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Prevalence, management and outcomes of unrecognized delirium in a National Sample of 1,493 older emergency department patients: how many were sent home and what happened to them?
Abstract
Background:
Retrospective studies estimate Emergency Department (ED) delirium recognition at <20%; few prospective studies have assessed delirium recognition and outcomes for patients with unrecognized delirium.
Objectives:
To prospectively measure delirium recognition by ED nurses and physicians, document their confidence in diagnosis and disposition, actual dispositions, and patient outcomes.
Methods:
Prospective observational study of people ≥65 years. We assessed delirium using the Confusion Assessment Method, then asked ED staff if the patient had delirium, confidence in their assessment, if the patient could be discharged, and contacted patients 1 week postdischarge. We report proportions and 95% confidence intervals (Cls).
Results:
We enrolled 1,493 participants; mean age was 77.9 years; 49.2% were female, 79 (5.3%, 95% CI 4.2-6.5%) had delirium. ED nurses missed delirium in 43/78 cases (55.1%, 95% CI 43.4-66.4%). Nurses considered 12/43 (27.9%) patients with unrecognized delirium safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 7.0/10. Physicians missed delirium in 10/20 (50.0%, 95% CI 27.2-72.8) cases and considered 2/10 (20.0%) safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 8.0/10. Fifteen patients with unrecognized delirium were sent home: 6.7% died at 1 week follow-up vs. none in those with recognized delirium and 1.1% in the rest of the cohort.
Conclusion:
Delirium recognition by nurses and physicians was sub-optimal at ~50% and may be associated with increased mortality. Research should explore root causes of unrecognized delirium, and novel strategies to systematically improve delirium recognition and patient outcomes.
... For example, a survey of 648 HPs in Italy revealed poor knowledge of the core features of delirium, including the acute onset and fluctuating course of symptoms, inattention, impaired level of consciousness, and disturbance of cognition [15]. Moreover, a study including 1,493 patients in seven academic hospitals in Canada documented that only half of older adults with delirium are recognized by medical and nursing staff in the emergency department [16]. Studies in long-term care settings have reported similar findings, suggesting that the low prevalence of delirium in long-term care facilities might be associated with missed delirium cases in daily practice due to lack of HPs' knowledge and detection skills [12]. ...
Background
Delirium is highly prevalent among older adults in various healthcare settings. Healthcare professionals’ knowledge is crucial for preventing, recognizing, and managing delirium and delirium-related adverse outcomes. Despite its importance, little is known about how delirium knowledge is assessed.
Objectives
To map instruments and items used to assess delirium knowledge among healthcare professionals.
Design
A scoping review based on the methodological framework of Arksey and O’Malley (Int J Soc Res Methodol 8:19-32, 2005).
Materials and methods
A systematic literature search was performed in Medline, Embase, CINAHL, Scopus, and PsycINFO to include studies that assessed delirium knowledge among healthcare professionals.
Results
After removing duplicates, 760 studies were assessed for eligibility and 98 studies were included. Delirium knowledge was mainly assessed among nurses (57/98, 58.8%) and physicians (12/98, 12.4%) with a focus on critical care (32/98, 33.0%) over long-term care settings (4/98, 4.1%). Most studies used self-developed instruments (50/93, 53%), followed by original or modified versions of the Delirium Knowledge Questionnaire (14/93, 15%). Among the 32 identified instruments, limited evidence of validity and reliability was reported for six (18.8%). Analysis at the item level (n = 392 items) revealed five domains: (a) definition, signs and symptoms (81 items); (b) risk factors, incidence, and prevention (139 items); (c) detection and tools (89 items); (d) management and therapy (64 items); and (e) outcomes, prognosis and consequences (19 items).
Conclusions
Delirium poses a significant burden on patients and on the healthcare system. This scoping review provides a comprehensive overview on how healthcare professionals’ delirium knowledge has been assessed. Further research in this field is needed to provide stronger evidence of instruments’ validity and reliability and to explore delirium knowledge among healthcare professionals in long-term care settings.
... Early detection of delirium, both for patients who arrive at a general acute care setting and for those who develop it in a general acute care setting, is crucial. Patients with unrecognised delirium are at a much higher risk for mortality upon discharge than patients with recognised delirium (Lee et al., 2022) and early diagnosis is a vital step in the treatment of delirium and is necessary in order to achieve the best outcomes (Zoremba & Coburn, 2019). However, despite the high occurrence of delirium and the importance of swift diagnosis, it is estimated that 50-75% cases are missed in such general acute care settings (Pezzullo et al., 2019). ...
Background Delirium is an acute, neuropsychiatric syndrome, characterized by an altered mental state. It often affects hospital in-patients and is associated with an increased risk of mortality, dementia, and functional decline. Delirium can be detected through the use of validated assessment tools, administered by nurses, and early detection is associated with improved outcomes for patients. However, validated tools are infrequently utilised and cases of delirium are frequently missed. A greater understanding of nurses’ use of validated delirium assessment tools is needed in order to reduce the number of missed cases. Objectives The aim of this scoping review is to identify how validated assessment tools are used by nurses in general acute care settings to assess for delirium and identify the barriers and enablers for said tools’ use. Methods This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. The databases CINAHL, PubMed, Web of Science, and Scopus will be searched using a search strategy. Grey literature will also be searched using Google Scholar and BASE. Results will be uploaded to Covidence where the sources will be screened for relevance. Data from relevant sources will be extracted using a data extraction tool. Results The PRISMA-ScR flow diagram will present the results of the search. Results will be mapped descriptively and presented as both tabulated results and a narrative summary. Conclusion This protocol outlines the structure of a scoping review that will analyse the existing literature surrounding nurses use of validated delirium assessment tools. This review aims to map the evidence of delirium assessment tool utilisation by nurses and identify any barriers to usage. This will support future researchers and policy makers in the improvement of delirium assessment in acute care settings.
