setting. OBJECTIVE This pilot study aimed to explore the accuracy of the DOS for identifying delirium in home hospice patients. DESIGN Prospective delirium evaluation using a convenience sample. SETTING/PARTICIPANTS Community hospice patients were approached for study inclusion. MEASUREMENTS Participants were assessed using the Delirium Rating Scale-Revised-98 (DRS-R-98), with results being categorized as "delirium" or "no delirium." The Delirium Observation Screening Scale scores, completed by hospice nurses during weekly patient assessment visits, were compared to the DRS-R-98 results. RESULTS Within this population, 30/78 (38%) assessments were categorized as delirious. In the majority of assessments, 69/75 (92%), the DRS-R-98 and DOS provided congruent results. There were 5 false positives and 1 false negative, demonstrating the DOS to be a clinically useful tool with a sensitivity of 0.97 and specificity of 0.89. CONCLUSION The DOS appears to be an accurate way to screen for delirium in home hospice patients. Validation of the DOS may help to improve delirium recognition and treatment and has the potential to increase quality of life in this vulnerable population. This input will also be taken into consideration in the development of a systematic screening procedure for delirium diagnosis at our local hospice, which we hope will be generalizable to other hospice agencies.
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Affiliation(s)
- Shea M Jorgensen
- 1 University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Ryan M Carnahan
- 2 University of Iowa College of Public Health, Iowa City, IA, USA
| | - Michelle T Weckmann
- 3 Department of Family Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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35
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O'Reilly M, Larkin P, Conroy M, Twomey F, Lucey M, Dunne C, Meagher DJ. The Impact of a Novel Tool for Comprehensive Assessment of Palliative Care (MPCAT) on Assessment Outcome at 6- and 12-Month Follow-Up. J Pain Symptom Manage 2016; 52:107-16. [PMID: 27233135 DOI: 10.1016/j.jpainsymman.2015.12.343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 12/07/2015] [Accepted: 12/24/2015] [Indexed: 11/28/2022]
Abstract
CONTEXT Assessment in palliative care settings should be focused, sensitive, specific, and effective to minimize discomfort to vulnerable and often highly morbid patients. This report describes the development of an admission assessment protocol for a Specialist Palliative Care Inpatient Unit and its implementation into clinical practice. OBJECTIVES The aim of this study was to develop and investigate the impact of the implementation of a Specialist Palliative Care admission assessment tool on documentation of key patient needs. METHODS The outcome of a systematic literature review was used to develop an admission assessment protocol (the intervention) in a Specialist Palliative Care Inpatient Unit. Mixed methods were used to facilitate a comprehensive evaluation pre- and post-intervention to test the effectiveness, feasibility, and acceptability of the intervention. RESULTS The documented evidence of pain assessment improved from a baseline rate of 71% to 100% post-intervention. This improvement was maintained 12 months post-introduction of the tool (P < 0.001). The documented evidence of screening for spiritual distress increased from a baseline rate of 23% to 70% at 6 months and to 82% at 12 months (P < 0.001). The number of referrals made in the first 24 hours after assessment increased post-intervention (physiotherapy, P = 0.001; occupational therapy, P = 0.001; social work, P = 0.005; pastoral care, P = 0.005); this was maintained at 12 months. Significantly, more clinicians (88%) agreed that palliative care domains were comprehensively assessed post-intervention in comparison with 59% pre-intervention (P = 0.01). CONCLUSION Introducing the Milford Palliative Care Assessment Tool was associated with significant improvement in assessment of multiple important aspects of patient need.
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Affiliation(s)
| | - Philip Larkin
- School of Nursing, Midwifery and Health Systems, University College Dublin, Limerick, Ireland
| | | | | | | | - Colum Dunne
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - David J Meagher
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
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Han JH, Wilson A, Graves AJ, Shintani A, Schnelle JF, Ely EW. A quick and easy delirium assessment for nonphysician research personnel. Am J Emerg Med 2016; 34:1031-6. [PMID: 27021131 DOI: 10.1016/j.ajem.2016.02.069] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 01/28/2016] [Accepted: 02/25/2016] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Delirium in the emergency department (ED) is an emerging field of research. Most ED research infrastructures utilize lay personnel to collect data, but delirium assessments that can be reliably performed by nonphysicians are lacking. We evaluated the diagnostic performance of the modified Brief Confusion Assessment Method (modified bCAM) for this purpose. METHODS This was a secondary analysis of a prospective observational study that enrolled ED patients 65years or older. The original bCAM was a brief (<2minutes) delirium assessment that assessed for inattention by asking the patient to recite the months backward from December to July. It was modified by adding the Vigilance A ("squeeze my hand when you hear the letter 'A'") to the inattention assessment. The elements of the modified bCAM were performed by a research assistant (RA) and emergency physician. The reference standard for delirium was a psychiatrist assessment performed within 3hours using Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Text Revision criteria. All assessors were blinded to each other. Sensitivities and specificities with their 95% confidence intervals (CIs) were calculated for the RA and emergency physician. RESULTS Of the 406 patients enrolled, 50 (12%) were delirious. The modified bCAM was 82.0% (95% CI, 71.4%-92.6%) sensitive and 96.1% (95% CI, 94.0%-98.1%) specific when performed by the RA. The emergency physician's modified bCAM exhibited similar diagnostic performance. CONCLUSIONS The modified bCAM may be a feasible and accurate method for nonphysicians to assess for delirium. Future studies are needed to confirm these findings.
