Delirium in Acute Stroke: A Survey of Screening and Diagnostic Practice in Scotland

Aims. To survey the use of delirium screening and diagnostic tools in patients with acute stroke across Scotland and to establish whether doctors and nurses felt the tools used were suitable for stroke patients. Methods. An invitation to participate in a web-based survey was e-mailed to 217 doctors and nurses working in acute stroke across Scotland. Descriptive statistics were used to report nominal data, and content analysis was used to interpret free text responses. Results. Sixty-five responses were logged (30% return rate). 48% of the respondents reported that they routinely screened newly admitted patients for delirium. Following initial screening, 38% reported that they screened for delirium as the need arises. 43% reported using clinical judgment to diagnose delirium, and 32% stated that they combined clinical judgment with a standardised tool. 28% of the clinicians reported that they used the Confusion Assessment Method; however, only 13.5% felt that it was suitable for stroke patients. Conclusions. Screening for delirium is inconsistent in Scottish stroke services, and there is uncertainty regarding the suitability of screening tools with stroke patients. As the importance of early identification of delirium on stroke outcomes is articulated in recent publications, validating a screening tool to detect delirium in acute stroke is recommended.

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Detecting delirium in patients with acute stroke: a systematic review of test accuracy

BMC Neurology ◽

10.1186/s12883-019-1547-4 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 5

Author(s):

Irene Mansutti ◽

Luisa Saiani ◽

Alvisa Palese

Keyword(s):

Acute Stroke ◽

Short Form ◽

Confusion Assessment Method ◽

Assessment Method ◽

Screening Tools ◽

Test Accuracy ◽

Mental Test ◽

Clock Drawing Test ◽

Abbreviated Mental Test ◽

Meta Analyses

Abstract Background Patients with acute stroke are particularly vulnerable to delirium episodes. Although delirium detection is important, no evidence-based recommendations have been established to date on how these patients should be routinely screened for delirium or which tool should be used for this purpose in this population. Therefore, the aim of this study was to identify delirium screening tools for patients with acute stroke and to summarise their accuracy. Methods Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of Medline, CINAHL and Scopus databases was performed to include: (a) diagnostic test accuracy studies; (b) evaluating tools detecting delirium among patients with acute stroke; (c) written in English; (d) published up to September 2018. The included studies were assessed in their quality by using the Quality Assessment of Diagnostic Accuracy Studies-2. Results A total of four studies have been performed to date in the field with a variable quality for the methodology used and documentation of the accuracy of mainly two tools, as (1) the 4-Assessment Test for delirium (4AT), reporting a range of sensitivity from 90.2 to 100% and a specificity from 64.5 to 86%; and (2) the Confusion Assessment Method-Intensive Care Unit (CAM-ICU) showing a sensitivity of 76% (95% Confidence of Interval [CI] 55–91) and a specificity of 98% (95%CI 93–100). Other tools have been studied as: The Abbreviated Mental Test-10, the Abbreviated Mental Test short form, the Clock Drawing Test, the Cognitive Examination derived from the National Institutes of Health Stroke Scale and the Glasgow Coma Scale. Moreover, the use of a single question—namely, ‘Does this patient have cognitive issues?’ as answered by the multidisciplinary team—has been subjected to a validation process. Conclusions To date a few primary studies have been published to test the accuracy of tools in their ability to detect post-stroke delirium; among those available, the 4AT and the CAM-ICU tools have been mostly studied. Research has just started to add evidence to the challenge of detecting and usefully assessing newly-acquired delirium among stroke patients: therefore, more studies are needed to improve the knowledge and allow a robust selection of the most useful tool to use in this population.

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Delirium Screening in the Emergency Department: A Systematic Review and Meta-analysis

10.21203/rs.3.rs-97690/v1 ◽

2020 ◽

Author(s):

Qian Zhang ◽

Meixi Chen ◽

Liangying Hou ◽

Ziqi Guo ◽

Qing Zhang ◽

...

