Diagnosing delirium in elderly Thai patients: utilization of the CAM algorithm

Factors predicting delirium among hospitalized older adults in an urban area, Thailand: A prospective cohort study

Background

Delirium is a common but often underrecognized complication in hospitalized older adults. It is associated with poor outcomes, including longer hospital stays, increased mortality, and long-term cognitive decline. While numerous studies have explored factors contributing to delirium, there is a lack of research on the context of older adults in Bangkok, Thailand. Understanding the predictors of delirium is crucial for early detection and prevention, particularly in an urban hospital setting.

Objective

This study aimed to determine the incidence rate of delirium and identify factors associated with its development in hospitalized older adults.

Methods

A prospective cohort study was conducted in four internal medicine wards of a large urban hospital in Bangkok, Thailand. Data were collected from 168 hospitalized older adults (≥60 years) over a 7-day period following admission. The Confusion Assessment Method (CAM), the Mini-Mental State Examination (TMSE), and the Systemic Inflammatory Response Syndrome (SIRS) scores were used to assess delirium and cognitive impairment. Data were collected between January 2022 and October 2022, and participants were evaluated on Day 1 (24 hours after admission), Day 3, and Day 7 or before discharge. Descriptive statistics and multivariate logistic regression were used to analyze predictors of delirium.

Results

The incidence rate of delirium among hospitalized older adults was 20.80%, with 19.00% developing delirium within the first 24-48 hours of admission. Multivariate analysis revealed that cognitive impairment (OR_adj = 7.81, p <0.001), infection (SIRS) (OR_adj = 3.80, p = 0.025), age (OR_adj = 1.09, p = 0.010), and the presence of caregivers prior to admission (OR_adj = 0.11, p = 0.008) were significant predictors of delirium. The model explained 35.30% of the variance in delirium occurrence.

Conclusion

This study highlights the high incidence of delirium among hospitalized older adults and identifies key risk factors, including cognitive impairment, infection, age, and the presence of caregivers. Early delirium screening, including the use of the CAM and TMSE, should be integrated into nursing care for delirium prevention. Infection prevention and effective management strategies should also be prioritized to reduce delirium risk.

Associated Factors of Functional Ability in Older Persons Undergoing Hip Surgery Immediately Post-Hospital Discharge: A Prospective Study

BACKGROUND

hip fractures commonly have an impact on older adults' health. Surgical treatment aims to reduce pain and promote functional ability. However, developing adverse health outcomes or complications post-hip surgery may impede older patients' recovery to return to functional ability as pre-fracture. We aimed to examine the association of personal factors and adverse health outcomes during hospitalization and post-hospital discharge on the functional ability of older people undergoing hip surgery.

METHODS

a total of 120 older people with hip fractures who were scheduled for surgery at three tertiary hospitals and met the inclusion criteria were recruited for this study. Data were obtained at admission, before discharge, and during the two-week postoperative follow-up using the Demographic, Hip Dysfunction and Osteoarthritis Outcome Score, Joint Replacement, the Confusion Assessment Method (CAM) Thai version, and Health Outcome Questionnaires. Descriptive statistics and multiple logistic regression analyses were performed to analyze the data.

RESULTS

most participants were female, with a mean age of 78.10 years (range = 60-93; SD = 8.37). The most common adverse health outcome during hospitalization was urinary tract infection, followed by delirium, pneumonia, deep vein thrombosis, and surgical site infection. At two weeks immediately post-hospital discharge, 16 participants experienced unpleasant events, including delirium, urinary tract infection, surgical site infection, and pneumonia. The significant predictors of poor functional ability at two weeks immediately post-hospital discharge were old age (OR = 1.114, p = 0.001), subtrochanteric fracture (OR = 13.48, p = 0.008), and type of surgery (OR = 4.105, p = 0.049).

Delirium assessment tools among hospitalized older adults: A systematic review and metaanalysis of diagnostic accuracy

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.

Risk factors for postoperative delirium in geriatric patients with hip fracture: A systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis was conducted to identify the potential risk factors for postoperative delirium in geriatric patients with hip fracture.

METHODS

PubMed, EMBASE, and Cochrane Library were searched from inception until December 31st, 2021. A combined searching strategy of subject words and free words was adopted. Studies involving risk factors for postoperative delirium in elderly patients undergoing hip fracture surgeries were reviewed. Qualities of included studies were assessed using the Newcastle-Ottawa Scale. Data were pooled and a meta-analysis was performed using Review Manager 5.3.