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Affiliation(s)
- Jin H Han
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Amanda Wilson
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy J Graves
- Department of Urologic Society, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ayumi Shintani
- Department of Clinical Epidemiology and Biostatistics, Osaka University, Osaka, Japan
| | - John F Schnelle
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee
| | - E Wesley Ely
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee
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Carrera Castro C, Romero Moreno FJ, González Pérez A. Revisión de la utilidad y fiabilidad de la Confusion Assessment Method en atención especializada y primaria, 2013. AVANCES EN ENFERMERÍA 2016. [DOI: 10.15446/av.enferm.v33n2.40385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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McLean SF. Case-Based Learning and its Application in Medical and Health-Care Fields: A Review of Worldwide Literature. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2016; 3:10.4137_JMECD.S20377. [PMID: 29349306 PMCID: PMC5736264 DOI: 10.4137/jmecd.s20377] [Citation(s) in RCA: 214] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 03/28/2016] [Accepted: 03/30/2016] [Indexed: 05/09/2023]
Abstract
INTRODUCTION Case-based learning (CBL) is a newer modality of teaching healthcare. In order to evaluate how CBL is currently used, a literature search and review was completed. METHODS A literature search was completed using an OVID© database using PubMed as the data source, 1946-8/1/2015. Key words used were "Case-based learning" and "medical education", and 360 articles were retrieved. Of these, 70 articles were selected to review for location, human health care related fields of study, number of students, topics, delivery methods, and student level. RESULTS All major continents had studies on CBL. Education levels were 64% undergraduate and 34% graduate. Medicine was the most frequently represented field, with articles on nursing, occupational therapy, allied health, child development and dentistry. Mean number of students per study was 214 (7-3105). The top 3 most common methods of delivery were live presentation in 49%, followed by computer or web-based in 20% followed by mixed modalities in 19%. The top 3 outcome evaluations were: survey of participants, knowledge test, and test plus survey, with practice outcomes less frequent. Selected studies were reviewed in greater detail, highlighting advantages and disadvantages of CBL, comparisons to Problem-based learning, variety of fields in healthcare, variety in student experience, curriculum implementation, and finally impact on patient care. CONCLUSIONS CBL is a teaching tool used in a variety of medical fields using human cases to impart relevance and aid in connecting theory to practice. The impact of CBL can reach from simple knowledge gains to changing patient care outcomes.
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Affiliation(s)
- Susan F. McLean
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
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De J, Wand APF. Delirium Screening: A Systematic Review of Delirium Screening Tools in Hospitalized Patients. THE GERONTOLOGIST 2015; 55:1079-99. [DOI: 10.1093/geront/gnv100] [Citation(s) in RCA: 163] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 06/04/2015] [Indexed: 11/14/2022] Open
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Yevchak AM, Doherty K, Archambault EG, Kelly B, Fonda JR, Rudolph JL. The association between an ultrabrief cognitive screening in older adults and hospital outcomes. J Hosp Med 2015; 10:651-7. [PMID: 26374602 PMCID: PMC4594206 DOI: 10.1002/jhm.2450] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 07/31/2015] [Accepted: 08/02/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Though often recommended, hospital cognitive assessment is infrequently completed due to clinical and time constraints. OBJECTIVE This analysis aimed to evaluate the relationship between performance on ultrabrief cognitive screening instruments and hospital outcomes. DESIGN This is a secondary data analysis of a quality improvement project. SETTING Tertiary Veterans Administration hospital in New England. PATIENTS Patients, ≥ 60 years old, admitted to the hospital. INTERVENTION None. MEASUREMENTS Upon admission, patients were administered 2 cognitive screening tools. The modified Richmond Agitation and Sedation Scale (mRASS) is a measure of arousal that can be completed in 15 seconds. The months of the year backward (MOYB) is a measure of attention that can be administered in ≤1 minute. In-hospital outcomes included restraints and mortality, whereas discharge outcomes included length of stay, discharge not home, and variable direct costs. Risk ratios were calculated for dichotomous outcomes and unadjusted Poisson regression for continuous outcomes. RESULTS Patients (n = 3232) were screened. Altered arousal occurred in 15% of patients (n = 495); incorrect MOYB was recorded in 45% (n = 1457). Relative to those with normal arousal and attention, those with abnormal mRASS and incorrect MOYB had increased length of stay (incident rate ratio [IRR]: 1.23, 95% confidence interval [CI]: 1.17-1.30); restraint use (risk ratio [RR]: 5.05, 95% CI: 3.29-7.75), in-hospital mortality (RR: 3.46, 95% CI: 1.24-9.63), and decreased discharge home (RR: 2.97, 95% CI: 2.42-3.64). Hospital variable direct costs were slightly, but not significantly, higher (IRR: 1.02, 95% CI: 0.88-1.17). CONCLUSION Impaired performance on ultrabrief cognitive assessments of arousal and attention provide valuable insights regarding hospital outcomes.
