Evaluation of the 3-Minute Diagnostic Confusion Assessment Method for Identification of Postoperative Delirium in Older Patients

Abstract Background Postoperative delirium (POD) is a relevant and underdiagnosed complication after cardiac surgery that is associated with increased intensive care unit (ICU) and hospital length of stay (LOS). The aim of this subgroup study was to compare the frequency of tested POD versus the coded International Statistical Classification of Diseases and Related Health Problems (ICD) diagnosis of POD and to evaluate the influence of POD on LOS in ICU and hospital. Methods 254 elective cardiac surgery patients (mean age, 70.5 ± 6.4 years) at the University Hospital Bonn between September 2018 and October 2019 were evaluated. The endpoint tested POD was considered positive, if one of the tests Confusion Assessment Method for ICU (CAM-ICU) or Confusion Assessment Method (CAM), 4 'A's Test (4AT) or Delirium Observation Scale (DOS) was positive on one day. Results POD occurred in 127 patients (50.0%). LOS in ICU and hospital were significantly different based on presence (ICU 165.0 ± 362.7 h; Hospital 26.5 ± 26.1 days) or absence (ICU 64.5 ± 79.4 h; Hospital 14.6 ± 6.7 days) of POD (p < 0.001). The multiple linear regression showed POD as an independent predictor for a prolonged LOS in ICU (48%; 95%CI 31–67%) and in hospital (64%; 95%CI 27–110%) (p < 0.001). The frequency of POD in the study participants that was coded with the ICD F05.0 and F05.8 by hospital staff was considerably lower than tests revealed by the study personnel. Conclusion Approximately 50% of elderly patients who underwent cardiac surgery developed POD, which is associated with an increased ICU and hospital LOS. Furthermore, POD is highly underdiagnosed in clinical routine.

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Postoperative Delirium after Urological Surgery: A Literature Review

Current Urology ◽

10.1159/000499280 ◽

2019 ◽

Vol 13 (3) ◽

pp. 133-140 ◽

Cited By ~ 2

Author(s):

Ioannis Leotsakos ◽

Ioannis Katafigiotis ◽

Ofer N. Gofrit ◽

Mordechai Duvdevani ◽

Dionysios Mitropoulos

Keyword(s):

Risk Factors ◽

Literature Search ◽

Postoperative Delirium ◽

Mini Mental State Examination ◽

Confusion Assessment Method ◽

Assessment Method ◽

Factors Associated ◽

Confusion Assessment ◽

Urological Surgery ◽

State Examination

Purpose: We aimed to thoroughly search and identify studies referring to risk factors associated with postoperative delirium (POD) in patients undergoing open as well as en-doscopic urological surgery. Methods: The review after a systematic literature search included 5 studies. Results: The incidence of POD was reported to be between 7.8 and 30% depending on the type of the urologic surgery, while in the majority of the studies the onset happened on the first postoperative day and the symptoms lasted 3 ± 0.8 days. Seventeen different risk factors for POD were identified and presented in detail. Conclusion: The Mini-Mental State Examination score and older age were significantly associated with the development of POD. However, the Confusion Assessment Method is very well validated against the diagnosis of delirium from the specialists.

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Serum protein S100 as marker of postoperative delirium after off-pump coronary artery bypass surgery: secondary analysis of two prospective randomized controlled trials

Clinical Chemistry and Laboratory Medicine (CCLM) ◽

10.1515/cclm-2015-1012 ◽

2016 ◽

Vol 54 (10) ◽

Cited By ~ 12

Author(s):

Layth Al Tmimi ◽

Marc Van de Velde ◽

Bart Meyns ◽

Bart Meuris ◽

Paul Sergeant ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Postoperative Delirium ◽

Artery Bypass ◽

Confusion Assessment Method ◽

Assessment Method ◽

Off Pump ◽

Confusion Assessment ◽

Opcab Surgery ◽

Pump Coronary Artery Bypass

AbstractBackground:To investigate the predictive value of S100 (biochemical marker of neuroglial injury) for the occurrence of postoperative delirium (POD) in patients undergoing off-pump coronary artery bypass (OPCAB)-surgery.Methods:We enrolled 92 patients older than 18 years undergoing elective OPCAB-surgery. Serum-levels of S100 were determined at baseline (BL), end of surgery (EOS) and on the first postoperative day (PD1). Postoperatively, all-patients were evaluated daily until PD5 for the presence of POD using the confusion assessment method (CAM) or the confusion assessment method for the intensive care unit (CAM-ICU) for patients in the intensive care unit (ICU).Results:The overall incidence of POD was 21%. S100-values on PD1 significantly predicted the occurrence of POD during the later hospital stay [area under the curve (AUC)=0.724 (95% confidence interval (CI): 0.619–0.814); p=0.0001] with an optimal cut-off level of 123 pg mLConclusions:S100-levels <123 pg mL