Keyword(s):

Emergency Department ◽

Diagnostic Accuracy ◽

Sensitivity And Specificity ◽

Meta Analysis ◽

Relative Sensitivity ◽

Confusion Assessment Method ◽

Assessment Method ◽

Screening Tools ◽

Cochrane Library ◽

Diagnostic Tools

Abstract Background: Delirium is a complex syndrome characterized by a disturbance in attention and awareness, with a prevalence of 10-20% in patients admitted to the Emergency Department (ED). Screening tools have been developed to identify delirium in the ED, but their accuracy of screening remains unclear. To address this challenge, we conducted a comprehensive meta-analysis to systematically review the accuracy of delirium screening tools currently being used to assess ED patients.Methods: PubMed, PsycINFO, EMBASE, and the Cochrane Library were searched. Studies involving ED inpatients which compared diagnostic tools with the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria as a reference standard were included. Two reviewers independently screened the studies, extracted data, and assessed the quality of studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 scale. We conducted a conventional meta-analysis for each screening tool. Then we used network meta-analysis method to calculate the relative sensitivity and specificity among the diagnostic tests. The diagnostic accuracies were then ranked through the superiority index.Results: Thirteen studies included six screening tools. The pooled sensitivity and specificity for the Confusion Assessment Method (CAM) were 0.71 and 0.98, and for 4AT (Arousal, Attention, Abbreviated Mental Test 4, Acute change) were 0.83 and 0.93, respectively. The other four tools used were only reported in one or two studies. Their sensitivity ranged from 0.70 to 1.00, and their specificity ranged from 0.64 to 0.99. Moreover, network meta-analysis indicated that the CAM and 4AT had a greater superiority index and a higher diagnostic accuracy.Conclusions: The available data suggested that both the CAM and 4AT can be used as efficient screening tools for the ED patients.

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“SQiD, the Single Question in Delirium; can a single question help clinicians to detect delirium in hospitalised cancer patients?” running heading Single Question in Delirium” (Bcan-D-20-01665)

BMC Cancer ◽

10.1186/s12885-020-07504-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Megan B. Sands ◽

Swapnil Sharma ◽

Lindsay Carpenter ◽

Andrew Hartshorn ◽

Jessica T. Lee ◽

...

Keyword(s):

Cancer Patients ◽

Clinical Care ◽

Length Of Hospital Stay ◽

Confusion Assessment Method ◽

Assessment Method ◽

Clinical Staff ◽

Screening Tools ◽

Diagnostic Values ◽

D 20 ◽

Single Question

Abstract Aim A serious syndrome for cancer in-patients, delirium risk increases with age and medical acuity. Screening tools exist but detection is frequently delayed or missed. We test the ‘Single Question in Delirium’ (SQiD), in comparison to psychiatrist clinical interview. Methods Inpatients in two comprehensive cancer centres were prospectively screened. Clinical staff asked informants to respond to the SQiD: “Do you feel that [patient’s name] has been more confused lately?”. The primary endpoint was negative predictive value (NPV) of the SQiD versus psychiatrist diagnosis (Diagnostic and Statistics Manual criteria). Secondary endpoints included: NPV of the Confusion Assessment Method (CAM), sensitivity, specificity and Cohen’s Kappa coefficient. Results Between May 2012 and July 2015, the SQiD plus CAM was applied to 122 patients; 73 had the SQiD and psychiatrist interview. Median age was 65 yrs. (interquartile range 54–74), 46% were female; median length of hospital stay was 12 days (5–18 days). Major cancer types were lung (19%), gastric or other upper GI (15%) and breast (14%). 70% of participants had stage 4 cancer. Diagnostic values were similar between the SQiD (NPV = 74, 95% CI 67–81; kappa = 0.32) and CAM (NPV = 72, 95% CI 67–77, kappa = 0.32), compared with psychiatrist interview. Overall the CAM identified only a small number of delirious cases but all were true positives. The specificity of the SQiD was 87% (74–95) The SQiD had higher sensitivity than CAM (44% [95% CI 41–80] vs 26% [10–48]). Conclusion The SQiD, administered by bedside clinical staff, was feasible and its psychometric properties are now better understood. The SQiD can contribute to delirium detection and clinical care for hospitalised cancer patients.