... Physician gestalt may be sufficient to recognize some geriatric syndromes, such as hyperactive delirium, but physicians and nurses are less accurate at identifying hypoactive delirium. 9 Similarly, ED physicians and nurses feel confident in consulting therapists for evaluation when the patient needs placement in skilled nursing facilities, but are less sure about when to consult them if a patient is likely to go home. 10 Geriatric screening tools may help physicians make these decisions, but it is also possible that emergency physician gestalt is sufficient to identify the need for multidisciplinary consultation and that the addition of screening tools does not change care. ...
Background
The Geriatric Emergency Department (ED) Guidelines recommend screening older patients for need for evaluation by geriatric medicine, physical therapy (PT), and occupational therapy (OT), but explicit evidence that geriatric screening changes care compared to physician gestalt is lacking. We assessed changes in multidisciplinary consultation after implementation of standardized geriatric screening in the ED.
Methods
Retrospective single‐site observational cohort of older adult ED patients from 2019 to 2023 with three time periods: (1) preimplementation, (2) implementation of geriatric screening, and (3) postimplementation. Geriatric, PT, and OT consultations/referrals were available during all time periods. Descriptive analysis was stratified by disposition: discharged, observation and discharged, observation and hospital admission, and hospital admission. The independent variable was completion of three geriatric screening tools by ED nurses. The dependent variable was consultation and/or referral to geriatrics, PT, and OT. Secondary outcomes were disposition, ED revisits, and 30‐day rehospitalizations.
Results
There were 57,775 qualifying ED visits of patients age ≥ 65 years during the time periods: implementation increased geriatric screening from 0.5% to 63.2%; postimplementation, discharge patients who received screening had more consultations/referrals to geriatrics (1.5% vs. 0.4%), PT (7.9% vs. 1.9%), and OT (6.5% vs. 1.2%) compared to unscreened patients. Patients observed and then discharged had more consultations/referrals to geriatrics (15.1% vs. 11.3%), PT (74.1% vs. 64.5%), and OT (65.7% vs. 56.5%). Admitted patients had no change in consultation rates. Geriatric screening was not associated with a change in 7‐day ED revisits for discharged patients but was associated with decreased revisits for patients discharged from observation (11.6% vs. 42.9%, p < 0.001).
Conclusion
Geriatric screening was associated with increased consultations/referrals to geriatrics, PT, and OT in the ED and ED observation unit. This suggests that geriatric screening changes ED care for older adults.
... Whilst other studies have used screening tools administered by participating clinicians, we did not use this approach due to concerns about reporting bias and missing data. 29 Funding sufficient trained researcher time to conduct patient assessments to diagnose delirium would be prohibitively expensive in a large, multisite trial, burdensome for patients and difficult to justify a waiver of opt-in consent. Research time needed for data extraction was documented, which will directly inform the funding request for a definitive trial. ...
Background
Delirium is a complex condition, stressful for all involved. Although highly prevalent in palliative care settings, it remains underdiagnosed and associated with poor outcomes. Guideline-adherent delirium care may improve its detection, assessment and management.
Aim
To inform a future definitive study that tests whether an implementation strategy designed to improve guideline-adherent delirium care in palliative care settings improves patient outcomes (reduced proportion of in-patient days with delirium).
Design
With Patient Involvement members, we conducted a feasibility study to assess the acceptability of and engagement with the implementation strategy by hospice staff (intervention), and whether clinical record data collection of process (e.g. guideline-adherent delirium care) and clinical outcomes (evidence of delirium using a validated chart-based instrument;) pre- and 12-weeks post-implementation of the intervention would be possible.
Setting/participants
In-patient admissions in three English hospices.
Results
Between June 2021 and December 2022, clinical record data were extracted from 300 consecutive admissions. Despite data collection during COVID-19, target clinical record data collection (n = 300) was achieved. Approximately two-thirds of patients had a delirium episode during in-patient stay at both timepoints. A 6% absolute reduction in proportion of delirium days in those with a delirium episode was observed. Post-implementation improvements in guideline-adherent metrics include: clinical delirium diagnosis 15%–28%; delirium risk assessment 0%–16%; screening on admission 7%–35%.
Conclusions
Collection of data on delirium outcomes and guideline-adherence from clinical records is feasible. The signal of patient benefit supports formal evaluation in a large-scale study.
... Due to this, we hypothesize many delirium patients go undetected in the ED. [12][13][14] As such, an algorithm that identifies patients most at risk for delirium was devised and rates contrasted with those detected through the traditional approach of delirium detection in a busy urban level I geriatric ED to quantify missed cases of delirium with the traditional approach. 15 . ...
... In one study of seven EDs in Canada, the team prospectively evaluated ED patients for delirium and found that staff were very self-confident in their ability to recognize delirium (8/10 confidence) but in practice missed half of the patients with CAM-ICU-positive delirium. 31 ED nurses have also reported that delirium screening is a low priority in the ED and that knowing who was delirious was less important than other clinical tasks. 9 The combination of high self-confidence and low prioritization makes convincing ED staff to use formal tools difficult and likely contributes to the low uptake seen in many studies. ...
Objective:
Implementation of evidence-based care processes (EBP) into the Emergency Department (ED) is challenging and there are only a few studies of real-world use of theory-based implementation frameworks. We report final implementation results and sustainability of an EBP geriatric screening program in the ED using the Consolidated Framework for Implementation Research (CFIR).
Methods:
The EBP involved nurses screening older patients for delirium (Delirium Triage Screen), fall risk (4 Stage Balance Test), and vulnerability (Identifying Seniors at Risk Score) with subsequent appropriate referrals to physicians, therapy specialists or social workers. The proportions of screened adults ≥65 years old were tracked monthly. Outcomes are reported January 2021 - December 2022. Barriers encountered were classified according to CFIR. Implementation strategies were classified according to the CFIR-Expert Recommendations for Implementing Change (ERIC).