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Affiliation(s)
| | - Kelly Doherty
- Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, MA
| | | | - Brittany Kelly
- Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, MA
- School of Nursing, Science and Health Professions, Regis College, Boston, MA
| | - Jennifer R. Fonda
- Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, MA
- Department of Epidemiology, Boston University, Boston MA
| | - James L. Rudolph
- Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, MA
- Division of Aging, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Toward a systematic approach to assessment and care planning in palliative care: A practical review of clinical tools. Palliat Support Care 2015; 14:161-73. [DOI: 10.1017/s1478951515000565] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
ABSTRACTObjective:Ensuring a consistent and systematic approach to the delivery of care for people with advanced disease is a priority for palliative care services worldwide. Many clinical tools are available to aid in this process; however, they are often used sporadically, and implementation of a routine set of clinical tools to guide care planning in the specialist palliative care sector in Australia has not been achieved. This study sought to recommend key clinical tools that may assist with the assessment and care planning of specialist palliative care provision for patients and family caregivers admitted to specialist palliative care settings (home, hospital, and hospice).Method:A mixed-methods sequential approach over four phases was employed, involving: (1) a palliative care sector survey, (2) a systematic literature review, (3) an appraisal of identified clinical tools, and (4) a focus group with an expert panel who critiqued and endorsed a final suite of clinical tools recommended for specialist palliative care.Results:Twelve tools with practical relevance were recommended for use across settings of care.Significance of Results:Palliative services should review current practices and seek to implement this recommended suite of tools to enhance assessment and guide care delivery across care settings. Subsequent evaluation should also occur.
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Abstract
Purpose of review Our review focuses on recent developments across many settings regarding the diagnosis, screening and management of delirium, so as to inform these aspects in the context of palliative and supportive care. Recent findings Delirium diagnostic criteria have been updated in the long-awaited Diagnostic Statistical Manual of Mental Disorders, fifth edition. Studies suggest that poor recognition of delirium relates to its clinical characteristics, inadequate interprofessional communication and lack of systematic screening. Validation studies are published for cognitive and observational tools to screen for delirium. Formal guidelines for delirium screening and management have been rigorously developed for intensive care, and may serve as a model for other settings. Given that palliative sedation is often required for the management of refractory delirium at the end of life, a version of the Richmond Agitation-Sedation Scale, modified for palliative care, has undergone preliminary validation. Summary Although formal systematic delirium screening with brief but sensitive tools is strongly advocated for patients in palliative and supportive care, it requires critical evaluation in terms of clinical outcomes, including patient comfort. Randomized controlled trials are needed to inform the development of guidelines for the management of delirium in this setting.
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Abstract
BACKGROUND The Confusion Assessment Method (CAM) is the most widely used delirium screening instrument. The aim of this study was to evaluate the reliability and validity of the European Portuguese version of CAM. METHODS The sample included elderly patients (≥65 years), admitted for at least 48 h, into two intermediate care units (ICMU) of Intensive Medicine and Surgical Services in a university hospital. Exclusion criteria were: score ≤11 on the Glasgow Coma Scale (GCS), blindness/deafness, inability to communicate and to speak Portuguese. For concurrent validity, a blinded assessment was conducted by a psychiatrist (DSM-IV-TR, as a reference standard) and by a trained researcher (CAM). This instrument was also compared with other cognitive measures to evaluate convergent validity. Inter-rater reliability was also assessed. RESULTS In this sample (n = 208), 25% (n = 53) of the patients had delirium, according to DSM-IV-TR. Using this reference standard, the CAM had a moderate sensitivity of 79% and an excellent specificity of 99%. The positive predictive value was 95%, indicating a strong ability to confirm delirium with a positive test result, and the negative predictive value was lower (93%). Good convergent validity was also found, in particular with Mini-Mental State Examination (MMSE) (rs = -0.676; p ≤0.01) and Digit Span Test (DST) forward (rs = -0.605; p ≤0.01), as well as a high inter-rater reliability (diagnostic k = 1.00; single items' k between 0.65 and 1.00). CONCLUSION Robust results on concurrent and convergent validity and good reliability were achieved. This version was shown to be a valid and reliable instrument for delirium detection in elderly patients hospitalized in intermediate care units.
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Meagher D, O'Regan N, Ryan D, Connolly W, Boland E, O'Caoimhe R, Clare J, Mcfarland J, Tighe S, Leonard M, Adamis D, Trzepacz PT, Timmons S. Frequency of delirium and subsyndromal delirium in an adult acute hospital population. Br J Psychiatry 2014; 205:478-85. [PMID: 25359923 DOI: 10.1192/bjp.bp.113.139865] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background The frequency of full syndromal and subsyndromal delirium is understudied. Aims We conducted a point prevalence study in a general hospital. Method Possible delirium identified by testing for inattention was evaluated regarding delirium status (full/subsyndromal delirium) using categorical (Confusion Assessment Method (CAM), DSM-IV) and dimensional (Delirium Rating Scale-Revised-98 (DRS-R98) scores) methods. Results In total 162 of 311 patients (52%) screened positive for inattention. Delirium was diagnosed in 55 patients (17.7%) using DSM-IV, 52 (16.7%) using CAM and 58 (18.6%) using DRS-R98⩾12 with concordance for 38 (12.2%) individuals. Subsyndromal delirium was identified in 24 patients (7.7%) using a DRS-R98 score of 7-11 and 41 (13.2%) using 2/4 CAM criteria. Subsyndromal delirium with inattention (v. without) had greater disturbance of multiple delirium symptoms. Conclusions The point prevalence of delirium and subsyndromal delirium was 25%. There was modest concordance between DRS-R98, DSM-IV and CAM delirium diagnoses. Inattention should be central to subsyndromal delirium definitions.
