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The Bedside Confusion Scale: Development of a Portable Bedside Test for Confusion and Its Application to the Palliative Medicine Population
Abstract
Clinical tests for confusion in medically ill patients are frequently burdensome and difficult to use. Available tests lack portability and tend to be shunned in clinical practice by physicians.
To develop a simple, sensitive bedside test for confusion.
Prospective comparison study.
An in-patient palliative medicine unit in a large urban hospital.
Thirty-one consecutive patients admitted to the unit.
None.
A 2-minute screening test, the Bedside Confusion Scale (BCS), which utilizes an observation of level of consciousness at the time of clinical interaction, followed by a timed task of attention, was administered to 31 consecutively admitted patients. The results were compared to a previously validated test, the Confusion Assessment Method (CAM). The BCS and the CAM were scored in standardized fashion and results of the two populations compared. Demographic and clinical characteristics of the patient population, along with the Karnofsky performance scores (KPS) and neurological findings were registered.
Using the CAM as the reference standard, the sensitivity of the BCS was 100%. Worsening KPS and more abnormalities on neurological examination were seen across normal (BCS = 0), borderline (BCS = 1), and abnormal (BCS >/= 2) groups (p > 0.01, trend test).
In an in-patient palliative medicine population, the BCS correlates with the previously validated CAM and exhibits high sensitivity, an essential quality of a useful screening test.
... 62 Twenty five studies were reported in English; two in Spanish 52,53 , one in Japanese. 47 Most studies included inpatient specialist palliative care units in hospitals (n = 21) 32,37,39,41,42,44,46,[48][49][50][51][52][53][55][56][57][58][59][60][61][62] or hospice (n = 5). 33,39,47,51,54 Three studies each included palliative care consultation teams 40,45,49 and palliative care community services 33,41,43 In 23 studies, all participants had a primary cancer diagnosis, 32,33,37,[40][41][42][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62] three studies included cancer and non-cancer diagnoses 39,43,44 , two studies did not report diagnoses. ...
... 47 Most studies included inpatient specialist palliative care units in hospitals (n = 21) 32,37,39,41,42,44,46,[48][49][50][51][52][53][55][56][57][58][59][60][61][62] or hospice (n = 5). 33,39,47,51,54 Three studies each included palliative care consultation teams 40,45,49 and palliative care community services 33,41,43 In 23 studies, all participants had a primary cancer diagnosis, 32,33,37,[40][41][42][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62] three studies included cancer and non-cancer diagnoses 39,43,44 , two studies did not report diagnoses. 39,45 Participants in 24 studies were in the late stages of illness (e.g. ...
... advanced or terminal cancer), 32,33,37,[39][40][41][42][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62] while in the remaining four studies participants' stage of illness was unclear. 39,[43][44][45] In 14 studies, only cross-sectional data was eligible for the review. 32,33,39,41,42,44,47,48,50,51,56,57,60 There were two prospective 43,49 , one retrospective 45 cohort studies (measuring delirium incidence); eight other prospective studies [52][53][54][55]58,59,61,62 , three retrospective chart reviews 36,37,40 (measuring delirium period prevalence). ...
Background
Delirium is common and distressing for patients receiving palliative care. Interventions targetting modifiable risk factors in other settings have been shown to prevent delirium. Research on delirium risk factors in palliative care can inform context-specific risk-reduction interventions.
Aim
To investigate risk factors for the development of delirium in adult patients receiving specialist palliative care.
Design
Systematic review and meta-analysis (PROSPERO CRD42019157168).
Data sources
CINAHL, Cochrane Database of Systematic Reviews, Embase, MEDLINE and PsycINFO (1980-2021) were searched for studies reporting the association of risk factors with delirium incidence/prevalence for patients receiving specialist palliative care. Study risk of bias and certainty of evidence for each risk factor were assessed.
Results
Of 28 included studies, 16 conducted only univariate analysis, 12 conducted multivariate analysis. The evidence for delirium risk factors was limited with low to very low certainty.
Potentially modifiable risk factors
Opioids and lower performance status were positively associated with delirium, with some evidence also for dehydration, hypoxaemia, sleep disturbance, liver dysfunction and infection. Mixed, or very limited, evidence was found for some factors targetted in multicomponent prevention interventions: sensory impairments, mobility, catheter use, polypharmacy (single study), pain, constipation, nutrition (mixed evidence).
Non-modifiable risk factors
Older age, male sex, primary brain cancer or brain metastases and lung cancer were positively associated with delirium.
Conclusions
Findings may usefully inform interventions to reduce delirium risk but more high quality prospective cohort studies are required to enable greater certainty about associations of different risk factors with delirium during specialist palliative care.
... The included studies originated from 11 different countries and presented data on a total of 3496 patients, with individual sample sizes ranging 19-2343. Most studies (n = 11) included data from one type of clinical care setting, [35][36][37][38][39][40][41][42][43][44][45] while six studies recruited patients from more than one type of care setting. [46][47][48][49][50][51] The included studies examined patients from inpatient palliative care units (PCU) (including inpatient hospice PCU) (n = 9), inpatient general medicine and inpatient oncology units (n = 8), and outpatient settings (including community hospice, outpatient clinics and emergency departments) (n = 5). ...
... 41,43,46,50 Of the remaining 13 studies that included patients with dementia, six did not report the proportion with dementia in their study sample. [37][38][39][40]45,48 The prevalence of dementia, as reported in seven studies, ranged from 3.8% to 40%. 35,36,42,44,47,49,51 The point prevalence of delirium across all study populations, as diagnosed by the study diagnostic reference standard, ranged from 19.9% to 68.3%. ...
... 35,36,42,44,47,49,51 The point prevalence of delirium across all study populations, as diagnosed by the study diagnostic reference standard, ranged from 19.9% to 68.3%. [35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51] Delirium diagnostic reference standards Four different delirium diagnostic reference standards were used to validate the accuracy of delirium screening tools in the included studies. Most studies (n = 14) used one delirium diagnostic reference standard, 36-40,42-50 while three studies used two different sets of diagnostic criteria. ...
Background:
Delirium is a distressing neuropsychiatric disorder affecting patients in palliative care. Although many delirium screening tools exist, their utility, and validation within palliative care settings has not undergone systematic review.
Aim:
To systematically review studies that validate delirium screening tools conducted in palliative care settings.
Design:
Systematic review with narrative synthesis (PROSPERO ID: CRD42019125481). A risk of bias assessment via Quality Assessment Tool for Diagnostic Accuracy Studies-2 was performed.
Data sources:
Five electronic databases were systematically searched (January 1, 1982-May 3, 2020). Quantitative studies validating a screening tool in adult palliative care patient populations were included. Studies involving alcohol withdrawal, critical or perioperative care were excluded.
Results:
Dual-reviewer screening of 3749 unique titles and abstracts identified 95 studies for full-text review and of these, 17 studies of 14 screening tools were included (n = 3496 patients). Data analyses revealed substantial heterogeneity in patient demographics and variability in screening and diagnostic practices that limited generalizability between study populations and care settings. A risk of bias assessment revealed methodological and reporting deficits, with only 3/17 studies at low risk of bias.
Conclusions:
The processes of selecting a delirium screening tool and determining optimal screening practices in palliative care are complex. One tool is unlikely to fit the needs of the entire palliative care population across all palliative care settings. Further research should be directed at evaluating and/or adapting screening tools and practices to fit the needs of specific palliative care settings and populations.
... Epidemiological data were extracted from studies in 23 inpatient palliative care settings; 12 were hospital-based, 46,53,54,59,62,[65][66][67][68][69][70][71] 7 were in inpatient hospices, 33,34,43,55,61,63,64 and 7 were in acute palliative care units within a cancer center. 32,35,37,40,50,52,72 The median (range) cumulative incidence of delirium in inpatient palliative care units during the entire admission was 29% (7%-45%). 37,44,46,55,57,66 Length of stay in relation to cumulative incidence was represented by a wide range of median values. ...
... Delirium incidence rate during admission was estimated in one study at 25.4/1000 person-days. 44 The point prevalence of delirium on admission was recorded in 18 different study populations 35,37,40,44,46,[52][53][54][55]57,59,61,63,64,66,68,71,72 with a median (range) of 32% (6.6%-73%). The median (range) period prevalence during the course of an entire inpatient admission was 60% (19%-88%, n = 11 studies, 12 distinct populations), 33,37,[44][45][46]50,55,67,[70][71][72] noting again that a wide range of median and mean lengths of stays were reported. ...
... Nearly all included studies (n = 36) performed some form of screening for delirium; however, the frequency of screening and screening tools varied substantially, with a total of 10 different screening tools used across the 36 studies. 31,[33][34][35][36][37][38][39][40][42][43][44][45][46][47][48][49][50][51][53][54][55][56][57]59,[61][62][63][64][66][67][68][69][70][71][72] This illustrates a need to further evaluate delirium diagnostic and screening strategies in palliative care settings, including their comparative metrics and burden, as well as their validity compared to a reference standard. A systemic review of the utility of delirium diagnostic and screening tools in palliative care settings would help to inform both the development of clinical practice guidelines on delirium assessment and the need for further primary studies. ...
Background:
Delirium is a common and distressing neurocognitive condition that frequently affects patients in palliative care settings and is often underdiagnosed.
Aim:
Expanding on a 2013 review, this systematic review examines the incidence and prevalence of delirium across all palliative care settings.
Design:
This systematic review and meta-analyses were prospectively registered with PROSPERO and included a risk of bias assessment.
Data sources:
Five electronic databases were examined for primary research studies published between 1980 and 2018. Studies on adult, non-intensive care and non-postoperative populations, either receiving or eligible to receive palliative care, underwent dual reviewer screening and data extraction. Studies using standardized delirium diagnostic criteria or valid assessment tools were included.
Results:
Following initial screening of 2596 records, and full-text screening of 153 papers, 42 studies were included. Patient populations diagnosed with predominantly cancer ( n = 34) and mixed diagnoses ( n = 8) were represented. Delirium point prevalence estimates were 4%-12% in the community, 9%-57% across hospital palliative care consultative services, and 6%-74% in inpatient palliative care units. The prevalence of delirium prior to death across all palliative care settings ( n = 8) was 42%-88%. Pooled point prevalence on admission to inpatient palliative care units was 35% (confidence interval = 0.29-0.40, n = 14). Only one study had an overall low risk of bias. Varying delirium screening and diagnostic practices were used.
