Predicting post-operative delirium in elective orthopaedic patients: The Delirium Elderly At-Risk (DEAR) instrument [1]

Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
Age and Ageing (Impact Factor: 3.64). 04/2005; 34(2):169-71. DOI: 10.1093/ageing/afh245
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Available from: Susan H Freter,
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    • "For the risk stratification instruments of Inouye ( 1993 ) , Marcantonio ( 1994 ) , Pompei ( 1994 ) , Martinez ( 2012 ) , and Kobayashi ( 2013 ) the cut - off point to identify persons at high risk of postoperative delirium was set at a score of >3 points , >3 points , >8 points , >1 point , and at high or quit high risk , respectively ( as advised by the authors ) [ 5 – 7 , 14 , 15 ] . For the risk stratification instruments of O ' Keeffe ( 1996 ) , Freter ( 2005 ) , Greene ( 2009 ) and Rudolph ( 2009 ) , we defined the cut - off point for high risk as >1 point , >2 points , >2 points and >1 point , respectively . For these risk stratification instruments , the authors did not propose cut - off points . "
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    ABSTRACT: Several risk stratification instruments for postoperative delirium in older people have been developed because early interventions may prevent delirium. We investigated the performance and agreement of nine commonly used risk stratification instruments in an independent validation cohort of consecutive elective and emergency surgical patients aged >50 years with >1 risk factor for postoperative delirium. Data was collected prospectively. Delirium was diagnosed according to DSM-IV-TR criteria. The observed incidence of postoperative delirium was calculated per risk score per risk stratification instrument. In addition, the risk stratification instruments were compared in terms of area under the receiver operating characteristic (ROC) curve (AUC), and positive and negative predictive value. Finally, the positive agreement between the risk stratification instruments was calculated. When data required for an exact implementation of the original risk stratification instruments was not available, we used alternative data that was comparable. The study population included 292 patients: 60% men; mean age (SD), 66 (8) years; 90% elective surgery. The incidence of postoperative delirium was 9%. The maximum observed incidence per risk score was 50% (95%CI, 15– 85%); for eight risk stratification instruments, the maximum observed incidence per risk score was #25%. The AUC (95%CI) for the risk stratification instruments varied between 0.50 (0.36–0.64) and 0.66 (0.48–0.83). No AUC was statistically significant from 0.50 (p>0.11). Positive predictive values of the risk stratification instruments varied between 0–25%, negative predictive values between 89–95%. Positive agreement varied between 0-66%. No risk stratification instrument showed clearly superior performance. In conclusion, in this independent validation cohort, the performance and agreement of commonly used risk stratification instruments for postoperative delirium was poor. Although some caution is needed because the risk stratification instruments were not implemented exactly as described in the original studies, we think that their usefulness in clinical practice can be questioned.
    PLoS ONE 12/2014; 9(12):e113946. DOI:10.1371/journal.pone.0113946 · 3.23 Impact Factor
    • "In relation to dehydration, there was no demonstrated relationship with the development of POD (Kalisvaart et al., 2006) and the procedure for identification of dehydration involves bloodtaking and it was felt this might reduce the rate of recruitment. Hearing impairment mentioned in Freter et al. (2005) was not included because it is difficult to identify the extent of impairment. Type of anaesthesia showed significant differences in the incidence of POD. "
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    ABSTRACT: Aims A prospective study was conducted to develop a Common Risk-factor Assessment Predictive Tool (CAP) for identifying factors associated with post-operative delirium (POD) in orthopaedic surgery. A high, moderate and low risk score system was developed. The incidence rate of POD was also determined. Background POD has been reported as contributing to complications and poor outcomes, consequently affecting recovery and health-care provision. Methods Thirteen risk factors were evaluated. Regression coefficient and odds ratios were used to determine the association of the risk factors with POD. These were then used to develop a tool. Validation of these associated risk factors was carried out to check their effectiveness in predicting the development of POD. Findings Fifty nine of 277 patients developed POD. Four major risk factors were identified: visual impairment (p = 0.011; scored as 2), cognitive impairment (p < 0.001; scored as 4), urinary tract or respiratory tract infection (p = 0.028; scored as 3) and use of urinary catheterisation (p = 0.046; scored as 3). Using a 12-point score system the cut-off values were 4.5 (61.0% sensitivity and 85.8% specificity) and 7 (11.9% sensitivity and 95% specificity) respectively. Conclusion The tool can predict different levels of risk for POD. Nurses can use the tool to communicate patients’ risk of POD and identify potential preventive strategies.
    International Journal of Orthopaedic and Trauma Nursing 08/2012; 16(3):147–159. DOI:10.1016/j.ijotn.2012.03.005
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    • "The situation is compounded because many elderly patients arrive at the ED with little or no baseline information from institutional carers or general practitioners regarding their usual level of cognitive function, while information on previous medical history, medications and allergies is generally provided. Patients with a pre-existing cognitive deficit are at particularly high risk of developing a delirium (Elie et al., 1998; Freter et al., 2005), but accurate assessment is difficult when data on the patient's usual level of cognitive function is unknown. Early identification of delirium on or after admission is important for effective management and treatment (Cole et al., 1998; Cole, 2004). "
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    ABSTRACT: Delirium occurs frequently among elderly patients in the Emergency Department (ED), and accurate assessment is difficult without knowledge of the patient's usual cognitive functioning. This audit was designed to determine whether routine cognitive screening of elderly patients in ED could lead to early identification of delirium. An audit using the abbreviate mental test (AMT) and Confusion Assessment Method (CAM) tools assessed 28 elderly ED patients for the presence of delirium. Fourteen (50%) of the 28 patients had no cognitive deficit on admission. Eleven (39.3%) displayed a cognitive deficit other than delirium and three (10.7%) had delirium, but only one had been diagnosed prior to the audit. The prevalence rate of delirium in elderly ED patients was similar to those reported in the literature. The audit demonstrated the importance of cognitive assessment, as cognitive changes can be an early and sensitive indicator of physiological dysfunction. However, the AMT had limitations which inhibited its use in ED. A four question version known as the AMT4 may be more suitable. ED nurses should routinely establish baseline cognitive functioning and assess for delirium. The AMT4 may be more suitable because of its brevity, but requires further research.
    International Emergency Nursing 04/2008; 16(2):73-9. DOI:10.1016/j.ienj.2008.01.005 · 0.72 Impact Factor
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