Results:
Implementation strategies increased geriatric screening from 5% to 68%. This did not meet our pre-specified goal of 80%. Change was sustained through several COVID-19 waves. Inner Setting barriers included culture and implementation climate. Initially, the ED was treated as a single Inner Setting, but we found different cultures and uptake between ED units, including night vs day shifts. Characteristics of Individuals barriers included high levels of staff turnover in both clinical and administrative roles and very low self-efficacy from stress and staff turnover. Initial attempts with individualized audit and feedback were not successful in improving self-efficacy and may have caused moral injury. Adjusting feedback to a team/unit level approach with unit-wide stretch goals worked better. Identifying early adopters and conducting on-shift education increased uptake. Lessons learned regarding ED culture, implementation in interconnected health systems, and rapid cycle process improvement are reported.
Conclusion:
The pandemic exacerbated barriers to implementation in the ED. Cognizance of a large ED as a sum of smaller units and using the CFIR model resulted in improvements.
... TAG-ME Only (the gamified Go/No-Go task) may also be useful in screening for delirium. The recent PREDICT study (Lee et al., 2022) used both TAG-Me Quick and TAG-ME Only games to screen for delirium and we will report the relative effectiveness of those two games in screening for delirium in a future publication. ...
BrainTagger (demo version: researcher-demo.braintagger.com) is a suite of Target Acquisition Games for Measurement and Evaluation (TAG-ME). Here we introduce TAG-ME Again, a serious game modeled after the well-established N-Back task, to assess working memory ability across three difficulty levels corresponding to 1-, 2-, and 3-back conditions. We also report on two experiments aimed at assessing convergent validity with the N-Back task. Experiment 1 examined correlations with N-Back task performance in a sample of adults (n ¼ 31, 18-54 years old) across three measures: reaction time; accuracy; a combined RT/accuracy metric. Significant correlations between game and task were found, with the strongest relationship being for the most difficult version of the task (3-Back). In Experiment 2 (n ¼ 66 university students, 18-22 years old), we minimized differences between the task and the game by equating stimulus-response mappings and spatial processing demands. Significant correlations were found between game and task for both the 2-Back and 3-Back levels. We conclude that TAG-ME Again is a gamified task that has conver-gent validity with the N-Back Task.
... 15,16 Patients with missed delirium diagnosis and who did not receive appropriate delirium care at discharge are at an increased risk of death. 17 Opportunities to integrate the NLP-CAM in real-time clinical practice to facilitate delirium detection during the hospital encounter itself, as opposed to retrospective detection, will have a huge impact on delirium management. Additional studies to understand the NLP-CAM algorithm's role in optimizing the health care staff time invested in delirium screening and detection need to be considered, especially when the personnel resources are strained or limited. ...
Delirium is known to be underdiagnosed and underdocumented. Delirium detection in retrospective studies occurs mostly by clinician diagnosis or nursing documentation. This study aims to assess the effectiveness of natural language processing-confusion assessment method (NLP-CAM) algorithm when compared to conventional modalities of delirium detection. A multicenter retrospective study analyzed 4351 COVID-19 hospitalized patient records to identify delirium occurrence utilizing three different delirium detection modalities namely clinician diagnosis, nursing documentation, and the NLP-CAM algorithm. Delirium detection by any of the 3 methods is considered positive for delirium occurrence as a comparison. NLP-CAM captured 80% of overall delirium, followed by clinician diagnosis at 55%, and nursing flowsheet documentation at 43%. Increase in age, Charlson comorbidity score, and length of hospitalization had increased delirium detection odds regardless of the detection method. Artificial intelligence-based NLP-CAM algorithm, compared to conventional methods, improved delirium detection from electronic health records and holds promise in delirium diagnostics.
... Adverse outcomes associated with identified delirium include prolonged hospital stay, hospitalrelated complications, nursing home admission, repeat ED visits, re-admission, functional and cognitive decline, and mortality [3][4][5][6][7]. Furthermore, unrecognized prevalent delirium among older adults increases mortality risk three fold [4,8]. Twenty to thirty percent of patients with delirium are discharged from the ED with unrecognized delirium, and 80% of these patients will be re-hospitalized within four days [4,[9][10][11]. ...
Objectives:
Unrecognized delirium is associated with significant adverse outcomes. Despite decades of effort and educational initiatives, validated screening tools have not improved delirium recognition in the emergency department (ED). There remains a fundamental knowledge gap of why it is consistently missed. The objective of this study was to explore the perceptions of ED physicians and nurses regarding factors contributing to missed delirium in older ED patients.
Methods:
We conducted a qualitative descriptive study at two academic tertiary care EDs in Toronto, Canada. Emergency physicians and nurses were interviewed by a trained qualitative researcher using a semi-structured interview guide. We coded transcripts with an iteratively developed codebook. Interviews were conducted until thematic saturation occurred. Thematic data analysis occurred in conjunction with data collection to continuously monitor emerging themes and areas for further exploration.
Results:
We interviewed 26 ED physicians and nurses. We identified key themes at four levels: clinical practice, provider attitudes, systematic processes, and education. The four themes include: (1) there are varied approaches to delirium recognition and infrequent use of screening tools; (2) delirium assessment is perceived as overly time consuming and of lower priority than other symptoms and syndromes; (3) it is unclear whose responsibility it is to recognize delirium; and (4) there is a need for a deeper or "functional" understanding of delirium that includes its consequences.
Conclusions:
Our findings demonstrate a need for ED leadership to identify clear team roles for delirium recognition, standardize use of delirium screening tools, and prioritize delirium as a symptom of an acute medical emergency.