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The detection of delirium in admitted oncology patients: a scoping review

European Geriatric Medicine ◽

10.1007/s41999-021-00586-1 ◽

2022 ◽

Author(s):

Megan B. Sands ◽

Ian Wee ◽

Meera Agar ◽

Janette L. Vardy

Keyword(s):

Cancer Patients ◽

Clinical Care ◽

Assessment Method ◽

Risk Of Bias ◽

Screening Tools ◽

Diagnostic Tools ◽

Tool Selection ◽

Oncology Patients ◽

Case Ascertainment ◽

Co Morbidity

Abstract Purpose Delirium leads to poor outcomes for patients and careers and has negative impacts on staff and service provision. Cancer rates in elderly populations are increasing and frequently, cancer diagnoses are a co-morbidity in the context of frailty. Data relating to the epidemiology of delirium in hospitalised cancer patients are limited. With the overarching purpose of improving delirium detection and reducing the morbidity and mortality of delirium in cancer patients, we reviewed the epidemiological data and approach to delirium detection in hospitalised, adult oncology patients. Methods MEDLINE, EMBASE, CINAHL, PsycINFO, and SCOPUS databases were searched from January 1996 to August 2017. Key concepts were delirium, cancer, inpatient oncology and delirium screening/detection. Results Of 896 unique studies identified; 91 met full-text review criteria. Of 12 eligible studies, four applied recommended case ascertainment methods to all patients, three used delirium screening tools alone or with case ascertainment tools sub-optimally applied, four used tools not recommended for delirium screening or case ascertainment, one used the Confusion Assessment Method with insufficient information to determine if it met case ascertainment status. Two studies presented delirium incidence rates: 7.8%, and 17% respectively. Prevalence rates ranged from 18–33% for general medical or oncology wards; 42–58% for Acute Palliative Care Units (APCU); and for older cancer patients: 22% and 57%. Three studies reported reversibility; 26% and 49% respectively (APCUs) and 30% (older patients with cancer). Six studies had a low risk of bias according to QUADAS-2 criteria; all studies in the APCU setting were rated at higher risk of bias. Tool selection, study flow and recruitment bias reduced study quality. Conclusion The knowledge base for improved interventions and clinical care for adults with cancer and delirium is limited by the low number of studies. A clear distinction between screening tools and diagnostic tools is required to provide an improved understanding of the rates of delirium and its reversibility in this population.

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Impact of Delirium and Its Motor Subtypes on Stroke Outcomes

Stroke ◽

10.1161/strokeaha.120.026425 ◽

2021 ◽

Vol 52 (4) ◽

pp. 1322-1329

Author(s):

Ivã Taiuan Fialho Silva ◽

Pedro Assis Lopes ◽

Tiago Timotio Almeida ◽

Saint Clair Ramos ◽

Ana Teresa Caliman Fontes ◽

...

Keyword(s):

Functional Outcome ◽

Functional Dependence ◽

Confusion Assessment Method ◽

Assessment Method ◽

Modified Rankin Scale ◽

Stroke Patients ◽

Risk Of Death ◽

Increased Risk ◽

And Behavior ◽

The Relationship

Background and Purpose: Delirium is an acute and fluctuating impairment of attention, cognition, and behavior. Although common in stroke, studies that associate the clinical subtypes of delirium with functional outcome and death are lacking. We aimed to evaluate the influence of delirium occurrence and its different motor subtypes over stroke patients’ prognosis. Methods: Prospective cohort of stroke patients with symptom onset within 72 hours before research admission. Delirium was diagnosed by Confusion Assessment Method for the Intensive Care Unit, and its motor subtypes were defined according to the Richmond Agitation-Sedation Scale. The main outcome was functional dependence or death (modified Rankin Scale>2) at 90 days comparing: delirium versus no delirium patients; and between motor subtypes. Secondary outcomes included modified Rankin Scale score >2 at 30 days and 90-day-mortality. Results: Two hundred twenty-seven patients were enrolled. Delirium occurred in 71 patients (31.3%), with the hypoactive subtype as the most frequent, in 41 subjects (57.8%). Delirium was associated with increased risk of death and functional dependence at 30 and 90 days and higher 90-day mortality. Multivariate analysis showed delirium (odds ratio, 3.28 [95% CI, 1.17–9.22]) as independent predictor of modified Rankin Scale >2 at 90 days. Conclusions: Delirium is frequent in stroke patients in the acute phase. Its occurrence—specifically in mixed and hypoactive subtypes—seems to predict worse outcomes in this population. To our knowledge, this is the first study to prospectively investigate differences between delirium motor subtypes over functional outcome three months poststroke. Larger studies are needed to elucidate the relationship between motor subtypes of delirium and functional outcomes in the context of acute stroke.