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Affiliation(s)
- D Meagher
- D. Meagher, MD, PhD, MRCPsych, Foundation Chair of Psychiatry, Head of Teaching and Research in Psychiatry, University of Limerick Medical School, Limerick, Director of the Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick and Department of Psychiatry, University Hospital Limerick, Ireland; N. O'Regan, MRCPI, D. Ryan, MRCPI, W. Connolly, MB, E. Boland, MB, R. O'Caoimhe, MB, J. Clare, MRCP, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland; J. Mcfarland, MD, MRCPsych, S. Tighe, MRCPsych, University of Limerick Medical School, Limerick and Clare-Limerick Mental Health Services, HSE-West, Mental Health Services, Ireland; M. Leonard, MD, MRCPsych, University of Limerick Medical School, Limerick and Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; D. Adamis, MD, MRCPsych, University of Limerick Medical School, Limerick, Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland, Sligo-Leitrim Mental Health Services, Sligo, Ireland, and Research and Academic Institute of Athens, Athens, Greece; P. T. Trzepacz, MD, Lilly Research Laboratories, Indianapolis, Indiana, University of Mississippi Medical School, Jackson, Tufts University School of Medicine, Massachusetts and Indiana University School of Medicine, Indiana, USA; S. Timmons, MD, MRCPI, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland
| | - N O'Regan
- D. Meagher, MD, PhD, MRCPsych, Foundation Chair of Psychiatry, Head of Teaching and Research in Psychiatry, University of Limerick Medical School, Limerick, Director of the Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick and Department of Psychiatry, University Hospital Limerick, Ireland; N. O'Regan, MRCPI, D. Ryan, MRCPI, W. Connolly, MB, E. Boland, MB, R. O'Caoimhe, MB, J. Clare, MRCP, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland; J. Mcfarland, MD, MRCPsych, S. Tighe, MRCPsych, University of Limerick Medical School, Limerick and Clare-Limerick Mental Health Services, HSE-West, Mental Health Services, Ireland; M. Leonard, MD, MRCPsych, University of Limerick Medical School, Limerick and Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; D. Adamis, MD, MRCPsych, University of Limerick Medical School, Limerick, Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland, Sligo-Leitrim Mental Health Services, Sligo, Ireland, and Research and Academic Institute of Athens, Athens, Greece; P. T. Trzepacz, MD, Lilly Research Laboratories, Indianapolis, Indiana, University of Mississippi Medical School, Jackson, Tufts University School of Medicine, Massachusetts and Indiana University School of Medicine, Indiana, USA; S. Timmons, MD, MRCPI, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland
| | - D Ryan
- D. Meagher, MD, PhD, MRCPsych, Foundation Chair of Psychiatry, Head of Teaching and Research in Psychiatry, University of Limerick Medical School, Limerick, Director of the Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick and Department of Psychiatry, University Hospital Limerick, Ireland; N. O'Regan, MRCPI, D. Ryan, MRCPI, W. Connolly, MB, E. Boland, MB, R. O'Caoimhe, MB, J. Clare, MRCP, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland; J. Mcfarland, MD, MRCPsych, S. Tighe, MRCPsych, University of Limerick Medical School, Limerick and Clare-Limerick Mental Health Services, HSE-West, Mental Health Services, Ireland; M. Leonard, MD, MRCPsych, University of Limerick Medical School, Limerick and Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; D. Adamis, MD, MRCPsych, University of Limerick Medical School, Limerick, Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland, Sligo-Leitrim Mental Health Services, Sligo, Ireland, and Research and Academic Institute of Athens, Athens, Greece; P. T. Trzepacz, MD, Lilly Research Laboratories, Indianapolis, Indiana, University of Mississippi Medical School, Jackson, Tufts University School of Medicine, Massachusetts and Indiana University School of Medicine, Indiana, USA; S. Timmons, MD, MRCPI, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland
| | - W Connolly
- D. Meagher, MD, PhD, MRCPsych, Foundation Chair of Psychiatry, Head of Teaching and Research in Psychiatry, University of Limerick Medical School, Limerick, Director of the Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick and Department of Psychiatry, University Hospital Limerick, Ireland; N. O'Regan, MRCPI, D. Ryan, MRCPI, W. Connolly, MB, E. Boland, MB, R. O'Caoimhe, MB, J. Clare, MRCP, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland; J. Mcfarland, MD, MRCPsych, S. Tighe, MRCPsych, University of Limerick Medical School, Limerick and Clare-Limerick Mental Health Services, HSE-West, Mental Health Services, Ireland; M. Leonard, MD, MRCPsych, University of Limerick Medical School, Limerick and Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; D. Adamis, MD, MRCPsych, University of Limerick Medical School, Limerick, Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland, Sligo-Leitrim Mental Health Services, Sligo, Ireland, and Research and Academic Institute of Athens, Athens, Greece; P. T. Trzepacz, MD, Lilly Research Laboratories, Indianapolis, Indiana, University of Mississippi Medical School, Jackson, Tufts University School of Medicine, Massachusetts and Indiana University School of Medicine, Indiana, USA; S. Timmons, MD, MRCPI, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland
| | - E Boland