With an explosive population growth of older adults, the incidence rates of neuropsychiatric syndromes, particularly delirium, are increasing in the community and hospital settings. Delirium is an acute disturbance in cognition and attention that may signify a serious medical, life-threatening condition and may mimic psychiatric–mental health issues. Although its prevalence rate is lower in the community, delirium affects up to 87% of hospitalized older adults and can cost up to $152 billion each year. Despite its common occurrence, delirium is often undetected in 50% to 60% across all care settings, delaying treatment and resulting in poor patient outcomes, such as increased mortality, prolonged hospital stays, cognitive and functional impairment, decreased quality of life, and institutionalization. The current article addresses strategies to recognize delirium and presents evidence-based approaches and future considerations for delirium management. [ Journal of Psychosocial Nursing and Mental Health Services, 62 (11), 11–18.]
Background
Delirium is a common acute mental disorder, and its adverse outcomes often cause distress to both patients and their families. Despite its prevalence in patients treated in emergency departments, delirium is frequently overlooked.
Aim
This study aims to systematically evaluated and meta‐analysis the prevalence of delirium among emergency patients, providing insights into its prevalence and offering guidance for its management and prevention.
Study Design
Observational studies on the prevalence of delirium in emergency departments were systematically searched in PubMed, Embase, the Cochrane Library and Medline databases. Relevant English‐language studies published up to 18 September 2023 were reviewed, and meta‐analysis was conducted using Stata 14.0 software. Quality assessment of included literature was performed using the methodological index for non‐randomized studies (MINORS), and publication bias was assessed using Egger's test.
Results
Thirteen studies encompassing a total sample size of 33 839 cases were included, with 3082 cases of delirium incidents. The findings revealed a 15% prevalence rate of delirium in emergency departments, with a 95% confidence interval (CI) of (0.10, 0.20) and an overall heterogeneity of 98.37% ( p = .000). Among emergency department patients over 65 years of age, the prevalence of delirium was 12%, with a 95% CI of (0.07, 0.19) and a heterogeneity of 94.59%. For patients over 18 years of age, the prevalence was 17%, with a 95% CI of (0.10, 0.25) and a heterogeneity of 98.94%.
Conclusions
This meta‐analysis reveals an overall 15% prevalence rate of delirium among patients in emergency departments.
Relevance to Clinical Practice
In clinical practice, emergency medical staff should strengthen the screening and management of emergency delirium patients.
Background:
Delirium has conventionally been considered a disorder of consciousness. Alertness and arousal are used as surrogates in clinical practice but are insufficient for the purposes of a more dimensional assessment of consciousness. We present a process of development and validation of candidate measures of phenomenal consciousness that could be applied to the diagnosis of delirium.
Methods:
First, a narrative review of available instruments in the fields of phenomenal consciousness, including prereflective consciousness, the phenomenal-sensed experience and reflective thought, was undertaken. Eligibility of tools in the context of applicability to delirium was based upon objectivity in test interpretation and the requirement for tester administration. Second, where there was a gap in suitable cognitive tools, new items were derived using the silent generation technique. A process of face and construct validity using a diverse panel of experts was performed, and readability was evaluated.
Results:
814 articles were screened from the literature review. Fourteen candidate tools were reported from the three domains of phenomenal consciousness. One of these met the eligibility criteria for a delirium assessment. Fifty-seven new tests of phenomenal consciousness were identified. After a process of item reduction, a total of 26 individual tests were identified. After content validity, 22 of the 26 items were retained. The scale average content validity index was 0.89. The agreement between raters was between 80% and 97%. 100% of responses for face validity were rated as positive. Flesch Reading Ease Score was 91.6 (very easy to read).
Conclusions:
Candidate measures of phenomenal consciousness are described, and early validity studies are promising.
Objective
As part of the Geriatric Emergency Department (ED) Guidelines 2.0 project, we conducted a systematic review to find risk factors or risk stratification approaches that can be used to identify subsets of older adults who may benefit from targeted ED delirium screening.
Methods
An electronic search strategy was developed with a medical librarian, conducted in April 2021 and November 2022. Full‐text studies of patients ≥65 years assessed for prevalent delirium in the ED were included. Risk of bias was assessed using the McMaster University Clarity Group tool. Outcomes measures pertained to the risk stratification method used. Due to heterogeneity of patient populations, risk stratification methods, and outcomes, a meta‐analysis was not conducted.
Results
Our search yielded 1878 unique citations, of which 13 were included. Six studies developed a novel delirium risk score with or without evaluation of specific risk factors, six studies evaluated specific risk factors only, and one study evaluated an existing nondelirium risk score for association with delirium. The most common risk factor was history of dementia, with odds ratios ranging from 3.3 (95% confidence interval [CI] 1.2–8.9) to 18.33 (95% CI 8.08–43.64). Other risk factors that were consistently associated with increased risk of delirium included older age, use of certain medications (such as antipsychotics, antidepressants, and opioids, among others), and functional impairments. Of the studies that developed novel risk scores, the reported area under the curve ranged from 0.77 to 0.90. Only two studies reported potential impact of the risk stratification tool on screening burden.
Conclusions
There is significant heterogeneity, but results suggest that factors such as dementia, age over 75, and functional impairments should be used to identify older adults who are at highest risk for ED delirium. No studies evaluated implementation of a risk stratification method for delirium screening or evaluated patient‐oriented outcomes.
Background
Health care professionals underestimate the recognition of delirium in emergency departments (EDs). In these settings, between 57% and 83% of cases of delirium go undetected. When delirium occurs, it causes an increase in the length of hospitalization, readmissions within 30 days, and mortality. No studies were carried out in Italy to assess the prevalence of delirium among elders in EDs.
Objectives
The primary goal of the study was to evaluate the prevalence of the risk of delirium in people 65 years and older hospitalized in the ED for a minimum of 8 hours. The study's secondary goal was to identify the variables that influenced the risk of delirium.
Method
A multicenter cross-sectional study was conducted in 2 EDs. The risk of delirium was assessed using the delirium screening tool 4 A's test. One hundred patients were enrolled. Data collection took place from June 28 to August 31, 2022.