Conclusion:
Delirium is prevalent across all palliative care settings, with one-third of patients delirious at the time of admission to inpatient palliative care. Study heterogeneity limits meta-analyses and highlights the future need for rigorous studies.
... In a first step, ED patients aged 65 years or older are screened for inattention by ED nurses, similar to the CAM-ICU approach [18]. Unlike the ICU, most ED patients are able to perform verbal tasks, so we used a timed recitation of the months of the year in reverse order from the Bedside Confusion Scale (BCS) [24] to assess inattention. Every omission scored one point. ...
... A delay of greater than 30 seconds scored one additional point. Following the approach of Stillman et al. [24], inattention was present with a score of 3 or more. When the BCS was validated against the CAM to detect delirium, a score of 3 or more had a sensitivity of 94% and a specificity of 85% [24]. ...
... Following the approach of Stillman et al. [24], inattention was present with a score of 3 or more. When the BCS was validated against the CAM to detect delirium, a score of 3 or more had a sensitivity of 94% and a specificity of 85% [24]. ...
Delirium in emergency department (ED) patients occurs frequently and often remains unrecognized. Most instruments for delirium detection are complex and therefore unfeasible for the ED. The aims of this pilot study were first, to confirm our hypothesis that there is an unmet need for formal delirium assessment by comparing informal delirium ratings of ED staff with formal delirium assessments performed by trained research assistants. Second, to test the feasibility of an algorithm for delirium screening, detection and management, which includes the newly developed modified Confusion Assessment Method for the Emergency Department (mCAM-ED) at the ED bedside. Third, to test interrater reliability of the mCAM-ED.
This was a pilot study with a pre-post-test design with two data collection periods before and after the implementation of the algorithm. Consecutive ED patients aged 65 years and older were screened and assessed in the ED of a tertiary care center by trained research assistants. The delirium detection rate of informal ratings by nurses and physicians was compared with the standardized mCAM-ED assessment performed by the research assistants. To show the feasibility at the ED bedside, defined as adherence of ED staff to the algorithm, only post-test data were used. Additionally, the ED nurses' assessments were analyzed qualitatively. To investigate the agreement between research assistants and the reference standard, the two data sets were combined.
In total, 207 patients were included in this study. We found that informal delirium assessment was inappropriate, even after a teaching intervention: Sensitivity of nurses to detect delirium without formal assessment was 0.27 pretest and 0.40 post-test, whilst sensitivity of physicians' informal rating was 0.45 pre-test and 0.6 post-test. ED staff demonstrated high adherence to the algorithm (76.5%). Research assistants assessing delirium with the mCAM-ED demonstrated a high agreement compared to the reference standard (kappa = 0.729).
Informal assessment of delirium is inadequate. The mCAM-ED proved to be useful at the ED bedside. Performance criteria need to be tested in further studies. The mCAM-ED may contribute to early identification of delirious ED patients.
... 16,17 Delirium is thought to be underdiagnosed in almost half of those affected. 18 Delirium has been thought to resolve with treatment of the underlying cause, but sometimes persists. 18 The objectives of this pilot survey were: (1) to evaluate the use of the bedside confusional scale (BSCS) in detecting delirium in advanced cancer; and (2) to determine the prevalence, cause, precipitating factors, and treatment of delirium in persons admitted to the palliative medicine unit at the Cleveland Clinic Foundation. ...
... 18 Delirium has been thought to resolve with treatment of the underlying cause, but sometimes persists. 18 The objectives of this pilot survey were: (1) to evaluate the use of the bedside confusional scale (BSCS) in detecting delirium in advanced cancer; and (2) to determine the prevalence, cause, precipitating factors, and treatment of delirium in persons admitted to the palliative medicine unit at the Cleveland Clinic Foundation. ...
... The BSCS seems clinically effective in the assessment of delirium. 18 BSCS is portable, simple, and easy to use, unlike other confusion or delirium scales, which are burdensome, difficult to use, and require special training (e.g., mini-mental state examination [MMSE], delirium rating scale, memorial delirium assessment scale, and confusion assessment method). 22-26 BSCS is reliable and previously validated against the confusion assessment method (CAM), 19 is rapidly done (less than 2 minutes), and can be repeated by any medical team member. ...
We conducted a prospective assessment of 50 consecutive admissions to an acute palliative medicine unit, using the bedside confusion scale (BSCS). Information including age, gender, diagnosis, and the presence or absence of brain metastasis was collected. Possible predisposing factors for delirium were recorded. Forty-one of 50 consecutive admissions were screened. There were 18 men and 23 women with a median age of 65 years (average: 60-75). The most common diagnoses among all were lung and breast cancer. Thirteen patients were delirious (BSCS score of > or = 2), 10 borderline (BSCS score = 1), and 21 normal (BSCS score = 0). Brain metastases and drugs appeared to be the most common predisposing factors of delirium. Forty percent of those that were delirious received haloperidol as symptomatic treatment. The BSCS is simple, portable, valid, quick, and easy to use by any medical team member. Delirium is common in hospitalized patients with advanced cancer.
... For regular ward patients, at the first DOS Score ≥ 3, more specific assessments are conducted with the Mental-Status-Questionnaire (MSQ) [6], the Monate Rückwärts Zählen (MRZ, "Bedsite Confusion Scale") instrument [7]and the [8]Confusion Assessment Method (CAM). The MSQ is a 10-item tool to assess cognition and attention [6]; the MRZ used includes one item from the Bedsite Confusion Scale (BCS); the BCS was developed by Stillman & Rybicki, 2000 to detect alteration in attention [7]; and the CAM is a 4-item diagnostic tool developed by Inouye (1990) to identify delirium based on defined criteria [8]. ...
... For regular ward patients, at the first DOS Score ≥ 3, more specific assessments are conducted with the Mental-Status-Questionnaire (MSQ) [6], the Monate Rückwärts Zählen (MRZ, "Bedsite Confusion Scale") instrument [7]and the [8]Confusion Assessment Method (CAM). The MSQ is a 10-item tool to assess cognition and attention [6]; the MRZ used includes one item from the Bedsite Confusion Scale (BCS); the BCS was developed by Stillman & Rybicki, 2000 to detect alteration in attention [7]; and the CAM is a 4-item diagnostic tool developed by Inouye (1990) to identify delirium based on defined criteria [8]. The tool is frequently used and shows good sensitivity (81%, 94% -100%) and specificity (63%, 89% 90%-95%), as well as good reliability and validity [8,9]. ...
... For regular ward patients, at the first DOS Score ≥ 3, more specific assessments are conducted with the Mental-Status-Questionnaire (MSQ) [6], the Monate Rückwärts Zählen (MRZ, "Bedsite Confusion Scale") instrument [7]and the [8]Confusion Assessment Method (CAM). The MSQ is a 10-item tool to assess cognition and attention [6]; the MRZ used includes one item from the Bedsite Confusion Scale (BCS); the BCS was developed by Stillman & Rybicki, 2000 to detect alteration in attention [7]; and the CAM is a 4-item diagnostic tool developed by Inouye (1990) to identify delirium based on defined criteria [8]. ...
... For regular ward patients, at the first DOS Score ≥ 3, more specific assessments are conducted with the Mental-Status-Questionnaire (MSQ) [6], the Monate Rückwärts Zählen (MRZ, "Bedsite Confusion Scale") instrument [7]and the [8]Confusion Assessment Method (CAM). The MSQ is a 10-item tool to assess cognition and attention [6]; the MRZ used includes one item from the Bedsite Confusion Scale (BCS); the BCS was developed by Stillman & Rybicki, 2000 to detect alteration in attention [7]; and the CAM is a 4-item diagnostic tool developed by Inouye (1990) to identify delirium based on defined criteria [8]. The tool is frequently used and shows good sensitivity (81%, 94% -100%) and specificity (63%, 89% 90%-95%), as well as good reliability and validity [8,9]. ...
Abstract Background Delirium is a well-known complication in cardiac surgery and intensive care unit (ICU) patients. However, in many other settings its prevalence and clinical consequences are understudied. The aims of this study were: (1) To assess delirium prevalence in a large, diverse cohort of acute care patients classified as either at risk or not at risk for delirium; (2) To compare these two groups according to defined indicators; and (3) To compare delirious with non-delirious patients regarding hospital mortality, ICU and hospital length of stay, nursing hours and cost per case. Methods This cohort study was performed in a Swiss university hospital following implementation of a delirium management guideline. After excluding patients aged
... Der Aufmerksamkeitstest der Kalendermonate rückwärts (Meagher et al. 2014) lehnt sich an die Bewertungskriterien von Stillman und Rybicki (2000) an. Er misst das Hauptmerkmal eines Delirs, die Aufmerksamkeit (Stillman & Rybicki, 2000). Die Sensitivität des Aufmerksamkeitstests wurde gegenüber der CAM getestet und liegt bei 100 %, die Spezifizität zwischen 53,8 und 84,6 % (Stillman & Rybicki, 2000). ...
... Er misst das Hauptmerkmal eines Delirs, die Aufmerksamkeit (Stillman & Rybicki, 2000). Die Sensitivität des Aufmerksamkeitstests wurde gegenüber der CAM getestet und liegt bei 100 %, die Spezifizität zwischen 53,8 und 84,6 % (Stillman & Rybicki, 2000). Beim Aufmerksamkeitstest werden Personen aktiv befragt, indem diese gebeten werden, die Kalendermonate rückwärts aufzuzählen. ...
BACKGROUND
Deliria have a massive effect on patients, from increased duration of hospitalization to higher mortality. Risk factors such as age, deprivation of substances, immobility as well as stress are known among others. Particularly in vulnerable persons minor factors can lead to a delirium. European studies report a prevalence rate between 17 % and 22 %, but can’t be compared to the Swiss hospital system. No national delirium prevalence data in acute hospitals is known.
AIM
On the one hand to measure the delirium prevalence in an acute hospital, to elaborate patient characteristics of delirium patients based on group comparison and to test sensitivity and specifity of the applied instruments, on the other hand to get information about the practicality of the study execution.
METHOD
Delirium point prevalence measurement has been conducted in a prospective cross-sectional study. On one determined day data of patients have been collected by nurses in an acute hospital.
RESULTS
A prevalence point rate of 14 % (6 / 43) based on CAM has been identified. Significant differences were found between the groups in respect of age, discipline, number of ICD diagnoses, care dependency and in all the three delirium instruments. Delirium patients were not only longer hospitalized but had almost twice as many ICD diagnosed, were high-maintenance patients and mostly didn’t claim to be in pain.