- D. Meagher, MD, PhD, MRCPsych, Foundation Chair of Psychiatry, Head of Teaching and Research in Psychiatry, University of Limerick Medical School, Limerick, Director of the Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick and Department of Psychiatry, University Hospital Limerick, Ireland; N. O'Regan, MRCPI, D. Ryan, MRCPI, W. Connolly, MB, E. Boland, MB, R. O'Caoimhe, MB, J. Clare, MRCP, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland; J. Mcfarland, MD, MRCPsych, S. Tighe, MRCPsych, University of Limerick Medical School, Limerick and Clare-Limerick Mental Health Services, HSE-West, Mental Health Services, Ireland; M. Leonard, MD, MRCPsych, University of Limerick Medical School, Limerick and Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; D. Adamis, MD, MRCPsych, University of Limerick Medical School, Limerick, Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland, Sligo-Leitrim Mental Health Services, Sligo, Ireland, and Research and Academic Institute of Athens, Athens, Greece; P. T. Trzepacz, MD, Lilly Research Laboratories, Indianapolis, Indiana, University of Mississippi Medical School, Jackson, Tufts University School of Medicine, Massachusetts and Indiana University School of Medicine, Indiana, USA; S. Timmons, MD, MRCPI, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland
| | - R O'Caoimhe
- D. Meagher, MD, PhD, MRCPsych, Foundation Chair of Psychiatry, Head of Teaching and Research in Psychiatry, University of Limerick Medical School, Limerick, Director of the Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick and Department of Psychiatry, University Hospital Limerick, Ireland; N. O'Regan, MRCPI, D. Ryan, MRCPI, W. Connolly, MB, E. Boland, MB, R. O'Caoimhe, MB, J. Clare, MRCP, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland; J. Mcfarland, MD, MRCPsych, S. Tighe, MRCPsych, University of Limerick Medical School, Limerick and Clare-Limerick Mental Health Services, HSE-West, Mental Health Services, Ireland; M. Leonard, MD, MRCPsych, University of Limerick Medical School, Limerick and Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; D. Adamis, MD, MRCPsych, University of Limerick Medical School, Limerick, Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland, Sligo-Leitrim Mental Health Services, Sligo, Ireland, and Research and Academic Institute of Athens, Athens, Greece; P. T. Trzepacz, MD, Lilly Research Laboratories, Indianapolis, Indiana, University of Mississippi Medical School, Jackson, Tufts University School of Medicine, Massachusetts and Indiana University School of Medicine, Indiana, USA; S. Timmons, MD, MRCPI, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland
| | - J Clare
- D. Meagher, MD, PhD, MRCPsych, Foundation Chair of Psychiatry, Head of Teaching and Research in Psychiatry, University of Limerick Medical School, Limerick, Director of the Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick and Department of Psychiatry, University Hospital Limerick, Ireland; N. O'Regan, MRCPI, D. Ryan, MRCPI, W. Connolly, MB, E. Boland, MB, R. O'Caoimhe, MB, J. Clare, MRCP, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland; J. Mcfarland, MD, MRCPsych, S. Tighe, MRCPsych, University of Limerick Medical School, Limerick and Clare-Limerick Mental Health Services, HSE-West, Mental Health Services, Ireland; M. Leonard, MD, MRCPsych, University of Limerick Medical School, Limerick and Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; D. Adamis, MD, MRCPsych, University of Limerick Medical School, Limerick, Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland, Sligo-Leitrim Mental Health Services, Sligo, Ireland, and Research and Academic Institute of Athens, Athens, Greece; P. T. Trzepacz, MD, Lilly Research Laboratories, Indianapolis, Indiana, University of Mississippi Medical School, Jackson, Tufts University School of Medicine, Massachusetts and Indiana University School of Medicine, Indiana, USA; S. Timmons, MD, MRCPI, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland
| | - J Mcfarland
- D. Meagher, MD, PhD, MRCPsych, Foundation Chair of Psychiatry, Head of Teaching and Research in Psychiatry, University of Limerick Medical School, Limerick, Director of the Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick and Department of Psychiatry, University Hospital Limerick, Ireland; N. O'Regan, MRCPI, D. Ryan, MRCPI, W. Connolly, MB, E. Boland, MB, R. O'Caoimhe, MB, J. Clare, MRCP, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland; J. Mcfarland, MD, MRCPsych, S. Tighe, MRCPsych, University of Limerick Medical School, Limerick and Clare-Limerick Mental Health Services, HSE-West, Mental Health Services, Ireland; M. Leonard, MD, MRCPsych, University of Limerick Medical School, Limerick and Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; D. Adamis, MD, MRCPsych, University of Limerick Medical School, Limerick, Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland, Sligo-Leitrim Mental Health Services, Sligo, Ireland, and Research and Academic Institute of Athens, Athens, Greece; P. T. Trzepacz, MD, Lilly Research Laboratories, Indianapolis, Indiana, University of Mississippi Medical School, Jackson, Tufts University School of Medicine, Massachusetts and Indiana University School of Medicine, Indiana, USA; S. Timmons, MD, MRCPI, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland
| | - S Tighe
- D. Meagher, MD, PhD, MRCPsych, Foundation Chair of Psychiatry, Head of Teaching and Research in Psychiatry, University of Limerick Medical School, Limerick, Director of the Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick and Department of Psychiatry, University Hospital Limerick, Ireland; N. O'Regan, MRCPI, D. Ryan, MRCPI, W. Connolly, MB, E. Boland, MB, R. O'Caoimhe, MB, J. Clare, MRCP, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland; J. Mcfarland, MD, MRCPsych, S. Tighe, MRCPsych, University of Limerick Medical School, Limerick and Clare-Limerick Mental Health Services, HSE-West, Mental Health Services, Ireland; M. Leonard, MD, MRCPsych, University of Limerick Medical School, Limerick and Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; D. Adamis, MD, MRCPsych, University of Limerick Medical School, Limerick, Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland, Sligo-Leitrim Mental Health Services, Sligo, Ireland, and Research and Academic Institute of Athens, Athens, Greece; P. T. Trzepacz, MD, Lilly Research Laboratories, Indianapolis, Indiana, University of Mississippi Medical School, Jackson, Tufts University School of Medicine, Massachusetts and Indiana University School of Medicine, Indiana, USA; S. Timmons, MD, MRCPI, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland