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Delirium in Hospitalized Older Patients: Recognition and Risk Factors

Journal of Geriatric Psychiatry and Neurology ◽

10.1177/089198879801100302 ◽

1998 ◽

Vol 11 (3) ◽

pp. 118-125 ◽

Cited By ~ 142

Author(s):

Sharon K. Inouye

Keyword(s):

Risk Factors ◽

High Risk ◽

Older Patients ◽

Confusion Assessment Method ◽

Assessment Method ◽

Precipitating Factors ◽

Acute Confusional State ◽

Confusional State ◽

Confusion Assessment ◽

Simplified Algorithm

Delirium, or acute confusional state, represents a common, serious, potentially preventable and increasing problem for older hospitalized patients. This study is intended to improve overall understanding of the problem of delirium and thus to lessen its adverse impact on the older population. The specific aims of this study are (1) to examine the epidemiology of delirium in older patients; (2) to evaluate barriers to recognition; (3) to present the Confusion Assessment Method (CAM) simplified algorithm to improve recognition; (4) to elucidate predisposing and precipitating factors for delirium; and (5) to propose preventive strategies. Delirium occurs in 10-60% of the older hospitalized population and is unrecognized in 32-66% of cases. The CAM algorithm provides a sensitive (94-100%), specific (90-95%), reliable, and easy to use means for identification of delirium. Four predisposing and five precipitating factors were identified and validated to identify patients at high risk for development of delirium. Primary prevention of delirium should address important delirium risk factors and target patients at intermediate to high risk for delirium at admission.

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Emergence delirium is associated with increased postoperative delirium in elderly: a prospective observational study

Journal of Anesthesia ◽

10.1007/s00540-020-02805-8 ◽

2020 ◽

Vol 34 (5) ◽

pp. 675-687

Author(s):

Yan Zhang ◽

Shu-Ting He ◽

Bin Nie ◽

Xue-Ying Li ◽

Dong-Xin Wang

Keyword(s):

Observational Study ◽

General Anesthesia ◽

Postoperative Delirium ◽

Prospective Observational Study ◽

Confusion Assessment Method ◽

Assessment Method ◽

Emergence Delirium ◽

Confusion Assessment ◽

Increased Risk ◽

Pacu Stay

Abstract Background The clinical significance of emergence delirium remains unclear. The purpose of this study was to investigate the association between emergence delirium and postoperative delirium in elderly after general anesthesia and surgery. Methods This prospective observational study was done in a tertiary hospital in Beijing, China. Elderly patients (65–90 years) who underwent major noncardiac surgery under general anesthesia and admitted to the postanesthesia care unit (PACU) after surgery were enrolled. Emergence delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit during PACU stay. Postoperative delirium was assessed with the Confusion Assessment Method during the first 5 postoperative days. The association between emergence delirium and postoperative delirium was analyzed with a multivariable logistic regression model. Results A total of 942 patients were enrolled and 915 completed the study. Emergence delirium developed in 37.0% (339/915) of patients during PACU stay; and postoperative delirium developed in 11.4% (104/915) of patients within the first 5 postoperative days. After adjusted confounding factors, the occurrence of emergence delirium is independently associated with an increased risk of postoperative delirium (OR 1.717, 95% CI 1.078–2.735, P = 0.023). Patients with emergence delirium stayed longer in PACU and hospital after surgery, and developed more non-delirium complications within 30 days. Conclusions Emergence delirium in elderly admitted to the PACU after general anesthesia and major surgery is independently associated with an increased risk of postoperative delirium. Patients with emergence delirium had worse perioperative outcomes. Chinese Clinical Trial Registry (chictr.org.cn) ChiCTR-OOC-17012734

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Assessment of Delirium Using the Confusion Assessment Method in Older Adult Inpatients in Malaysia

Geriatrics ◽

10.3390/geriatrics4030052 ◽

2019 ◽

Vol 4 (3) ◽

pp. 52

Author(s):

Khor ◽

Ong ◽

Tan ◽

Low ◽

Saedon ◽

...