RESULTS

A total of 37 studies were included. The following risk factors were significant: advanced age (per year increase) (OR: 1.05, 95% CI 1.04-1.07), age>80 years (OR: 2.26, 95% CI 1.47-3.47), male (OR: 1.53, 95% CI 1.37-1.70), preoperative cognitive impairment (OR:3.20, 95% CI 2.12-4.83), preoperative dementia (OR: 2.74, 95% CI 2.18-3.45), preoperative delirium (OR: 9.23, 95% CI 8.26-10.32), diabetes (OR: 1.18, 95% CI 1.05-1.33), preoperative functional dependence (OR: 1.31, 95% CI 1.11-1.56), ASA level (per level increase) (OR: 1.63, 95% CI 1.04-2.57), ASA level≥3(OR: 1.76, 95% CI 1.39-2.24), low albumin (OR: 3.30, 95% CI 1.44-7.55), medical comorbidities (OR: 1.15, 95% CI 1.06-1.25), Parkinson's disease (OR: 4.17, 95% CI 1.68-10.31) and surgery delay>48 h (OR: 1.90, 95% CI 1.36-2.65).

CONCLUSIONS

Clinicians should be alert to patients with those risk factors. To identify the risk factors more precisely, more research studies with larger sample size and better design should be conducted.

Risk factors and adverse clinical outcomes of postoperative delirium in Thai elderly patients: A prospective cohort study

PURPOSE

To determine the incidence, risk factors, and adverse clinical outcomes of postoperative delirium (POD) in elderly patients.

DESIGN AND METHODS

A total of 429 patients scheduled to undergo noncardiac surgery were recruited. Delirium was assessed using the confusion assessment method.

FINDINGS

The incidence of POD was 5.4%. Risk factors of POD were age over 70 years, an American Society of Anesthesiologist physical status 2 and 3, cognitive impairment, history of psychiatric illness, and preoperative hemoglobin ≤ 10 g/dl.

PRACTICE IMPLICATIONS

The correction of modifiable risk factors, the use of preventive strategies, and the monitoring of POD are advisable to improve the quality of perioperative care.

Efficacy of quetiapine for delirium prevention in hospitalized older medical patients: a randomized double-blind controlled trial

Background

Delirium is a common disorder among hospitalized older patients and results in increased morbidity and mortality. The prevention of delirium is still challenging in older patient care. The role of antipsychotics in delirium prevention has been limited. Therefore, we conducted a trial to investigate the efficacy of quetiapine use to prevent delirium in hospitalized older medical patients.

Methods

This study was a randomized double-blind controlled trial conducted at Ramathibodi Hospital, Bangkok, Thailand. Patients aged ≥65 years hospitalized in the internal medicine service were randomized to quetiapine 12.5 mg or placebo once daily at bedtime for a maximum 7-day duration. The primary end point was delirium incidence. Secondary end points were delirium duration, length of hospital stay, ICU admission, rehospitalization and mortality within 30 and 90 days.

Results

A total of 122 patients were enrolled in the study. Eight (6.6%) left the trial before receiving the first dose of the intervention, whereas 114 (93.4%) were included in an intention-to-treat analysis allocated to the quetiapine or placebo group (n = 57 each). The delirium incidence rates in the quetiapine and placebo groups were 14.0 and 8.8% (OR = 1.698, 95% CI 0.520–5.545, P = 0.381), respectively. Other endpoints in the quetiapine and placebo groups were the median length of hospital stay, 6 (4–8) days versus 5 (4–8) days (P = 0.133), respectively; delirium duration, 4 (2.3–6.5) versus 3 (1.5–4.0) days (P = 0.557), respectively; ICU admission, 3 (5.3%) patients from both groups (P = 1.000); and mortality in the quetiapine and placebo groups, 1 (1.8%) versus 2 (3.5%) at 30 days (P = 0.566) and 7 (12.3%) versus 9 (15.8%) days at 90 days (P = 0.591). There were no significant differences in other outcomes. None of the participants reported adverse events.

Conclusions

Quetiapine prophylaxis did not reduce delirium incidence in hospitalized older medical patients. The use of quetiapine to prevent delirium in this population group should not be recommended.