CONCLUSION
This is the first prevalence study in a Swiss acute hospital. The utilized instruments are reliable and the study execution is practicable and could be conducted with a larger sample. Most known risk factors were confirmed.
... The BCS is designed for the palliative medicine population, requires minimal training, and takes approximately 2 minutes to complete. 43 The Delirium Index measures the severity of symptoms of delirium and is based on observation of the patient, without additional information from informants. 44 (For additional details on the psychometric properties of each instrument, consult the detailed reference list at the end of this article). ...
... Bedside Confusion Scale (BCS) 43 The BCS incorporates a 2-min screening test to observe the level of consciousness at the time of clinical interaction, followed by a timed task of attention using recitation of the months of the year backward. ...
Delirium is a very common neuropsychiatric disorder seen in the very ill and at the end of life and is distressing to patients, families, and caregivers. Although common, delirium is frequently misdiagnosed and poorly managed. Too often, patients are merely labeled as confused or agitated. This lack of recognition, assessment, and treatment can lead to poor outcomes, including functional decline, new nursing home placement, and even death. Prompt assessment, prevention, and both pharmacologic and nonpharmacologic intervention by nurses and the interdisciplinary team can significantly reduce distress, assure comfort, and maximize safety in all care settings.
... Il existe d'autres outils rapides disponibles (par exemple Bedside Confusion Scale BCS [52], Confusion Rating Scale CRS [53], Delirium Diagnostic Tool-provisional DDT-Pro [54]. . .), développés dans différentes situations cliniques (soins palliatifs, traumatismes crâniens, fractures du fémur. . ...
Delirium is very common in hospitalized older patients and associated with serious clinical outcomes, notably increased risk of functional decline and death. Despite its high prevalence in the hospital setting, delirium is still underdiagnosed. A better identification would allow an early management and a reduction of its complications. To achieve this, the validation of formalized, easy-to-use and quick tools for the identification of delirium and their implementation in our clinical practice are necessary. The objective of this narrative review is to describe the available tools for delirium identification most commonly used in clinical practice and in research, followed by those that are quick to very quick to complete (i.e., less than 3 minutes). This review identified 4 tools frequently used internationally (CAM, DRS-R-98, DOSS, MDAS). Their completion time varies from 5 to 30 minutes. Rapid or very rapid tools exist, with very good diagnostic performance. Among them, the 4AT, the 3D-CAM and the UB-CAM seem particularly promising. These last tools seem interesting for a large-scale implementation at the national level, but a validation in French remains to be done.
... These patients were included in the study sample of Hasemann et al. [25,30] and were also screened using the mCAM-ED [30]. It consists of the month of the year backwards test (MOTYB) [32], the Mental Status Questionnaire (MSQ) [33], the Comprehension Test [34] as well as the evaluation of an acute onset of symptoms, fluctuation over the course of the day and altered level of consciousness, as measured by the Modified Richmond Agitation and Sedation Scale (mRASS) in our study [35] (Appendix E). ...
Purpose
Early delirium detection in nursing home residents is vital to prevent adverse outcomes. Despite the potential of structured delirium screening tools to enhance delirium detection, they are rarely used in nursing homes. To promote delirium screening tools in nursing homes, they should be easy to integrate into the daily routine of care workers. The I-AGeD, was developed as a simple and easily understandable tool to detect delirium in older adults. The aims of this study were to record the prevalence of delirium, to investigate the feasibility of the I-AGeD, and to compare these results with the DSM-5 as the reference standard.
Methods
This is a cross-sectional prospective single-center pilot study. Seven registered nurses assessed the participants with the I-AGeD. The research assistant conducted delirium assessments based on the DSM-5 criteria, to identify delirium symptoms for the same participants. The feasibility test was verified using a five-point Likert scale ranging from very easy to very difficult.
Results
85 nursing home residents participated in the study. A delirium prevalence of 5.9% was found. The sensitivity was 60% and specificity 94% at a cut point of ≥ 4 to indicate delirium. The feasibility test showed that the 10 items of the I-AGeD were easy or very easy to answer.
Conclusion
The I-AGeD showed an acceptable performance to assess delirium in nursing home residents. Additionally, it was found feasible and due to its brevity the I-AGeD could easily be integrated into the routine of daily care in nursing homes.
... Besides, i.e. touchless interaction techniques [201], the recognition of strategies of surgeons during an operation [151] are investigated. The recognition of skill [110], [153], [202], [203] or states of confusion [204], [205] of surgeons play a central role in interaction design, as they can help to draw a picture of a surgeons' skills and to find weak-spots that need to be focused on in training. This is done to maximize the output of surgeons and to improve their training. ...
Digitization is penetrating more and more areas of life. Tasks are increasingly being completed digitally, and are therefore not only fulfilled faster, more efficiently but also more purposefully and successfully. The rapid developments in the field of artificial intelligence in recent years have played a major role in this, as they brought up many helpful approaches to build on. At the same time, the eyes, their movements, and the meaning of these movements are being progressively researched. The combination of these developments has led to exciting approaches. In this dissertation, I present some of these approaches which I worked on during my Ph.D. First, I provide insight into the development of models that use artificial intelligence to connect eye movements with visual expertise. This is demonstrated for two domains or rather groups of people: athletes in decision-making actions and surgeons in arthroscopic procedures. The resulting models can be considered as digital diagnostic models for automatic expertise recognition. Furthermore, I show approaches that investigate the transferability of eye movement patterns to different expertise domains and subsequently, important aspects of techniques for generalization. Finally, I address the temporal detection of confusion based on eye movement data. The results suggest the use of the resulting model as a clock signal for possible digital assistance options in the training of young professionals. An interesting aspect of my research is that I was able to draw on very valuable data from DFB youth elite athletes as well as on long-standing experts in arthroscopy. In particular, the work with the DFB data attracted the interest of radio and print media, namely DeutschlandFunk Nova and SWR DasDing. All resulting articles presented here have been published in internationally renowned journals or at conferences.
... Efforts have been made to further simplify the scoring method while maintaining good psychometric properties [23]. Another instrument, the bedside confusion scale (BCS), includes the MOTYB and adds one more question to assess a second delirium feature: psychomotor disturbance [52]. ...
Background
Delirium is a frequent psychopathological syndrome in geriatric patients. It is sometimes the only symptom of acute illness and bears a high risk for complications. Therefore, feasible assessments are needed for delirium detection.
Objective and methods
Rapid review of available delirium assessments based on a current Medline search and cross-reference check with a special focus on those implemented in acute care hospital settings.
Results
A total of 75 delirium detection tools were identified. Many focused on inattention as well as acute onset and/or fluctuating course of cognitive changes as key features for delirium. A range of assessments are based on the confusion assessment method (CAM) that has been adapted for various clinical settings. The need for a collateral history, time resources and staff training are major challenges in delirium assessment. Latest tests address these through a two-step approach, such as the ultrabrief (UB) CAM or by optional assessment of temporal aspects of cognitive changes (4 As test, 4AT). Most delirium screening assessments are validated for patient interviews, some are suitable for monitoring delirium symptoms over time or diagnosing delirium based on collateral history only.
Conclusion
Besides the CAM the 4AT has become well-established in acute care because of its good psychometric properties and practicability. There are several other instruments extending and improving the possibilities of delirium detection in different clinical settings.
... The five-item Nursing delirium screening scale (Nu-DESC) allows to rate attending nurses' observations concerning disorientation, inappropriate behavior and communication, hallucinations and psychomotor retardation over a 24-h period [32]. For the interventional part of the study two easy to use screening instruments for delirium were added to the assessment battery: The bedside confusion scale (BCS) as a simple and short test for delirium that can be derived from 3D-CAM assessment and focuses on the items psychomotor disturbance and awareness [33]. In addition, attending nurses and primary caregivers will be asked the Single Question in Delirium assessment (SQiD): 'Do you think [name of patient] has been more confused lately?' [34]. ...
Background
Among potentially modifiable risk factors for delirium, transfers between wards, hospitals and other facilities have been mentioned with low evidence. TRADE (TRAnsport and DElirium in older people) was set up to investigate i) the impact of transfer and/or discharge on the onset of delirium in older adults and ii) feasibility and acceptance of a developed complex intervention targeting caregiver’s participation during and after hospital discharge or transfer on cognition and the onset of delirium in older adults.
Methods
The study is designed according to the guidelines of the UK Medical Research Council (MRC) for development and evaluation of complex interventions and comprises two steps: development and feasibility/piloting. The development phase includes i) a multicenter observational prospective cohort study to assess delirium incidence and cognitive decline associated with transfer and discharge, ii) a systematic review of the literature, iii) stakeholder focus group interviews and iv) an expert workshop followed by a Delphi survey. Based on this information, a complex intervention to better and systematically involve family caregivers in discharge and transport was developed. The intervention will be tested in a pilot study using a stepped wedge design with a detailed process and health economic evaluation. The study is conducted at four acute care hospitals in southwest Germany. Primary endpoints are the delirium incidence and cognitive function. Secondary endpoints include prevalence of caregiver companionship, functional decline, cost and cost effectiveness, quality of discharge management and quality of admission management in admitting hospitals or nursing homes. Data will be collected prior to discharge as well as after 3, 7 and 90 days.
Discussion
TRADE will help to evaluate transfer and discharge as a possible risk factor for delirium. In addition, TRADE evaluates the impact and modifiability of caregiver’s participation during patient’s transfer or discharge on delirium incidence and cognitive decline providing the foundation for a confirmatory implementation study.
Trial registration
DRKS (Deutsches Register für klinische Studien) DRKS00017828 . Registered on 17th September 2019. Retrospectively registered.
... Besides, i.e. touchless interaction techniques [20], the recognition of strategies of surgeons during an operation [24] are investigated. The recognition of skill [1,25,30,31] or states of confusion [26,33] of surgeons play a central role in interaction design, as they can help to draw a picture of a surgeons' skills and to find weak-spots which need to be focused on in training. This is done to maximize the output of surgeons and to improve their training. ...
... Other methods include analysis of specific response patterns, for example, omissions of two or more months, repetitions or commissions [17,18]. The time taken to complete MOTYB has also been used as a performance measure [19]. Yet the extent to which response patterns might differ in delirium or dementia has not been reported. ...
Purpose
To investigate performance of the Months of the Year Backwards (MOTYB) test in older hospitalised patients with delirium, dementia, and no cognitive impairment.