Results
The risk of delirium was detected in 29% of the sample, whereas the risk of cognitive impairment was 13%. The use of psychotropic drugs increased the risk of delirium by 11.8 times (odds ratio [OR], 11.80; P = .003). Bed confinement increased the risk by 4.3 times (OR, 4.31; P = .009). Being dehydrated increased the risk of onset by 4.6 times (OR, 4.62; P = .010). Having dementia increased the risk of delirium manifestation by 4.4 times (OR, 4.35; P = .021).
Discussion
The risk of delirium was detected in a considerable portion of the sample. The results of this study can be used by health care professionals to implement preventive measures as well as support clinical judgment and establish priorities of care for patients at risk of developing delirium.
Background
Delirium is frequently disproportionately under‐recognized despite its high prevalence, detrimental impact, and potential lethality. Informant‐based delirium detection tools can offer structured assessment and increase the timeliness and frequency of detection. We aimed to examine the diagnostic accuracy of the Family Confusion Assessment Method (FAM‐CAM) for delirium detection.
Methods
We systematically searched the MEDLINE, EMBASE, PsycINFO, CINAHL, CNKI, WANFANG, and SinoMed databases from January 1988 to December 2022. Two reviewers independently screened studies and evaluated methodological quality using the revised quality assessment of diagnostic accuracy studies (QUADAS‐2) tool. A bivariate random effects model was undertaken, and univariable meta‐regression was carried out to explore heterogeneity.
Results
Seven studies with 483 dyads of participants and family caregivers were identified. Pooled sensitivity and specificity were 0.74 (95% CI: 0.59, 0.86) and 0.91 (95% CI: 0.83, 0.95), respectively, with an area under curve (AUC) of 0.91. The positive likelihood ratio was 8.27 (95% CI: 3.97, 17.25), and the negative likelihood ratio was 0.28 (95% CI: 0.16, 0.50). Settings impacted specificity ( p = 0.02).
Conclusions
Available evidence indicates that FAM‐CAM exhibits moderate sensitivity and high specificity for delirium screening in adults. The FAM‐CAM is concise and easy to use, making it appropriate for routine clinical practice, which might benefit early delirium detection and potentially foster delirium management.
PROSPERO Registration Number
CRD42022378742.
Background
Delirium detection is challenging due to the fluctuating nature and frequent hypoactive presentation. This study aimed to determine an optimal strategy that detects delirium with higher sensitivity but lower effort in older patients admitted to the intensive care unit (ICU) after surgery.
Methods
This was a secondary analysis of the database from a randomized trial. Seven hundred older patients (aged ≥65 years) who were admitted to the ICU after elective noncardiac surgery were enrolled. Delirium was assessed with the Confusion Assessment Method for the ICU (CAM-ICU) twice daily during the first 7 days postoperatively. The sensitivity of different strategies in detecting delirium were analyzed and compared.
Results
Of all enrolled patients, 111 (15.9%; 95% CI: 13.3% to 18.8%) developed at least one episode of delirium during the first 7 postoperative days. Among patients who developed delirium, 60.4% (67/111) had their first delirium onset on postoperative day 1, 84.7% (94/111) by the end of day 2, 91.9% (102/111) by the end of day 3, and 99.1% (110/111) by the end of day 4. Compared with delirium assessment twice daily for 7 days, twice-daily measurements for 5 days detected 100% of delirium patients with 71% efforts; twice-daily measurements for 4 days detected 99% (95% CI: 94% to 100%) of delirium patients with 57% efforts; twice-daily assessment for 3 days detected 92% (95% CI: 85% to 96%) of delirium patients with only 43% efforts.
Conclusions
For older patients admitted to the ICU after elective noncardiac surgery, it is reasonable to detect delirium with the CAM-ICU twice daily for no more than 5 days, and if the personnel and funds are insufficient, 4 days could be sufficient.
Objective:
Delirium is dangerous and a predictor of poor patient outcomes. We have previously reported the utility of the bispectral EEG (BSEEG) with a novel algorithm for the detection of delirium and prediction of patient outcomes including mortality. The present study employed a normalized BSEEG (nBSEEG) score to integrate the previous cohorts to combine their data to investigate the prediction of patient outcomes. We also aimed to test if the BSEEG method can be applicable regardless of age, and independent of delirium motor subtypes.
Methods:
We calculated nBSEEG score from raw BSEEG data in each cohort and classified patients into BSEEG-positive and BSEEG-negative groups. We used log-rank test and Cox proportional hazards models to predict 90-day and 1-year outcomes for the BSEEG-positive and -negative groups in all subjects and motor subgroups.
Results:
A total of 1,077 subjects, the BSEEG-positive group showed significantly higher 90-day (hazard ratio 1.33 [95% CI 1.16-1.52] and 1-year (hazard ratio 1.22 [95% CI 1.06-1.40] mortality rates than the negative group after adjustment for covariates such as age, sex, CCI, and delirium status. Among patients with different motor subtypes of delirium, the hypoactive group showed significantly higher 90-day (hazard ratio 1.41 [95% CI 1.12-1.76] and 1-year mortality rates (hazard ratio 1.32 [95% CI 1.05-1.67], which remained significant after adjustment for the same covariates.
Conclusion:
We found that the BSEEG method is capable of capturing patients at high mortality risk.
Delirium, which may present as acute fluctuation in arousal and attention and changes in a person's behaviours, can increase the risk of falls, while a fall can increase the risk of developing delirium. There is, therefore, a fundamental relationship between delirium and falls. This article describes the main types of delirium and the challenges associated with recognition of the condition and discusses the relationship between delirium and falls. The article also describes some of the validated tools used to screen patients for delirium and includes two brief case studies to illustrate this in practice.
Background
The term delirium has been defined in medical diagnosis criteria as a multidimensional disorder. However, the term acute confusion is included in nursing classifications. Delirium can be a serious complication assessed in a patient after a surgical procedure. Still, the patient's delirium frequently remains unrecognised. Care of patients with delirium after surgical procedure is complex, and it challenges nursing expertise. From the nurses’ viewpoint, delirium is associated with ambiguity of concepts and lack of knowledge.