Trial registration

This trial was retrospectively registered with the Thai clinical trials registry (TCTR) at clinicaltrials.in.th (TCTR20190927001) on September 26, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02160-7.

Role of perceived stress in postoperative delirium: an investigation among elderly patients

Objectives: This study examined levels of perceived stress (PS), postoperative delirium (POD) and associated factors among Thai elderly patients undergoing elective noncardiac surgery.Background and aims: Preoperative PS and change after operation have not been widely studied. Moreover, psychological factors associated with PS and POD has been poorly investigated.Materials and Methods: In total, 429 elderly patients were recruited at a university hospital. The preoperative evaluation included sociodemographic data, health behaviors at risk, Perceived Stress Scale (PSS-10), Neuroticism Inventory (NI), Mental State Examination T10 (MSET10), Montreal Cognitive Assessment (MoCA) and Geriatric Depression Scale (GDS-15). Three-day postoperative evaluation included PSS-10 and Confusion Assessment Method Algorithm (CAM) or CAM-ICU for Delirium. Multiple regression and logistic regression analysis were performed to determine potential predictors.Results: Females were 58.97%, and the mean age was 69.93 ± 6.87 years. Mean pre- and postoperative PS were 12.77 ± 5.41 and 13.39 ± 5.26, respectively (P < 0.05). Multiple regression revealed that neuroticism, depression, and BMI predicted PS significantly. None of the independent variables was found to predict postoperative PS except for preoperative PS (p <.001). POD at the recovery room was predicted by preoperative PS (odds ratio = 1.181, 95% CI = 1.019-1.369), whereas overall POD was predicted by MoCA (odds ratio = .864, 95% CI = .771 -.968).Conclusion: Preoperative PS was significant in that it was associated with postoperative PS and POD. A careful assessment of preoperative PS as well as providing brief interventions for patients with high levels of this condition may reduce the risk of POD.

Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method

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.

Processed electroencephalogram and evoked potential techniques for amelioration of postoperative delirium and cognitive dysfunction following non-cardiac and non-neurosurgical procedures in adults

BACKGROUND

Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) may complicate a patient's postoperative recovery in several ways. Monitoring of processed electroencephalogram (EEG) or evoked potential (EP) indices may prevent or minimize POD and POCD, probably through optimization of anaesthetic doses.

OBJECTIVES

To assess whether the use of processed EEG or auditory evoked potential (AEP) indices (bispectral index (BIS), narcotrend index, cerebral state index, state entropy and response entropy, patient state index, index of consciousness, A-line autoregressive index, and auditory evoked potentials (AEP index)) as guides to anaesthetic delivery can reduce the risk of POD and POCD in non-cardiac surgical or non-neurosurgical adult patients undergoing general anaesthesia compared with standard practice where only clinical signs are used.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and clinical trial registry databases up to 28 March 2017. We updated this search in February 2018, but these results have not been incorporated in the review.

SELECTION CRITERIA

We included randomized or quasi-randomized controlled trials comparing any method of processed EEG or evoked potential techniques (entropy, BIS, AEP etc.) against a control group where clinical signs were used to guide doses of anaesthetics in adults aged 18 years or over undergoing general anaesthesia for non-cardiac or non-neurosurgical elective operations.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were: occurrence of POD; and occurrence of POCD. Secondary outcomes included: all-cause mortality; any postoperative complications; and postoperative length of stay. We used GRADE to assess the quality of evidence for each outcome.

MAIN RESULTS

We included six randomized controlled trials (RCTs) with 2929 participants comparing processed EEG or EP indices-guided anaesthesia with clinical signs-guided anaesthesia. There are five ongoing studies and one study awaiting classification.Anaesthesia administration guided by the indices from a processed EEG (bispectral index) probably reduces the risk of POD within seven days after surgery with risk ratio (RR) of 0.71 (95% CI 0.59 to 0.85; number needed to treat for an additional beneficial outcome (NNTB) of 17, 95% CI 11 to 34; 2197 participants; 3 RCTs; moderate quality of evidence). Three trials also showed the lower rate of POCD at 12 weeks after surgery (RR 0.71, 95% CI 0.53 to 0.96; NNTB 38, 95% CI 21 to 289; 2051 participants; moderate-quality evidence), but it is uncertain whether processed EEG indices reduce POCD at one week (RR 0.84, 95% CI 0.69 to 1.02; 3 trials; 1989 participants; moderate-quality evidence), and at 52 weeks (RR 0.30, 95% CI 0.05 to 1.80; 1 trial; 59 participants; very low quality of evidence). There may be little or no effect on all-cause mortality (RR 1.01, 95% CI 0.62 to 1.64; 1 trial; 1155 participants; low-quality evidence). One trial suggested a lower risk of any postoperative complications with processed EEG (RR 0.51, 95% CI 0.37 to 0.71; 902 participants, moderate-quality evidence). There may be little or no effect on reduced postoperative length of stay (mean difference -0.2 days, 95% CI -2.02 to 1.62; 1155 participants; low-quality evidence).