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Dysphagia screening tools for acute stroke patients available for nurses: A systematic review

Nursing Practice Today ◽

10.18502/npt.v6i3.1253 ◽

2019 ◽

Author(s):

Isabel de Jesus Oliveira ◽

Liliana Andreia Neves Da Mota ◽

Susana Vaz Freitas ◽

Pedro Lopes Ferreira

Keyword(s):

Systematic Review ◽

Acute Stroke ◽

Methodological Quality ◽

Selection Index ◽

Significant Proportion ◽

Screening Tools ◽

Quality Analysis ◽

Diagnostic Process ◽

Index Test ◽

Stroke Patients

Background & Aim: There is a high incidence of dysphagia after stroke that, depending on the assessment, methodology and time elapsed, can range from 8.1% to 80%. Early and systemic dysphagia screening is associated with a decreased risk of aspiration pneumonia and prevents inadequate hydration/nutrition. The purpose of this systematic review was to identify dysphagia screening tools for acute stroke patients available for nurses validated against reference test. The research question was: which dysphagia screening tools for acute stroke patients available for nurses? Methods & Materials: Three electronic databases were searched from January 2007 to November 2017: on PubMed, Scielo and CINAHL Plus. Two independent reviewers screened all titles and abstracts, assessed methodological quality and extracted data. The methodological quality analysis and evaluation was guided according to four domains: patient selection, index test, reference standard and flow and timing. Divergences between reviewers in data extraction were consensualized through discussion. Results: From the 377 articles retrieved, only three articles met criteria for review: Barnes-Jewish Hospital-Stroke Dysphagia Screen; the Gugging Swallowing Screen and, The Toronto Bedside Swallowing Screening Test. None of the screening tools complies with all psychometric properties, which means that a still significant proportion of patients will be kept nil by mouth without being necessary or that some patients will “fall through the cracks” interrupting the diagnostic process. The tools identified are different from each other, making their comparison impracticable. Conclusion: Due to psychometric proprieties and dietary recommendations adjusted to dysphagia severity, of all available tools, GUSS is a suitable screening tool for nurses in clinical practice.

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Abstract W P224: SOS Score: an Optimized Score to Screen Acute Stroke Patients for Obstructive Sleep Apnea

Stroke ◽

10.1161/str.45.suppl_1.wp224 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Millene R Camilo ◽

Heidi H Sander ◽

Alan L Eckeli ◽

Regina M Fernandes ◽

Taiza E Santos-Pontelli ◽

...

Keyword(s):