Objective
The aim of this study was to describe the concepts of delirium and acute confusion, as well as the associated dimensions, in adult patients in a surgical context from the nursing perspective.
Design
The study used Schwartz and Barcott's hybrid concept analysis with theoretical, fieldwork, and final analytical phases.
Settings
Surgical wards, surgical intensive care units, and post-anaesthesia care units
Data sources
A systematic literature search was performed through Pubmed (Medline), Cinahl, PsycInfo, and Embase.
Participants
Registered nurses and licensed practical nurses (n = 105) participated in the fieldwork phase.
Methods
In the theoretical phase, the concepts’ working definitions were formulated based on a systematic literature search with the year limitations from 2000 until February 2021. At the fieldwork phase, the nurses’ descriptions of patients with delirium were analysed using the deductive content analysis method. At the final analytical phase, findings were combined and reported.
Results
The concepts of delirium, subsyndromal delirium, and acute confusion are well defined in the literature. From the perspective of the nurses in the study, concepts were seen as a continuum not as individual diagnoses. Nurses described the continuum of delirium as a process with acute onset, duration, and recovery with the associated dimensions of symptoms, symptom severity, risk factors, and early signs. The acute phase of delirium was emphasised, and preoperative or prolonged disturbance did not seem to be relevant in the surgical care context. Patients’ compliance with care may be decreased with the continuum of delirium, which might challenge both patients’ recovery from surgery and the quality of nursing care.
Conclusions
In clinical practice the nurses used term confusion inaccurately. The term acute confusion might be used when illustrating an early stage of delirium. Nurses could benefit from further education where the theoretical knowledge is combined with the clinical practice. The discussion about the delirium, which covers the time both before surgery and after the acute phase should be increased.
Objective
To assess if ongoing delirium research activity within an acute admissions unit impacts on prevalent delirium recognition.
Design
Prospective cohort study.
Setting
Single-site tertiary university teaching hospital.
Participants
125 patients with delirium, as diagnosed by an expert using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition reference criteria, were recruited to a prospective cohort study investigating use of informant tools to detect unrecognised dementia. This study evaluated recognition of delirium and documentation of delirium by medical staff.
Interventions
The main study followed an observational design; the intervention discussed was the implementation of this study itself.
Primary and secondary outcome measures
The primary outcome was recognition of delirium by the admitting medical team prior to study diagnosis. Secondary outcomes included recording of or description of delirium in discharge summaries, and factors which may be associated with unrecognised delirium.
Results
Delirium recognition improved between the first half (48%) and second half (71%) of recruitment (p=0.01). There was no difference in recording of delirium or description of delirium in the text of discharge summaries.
Conclusion
Delirium research activity can improve recognition of delirium. This has the potential to improve patient outcomes.
Delirium is a common and serious condition that is underrecognized in older adults in a variety of healthcare settings. It is poorly recognized because of deficiencies in provider knowledge and its atypical presentation. Early recognition of delirium is warranted to better manage the disease and prevent the adverse outcomes associated with it. The purpose of this article is to review the literature concerning educational interventions focusing on recognition of delirium. The Medline and Cumulative Index to Nursing and Allied Health Literature (CINHAL) databases were searched for studies with specific educational focus in the recognition of delirium, and 26 studies with various designs were identified. The types of interventions used were classified according to the Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model, and outcomes were sorted according to Kirkpatrick's hierarchy. Educational strategies combining predisposing, enabling, and reinforcing factors achieved better results than strategies that included one or two of these components. Studies using predisposing, enabling, and reinforcing strategies together were more often effective in producing changes in staff behavior and participant outcomes. Based on this review, improvements in knowledge and skill alone seem insufficient to favorably influence recognition of delirium. Educational interventions to recognize delirium are most effective when formal teaching is interactive and is combined with strategies including engaging leadership and using clinical pathways and assessment tools. The goal of the current study was to systematically review the published literature to determine the effect of educational interventions on recognition of delirium.
To determine the sensitivity of an emergency physician's conventional evaluation compared with the validated Confusion Assessment Method (CAM) regarding the recognition of acute confusional states (delirium) in elderly Emergency Department (ED) patients, a cohort of 385 patients presenting to an urban teaching hospital ED was systematically assembled. Patients had to be conscious, able to speak and older than 64 years of age. After the ED physician had examined the patient and test results had been obtained, a series of geriatric assessment results, including one for the likely presence of delirium, was made available to the ED physician; however, no result was specifically highlighted. All patients were assessed by an attending ED physician in the customary fashion. In addition, a study nurse interviewed patients using the CAM and followed patient outcomes for three months. The ED record for all patients with delirium or "probable" delirium, as determined by the CAM, were reviewed for physician diagnosis and disposition to determine how often delirium had been recognized by the emergency physician. Thirty-eight of the 385 patients screened (10%) met criteria for delirium or "probable" delirium; ED charts were complete for 35 of these, which constituted the study sample. The ED diagnosis included delirium or an acceptable synonym in 6 (17%) of these patients. In the 21 patients (62%) admitted to the hospital, the most common ED diagnosis was infection "rule out sepsis" (n = 7). Six of 13 patients discharged (46%) were diagnosed as "status post fall" without evidence of significant injury.(ABSTRACT TRUNCATED AT 250 WORDS)
To investigate whether different methods of obtaining informed consent affected recruitment to a study of delirium in older, medically ill hospital inpatients.
Open randomised study.
Acute medical service for older people in an inner city teaching hospital.
Patients 70 years or older admitted to the unit within three days of hospital admission randomised into two groups.
Attempted recruitment of subjects to a study of the natural history of delirium. This was done by either (a) a formal test of capacity, followed by either a request for consent or an attempt at obtaining assent from a proxy, or (b) a combined informal capacity/consent process.
Prevalence and severity of delirium, and, as case mix measures, length of hospital stay and destination on discharge.