Methods
Secondary analysis of data from a case–control study of 149 hospitalised patients aged ≥ 65 years with delirium [with or without dementia ( N = 50)], dementia [without delirium ( N = 46)], and no cognitive impairment ( N = 53). Verbatim transcripts of MOTYB audio recordings were analysed to determine group differences in response patterns.
Results
In the total sample [median age 85y (IQR 80–88), 82% female], patients with delirium were more often unable to recite months backward to November (36/50 = 72%) than patients with dementia (21/46 = 46%; p < 0.01) and both differed significantly from patients without cognitive impairment (2/53 = 4%; p ’s < 0.001). 121/149 (81%) of patients were able to engage with the test. Patients with delirium were more often unable to engage with MOTYB (23/50 = 46%; e.g., due to reduced arousal) than patients with dementia (5/46 = 11%; p < 0.001); both groups differed significantly ( p ’s < 0.001) from patients without cognitive impairment (0/53 = 0%). There was no statistically significant difference between patients with delirium (2/27 = 7%) and patients with dementia (8/41 = 20%) in completing MOTYB to January, but performance in both groups differed ( p < 0.001 and p < 0.02, respectively) from patients without cognitive impairment (35/53 = 66%).
Conclusion
Delirium was associated with inability to engage with MOTYB and low rates of completion. In patients able to engage with the test, error-free completion rates were low in delirium and dementia. Recording of engagement and patterns of errors may add useful information to MOTYB scoring.
... Besides, i.e. touchless interaction techniques [19], the recognition of strategies of surgeons during an operation [22] are investigated. The recognition of skill [1,23,28,29] or states of confusion [24,31] of surgeons play a central role in interaction design, as they can help to draw a picture of a surgeons' skills and to find weak-spots which need to be focused on in training. This is done to maximize the output of surgeons and to improve their training. ...
During arthroscopic surgeries, surgeons are faced with challenges like cognitive re-projection of the 2D screen output into the 3D operating site or navigation through highly similar tissue. Training of these cognitive processes takes much time and effort for young surgeons, but is necessary and crucial for their education. In this study we want to show how to recognize states of confusion of young surgeons during an arthroscopic surgery, by looking at their eye and head movements and feeding them to a machine learning model. With an accuracy of over 94\% and detection speed of 0.039 seconds, our model is a step towards online diagnostic and training systems for the perceptual-cognitive processes of surgeons during arthroscopic surgeries.
... 21,22 The BCS has been validated against the CAM and takes about 2 minutes to complete. [22][23][24] Like the CAC, it is designed for nonexperts. 20 The CTD was originally developed for the ICU and for patients who are intubated and cannot speak. ...
Objective
In this survey, we assessed the current clinical management of postoperative delirium (POD) among Chinese anesthesiologists, after publishing the European POD guideline.
Methods
We administered an electronic survey, designed according to the European POD guideline. The survey was completed using mobile devices.
Results
In total, 1,514 respondents from China participated in the survey. Overall, 74.4% of participants reported that delirium is very important. More than 95% of participants stated that they routinely assessed POD. In total, 61.4% screened for POD using clinical observation and 37.6% used a delirium screening tool. Although the depth of anesthesia (a POD risk factor) was monitored, electroencephalogram monitoring was unavailable to 30.6% of respondents. Regarding treatment, only 24.1% of respondents used a standard algorithm; 58.5% used individualized treatment.
Conclusion
Our survey showed that there are high awareness levels among Chinese anesthesiologists regarding the importance of POD. However, routine assessment and monitoring of all patients, including perioperative anesthesia depth monitoring, and a treatment algorithm need to be implemented on a larger scale. According to the results, efforts should be made to improve the knowledge of POD among Chinese anesthesiologists.
... Additionally, the involved departments were supported by the delirium task force during the study's initiation period and continuously on-demand throughout the study. In all patients with a DOS ≥ 3 additional delirium scores-Bedside Confusion Scale (BCS) [32], Mental Status Questionnaire (MSQ) [19], Confusion Assessment Method (CAM) [17]-were performed to improve accuracy of the delirium diagnosis. When delirium scores were positive, the assessment was continued three times per day. ...
Background:
Delirium is the most common neuropsychiatric presentation during hospitalization. In neurosurgery, studies on predisposing and precipitating risk factors for the development of delirium are rare but required for the individual risk estimation.
Methods:
Prospective cohort study in a tertiary university center. In total, 949 neurosurgical patients, 307 with and 642 without delirium, were included. Demographic factors, neurosurgery-related, neurological, and medical clusters were tested as predictors of delirium in multiple logistic regression analyses.
Results:
The incidence of delirium in this cohort of neurosurgical patients was 32.4%. Compared to patients without delirium, those with delirium were significantly older, more cognitively and neurologically impaired, transferred from hospitals and nursing homes, admitted as emergencies, longer hospitalized (16.2 vs. 9.5 days; p < 0.001), in greater need of intensive care management, and more frequently transferred to rehabilitation. Predisposing factors of delirium were stroke (OR 5.45, CI 2.12-14.0, p < 0.001), cardiac insufficiency (OR 4.59, CI 1.09-19.26, p = 0.038), cerebral neoplasm (OR 1.53, CI 0.92-2.54, p = 0.019), and age ≥ 65 years (OR 1.47, CI 1.03-2.09, p = 0.030). Precipitating factors of delirium were acute cerebral injury (OR 3.91, CI 2.24-6.83, p < 0.001), hydrocephalus (OR 3.10, CI 1.98-4.87, p < 0.001), and intracranial hemorrhage (OR 1.90, CI 1.23-2.94, p = 0.004).
Conclusions:
Delirium in acute neurosurgical patients was associated with longer hospitalization. Whereas common etiologies of delirium like infections and dementia, did not predict delirium, pre-existing neurovascular and traumatic diseases, as well as surgery-related events seem important risk factors contributing to delirium in neurosurgery.
... Additionally, the involved departments were supported by the delirium task force during the study's initiation period and continuously on-demand throughout the study. In all patients with a DOS ≥ 3 additional delirium scores-Bedside Confusion Scale (BCS) [32], Mental Status Questionnaire (MSQ) [19], Confusion Assessment Method (CAM) [17]-were performed to improve accuracy of the delirium diagnosis. When delirium scores were positive, the assessment was continued three times per day. ...
BACKGROUND:
Delirium is the most common neuropsychiatric presentation during hospitalization. In neurosurgery, studies on predisposing and precipitating risk factors for the development of delirium are rare but required for the individual risk estimation.
METHODS:
Prospective cohort study in a tertiary university center. In total, 949 neurosurgical patients, 307 with and 642 without delirium, were included. Demographic factors, neurosurgery-related, neurological, and medical clusters were tested as predictors of delirium in multiple logistic regression analyses.
RESULTS:
The incidence of delirium in this cohort of neurosurgical patients was 32.4%. Compared to patients without delirium, those with delirium were significantly older, more cognitively and neurologically impaired, transferred from hospitals and nursing homes, admitted as emergencies, longer hospitalized (16.2 vs. 9.5 days; p < 0.001), in greater need of intensive care management, and more frequently transferred to rehabilitation. Predisposing factors of delirium were stroke (OR 5.45, CI 2.12-14.0, p < 0.001), cardiac insufficiency (OR 4.59, CI 1.09-19.26, p = 0.038), cerebral neoplasm (OR 1.53, CI 0.92-2.54, p = 0.019), and age ≥ 65 years (OR 1.47, CI 1.03-2.09, p = 0.030). Precipitating factors of delirium were acute cerebral injury (OR 3.91, CI 2.24-6.83, p < 0.001), hydrocephalus (OR 3.10, CI 1.98-4.87, p < 0.001), and intracranial hemorrhage (OR 1.90, CI 1.23-2.94, p = 0.004).
CONCLUSIONS:
Delirium in acute neurosurgical patients was associated with longer hospitalization. Whereas common etiologies of delirium like infections and dementia, did not predict delirium, pre-existing neurovascular and traumatic diseases, as well as surgery-related events seem important risk factors contributing to delirium in neurosurgery.
... Participants were eligible if over 18 years with no previous cancer diagnosis, right hand dominant, and reported a subjective fatigue score greater than 3 on a 0-10 Numerical Rating Scale. Exclusion criteria included life-expectancy less than 7 days, Eastern Cooperative Oncology Group (ECOG) performance score greater than 2, dementia, Bedside Confusion Scale score of 2 or more [18], oxygen dependence or saturation less than 90%, a paraneoplastic condition affecting muscle function, or a previous wrist injury. Concurrent stimulant and sedative medications were also recorded. ...
Purpose
Cancer-related fatigue (CRF) biology remains poorly understood. Responsible mechanisms may be central or peripheral and originate anywhere from the brain to muscle fiber. Objective measurement is complex and previously limited to specialized laboratories. Portable electroencephalography (EEG) and electromyography (EMG) may enhance objective measurement. This study evaluated the feasibility and acceptability of portable EMG-EEG in CRF assessment.
Methods
A prospective observational feasibility study compared ten outpatients with inoperable, treatment-naïve non-small cell lung cancer and CRF to ten healthy volunteers. All completed a sustained isometric hand-grip contraction at 30% maximal level until self-perceived exhaustion. 128-channel EEG and 2-channel EMG signals of forearm muscles were recorded. Device acceptability was evaluated by questionnaire.
Results
The task was evaluated in two stages; first and last 20 s. CRF cohort perceived exhaustion earlier than volunteers (mean 137 ± 76 s vs 208 ± 51 s). As fatigue progressed, EMG amplitude increased significantly (CRF p = 0.02; volunteers: p = 0.04) in both groups as did EMG beta band power (CRF p = 0.008; volunteers: p = 0.006). The increase was significantly less in CRF (amplitude p = 0.032; beta power: p = 0.014). EEG beta band power in the contralateral motor cortex increased significantly (CRF p = 0.03; volunteers: p = 0.019) in both cohorts but to greater extent (p = 0.024) in CRF. One hundred percent device acceptability was reported.
Conclusions
A laboratory-based evaluation was successfully adapted to the outpatient setting during routine visits. High acceptability supports clinical utility. In CRF, a higher degree of cortical activation was required to drive a much lower level of muscle performance. This suggests impairment of both central and peripheral mechanisms in CRF.
... Few validation studies have either been carried out in populations of people with cancer or have included sufficient medical diagnostic detail to allow a determination of whether people with cancer were included in the study. Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) guidelines [64] were employed to assess the study quality of the five studies identified from our systematic literature review [52,[65][66][67][68] (see Supplementary Tables S3 and S4, available at Annals of Oncology online). All studies are vulnerable to bias due to spectrum or review bias or use of an inappropriate reference standard. ...