Keyword(s):

Older Patients ◽

Altered Mental Status ◽

Confusion Assessment Method ◽

Assessment Method ◽

Assessment Tools ◽

University Hospital ◽

Cognitive Screening ◽

Cross Sectional ◽

Confusion Assessment ◽

Severity Scores

The detection of delirium in acutely ill older patients is challenging with the lack of informants and the necessity to identify subtle and fluctuating signs. We conducted a cross-sectional study among older patients admitted to a university hospital in Malaysia to determine the presence, characteristics, and mortality outcomes of delirium. Consecutive patients aged ≥65years admitted to acute medical wards were recruited from August to September 2016. Cognitive screening was performed using the mini-mental test examination (MMSE) and the Confusion Assessment Method (CAM). The CAM-Severity (CAM-S) score was also performed in all patients. Of 161 patients recruited, 43 (26.7%) had delirium. At least one feature of delirium from the CAM-S short and long severity scores were present in 48.4% and 67.1%, respectively. Older age (OR: 1.07, 95% CI: 1.01–1.14), immobility (OR: 3.16, 95% CI: 1.18–8.50), cognitive impairment (OR: 5.04, 95% CI: 2.07–12.24), and malnutrition (OR: 3.37; 95% CI: 1.15–9.85) were significantly associated with delirium. Older patients with delirium had a higher risk of mortality (OR: 7.87, 95% CI: 2.42–25.57). Delirium is common among older patients in our setting. A large proportion of patients had altered mental status on admission to hospital although they did not fulfill the CAM criteria of delirium. This should prompt further studies on strategies to identify delirium and the use of newer, more appropriate assessment tools in this group of vulnerable individuals.

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Ultrabrief Screens for Detecting Delirium in Postoperative Cognitively Intact Older Adults

Journal of Hospital Medicine ◽

10.12788/jhm.3410 ◽

2020 ◽

Vol 15 (9) ◽

pp. 544-547

Author(s):

Andrea Yevchak Sillner ◽

Long Ngo ◽

Yoojin Jung ◽

Sharon Inouye ◽

Marie Boltz ◽

...

Keyword(s):

Older Adults ◽

Postoperative Delirium ◽

Elective Surgery ◽

Confusion Assessment Method ◽

Assessment Method ◽

Reference Standard ◽

Patient Reports ◽

Confusion Assessment ◽

Overall Performance ◽

Cognitively Intact

The authors’ sought to develop an ultrabrief screen for postoperative delirium in cognitively intact patients older than 70 years undergoing major elective surgery. All possible combinations of one-, two- and three-item screens and their sensitivities, specificities, and 95% confidence intervals were calculated and compared with the delirium reference standard Confusion Assessment Method (CAM). Among the 560 participants (mean age, 77 years; 58% women), delirium occurred in 134 (24%). We considered 1,100 delirium assessments from postoperative days 1 and 2. The screen with the best overall performance consisted of three items: (1) Patient reports feeling confused, (2) Months of the year backward, and (3) “Does the patient appear sleepy?” with sensitivity of 92% and specificity of 72%. This brief, three-item screen rules out delirium quickly, identifies a subset of patients who require further testing, and may be an important tool to improve recognition of postoperative delirium.

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Protocol for the electroencephalography guidance of anesthesia to alleviate geriatric syndromes (ENGAGES-Canada) study: A pragmatic, randomized clinical trial

F1000Research ◽

10.12688/f1000research.19213.1 ◽

2019 ◽

Vol 8 ◽

pp. 1165 ◽

Cited By ~ 2

Author(s):

Alain Deschamps ◽

Tarit Saha ◽

Renée El-Gabalawy ◽

Eric Jacobsohn ◽

Charles Overbeek ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Postoperative Delirium ◽

Anesthetic Management ◽

Confusion Assessment Method ◽

Assessment Method ◽

Adverse Outcomes ◽

Minimum Concentration ◽

Confusion Assessment

Background: There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery. There is limited evidence in this regard for cardiac surgery. A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death. However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes. Methods: The Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites. The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery. One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25). The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients. The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review. Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation. Discussion: The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD. Registration: ClinicalTrials.gov (NCT02692300) 26/02/2016

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Intraoperative Tight Glucose Control Using Hyperinsulinemic Normoglycemia Increases Delirium after Cardiac Surgery

Anesthesiology ◽

10.1097/aln.0000000000000669 ◽

2015 ◽

Vol 122 (6) ◽

pp. 1214-1223 ◽

Cited By ~ 20

Author(s):

Leif Saager ◽

Andra E. Duncan ◽

Jean-Pierre Yared ◽

Brian D. Hesler ◽

Jing You ◽

...