AUTHORS' CONCLUSIONS

There is moderate-quality evidence that optimized anaesthesia guided by processed EEG indices could reduce the risk of postoperative delirium in patients aged 60 years or over undergoing non-cardiac surgical and non-neurosurgical procedures. We found moderate-quality evidence that postoperative cognitive dysfunction at three months could be reduced in these patients. The effect on POCD at one week and over one year after surgery is uncertain. There are no data available for patients under 60 years. Further blinded randomized controlled trials are needed to elucidate strategies for the amelioration of postoperative delirium and postoperative cognitive dysfunction, and their consequences such as dementia (including Alzheimer's disease (AD)) in both non-elderly (below 60 years) and elderly (60 years or over) adult patients. The one study awaiting classification and five ongoing studies may alter the conclusions of the review once assessed.

Physical activity and depression in older adults with and without cognitive impairment

Low physical activity and depression may be related to cognitive impairment in the elderly.

Psychometric properties and feasibility of instruments for the detection of delirium in older hospitalized patients: a systematic review

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.

Delirium in critical care: a study of incidence, prevalence, and associated factors in the tertiary care hospital of older Thai adults

OBJECTIVES

Delirium is a common condition in older adults which can have devastating outcomes. The studies about delirium in intensive care units (ICU) are relatively rare compared to studies in the non-ICU setting. This study aimed to study the prevalence, incidence, and risk factors of delirium among older Thai adults in ICU.

METHOD

Participants were older patients who were admitted to the ICU of Srinagarind Medical School, KhonKaen, Thailand from May 2013 to August 2014. Baseline characteristics were collected. Delirium was rated by trained clinical researchers using the Confusion Assessment Method for the ICU (CAM-ICU). Demographic data were analyzed using descriptive statistics. Regression analyses were used to analyze the outcomes.

RESULTS

Delirium occurred in 44 of 99 patients (44.4%) with an incidence rate of 22.2% (22/99). The prevalence of delirium in mechanically ventilated patients was 62.5% (30/48). The majority of the patients had delirium within five days of ICU admission. Seven independent predisposing factors were identified using bivariate regressions: age, functional status, disease severity, having pneumonia, cognitive impairment, depression, or previous stroke. Numbers of additional drugs, bed changes, physical restraints, sleep deprivation, use of bladder catheters, and patients with mechanical ventilators were independent precipitating factors. For multivariate regressions, previous stroke, multiple bed changes, and physical restraints were the significant factors.

CONCLUSION

The prevalence and incidence of delirium of older adults in the ICU setting in this study was high and comparable to prior studies. There are several significant risk factors associated with delirium which could be modified. These factors should be considered when designing effective preventive strategies of delirium.

Under-recognition of delirium in older adults by nurses in the intensive care unit setting

BACKGROUND

Nurses have the key roles to detect delirium in hospitalized older patients but under-recognition of delirium among nurses is prevalent. The objectives of this study were to identify the under-recognition rate of delirium by intensive care nurses (ICU) using Confusion Assessment Method for the ICU (CAM-ICU) and factors associated with under-recognition.

METHODS

Participants were older patients aged ≥65 years who were admitted to the ICU of Srinagarind Medical School, Khon Kaen, Thailand from May 2013 to August 2014. Baseline characteristics were collected. Delirium was rated by a trained clinical researcher using the CAM-ICU. Demographic data were analyzed using descriptive statistics. Univariate and multiple logistic regressions were used to analyze the outcomes.