Delirium is a neurocognitive syndrome that commonly occurs in older populations and people with cancer, particularly in those with advanced disease and in the last hours or days of life. While an underlying malignancy and its complications predispose a person to develop delirium, many of the treatments used in the management of cancer also increase the risk of delirium [1]. In addition to being associated with an increased risk of mortality and causing significant physical morbidity, delirium is often a severely distressing experience, not only for patients, but also for families and professional caregivers [1]. The target population for this European Society for Medical Oncology (ESMO) Clinical Practice Guideline (CPG) is adults with cancer who are at risk of delirium or have been diagnosed with delirium. The intended users for this CPG are healthcare professionals working in the field of oncology, in order to inform both clinical decisions and standards of care.
... Le test «Months Backwards» (réciter les mois à l'envers) a fait ses preuves en matière de vérification de l'attention [20]. Lors de ce test, une erreur est tolérée. ...
... Zur Prüfung der Aufmerksamkeit hat sich der «Months Backwards Test» (Rückwärtsaufsagen der Monate) [20] Das Delir stellt keine eigenständige Krankheits- entität, sondern einen je nach Akuität unter- schiedlich ausgeprägten Symptomenkomplex dar. ...
... Some of these scores, such as the Delirium Rating Scale-98 180 or the Memorial Delirium Assessment Scale, 181 might be useful to evaluate postoperative patients, but they might take longer to perform in a busy recovery room setting. Several scores can be used as alternatives: the Bedside Confusion Scale, 182 Clinical Assessment of Confusion, 139 Confusion Rating Scale, 184 the Delirium-O-Meter, 185 Delirium Observation Screening, 186 the delirium symptom interview (DSI), 187 the Neelon and Champagne Confusion Scale 188 or the 4 'A's Test. 189 In general, the team (including nurses and physicians) should be involved in the choice of which score to use. ...
The purpose of this guideline is to present evidence-based and consensus-based recommendations for the prevention and treatment of postoperative delirium. The cornerstones of the guideline are the preoperative identification and handling of patients at risk, adequate intraoperative care, postoperative detection of delirium and management of delirious patients. The scope of this guideline is not to cover ICU delirium. Considering that many medical disciplines are involved in the treatment of surgical patients, a team-based approach should be implemented into daily practice. This guideline is aimed to promote knowledge and education in the preoperative, intraoperative and postoperative setting not only among anaesthesiologists but also among all other healthcare professionals involved in the care of surgical patients.
... 4,35 The most recent study reported 58% delirium prevalence in patients (n = 51) who died during admission. 35 Only one study explicitly measured and reported occurrence of delirium in the last 6 h of life in an the Bedside Confusion Scale (BCS) used by medical investigators 40,46 ; and the Delirium Observational Checklist Scale (DOCS), an instrument developed by study investigators for ward nurse's use. 4 Although the BCS was previously validated in the palliative care setting, it requires further investigation of its psychometric properties. 43 The CRS requires further validation, and the DOCS is not a validated delirium-screening tool. ...
Background
Delirium is a serious neuropsychiatric syndrome frequently experienced by palliative care inpatients. This syndrome is under-recognized by clinicians. While screening increases recognition, it is not a routine practice.
Aim and design
This systematic review aims to examine methods, quality, and results of delirium prevalence and incidence studies in palliative care inpatient populations and discuss implications for delirium screening.
Data sources
A systematic search of the literature identified prospective studies reporting on delirium prevalence and/or incidence in inpatient palliative care adult populations from 1980 to 2012. Papers not in English or those reporting the occurrence of symptoms not specifically identified as delirium were excluded.
Results
Of the eight included studies, the majority (98.9%) involved participants (1079) with advanced cancer. Eight different screening and assessment tools were used. Delirium incidence ranged from 3% to 45%, while delirium prevalence varied, with a range of: 13.3%–42.3% at admission, 26%–62% during admission, and increasing to 58.8%–88% in the weeks or hours preceding death. Studies that used the Diagnostic and Statistical Manual–Fourth Edition reported higher prevalence (42%–88%) and incidence (40.2%–45%), while incidence rates were higher in studies that screened participants at least daily (32.8%–45%). Hypoactive delirium was the most prevalent delirium subtype (68%–86% of cases).
Conclusion
The prevalence and incidence of delirium in palliative care inpatient settings supports the need for screening. However, there is limited consensus on assessment measures or knowledge of implications of delirium screening for inpatients and families. Further research is required to develop standardized methods of delirium screening, assessment, and management that are acceptable to inpatients and families.
... This Bedside Confusion Scale (BCS) has been designed and has been evaluated in patients with cancer. It has two items and it takes about two minutes to administer (Stillman & Rybicki, 2000). A total score of 0 is considered as normal, one as borderline and a total of two and above as delirium. ...
Delirium is a common neuropsychiatric condition with many adverse outcomes in elderly populations including death. Despite this, it is often misdiagnosed and mistreated. A number of scales can be used to detect delirium. We review scales that have been used in delirium studies and report their psychometric properties.
An extensive MEDLINE database search and subsequent examination of reference lists was conducted to identify the various delirium scales that have been designed, primarily for use in the elderly.
Twenty-four scales were identified. Delirium instruments differed according to the classification system they were based on, length of time to administer, the rater and whether they were screening scales or measured symptom severity. The psychometric properties of each scale is reported.
A large number of scales exist, but not all are properly evaluated in terms of psychometric properties, and there is not unanimity about which scale is the best. However, a small number of scales may be considered already to be robust and useable: the CAM, the DRS, the MDAS and the NEECHAM.
... A copy of the evaluation tool is in Fig. 1. The Bedside Confusion Scale (BCS) [7], which utilizes an observation of alertness at the time of patient interaction followed by a timed task of attention, was administered to all eligible patients (0-not confused, 1-borderline, and >2-confused) to determine cognitive function and its possible effect on symptom reporting. ...
This study examined symptoms reported by patients after open-ended questioning vs those systematically assessed using a 48-question survey.
Consecutive patients referred to the palliative medicine program at the Cleveland Clinic Foundation were screened. Open-ended questions were asked initially followed by a 48-item investigator-developed symptom checklist. Each symptom was rated for severity as mild, moderate, or severe. Symptom distress was also evaluated. Data were collected using standardized pre-printed forms.
Two hundred and sixty-five patients were examined and 200 were eligible for assessment. Of those assessed, the median age was 65 years (range 17-90), and median ECOG performance status was 2 (range 1-4). A total of 2,397 symptoms were identified, 322 volunteered and 2,075 by systematic assessment. The median number of volunteered symptoms was one (range zero to six). Eighty-three percent of volunteered symptoms were moderate or severe and 17% mild. Ninety-one percent were distressing. Fatigue was the most common symptom identified by systematic assessment but pain was volunteered most often. The median number of symptoms found using systematic assessment was ten (0-25). Fifty-two percent were rated moderate or severe and 48% mild. Fifty-three percent were distressing. In total, 69% of 522 severe symptoms and 79% of 1,393 distressing symptoms were not volunteered. Certain symptoms were more likely to be volunteered; this was unaffected by age, gender, or race.
The median number of symptoms found using systematic assessment was tenfold higher (p<0.001) than those volunteered. Specific detailed symptom inquiry is essential for optimal palliation in advanced disease.
Rationale: Delirium is a serious, morbid condition affecting 2.6 million older Americans annually. A major problem plaguing delirium research is difficulty in identification, given a plethora of existing tools. The lack of consensus on key features and approaches has stymied progress in delirium research. The goal of this project was to use advanced measurement methods to improve delirium’s identification. Aims and Findings: (1) Determine the 4 most commonly used and well-validated instruments for delirium identification. Through a rigorous systematic review, I identified the Confusion Assessment Method (CAM), Delirium Observation Screening Scale (DOSS), Delirium Rating Scale-Revised-98 (DRS-R-98), and Memorial Delirium Assessment Scale (MDAS). (2) Harmonize the 4 instruments to generate a delirium item bank (DEL-IB), a dataset containing items and estimates of their population level parameters. In a secondary analysis of 3 datasets, I equated instruments on a common metric and created crosswalks. (3) Explore applications of the harmonized item bank through several approaches. First, identifying different cut-points that will optimize: (a) balanced high accuracy (Youden’s J-Statistic), (b) screening (sensitivity), and (c) confirmation of diagnosis (specificity) in identification of delirium. Second, comparing performance characteristics of example forms developed from the DEL-IB. Impact: The knowledge gained includes harmonization of 4 instruments for identification of delirium, with crosswalks on a common metric. This will pave the way for combining studies, such as meta-analyses of new treatments, essential for developing guidelines and advancing clinical care. Additionally, the DEL-IB will facilitate creating big datasets, such as for omics studies to advance pathophysiologic understanding of delirium.
Background
Communication within the circle of care is central to coordinated, safe, and effective care; yet patients, caregivers, and health care providers often experience poor communication and fragmented care. Through a sequential program of research, the Loop Research Collaborative developed a web-based, asynchronous clinical communication system for team-based care. Loop assembles the circle of care centered on a patient, in private networking spaces called Patient Loops. The patient, their caregiver, or both are part of the Patient Loop. The communication is threaded, it can be filtered and sorted in multiple ways, it is securely stored, and can be exported for upload to a medical record.
Objective
The objective of this study was to implement and evaluate Loop. The study reporting adheres to the Standards for Reporting Implementation Research.
Methods
The study was a hybrid type II mixed methods design to simultaneously evaluate Loop’s clinical and implementation effectiveness, and implementation barriers and facilitators in 6 health care sites. Data included monthly user check-in interviews and bimonthly surveys to capture patient or caregiver experience of continuity of care, in-depth interviews to explore barriers and facilitators based on the Consolidated Framework for Implementation Research (CFIR), and Loop usage extracted directly from the Loop system.
ResultsWe recruited 25 initiating health care providers across 6 sites who then identified patients or caregivers for recruitment. Of 147 patient or caregiver participants who were assessed and met screening criteria, 57 consented and 52 were enrolled on Loop, creating 52 Patient Loops. Across all Patient Loops, 96 additional health care providers consented to join the Loop teams. Loop usage was followed for up to 8 months. The median number of messages exchanged per team was 1 (range 0-28). The monthly check-in and CFIR interviews showed that although participants acknowledged that Loop could potentially fill a gap, existing modes of communication, workflows, incentives, and the lack of integration with the hospital electronic medical records and patient portals were barriers to its adoption. While participants acknowledged Loop’s potential value for engaging the patient and caregiver, and for improving communication within the patient’s circle of care, Loop’s relative advantage was not realized during the study and there was insufficient tension for change. Missing data limited the analysis of continuity of care.