| | - M Leonard
- D. Meagher, MD, PhD, MRCPsych, Foundation Chair of Psychiatry, Head of Teaching and Research in Psychiatry, University of Limerick Medical School, Limerick, Director of the Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick and Department of Psychiatry, University Hospital Limerick, Ireland; N. O'Regan, MRCPI, D. Ryan, MRCPI, W. Connolly, MB, E. Boland, MB, R. O'Caoimhe, MB, J. Clare, MRCP, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland; J. Mcfarland, MD, MRCPsych, S. Tighe, MRCPsych, University of Limerick Medical School, Limerick and Clare-Limerick Mental Health Services, HSE-West, Mental Health Services, Ireland; M. Leonard, MD, MRCPsych, University of Limerick Medical School, Limerick and Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; D. Adamis, MD, MRCPsych, University of Limerick Medical School, Limerick, Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland, Sligo-Leitrim Mental Health Services, Sligo, Ireland, and Research and Academic Institute of Athens, Athens, Greece; P. T. Trzepacz, MD, Lilly Research Laboratories, Indianapolis, Indiana, University of Mississippi Medical School, Jackson, Tufts University School of Medicine, Massachusetts and Indiana University School of Medicine, Indiana, USA; S. Timmons, MD, MRCPI, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland
| | - D Adamis
- D. Meagher, MD, PhD, MRCPsych, Foundation Chair of Psychiatry, Head of Teaching and Research in Psychiatry, University of Limerick Medical School, Limerick, Director of the Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick and Department of Psychiatry, University Hospital Limerick, Ireland; N. O'Regan, MRCPI, D. Ryan, MRCPI, W. Connolly, MB, E. Boland, MB, R. O'Caoimhe, MB, J. Clare, MRCP, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland; J. Mcfarland, MD, MRCPsych, S. Tighe, MRCPsych, University of Limerick Medical School, Limerick and Clare-Limerick Mental Health Services, HSE-West, Mental Health Services, Ireland; M. Leonard, MD, MRCPsych, University of Limerick Medical School, Limerick and Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; D. Adamis, MD, MRCPsych, University of Limerick Medical School, Limerick, Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland, Sligo-Leitrim Mental Health Services, Sligo, Ireland, and Research and Academic Institute of Athens, Athens, Greece; P. T. Trzepacz, MD, Lilly Research Laboratories, Indianapolis, Indiana, University of Mississippi Medical School, Jackson, Tufts University School of Medicine, Massachusetts and Indiana University School of Medicine, Indiana, USA; S. Timmons, MD, MRCPI, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland
| | - P T Trzepacz
- D. Meagher, MD, PhD, MRCPsych, Foundation Chair of Psychiatry, Head of Teaching and Research in Psychiatry, University of Limerick Medical School, Limerick, Director of the Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick and Department of Psychiatry, University Hospital Limerick, Ireland; N. O'Regan, MRCPI, D. Ryan, MRCPI, W. Connolly, MB, E. Boland, MB, R. O'Caoimhe, MB, J. Clare, MRCP, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland; J. Mcfarland, MD, MRCPsych, S. Tighe, MRCPsych, University of Limerick Medical School, Limerick and Clare-Limerick Mental Health Services, HSE-West, Mental Health Services, Ireland; M. Leonard, MD, MRCPsych, University of Limerick Medical School, Limerick and Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; D. Adamis, MD, MRCPsych, University of Limerick Medical School, Limerick, Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland, Sligo-Leitrim Mental Health Services, Sligo, Ireland, and Research and Academic Institute of Athens, Athens, Greece; P. T. Trzepacz, MD, Lilly Research Laboratories, Indianapolis, Indiana, University of Mississippi Medical School, Jackson, Tufts University School of Medicine, Massachusetts and Indiana University School of Medicine, Indiana, USA; S. Timmons, MD, MRCPI, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland
| | - S Timmons
- D. Meagher, MD, PhD, MRCPsych, Foundation Chair of Psychiatry, Head of Teaching and Research in Psychiatry, University of Limerick Medical School, Limerick, Director of the Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick and Department of Psychiatry, University Hospital Limerick, Ireland; N. O'Regan, MRCPI, D. Ryan, MRCPI, W. Connolly, MB, E. Boland, MB, R. O'Caoimhe, MB, J. Clare, MRCP, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland; J. Mcfarland, MD, MRCPsych, S. Tighe, MRCPsych, University of Limerick Medical School, Limerick and Clare-Limerick Mental Health Services, HSE-West, Mental Health Services, Ireland; M. Leonard, MD, MRCPsych, University of Limerick Medical School, Limerick and Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; D. Adamis, MD, MRCPsych, University of Limerick Medical School, Limerick, Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland, Sligo-Leitrim Mental Health Services, Sligo, Ireland, and Research and Academic Institute of Athens, Athens, Greece; P. T. Trzepacz, MD, Lilly Research Laboratories, Indianapolis, Indiana, University of Mississippi Medical School, Jackson, Tufts University School of Medicine, Massachusetts and Indiana University School of Medicine, Indiana, USA; S. Timmons, MD, MRCPI, Centre for Gerontology and Rehabilitation, St Finbarr's Hospital, Cork, Ireland