Recruitment of subjects through establishing formal capacity and then informed consent was less successful (43.9% v 74% of those approached) and, compared with those recruited through the usual combined capacity/consent approach, yielded a sample with less cognitive impairment, lower severity of delirium, lower probability of case note diagnosis of delirium and lower rate of entering a care home.
Methods of obtaining informed consent may significantly influence the case mix of subjects recruited to a study of delirium. Stringent testing of capacity may exclude patients with delirium from studies, thus rendering findings less generalizable. A different method is necessary to achieve an ethical balance between respecting autonomy through obtaining adequate informed consent and avoiding sample bias.
Objectives:
Recognition of delirium in the emergency department (ED) is poor. Our objectives were to assess: (1) the diagnostic accuracy of the Predicting Emergency department Delirium with an Interactive Computer Tablet (PrEDICT) "serious game" to identify older ED patients with delirium compared to clinical recognition and (2) the feasibility of the PrEDICT application compared to existing tests of attention.
Design:
Prospective observational study.
Setting:
ED of a Canadian tertiary care center.
Participants:
We included ED patients, aged 70 years and older, with a minimum 4-hour stay. We excluded anyone with critical illness, communication barriers, and visual impairment or those unable to use a computer tablet. None had prevalent delirium by ED clinicians' routine clinical assessment.
Measurements:
Participants were asked to tap targets on a tablet at four difficulty levels. Time and accuracy were automatically recorded. Other measures included the Confusion Assessment Method, the Delirium Severity Index, the Digit Vigilance Test (DVT), and the Choice Reaction Test (CRT).
Results:
We enrolled 203 patients. Their average age was 80.6 years, 49.8% were female, and their average ED length of stay was 15.9 hours. Sixteen subjects had clinically unrecognized delirium, and 14 of them completed the PrEDICT game (87.5%). We developed a threshold score with 100% sensitivity (95% confidence interval [CI] = 76.8%-100.0%) and 59.7% specificity (95% CI = 52.3%-66.6%) to identify patients with clinically unrecognized delirium. The area under the curve was 0.86 (95% CI = 0.77-0.94). Completion rates were 196/203 (96.6%) for the PrEDICT serious game compared to 128/203 (63.1%) for the CRT and 51/203 (25.1%) for the DVT.
Conclusion:
Older ED patients were able to use our serious game, including 87.5% of those with clinically unrecognized delirium. The PrEDICT application has potential to act as a sensitive screening tool to identify older ED patients with clinically unrecognized delirium. J Am Geriatr Soc 67:2370-2375, 2019.
Background:
It is documented that health professionals from various settings fail to detect > 50% of delirium cases.
Objective:
This study aimed to describe the proportion of unrecognized incident delirium in five emergency departments (EDs). Secondary objectives were to compare the two groups (recognized/unrecognized) and assess the impact of unrecognized delirium at 60 days regarding 1) unplanned consultations and 2) functional and cognitive decline.
Method:
This is a sub-analysis of a multicenter prospective cohort study. Independent patients aged ≥ 65 years who tested negative for delirium on the initial interview with an ED stay ≥ 8 h were enrolled. Patients were assessed twice daily using the Confusion Assessment Method (CAM) and the Delirium Index up to 24 h into hospital admission. Medical records were reviewed to assess whether delirium was recognized or not.
Results:
The main study reported a positive CAM in 68 patients. Three patients' medical files were incomplete, leaving a sample of 65 patients. Delirium was recognized in 15.4% of our participants. These patients were older (p = 0.03) and female (p = 0.01) but were otherwise similar to those with unrecognized delirium. Delirium Index scores were higher in patients with recognized delirium (p = 0.01) and they experienced a more important functional decline at 60 days (p = 0.02). No association was found between delirium recognition and health care services utilization or decline in cognitive function.
Conclusions:
This study confirms reports of high rates of missed or unrecognized delirium (84.6%) in ED patients compared to routine structured screening using the CAM performed by a research assistant. Patients with recognized delirium were older women with a greater severity of symptoms and experienced a more significant functional decline at 60 days.
To compare the recognition of delirium by emergency physicians based on observations made during routine clinical care with concurrent ratings made by a trained researcher after formal cognitive assessment and to examine each of the four individual features of delirium separately to determine the variation in identification across features.
In a prospective study, a convenience sample of 259 patients, aged ≥65 years, who presented to two urban, teaching hospital emergency departments (EDs) in Western Pennsylvania between 21 June and 29 August 2011, underwent paired delirium ratings by an emergency physician and a trained researcher. Emergency physicians were asked to use their clinical judgment to decide whether the patient had any of the following delirium features: (1) acute change in mental status, (2) inattention, (3) disorganised thinking and (4) altered level of consciousness. Questions were prompted with examples of delirium features from the Confusion Assessment Method. Concurrently, a trained researcher interviewed surrogates to determine feature 1, conducted a cognitive test for delirium (Confusion Assessment Method for the intensive care unit) to determine delirium features 2 and 3 and used the Richmond Agitation and Sedation Scale to determine feature 4.
In the 2-month study period, trained researchers identified delirium in 24/259 (9%; 95% CI 0.06 to 0.13) older patients admitted to the ED. However, attending emergency physicians recognised delirium in only 8 of the 24 and misidentified delirium in a further seven patients. Emergency physicians were particularly poor at recognising altered level of consciousness but were better at recognising acute change in mental status and inattention.
When emergency physicians use routine clinical observations, they may miss diagnosing up to two-thirds of patients with delirium. Recognition of delirium can be enhanced with standardised cognitive testing.