Conclusions
Fundamental structural and implementation challenges persist toward realizing Loop’s potential as a shared system of asynchronous communication. Barriers include health information system integration; system, organizational, and individual tension for change; and a fee structure for health care provider compensation for asynchronous communication.
Introduction:
Different scoring methods exist for the Month of the Year Backward Test (MBT), which is designed to detect inattention, the core feature of delirium. When used as a part of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED), each error in the MBT scores one point. Because this scoring procedure is complex, we aimed to simplify the scoring method of the MBT.
Methods:
This is a secondary analysis of a single center prospective validation study of the mCAM-ED comprising a sample of Emergency Department (ED) patients aged 65 or older presenting to our ED.
Data collection:
Research assistants (RAs) who were trained nurses conducted the MBT. Geriatricians conducted the reference standard delirium assessment within 1 h of the RA.
Results:
For the scoring method "number of errors", optimal performance according the Youden index was achieved when 8 or more errors were reached resulting in an overall sensitivity of 0.95 and overall specificity of 0.94. The scoring method "number of errors in combination with time needed" resulted in a comparable result with minimally lower positive likelihood ratios. For the scoring method "last month in correct order", optimal performance according the Youden index was achieved with the month of September resulting in an overall sensitivity of 0.90 and an overall specificity of 0.89.
Discussion:
We suggest omitting the factor time and using a more practical scoring method with good performance: "last month in correct order" with the requirement to reach September to rule out delirium.
Delirium is frequent in older Emergency Department (ED) patients, but detection rates for delirium in the ED are low. To aid in identifying delirium, we developed and implemented a two-step systematic delirium screening and assessment tool in our ED: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Components of the mCAM-ED include: (1) screening for inattention, the main feature of delirium, which was performed with the Months Backwards Test (MBT); (2) delirium assessment based on a structured interview with questions from the Mental Status Questionnaire by Kahn et al. and the Comprehension Test by Hart et al. The aims of our study are (1) to investigate the performance criteria of the mCAM-ED tool in a consecutive sample of older ED patients, (2) to evaluate the performance of the mCAM-ED in patients with and without dementia and (3) to test whether this tool is efficient in keeping evaluation time to a minimum and reducing screening and assessment burden on the patient. For this prospective validation study, we recruited a consecutive sample of ED patients aged 65 and older during an 11-day period in November 2015. Trained nurses assessed patients with the mCAM-ED. Results were compared to the reference standard [i.e. the geriatricians’ delirium diagnosis based on the criteria of the Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)]. Performance criteria were computed. We included 286 consecutive ED patients aged 65 and older. The median age was 80.02 (Q1 = 72.15; Q3 = 86.76), 58.7% of included patients were female, 14.3% had dementia. We found a delirium prevalence of 7.0%. In patients with dementia, specificity and positive likelihood ratio were lower. When compared to the reference standard, delirium assessment with the mCAM-ED has a 0.98 specificity and a 39.9 positive likelihood ratio. In 80.0% of all cases, the first step of the mCAM-ED, i.e. screening for inattention with the MBT, took less than 30 s. On average, the complete mCAM-ED assessment required 3.2 (SD 2.0), 5.6 (SD 3.2), and 6.2 (SD 2.3) minutes in cognitively unimpaired patients, patients with dementia and patients with dementia or delirium, respectively. The mCAM-ED is able to efficiently rule out delirium as well as confirm the diagnosis of delirium in elderly patients with and without dementia and applies minimal screening and assessment burden on the patient.
Ensuring a consistent and systematic approach to the delivery of care for people with advanced disease is a priority for palliative care services worldwide. Many clinical tools are available to aid in this process; however, they are often used sporadically, and implementation of a routine set of clinical tools to guide care planning in the specialist palliative care sector in Australia has not been achieved. This study sought to recommend key clinical tools that may assist with the assessment and care planning of specialist palliative care provision for patients and family caregivers admitted to specialist palliative care settings (home, hospital, and hospice).
A mixed-methods sequential approach over four phases was employed, involving: (1) a palliative care sector survey, (2) a systematic literature review, (3) an appraisal of identified clinical tools, and (4) a focus group with an expert panel who critiqued and endorsed a final suite of clinical tools recommended for specialist palliative care.
Twelve tools with practical relevance were recommended for use across settings of care.
Palliative services should review current practices and seek to implement this recommended suite of tools to enhance assessment and guide care delivery across care settings. Subsequent evaluation should also occur.
The need to ascertain appropriate decision-making capacity is greatest when dealing with refusals of lifesaving or life-prolonging treatment. This may be complicated by delirium, concurrent depression, metabolic disturbances or significant symptom burden, family conflicts, and social issues. This is a case of a 48-year-old patient with a long-standing history of a symptomatic pan-invasive pituitary adenoma who refused life-prolonging treatment. Ultimately, a patient must be able to understand the information given to him, evaluate the consequences of the options presented, deliberate on these options based on his values, communicate this choice, and maintain consistency overtime. These refusals of treatment may fluctuate with time and intensity of the illness. Denial of this right of autonomy and self-determination may worsen the individual's physical and existential suffering.
Screening for impaired cognition is very important in geriatric and palliative medicine. There are several validated screening tools for delirium; the Confusion Assessment Method, The Memorial Delirium Assessment Scale, and the Bedside Confusion Scale. The Clock Drawing Test, which was initially described in 1963, has also been used to assess cognition and is validated in Alzheimer's disease and in elderly hospice patients with a negative predictive value greater than 0.95. The Clock Drawing Test is quickly and easily performed by patients and can be kept in the patient's medical record for future reference. However, very few studies have used the Clock Drawing Test to assess delirium in cancer and even fewer have used the Clock Drawing Test to determine response to interventions for delirium.
The National Consensus Project (NCP) 2004 Clinical Practice Guidelines for Quality Palliative Care defines eight domains of care essential for palliative care clinical practice. The National Quality Forum (NQF) 2006 document entitled A National Framework and Preferred Practices for Palliative and Hospice Care Quality: A Consensus Report is based on the NCP Guidelines. The NQF document identifies 38 evidence-based preferred practices for palliative care. This paper demonstrates how the Guidelines and Preferred Practices may be operationalized by pharmacotherapists to better treat symptoms of debilitating or chronic illnesses falling under Domain 2 of the Guidelines, "Physical Care." Specifically, dementia and dyspnea are used as illustrative examples.
Patients with cancer suffer from a multitude of symptoms. Effective treatment strategies are available for a number of the common symptoms. A major reason for inadequate symptom relief is lack of effective symptom assessment. Accurate assessment of symptoms is necessary before any treatment can be undertaken. Although there are many complexities involved in the assessment of symptoms, simple, effective tools are available for identification and scoring of symptoms in clinical practice. This review describes recent advances in the study of symptom assessment in cancer patients. Several common symptoms are presented individually, followed by an overview of efforts addressing the assessment of multiple symptoms. Also, new tools in the evaluation of symptoms, including computer-based questionnaires, are discussed.
Confusion is common among ill patients and has broad consequences for their care and well-being. The prevalence of confusion in hospice patients is unknown.
Describe the prevalence, severity, and manifestations of nurse-identified confusion and estimate the prevalence of delirium in hospice patients.
Cross-sectional descriptive study.
Nineteen hospices in the Population-based Palliative Care Research Network (PoPCRN).
Adult patients receiving care from participating hospices, February 15 to April 1, 2000. MEASUREMENT/ANALYSIS: Hospice nurses estimated prevalence, severity, behavioral manifestations, and consequences of confusion during the preceding week. Confused and nonconfused patients were compared using standard bivariate and stratification techniques. Logistic regression identified manifestations associated with problematic confusion.
Median age of the 299 patients was 78 years; 59% were female, 52% lived at home, and cancer was the most common diagnosis (54%). Fifty percent were confused during the preceding week, 36% of those were severely confused or disabled by confusion. Compared with nonconfused patients, confused patients were less likely to have cancer (64% vs. 43%, p < or = 0.001) and more likely to live in nursing home/assisted living (21% vs. 33%, p < or = 0.01). Disorientation to time or place, impaired short-term memory, drowsiness, and easy distractibility were common manifestations of confusion. When present, confusion caused a problem for the patient, someone else, or both 79% of the time. Inappropriate mood, cancer diagnosis, agitation, and age were the variables predicting problematic confusion. Only 14% of confused patients met criteria for delirium.
Confusion among hospice patients was common, frequently severe, and usually problematic.
The most commonly encountered clinical conditions presenting with cognitive failure (CF) are delirium, dementia and amnestic disorders. Of these, delirium is probably the most prevalent in palliative care, and it is potentially reversible. Thus, improvement in diagnostics seems warranted. The objectives of this review were to examine the methods for assessment of CF and delirium in palliative care.
Twenty-two studies were reviewed: 64% were published in 2000 or later. Twelve reports focused on delirium, six on CF, while the remaining four assessed confusion (2), hallucinations and general psychological morbidity. Median sample size was 100 (20–393). Ten different instruments were used: The Mini Mental State Exam was used in 13 studies. Five studies were validation reports of new or existing instruments.
The term CF is an imprecise description of a loss in one or more of the cognitive functions. The interchangeable use of CF as a description of specific diagnoses should be avoided, as this contributes to prevalence rates that are not representative. Assessment tools that discriminate between the different diagnostic entities presenting with CF should be used in future studies.
Research investigating the psychological distress of palliative care patients has contributed to our understanding of the needs and experiences of individuals approaching death. This paper aims to provide a brief review of such measurement of psychological distress in palliative care, focusing on established psychiatric and psychological research tools, and quantitative research methods. This includes clinical screening and diagnostic assessment instruments used to identify key distress-related symptoms and the presence of common clinical syndromes, such as depression, anxiety, delirium, as well as the broader psychological dimensions of suffering, such as existential concerns, spirituality, hope and demoralisation. There are important considerations in undertaking psychological research in palliative care, such as maintaining a balance between the methods and measurements that will address key research questions, and sensitivity to the range of physical and emotional demands facing individuals at the point of receiving palliative care. The clinical application of psychological and psychiatric research tools and methods can aid the detection of psychological distress, aid the thorough assessment of the psychological dimension of the patients' illness and care, aid the identification of individuals who would benefit from specific psychotherapeutic or pharmacologic interventions, and the evaluation of response to treatments.