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Neufeld KJ, Nelliot A, Inouye SK, Ely EW, Bienvenu OJ, Lee HB, Needham DM. Delirium diagnosis methodology used in research: a survey-based study. Am J Geriatr Psychiatry 2014; 22:1513-21. [PMID: 24745562 PMCID: PMC4164600 DOI: 10.1016/j.jagp.2014.03.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 03/05/2014] [Accepted: 03/06/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe methodology used to diagnose delirium in research studies evaluating delirium detection tools. METHODS The authors used a survey to address reference rater methodology for delirium diagnosis, including rater characteristics, sources of patient information, and diagnostic process, completed via web or telephone interview according to respondent preference. Participants were authors of 39 studies included in three recent systematic reviews of delirium detection instruments in hospitalized patients. RESULTS Authors from 85% (N = 33) of the 39 eligible studies responded to the survey. The median number of raters per study was 2.5 (interquartile range: 2-3); 79% were physicians. The raters' median duration of clinical experience with delirium diagnosis was 7 years (interquartile range: 4-10), with 5% having no prior clinical experience. Inter-rater reliability was evaluated in 70% of studies. Cognitive tests and delirium detection tools were used in the delirium reference rating process in 61% (N = 21) and 45% (N = 15) of studies, respectively, with 33% (N = 11) using both and 27% (N = 9) using neither. When patients were too drowsy or declined to participate in delirium evaluation, 70% of studies (N = 23) used all available information for delirium diagnosis, whereas 15% excluded such patients. CONCLUSION Significant variability exists in reference standard methods for delirium diagnosis in published research. Increasing standardization by documenting inter-rater reliability, using standardized cognitive and delirium detection tools, incorporating diagnostic expert consensus panels, and using all available information in patients declining or unable to participate with formal testing may help advance delirium research by increasing consistency of case detection and improving generalizability of research results.
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Affiliation(s)
- KJ Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland USA
| | - A Nelliot
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland USA
| | - SK Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts USA,Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts USA
| | - EW Ely
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Center for Health Services Research, Vanderbilt School of Medicine, Nashville, Tennessee USA,Geriatric Research, Education and Clinical Center, (GRECC) Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee USA
| | - OJ Bienvenu
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland USA
| | - HB Lee
- Psychological Medicine Service, Yale-New Haven Hospital, New Haven, Connecticut USA
| | - DM Needham
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland USA,Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland USA
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47
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Hosie A, Lobb E, Agar M, Davidson PM, Phillips J. Identifying the barriers and enablers to palliative care nurses' recognition and assessment of delirium symptoms: a qualitative study. J Pain Symptom Manage 2014; 48:815-30. [PMID: 24726761 DOI: 10.1016/j.jpainsymman.2014.01.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 01/21/2014] [Accepted: 02/07/2014] [Indexed: 12/27/2022]
Abstract
CONTEXT Delirium is underrecognized by nurses, including those working in palliative care settings where the syndrome occurs frequently. Identifying contextual factors that support and/or hinder palliative care nurses' delirium recognition and assessment capabilities is crucial, to inform development of clinical practice and systems aimed at improving patients' delirium outcomes. OBJECTIVES The aim of the study was to identify nurses' perceptions of the barriers and enablers to recognizing and assessing delirium symptoms in palliative care inpatient settings. METHODS A series of semistructured interviews, guided by critical incident technique, were conducted with nurses working in Australian palliative care inpatient settings. A hypoactive delirium vignette prompted participants' recall of delirium and identification of the perceived factors (barriers and enablers) that impacted on their delirium recognition and assessment capabilities. Thematic content analysis was used to analyze the qualitative data. RESULTS Thirty participants from nine palliative care services provided insights into the barriers and enablers of delirium recognition and assessment in the inpatient setting that were categorized as patient and family, health professional, and system level factors. Analysis revealed five themes, each reflecting both identified barriers and current and/or potential enablers: 1) value in listening to patients and engaging families, 2) assessment is integrated with care delivery, 3) respecting and integrating nurses' observations, 4) addressing nurses' delirium knowledge needs, and 5) integrating delirium recognition and assessment processes. CONCLUSION Supporting the development of palliative care nursing delirium recognition and assessment practice requires attending to a range of barriers and enablers at the patient and family, health professional, and system levels.
