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Predicting post-operative delirium in elective orthopaedic patients: the Delirium Elderly At-Risk (DEAR) instrument

Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
Age and Ageing (Impact Factor: 3.11). 04/2005; 34(2):169-71. DOI: 10.1093/ageing/afh245
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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 · 3.53 Impact Factor
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    ABSTRACT: Postoperative delirium (POD) is a common neuropsychiatric disorder characterized by inattention, fluctuating levels of consciousness, and disorganized thinking. POD can have serious consequences, including institutionalization and death. Risk stratification may target prevention to individuals at greater risk of POD. The objective of this study was to identify all published POD risk prediction models (RPMs) and to compare them with regard to their clinical practicability and predictive and discriminative performance. PubMed and EMBASE were searched from inception to January 1, 2013, for articles describing POD RPMs. Studies were included if they presented data from a cohort study, examined one or more RPMs, examined POD as an outcome, and assessed the performance of the RPM(s). Thirty of 2,246 articles were included, and 37 RPMs were found. Sixteen and six studies described individuals who had undergone cardiovascular and orthopedic surgery, respectively. The Confusion Assessment Method (CAM) for the intensive care unit checklist was the most often used diagnostic method (65%), followed by the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition criteria (16%). Predictors most often used in RPMs were age (20), preoperative Mini-Mental State Examination score (10), and preoperative increased alcohol use (7). Thirty RPMs were not validated, three were validated internally, and four were validated externally. Size of the models was not associated with their discriminatory performance. Instead of creating steadily new RPMs, existing RPMs should be further tested, improved, and meta-analytically integrated. It may be too early to implement a particular PODRPM in clinical practice with confidence.
    Journal of the American Geriatrics Society 12/2014; 62(12). DOI:10.1111/jgs.13138 · 4.22 Impact Factor
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    ABSTRACT: Purpose: The purpose of this study was to develop and test a scale for predicting POD in patients undergoing cerebrovascular surgery. Methods: The predictive scale for POD was composed of 32 items reflecting the strongest risk factors as determined by a literature review. The NEECHAM Confusion Scale determined POD onset and severity. Results: Delirium developed in 38 (31.1%) of the 122 patients in our sample. Logistic regression revealed the following risk factors: dehydration, age, disturbance of consciousness, underlying illness, and anxiety or depression. The final scale was weighted by referring to odds ratios. The area under the curve was 0.844 (95% CI = 0.766-0.921). The possible total score on this scale was 20 points. A cutoff score of 11 was set for risk of POD (patients scoring over 12 were considered at higher risk). The median score was 8 (range: 4-9) in the non-delirium group and 13 (range: 9-16) in the delirium group (U = 499.0; df = 120; p < 0.001). Scale scores were moderately correlated with delirium duration (rho = 0.532; p < 0.001). Conclusion: The present scale is a promising a tool for predicting POD but needs to be studied further.
    Archives of Gerontology and Geriatrics 05/2014; 59(2). DOI:10.1016/j.archger.2014.05.007 · 1.53 Impact Factor

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