Cognitive impairment is common in patients with advanced disease and has significant implications for the patient, their carers and hospice staff. The effectiveness of screening tools is limited by a number of factors. The clock-drawing test (CDT) has performed well in other settings but has rarely been studied in the hospice setting.
To assess the performance of the CDT in a hospice population.
Consecutive admissions to a large hospice over three months were assessed using the CDT, the abbreviated mental test score and brief tests of attention and memory function.
One-hundred and nine eligible patients were admitted and 77% took part. Thirty per cent were cognitively impaired. The CDT had a sensitivity of 0.92, a specificity of 0.73 and a negative predictive value of 0.95. No patient refused to complete it.
The CDT performs well as a screening tool for cognitive impairment in a hospice population.
A patient with pain associated with metastatic leiomyosarcoma received escalating doses of opioids. Upon discontinuation of intravenous morphine, transdermal fentanyl was initiated, and after several days, the dose was increased to 200microg/hour for persistent, severe pain. The patient became somnolent, and further dose adjustments and route change were carried out. She then exhibited severe allodynia, myoclonus, and delirium thereafter fentanyl was stopped. All symptoms resolved with discontinuation of fentanyl and subsequent introduction of a weak opioid. Pain was well controlled. Gradually increasing standard doses of fentanyl may lead to severe neurotoxicity, which may respond to opioid discontinuation and/or rotation. Vigilant scrutiny of all possible causes of apparent analgesic failure followed by consideration of opioid reduction and rotation is warranted in cases of neurotoxicity accompanying opioid treatment.
We evaluated the occurrence and persistence of delirium in 325 elderly patients admitted to a teaching hospital from either a defined community or a long-term care facility. Of the study participants, 34 (10.5%) had Diagnostic and Statistical Manual of Mental Disorders, Third Edition-defined delirium at initial evaluation; of the remaining patients, 91 (31.3%) developed new-onset delirium. An additional 110 patients also experienced individual symptoms of delirium without meeting full criteria. Preexisting cognitive impairment and advanced age were associated with increased risk of incident delirium in the community sample but not the institutional one. Delirium was not associated with an increased risk of mortality, but it was associated with a prolonged hospital stay and an increased risk of institutional placement among community-dwelling elderly. Only five patients (4%) experienced resolution of all new symptoms of delirium before hospital discharge, and only 20.8% and 17.7%, respectively, had resolution of all new symptoms by 3 and 6 months after hospital discharge. These data suggest that delirium is a common disorder that may be substantially less transient than currently believed and that incomplete manifestations of the syndrome may be frequent.
(Arch Intern Med. 1992;152:334-340)
Delirium, a common and often overlooked syndrome in acutely ill elderly patients, may present with signs and symptoms of depression.
To determine (1) how often health care providers mistake delirium for a depressive disorder in older hospitalized patients referred to a psychiatric consultation service for depressive symptoms and (2) which signs and symptoms of depression and delirium characterize these patients.
Patients older than 60 years, admitted to a Veterans Affairs teaching hospital, and consecutively referred to a psychiatric consultation service for evaluation and treatment of a depressive disorder.
The diagnosis of delirium was based on two independent assessments: (1) a clinical interview by a member of the psychiatric consultation service and (2) a structured bedside evaluation performed by one of the investigators, who was not a member of the psychiatric consultation service. The investigator administered the Confusion Assessment Method Instrument, Mini-Mental State Examination, digit span forward, and months of year backward. The investigator also administered the Diagnostic Interview Schedule items for depression to elicit depressive symptoms.
Twenty-eight (41.8%) of the 67 subjects referred for evaluation or treatment of a depressive disorder were found to be delirious. Compared with nondelirious subjects, the delirious subjects were older and more impaired in activities of daily living. The delirious subjects often endorsed depressive symptoms, such as low mood (60%), worthlessness (68%), and frequent thoughts of death (52%). The referring health care provider had considered delirium in the differential diagnosis of the mood disturbance in only three subjects.
Health care providers should consider the diagnosis of delirium in hospitalized elderly patients who appear to be depressed.
Since in hospitalized older patients delirium is associated with poor outcomes, we evaluated the effectiveness of a multicomponent strategy for the prevention of delirium.
We studied 852 patients 70 years of age or older who had been admitted to the general-medicine service at a teaching hospital. Patients from one intervention unit and two usual-care units were enrolled by means of a prospective matching strategy. The intervention consisted of standardized protocols for the management of six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Delirium, the primary outcome, was assessed daily until discharge.
Delirium developed in 9.9 percent of the intervention group as compared with 15.0 percent of the usual-care group, (matched odds ratio, 0.60; 95 percent confidence interval, 0.39 to 0.92). The total number of days with delirium (105 vs. 161, P=0.02) and the total number of episodes (62 vs. 90, P=0.03) were significantly lower in the intervention group. However, the severity of delirium and recurrence rates were not significantly different. The overall rate of adherence to the intervention was 87 percent, and the total number of targeted risk factors per patient was significantly reduced. Intervention was associated with significant improvement in the degree of cognitive impairment among patients with cognitive impairment at admission and a reduction in the rate of use of sleep medications among all patients. Among the other risk factors per patient there were trends toward improvement in immobility, visual impairment, and hearing impairment.
The risk-factor intervention strategy that we studied resulted in significant reductions in the number and duration of episodes of delirium in hospitalized older patients. The intervention had no significant effect on the severity of delirium or on recurrence rates; this finding suggests that primary prevention of delirium is probably the most effective treatment strategy.
Features of coma during the first week after sever head injury were analysed in 700 patients. Coma is best defined as inability to obey commands, to speak, or to open the eyes. If eye opening is omitted from the definition then some less severly affected patients will be included in the early stages, the duration of coma will be overestimated, and in the later stages the distiction between coma and other unresponsive states may be blurred. Other features which correlate with responsiveness (as judged by motor response, speech, and eye opening) are pupil reactions and eye movements; respiratory abnormalities are less common and less closely related to other aspects of severity. A rigorous fefinition of coma is necessary for valid commparisons between individual patients and between different series of patients with head injury. This is essential for the assessment of alternative management regimens and for establishing predictive criteria.
The purpose of this paper is to provide a comprehensive review of information accumulated over the past 26 years regarding the psychometric properties and utility of the Mini-Mental State Examination (MMSE).
The reviewed studies assessed a wide variety of subjects, ranging from cognitively intact community residents to those with severe cognitive impairment associated with various types of dementing illnesses.
The validity of the MMSE was compared against a variety of gold standards, including DSM-III-R and NINCDS-ADRDA criteria, clinical diagnoses, Activities of Daily Living measures, and other tests that putatively identify and measure cognitive impairment.
Reliability and construct validity were judged to be satisfactory. Measures of criterion validity showed high levels of sensitivity for moderate-to-severe cognitive impairment and lower levels for mild degrees of impairment. Content analyses revealed the MMSE was highly verbal, and not all items were equally sensitive to cognitive impairment. Items measuring language were judged to be relatively easy and lacked utility for identifying mild language deficits. Overall, MMSE scores were affected by age, education, and cultural background, but not gender.
In general, the MMSE fulfilled its original goal of providing a brief screening test that quantitatively assesses the severity of cognitive impairment and documents cognitive changes occurring over time. The MMSE should not, by itself, be used as a diagnostic tool to identify dementia. Suggestions for the clinical use of the MMSE are made.
To develop and validate a new standardized confusion assessment method (CAM) that enables nonpsychiatric clinicians to detect delirium quickly in high-risk settings.
Prospective validation study.
Conducted in general medicine wards and in an outpatient geriatric assessment center at Yale University (site 1) and in general medicine wards at the University of Chicago (site 2).
The study included 56 subjects, ranging in age from 65 to 98 years. At site 1, 10 patients with and 20 without delirium participated; at site 2, 16 patients with and 10 without delirium participated.
An expert panel developed the CAM through a consensus building process. The CAM instrument, which can be completed in less than 5 minutes, consists of nine operationalized criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). An a priori hypothesis was established for the diagnostic value of four criteria: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. The CAM algorithm for diagnosis of delirium required the presence of both the first and the second criteria and of either the third or the fourth criterion. At both sites, the diagnoses made by the CAM were concurrently validated against the diagnoses made by psychiatrists. At sites 1 and 2 values for sensitivity were 100% and 94%, respectively; values for specificity were 95% and 90%; values for positive predictive accuracy were 91% and 94%; and values for negative predictive accuracy were 100% and 90%. The CAM algorithm had the highest predictive accuracy for all possible combinations of the nine features of delirium. The CAM was shown to have convergent agreement with four other mental status tests, including the Mini-Mental State Examination. The interobserver reliability of the CAM was high (kappa = 0.81 - 1.0).
The CAM is sensitive, specific, reliable, and easy to use for identification of delirium.
Identifying the cancer patient who is at increased risk for suicide is the first step in prevention, and allows for appropriate psychosocial interventions to be initiated. The author presents a list of vulnerability factors that contribute to high suicide potential.
The authors present a 10-item clinician-rated symptom rating scale for delirium. Compared to demented, schizophrenic, and normal control groups, 20 delirious subjects scored significantly higher on the scale, which quantitates multiple parameters affected by delirium. The scale can be used alone or in conjunction with an electroencephalogram and bedside cognitive tests to assess the delirious subject.
Delirium (acute confusional states), a common and often overlooked psychiatric disorder, can occur at any age, but elderly persons are especially prone to develop it. In later life, it is often a conspicuous feature of systemic or cerebral disease and drug (notably anticholinergic) toxicity, and it may constitute a grave prognostic sign. Its development in a hospitalized patient may interfere with his or her management, disrupt ward routine, and cause medicolegal complications as a result of patient injury. Acute onset of a fluctuating level of awareness, accompanied by sleep-wake cycle disruption, lethargy or agitation, and nocturnal worsening of symptoms, are diagnostic. Early recognition of delirium and treatment of its underlying cause are essential.
Twenty-four patients with metabolic or toxic disorders of rapid onset, and without focal brain lesion, were selected as “confused” on the basis of an alteration of attention. They were given a short neuropsycho-logical examination, their performances being compared to those of ten controls and to their own after recovering from confusion.