Keyword(s):

Cardiac Surgery ◽

Blood Glucose ◽

Glucose Control ◽

Postoperative Delirium ◽

Confusion Assessment Method ◽

Assessment Method ◽

Tight Glucose Control ◽

Double Blind ◽

Mortality And Morbidity ◽

Confusion Assessment

Abstract Background: Postoperative delirium is common in patients recovering from cardiac surgery. Tight glucose control has been shown to reduce mortality and morbidity. Therefore, the authors sought to determine the effect of tight intraoperative glucose control using a hyperinsulinemic–normoglycemic clamp approach on postoperative delirium in patients undergoing cardiac surgery. Methods: The authors enrolled 198 adult patients having cardiac surgery in this randomized, double-blind, single-center trial. Patients were randomly assigned to either tight intraoperative glucose control with a hyperinsulinemic–normoglycemic clamp (target blood glucose, 80 to 110 mg/dl) or standard therapy (conventional insulin administration with blood glucose target, <150 mg/dl). Delirium was assessed using a comprehensive delirium battery. The authors considered patients to have experienced postoperative delirium when Confusion Assessment Method testing was positive at any assessment. A positive Confusion Assessment Method was defined by the presence of features 1 (acute onset and fluctuating course) and 2 (inattention) and either 3 (disorganized thinking) or 4 (altered consciousness). Results: Patients randomized to tight glucose control were more likely to be diagnosed as being delirious than those assigned to routine glucose control (26 of 93 vs. 15 of 105; relative risk, 1.89; 95% CI, 1.06 to 3.37; P = 0.03), after adjusting for preoperative usage of calcium channel blocker and American Society of Anesthesiologist physical status. Delirium severity, among patients with delirium, was comparable with each glucose management strategy. Conclusion: Intraoperative hyperinsulinemic–normoglycemia augments the risk of delirium after cardiac surgery, but not its severity.

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Is preoperative anxiety associated with postoperative delirium in older persons undergoing cardiac surgery? Secondary data analysis of a randomized controlled trial

BMC Geriatrics ◽

10.1186/s12877-020-01872-6 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Koen Milisen ◽

Bastiaan Van Grootven ◽

Wim Hermans ◽

Karen Mouton ◽

Layth Al Tmimi ◽

...

Keyword(s):

Risk Factors ◽

Cardiac Surgery ◽

State Anxiety ◽

Postoperative Delirium ◽

Controlled Trial ◽

Secondary Data ◽

Confusion Assessment Method ◽

Assessment Method ◽

Preoperative Anxiety ◽

Confusion Assessment

Abstract Background Although many studies have reported numerous risk factors for postoperative delirium, data are scarce about preoperative anxiety as a risk factor. The study aimed to investigate the association between preoperative anxiety and postoperative delirium in older patients undergoing cardiac surgery. Methods Secondary data analysis of a randomized, observer-blind, controlled trial. A total of 190 patients 65 years or older and admitted to the intensive care unit and cardiac surgery unit of a university hospital scheduled for elective on-pump cardiac surgery were included. State anxiety was measured preoperatively using the Amsterdam Preoperative Anxiety and Information Scale and the Visual Analogue Scale for anxiety. Incidence of delirium was measured during the first 5 postoperative days using the Confusion Assessment Method for Intensive Care Unit (when ventilated), or the 3 Minute Diagnostic Interview for Confusion Assessment Method (when extubated) and by daily chart review. Results Preoperative state anxiety was reported by 31% of the patients and 41% had postoperative delirium. A multiple step logistic regression analyses revealed no association between preoperative anxiety and postoperative delirium. Significant risk factors for postoperative delirium were age (OR = 1.10, 95% CI (1.03–1.18)), activities of daily living (0.69, 95% CI (0.50–0.96)), diabetes mellitus (OR = 3.15, 95% CI (1.42–7.00)) and time on cardiopulmonary bypass (OR = 1.01, 95% CI (1.00 to 1.02)). Conclusions No relationship could be found between preoperative anxiety and postoperative delirium.

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