RESULTS

Delirium occurred in 44 of 99 patients (44.4 %). Nurses could not identify delirium in 29.6 % of patients compared with researchers. Pre-existing dementia and depression were found in 47.7 % of patients. Pneumonia or other causes of respiratory failure were the most common causes of admission to ICU (47.7 %). Independent factors associated with under-recognition by nurses were identified-heart failure [adjusted odds ratio (OR), 77.8; 95 % confidence interval (CI) 2.5-2,543, p = 0.01] and pre-existing taking treatment with benzodiazepines (adjusted OR, 22.6; 95 % CI 1.8-85, p = 0.01).

DISCUSSION

Under-recognition of delirium is a frequent issue. New independent factors associated with under-recognition were identified. Awareness of delirium in the patients with these factors is recommended.

CONCLUSIONS

This study supports the finding of high under-recognition rates of delirium among hospitalized older adults in ICU. Patients with heart failure and receiving benzodiazepines were identified as barriers of recognition of delirium.

Validation study of the European Portuguese version of the Confusion Assessment Method (CAM)

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.

Pilot study on the European Portuguese version of the Confusion Assessment Method

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.

Validity and reliability of the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)

Purpose

The purpose of this study was to determine the validity and reliability of the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), when compared to the diagnoses made by delirium experts.

Patients and methods

This was a cross-sectional study conducted in both surgical intensive care and subintensive care units in Thailand between February–June 2011. Seventy patients aged 60 years or older who had been admitted to the units were enrolled into the study within the first 48 hours of admission. Each patient was randomly assessed as to whether they had delirium by a nurse using the Thai version of the CAM-ICU algorithm (Thai CAM-ICU) or by a delirium expert using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.

Results

The prevalence of delirium was found to be 18.6% (n=13) by the delirium experts. The sensitivity of the Thai CAM-ICU’s algorithms was found to be 92.3% (95% confidence interval [CI] =64.0%−99.8%), while the specificity was 94.7% (95% CI =85.4%−98.9%). The instrument displayed good interrater reliability (Cohen’s κ =0.81; 95% CI =0.64−0.99). The time taken to complete the Thai CAM-ICU was 1 minute (interquatile range, 1−2 minutes).

Conclusion

The Thai CAM-ICU demonstrated good validity, reliability, and ease of use when diagnosing delirium in a surgical intensive care unit setting. The use of this diagnostic tool should be encouraged for daily, routine use, so as to promote the early detection of delirium and its rapid treatment.

The Group Cohesiveness Scale (GCS) for psychiatric inpatients

PURPOSE

This study aimed to examine the psychometric properties of the seven-item Group Cohesiveness Scale (GCS).

DESIGN AND METHODS

In total, 96 inpatients completed the GCS along with the Cohesion to Therapist Scale Questionnaire and the Group Benefit Questionnaire after participating in group therapy sessions. Construct and concurrent validities and internal consistency were analyzed.

FINDINGS

It yielded a Cronbach's alpha of .87, with a one-factor solution with excellent fit indices. A significant correlation was found between the GCSc, the Cohesion to Therapist Scale, and the Group Benefit Questionnaire.

PRACTICE IMPLICATIONS

The scale shows good internal consistency, and its brevity makes it suitable for use with psychiatric inpatients.

Confusion assessment method: a systematic review and meta-analysis of diagnostic accuracy

BACKGROUND

Delirium is common in the early stages of hospitalization for a variety of acute and chronic diseases.

OBJECTIVES

To evaluate the diagnostic accuracy of two delirium screening tools, the Confusion Assessment Method (CAM) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

METHODS

We searched MEDLINE, EMBASE, and PsychInfo for relevant articles published in English up to March 2013. We compared two screening tools to Diagnostic and Statistical Manual of Mental Disorders IV criteria. Two reviewers independently assessed studies to determine their eligibility, validity, and quality. Sensitivity and specificity were calculated using a bivariate model.

RESULTS

Twenty-two studies (n = 2,442 patients) met the inclusion criteria. All studies demonstrated that these two scales can be administered within ten minutes, by trained clinical or research staff. The pooled sensitivities and specificity for CAM were 82% (95% confidence interval [CI]: 69%-91%) and 99% (95% CI: 87%-100%), and 81% (95% CI: 57%-93%) and 98% (95% CI: 86%-100%) for CAM-ICU, respectively.

CONCLUSION

Both CAM and CAM-ICU are validated instruments for the diagnosis of delirium in a variety of medical settings. However, CAM and CAM-ICU both present higher specificity than sensitivity. Therefore, the use of these tools should not replace clinical judgment.