The Karnofsky Performance Status Scale (KPS) is widely used to quantify the functional status of cancer patients. However, limited data exist documenting its reliability and validity. The KPS is used in the National Hospice Study (NHS) as both a study eligibility criterion and an outcome measure. As part of intensive training, interviewers were instructed in and tested on guidelines for determining the KPS levels of patients. After 4 months of field experience, interviewers were again tested based on narrative patient descriptions. The interrator reliability of 47 NHS interviewers was found to be 0.97. The construct validity of the KPS was analyzed, and the KPS was found to be strongly related (P less than 0.001) to two other independent measures of patient functioning. Finally, the relationship of the KPS to longevity (r = 0.30) in a population of terminal cancer patients documents its predictive validity. These findings suggest the utility of the KPS as a valuable research tool when employed by trained observers.
Nineteen patients believed to be in the terminal stages of cancer were evaluated for signs of delirium. Six patients improved; 13 who died during hospitalization were studied until their death. Patients were interviewed three times a week using a delirium scale; medical records also were used to gather data. Eleven (85%) of the 13 patients developed delirium. In most patients, delirium was caused by multiple factors. The authors outline strategies for management of terminal cancer patients with delirium.
Synopsis
With a psychiatrist's standardized clinical diagnosis as the criterion, the ‘Mini-Mental State’ Examination (MMSE) was 87% sensitive and 82% specific in detecting dementia and delirium among hospital patients on a general medical ward. The false positive ratio was 39% and the false negative ratio was 5 %. All false positives had less than 9 years of education; many were 60 years of age or older. Performance on specific MMSE items was related to education or age. These findings confirm the MMSE's value as a screen instrument for dementia and delirium when later, more intensive diagnostic enquiry is possible; they reinforce earlier suggestions that the MMSE alone cannot yield a diagnosis for these conditions.
This paper reviews various types of assessment instruments for delirium, including nursing screening scales, symptom checklists, an analog scale, an interview schedule, and symptom rating scales. Their structures and applicability to the clinical and research assessment of delirium are described. Despite the seeming plethora of assessment methods, only a few are suitable for use by researchers.
Delirium, with occurrence rates from 14% to 56%, associated mortality rates from 10% to 65%, and excess annual health care expenditures from $1 to $2 billion, poses a common and serious problem for hospitalized elderly patients. Delirium is often unrecognized or misdiagnosed by physicians caring for elderly patients. Cognitive testing is rarely done as part of the admission evaluation of elderly hospitalized patients. Specific diagnosis has been difficult, since diagnostic criteria and instruments are still being developed. The etiology of delirium is complex and multifactorial, and both predisposing (host vulnerability) and precipitating factors must be considered. The recommended approach to the evaluation of delirium is empiric, in the absence of objective efficacy data. The cornerstone of evaluation includes a careful history, physical examination, and review of the medication list--since medications are the most common reversible cause of delirium. Research is needed to establish a cost-effective approach and to clarify the role of further testing, such as cerebrospinal fluid examination, brain imaging, and electroencephalography. This article is intended to heighten the awareness of clinicians as well as to stimulate research to address this important, neglected problem for elderly hospitalized patients.
To prospectively develop and validate a predictive model for the occurrence of new delirium in hospitalized elderly medical patients based on characteristics present at admission.
Two prospective cohort studies done in tandem.
University teaching hospital.
The development cohort included 107 hospitalized general medical patients 70 years or older who did not have dementia or delirium at admission. The validation cohort included 174 comparable patients.
Patients were assessed daily for delirium using a standardized, validated instrument. The predictive model developed in the initial cohort was then validated in a separate cohort of patients.
Delirium developed in 27 of 107 patients (25%) in the development cohort. Four independent baseline risk factors for delirium were identified using proportional hazards analysis: These included vision impairment (adjusted relative risk, 3.5; 95% Cl, 1.2 to 10.7); severe illness (relative risk, 3.5; Cl, 1.5 to 8.2); cognitive impairment (relative risk, 2.8; Cl, 1.2 to 6.7); and a high blood urea nitrogen/creatinine ratio (relative risk, 2.0; Cl, 0.9 to 4.6). A risk stratification system was developed by assigning 1 point for each risk factor present. Rates of delirium for low- (0 points), intermediate- (1 to 2 points), and high-risk (3 to 4 points) groups were 9%, 23%, and 83% (P < 0.0001), respectively. The corresponding rates in the validation cohort, in which 29 of 174 patients (17%) developed delirium, were 3%, 16%, and 32% (P < 0.002). The rates of death or nursing home placement, outcomes potentially related to delirium, were 9%, 16%, and 42% (P = 0.02) in the development cohort and 3%, 14%, and 26% (P = 0.007) in the validation cohort.
Delirium among elderly hospitalized patients is common, and a simple predictive model based on four risk factors can be used at admission to identify elderly persons at the greatest risk.
Synopsis
Seventy consecutive elderly patients meeting the DSM-III criteria for non-alcohol delirium were examined during the acute stage and followed to four years later. The mean age of the patients at the beginning of the index admission was 74, 8±6, 4 years. The most common aetiologies for delirium were stroke, infections and metabolic disorders. Coexistent structural brain disease predisposing to delirium was found in 57 cases (81%). During the index admission, the cognitive dysfunction associated with delirium ameliorated significantly (mean±S.D. Mini Mental State Examination score 9·7±6·6 at admission and 13·9±7·2 at discharge, P < 0·001), but during the follow-up period of four years progression of the basic central nervous system disease was observed together with declining cognition and deteriorating functions of daily living. Four patients died during the index admission and 42 patients during the follow-up period. In deceased patients there was a statistically significant connection between the levels of cognitive functioning and functions of daily living at the end of the index admission and the life span after delirium.
To prospectively develop and validate a predictive model for delirium based on precipitating factors during hospitalization, and to examine the interrelationship of precipitating factors and baseline vulnerability.
Two prospective cohort studies, in tandem.
General medical wards, university teaching hospital.
For the development cohort, 196 patients aged 70 years and older with no delirium at baseline, and for the validation cohort, 312 comparable patients.
New-onset delirium by hospital day 9, defined by the Confusion Assessment Method diagnostic criteria.
Delirium developed in 35 patients (18%) in the development cohort. Five independent precipitating factors for delirium were identified; use of physical restraints (adjusted relative risk [RR], 4.4; 95% confidence interval [CI], 2.5 to 7.9), malnutrition (RR, 4.0; 95% CI, 2.2 to 7.4), more than three medications added (RR, 2.9; 95% CI, 1.6 to 5.4), use of bladder catheter (RR, 2.4; 95% CI, 1.2 to 4.7), and any iatrogenic event (RR, 1.9; 95% CI, 1.1 to 3.2). Each precipitating factor preceded the onset of delirium by more than 24 hours. A risk stratification system was developed by adding 1 point for each factor present. Rates of delirium for low-risk (0 points), intermediate-risk (1 to 2 points), and high-risk groups (> or equal to 3 points) were 3%, 20%, and 59%, respectively (P < .001). The corresponding rates in the validation cohort, in which 47 patients (15%) developed delirium, were 4%, 20%, and 35%, respectively (P < .001). When precipitating and baseline factors were analyzed in cross-stratified format, delirium rates increased progressively from low-risk to high-risk groups in all directions (double-gradient phenomenon). The contributions of baseline and precipitating factors were documented to be independent and statistically significant.
A simple predictive model based on the presence of five precipitating factors can be used to identify elderly medical patients at high risk for delirium. Precipitating and baseline vulnerability factors are highly interrelated and contribute to delirium in independent substantive, and cumulative ways.
After passage, in November 1994, of Oregon's ballot measure legalizing physician-assisted suicide for terminally ill persons, the authors surveyed psychiatrists in Oregon to determine their attitudes toward assisted suicide, the factors influencing these attitudes, and how they might both respond to and follow up a request by a primary care physician to evaluate a terminally ill patient desiring assisted suicide.
An anonymous questionnaire was sent to all 418 Oregon psychiatrists.
Seventy-seven percent of psychiatrists (N = 321) returned the questionnaire. Two-thirds endorsed the view that a physician should be permitted, under some circumstances, to write a prescription for a medication whose sole purpose would be to allow a patient to end his or her life. One-third endorsed the view that this practice should never be permitted. Over half favored Oregon's assisted suicide initiative becoming law. Psychiatrists' position on legalization of assisted suicide influenced the likelihood that they would agree to evaluate patients requesting assisted suicide and how they would follow up an evaluation of a competent patient desiring assisted suicide. Only 6% of psychiatrists were very confident that in a single evaluation they could adequately assess whether a psychiatric disorder was impairing the judgment of a patient requesting assisted suicide.
Psychiatrists in Oregon are divided in their belief about the ethical permissibility of assisted suicide, and their moral beliefs influence how they might evaluate a patient requesting assisted suicide, should this practice be legalized. Psychiatrists' confidence in their ability to determine whether a psychiatric disorder such as depression was impairing the judgment of a patient requesting assisted suicide was low.
We conducted two studies with medically hospitalized cancer and acquired immunodeficiency syndrome (AIDS) patients to assess the reliability and validity of a new measure of delirium severity, the Memorial Delirium Assessment Scale (MDAS). The first study used multiple raters who jointly administered the MDAS to 33 patients, 17 of whom met DSM III-R/DSM IV criteria for delirium, 8 met diagnostic criteria for another cognitive impairment disorder (for example, dementia), and 8 had non-cognitive psychiatric disorders (for example, adjustment disorder). Results indicate high levels of inter-rater reliability for the MDAS (0.92) and the individual MDAS items (ranging from 0.64 to 0.99), as well as high levels of internal consistency (coefficient alpha = 0.91). Mean MDAS ratings differed significantly between delirious patients and the comparison sample of patients with other cognitive impairment disorders or no cognitive impairment (P < 0.0002). The second study compared MDAS ratings of 51 medically hospitalized delirious patients with cancer and AIDS made by one clinician to ratings on several other measures of delirium (Delirium Rating Scale, clinician's ratings of delirium severely) and cognitive functioning (Mini-Mental State Examination) made by a second clinician. Results demonstrated a high correlation between MDAS scores and ratings on the Delirium Rating Scale (r = 0.88, p < 0.0001), the Mini-Mental State Examination (r = -0.91, P < 0.0001), and clinician's global ratings of delirium severity (r = 0.89, P < 0.0001). Thus, our findings indicate that the MDAS is a brief, reliable tool for assessing delirium severity among medically ill populations that can be reliably scored by multiple raters. The MDAS is highly correlated with existing measures of delirium and cognitive impairment, yet offers several advantages over these instruments for repeated assessments which are often necessary in clinical research.
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