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Affiliation(s)
- Annmarie Hosie
- School of Nursing, The University of Notre Dame, Sydney, Darlinghurst, New South Wales, Australia.
| | - Elizabeth Lobb
- School of Nursing, The University of Notre Dame, Sydney, Darlinghurst, New South Wales, Australia; Palliative Care Department, Calvary Health Care Sydney, Kogarah, New South Wales, Australia; Cunningham Centre for Palliative Care, Sacred Heart Hospice, St. Vincent's Health Network, Darlinghurst, New South Wales, Australia; ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | - Meera Agar
- ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Prairiewood, New South Wales, Australia; Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Patricia M Davidson
- ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia; Faculty of Health, University of Technology, Broadway, New South Wales
| | - Jane Phillips
- School of Nursing, The University of Notre Dame, Sydney, Darlinghurst, New South Wales, Australia; Cunningham Centre for Palliative Care, Sacred Heart Hospice, St. Vincent's Health Network, Darlinghurst, New South Wales, Australia; ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
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Pilot study on the European Portuguese version of the Confusion Assessment Method. Acta Neuropsychiatr 2014; 26:321-4. [PMID: 25241759 DOI: 10.1017/neu.2014.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To present the pilot study on the European Portuguese validation of the Confusion Assessment Method (CAM). METHODS The translation process was carried out according to International Society Pharmacoeconomics and Outcomes Research guidelines with trained researchers and inter-rater reliability assessment. The study included 50 elderly patients, admitted (≥24 h) to two intermediate care units. Exclusion criteria were: Glasgow Coma Scale (total score ≤11), blindness/deafness, inability to communicate and not able to speak Portuguese. The sensitivity and specificity of CAM were assessed, with DSM-IV-TR criteria of delirium used as a reference standard. RESULTS Findings revealed excellent inter-rater reliability (k>0.81), moderate sensitivity (73%) and excellent specificity (95%). CONCLUSION These preliminary results suggested that this version emerges as a promising diagnostic instrument for delirium.
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O'Regan NA, Ryan DJ, Boland E, Connolly W, McGlade C, Leonard M, Clare J, Eustace JA, Meagher D, Timmons S. Attention! A good bedside test for delirium? J Neurol Neurosurg Psychiatry 2014; 85:1122-31. [PMID: 24569688 PMCID: PMC4173985 DOI: 10.1136/jnnp-2013-307053] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Routine delirium screening could improve delirium detection, but it remains unclear as to which screening tool is most suitable. We tested the diagnostic accuracy of the following screening methods (either individually or in combination) in the detection of delirium: MOTYB (months of the year backwards); SSF (Spatial Span Forwards); evidence of subjective or objective 'confusion'. METHODS We performed a cross-sectional study of general hospital adult inpatients in a large tertiary referral hospital. Screening tests were performed by junior medical trainees. Subsequently, two independent formal delirium assessments were performed: first, the Confusion Assessment Method (CAM) followed by the Delirium Rating Scale-Revised 98 (DRS-R98). DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) criteria were used to assign delirium diagnosis. Sensitivity and specificity ratios with 95% CIs were calculated for each screening method. RESULTS 265 patients were included. The most precise screening method overall was achieved by simultaneously performing MOTYB and assessing for subjective/objective confusion (sensitivity 93.8%, 95% CI 82.8 to 98.6; specificity 84.7%, 95% CI 79.2 to 89.2). In older patients, MOTYB alone was most accurate, whereas in younger patients, a simultaneous combination of SSF (cut-off 4) with either MOTYB or assessment of subjective/objective confusion was best. In every case, addition of the CAM as a second-line screening step to improve specificity resulted in considerable loss in sensitivity. CONCLUSIONS Our results suggest that simple attention tests may be useful in delirium screening. MOTYB used alone was the most accurate screening test in older people.
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Affiliation(s)
- Niamh A O'Regan
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | - Daniel J Ryan
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | | | | | - Ciara McGlade
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | - Maeve Leonard
- Department of Psychiatry, University of Limerick, Limerick, Ireland
| | - Josie Clare
- Department of Geriatric Medicine, Waterford Regional Hospital, Waterford, Ireland
| | - Joseph A Eustace
- HRB Clinical Research Facility at UCC, University College Cork, Cork, Ireland
| | - David Meagher
- Department of Psychiatry, University of Limerick, Limerick, Ireland Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
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