In the absence of specific therapies, interventions for delirium are largely educational. This paper reviews educational interventions targeted at physicians, nurses, patients and their families. Most studies to date have had methodological deficiencies, and few have been developed in keeping with current principles for adult learning. Early studies focused on increased recognition of delirium, with less consistent measurement of patient centred outcomes. Subsequent studies provide limited evidence to suggest that, as a result of educational interventions, individual symptoms can be prevented, and, when delirium is present, its consequences - including death and prolonged hospital stays - can be diminished. Future studies should incorporate principles of adult learning and have improved methodological rigour. The strength of educational interventions needs to be assessed carefully. Interventions which are time-sensitive, less complex, directed to observable, patient-focused endpoints are more likely to be successful.
We sought to determine the prevalence of mental status impairment in elderly emergency department patients and to assess documentation of and referrals by emergency physicians for mental status impairment after discharge from the ED.
We performed a prospective, observational study of a convenience sample of 297 patients 70 years or older presenting to an urban teaching hospital ED over a 12-month period. Patients were screened with the Orientation-Memory-Concentration examination for cognitive impairment and the Confusion Assessment Method for delirium. Documentation, dispositions, and referrals were abstracted from chart review.
Two hundred ninety-seven of the 337 eligible patients were enrolled. Seventy-eight of the 297 (26%; 95% confidence interval [CI] 21% to 31%) patients had mental status impairment; 30 (10%; 95% CI 7% to 14%) had delirium; 48 (16%; 95% CI 12% to 20%) had cognitive impairment without delirium; 17 (6%; 95% CI 3% to 9%) screened positive on both examinations. Only 22 (28%; 95% CI 19% to 40%) of the 78 patients had any documentation of mental status impairment by the emergency physician. Specific mention of delirium, cognitive impairment, or an acceptable synonym was noted in 13 (17%; 95% CI 9% to 27%). Of 34 (44%; 95% CI 32% to 55%) patients with mental status impairment discharged home, only 6 (18%; 95% CI 7% to 35%) had plans documented by the emergency physician to address impairment. Eleven (37%; 95% CI 20% to 56%) of the 30 patients with delirium were discharged home. Sixteen (70%; 95% CI 47% to 87%) of the 23 patients with cognitive impairment who were discharged home had no prior history of dementia; these patients were less likely to have specialized assistance with care (13%; 95% CI 4% to 27%) than those with known dementia (58%; 95% CI 28% to 85%).
Impaired mental status is common among older ED patients. Lack of documentation, admission, or referral by emergency physicians suggests a lack of recognition of this important problem.
To determine whether prevalent delirium is an independent predictor of mortality in older patients seen in emergency departments (EDs) and discharged home without admission.
Prospective study with 18 months of follow-up.
EDs in two Montreal hospitals.
From a cohort study of prognosis for delirium (107 delirious and 161 nondelirious subjects), 30 delirious and 77 nondelirious subjects aged 66 and older who were discharged home without admission were identified.
Detailed interviews with patients and their proxies and review of medical charts were performed at enrollment. Trained lay interviewers determined delirium status using the Confusion Assessment Method. Subjects were followed up at 6-month intervals for a total of 18 months. Dates of death were obtained from the Ministère de la Santé et des Service Sociaux (Ministry of Health and Social Services). Survival analysis was performed using the Cox proportional hazards modeling adjusting for potential confounding variables.
The analysis revealed a statistically significant association between delirium and mortality after adjustments for age, sex, functional level, cognitive status, comorbidity, and number of medications for the first 6 months of follow-up (hazard ratio = 7.24; 95% confidence interval = 1.62-32.35). The subjects whose delirium was not detected by the ED physician or nurse had the highest mortality over 6 months (30.8%). The mortality of delirious subjects detected in the ED was similar to that of the nondelirious subjects (11.8 vs 14.3%).
The results of this study suggests that nondetection of delirium in the ED may be associated with increased mortality within 6 months after discharge. Further research is necessary to examine the effectiveness of improving detection on subsequent prognosis of older patients with delirium.
We determine the effect of screening examinations for mental status impairment on the care of elderly patients in the emergency department and prospectively assess recognition of mental status impairment by emergency physicians.
We performed a prospective cross-sectional study. Patients were 70 years of age or older and presented to an urban teaching hospital ED over a 17-month period. Mental status impairment screening comprised the Orientation Memory Concentration examination for cognitive impairment and the Confusion Assessment Method for delirium. Emergency physicians who were blinded to the patient's screening results were interviewed to assess recognition of mental status impairment, dispositions, and referrals. Results of mental status impairment screens were then given to emergency physicians, and emergency physicians were reinterviewed regarding any change in care.
Two hundred seventy-one of the 327 eligible patients were enrolled. Seventy-four (27%; 95% confidence interval [CI] 22% to 33%) patients had impaired mental status. Nineteen (7%; 95% CI 4% to 11%) had delirium, and 55 (20%; 95% CI 16% to 25%) had cognitive impairment without delirium. Mental status impairment was recognized in only 28 (38%; 95% CI 27% to 50%) of 74 patients: 3 (16%; 95% CI 3% to 40%) of 19 with delirium and 25 (46%; 95% CI 32% to 59%) of 55 with cognitive impairment without delirium. Emergency physicians altered management in none of the study patients on the basis of survey results. Five (26%; 95% CI 9% to 51%) of the 19 patients with delirium were discharged to home. Of these 5 patients discharged to home with unrecognized delirium, 1 presented with fall, 2 returned 3 days later and required hospitalization, and 1 with a history of colon cancer was given a new diagnosis of metastatic disease 4 days after the initial ED visit.
Mental status impairment is highly prevalent in older ED patients. There is a lack of recognition by emergency physicians of mental status impairment in this group. Screening tools for mental status impairment in the ED did not substantially alter the care of elderly patients with mental status impairment.
Recognition of delirium in the emergency department: a meta-analysis
- D Ma
- L Rose
- L Bury
- X Cao
- A Kiss
- J Lee
Ma D, Rose L, Bury L, Cao X, Kiss A, Lee J. Recognition
of delirium in the emergency department: a meta-analysis.
International Conference on Emergency MEdicine. Dubai,
UAE: Emergency Medicine (in press) 2021.