Obstructive Sleep Apnea ◽

Ischemic Stroke ◽

Sleep Apnea ◽

Acute Stroke ◽

Predictive Value ◽

Screening Tools ◽

Berlin Questionnaire ◽

Stroke Patients ◽

Obstructive Sleep ◽

The Mean

Background: Obstructive sleep apnea (OSA) is frequent in acute stroke patients and is associated with increased mortality and poor functional outcome. Polysomnography (PSG) is the gold standard diagnostic method for OSA, but it is impracticable as a routine for all acute stroke patients. We evaluated how OSA screening tools such as the Berlin Questionnaire (BQ) and the Epworth Sleepiness Scale (ESS) would perform when administered to relatives of stroke patients in the acute setting, and compared these individual tools against a combined screening score (SOS score). Methods: Ischemic stroke patients were submitted to a full PSG at the first night after symptoms onset. OSA severity was measured by apnea-hypopnea index (AHI). BQ and ESS were administered to relatives of stroke patients before the PSG. We combined elements of the BQ and ESS to create a new screening tool for OSA named Sleep Obstructive apnea score optimized for Stroke (SOS score). Results: Thirty-nine consecutives ischemic stroke patients were enrolled in our study. The mean age was 62.3 ±12.2 years. Age was significantly different between those with and without OSA (p=0.02). The mean body mass index and neck circumference were 26.7 ± 4.7 and 38.9 ± 4.0cm, respectively. OSA (AHI ≥ 10) was present in 76.9%. The area under the curve for SOS score (AUC:0.812; p=0.005) was superior to BQ (AUC:0.567; p=0.549) and also to ESS (AUC:0.646; p=0.119 vs. AUC:0.686; p=0.048) for severe OSA (IAH ≥ 30). The threshold of SOS ≤ 10 (present in 20.5% of patients) showed high sensitivity (90%) and negative predictive value (96.2%) for OSA; SOS ≥20 (17.9% of patients) showed high specificity (100%) and positive predictive value (92.5%) for severe OSA. Using SOS as a screening approach would decrease by around 40% the demand for PSG during the acute stroke setting. Conclusions: The SOS score when administered to relatives of stroke patients appears to be an appropriate tool to screen acute stroke patients for OSA, while decreasing the need for a formal sleep study during the acute stroke setting. The new derived SOS score is superior to BQ and ESS for identifying patients with OSA and Severe OSA during the acute phase of stroke.

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Measurement of Oxygen Desaturation Is Not Useful for the Detection of Aspiration in Dysphagic Stroke Patients

Cerebrovascular Diseases Extra ◽

10.1159/000453083 ◽

2017 ◽

Vol 7 (1) ◽

pp. 44-50 ◽

Cited By ~ 3

Author(s):

Thomas Marian ◽

Jens Schröder ◽

Paul Muhle ◽

Inga Claus ◽

Stephan Oelenberg ◽

...

Keyword(s):

Acute Stroke ◽

Screening Tool ◽

Oxygen Desaturation ◽

Screening Tools ◽

Endoscopic Evaluation ◽

National Guidelines ◽

Stroke Patients ◽

Severe Dysphagia ◽

A Minor ◽

Swallowing Assessment

Background: Dysphagia is one of the most dangerous symptoms of acute stroke. Various screening tools have been suggested for the early detection of this condition. In spite of conflicting results, measurement of oxygen saturation (SpO2) during clinical swallowing assessment is still recommended by different national guidelines as a screening tool with a decline in SpO2 ≥2% usually being regarded as a marker of aspiration. This paper assesses the sensitivity of SpO2 measurements for the evaluation of aspiration risk in acute stroke patients. Methods: Fifty acute stroke patients with moderate to severe dysphagia were included in this study. In all patients, fiberoptic endoscopic evaluation of swallowing (FEES) was performed according to a standardised protocol. Blinded to the results of FEES, SpO2 was monitored simultaneously. The degree of desaturation during/after swallows with aspiration was compared to the degree of desaturation during/after swallows without aspiration in a swallow-to-swallow analysis of each patient. To minimise potential confounders, every patient served as their control. Results: In each subject, a swallow with and a swallow without aspiration were analysed. Overall, aspiration seen in FEES was related to a minor decline in SpO2 (mean SpO2 without aspiration 95.54 ± 2.7% vs. mean SpO2 with aspiration 95.28 ± 2.7%). However, a significant desaturation ≥2% occurred only in 5 patients during/after aspiration. There was no correlation between aspiration/dysphagia severity or the amount of aspirated material and SpO2 levels. Conclusions: According to this study, measurement of oxygen desaturation is not a suitable screening tool for the detection of aspiration in stroke patients.

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Recognition and management of delirium among doctors, nurses, physiotherapists, and psychologists: an Italian survey

International Psychogeriatrics ◽

10.1017/s1041610214001653 ◽

2014 ◽

Vol 26 (12) ◽

pp. 2093-2102 ◽

Cited By ~ 22

Author(s):

G. Bellelli ◽

A. Morandi ◽

E. Zanetti ◽

M. Bozzini ◽

E. Lucchi ◽

...

Keyword(s):

At Risk ◽

Confusion Assessment Method ◽

Assessment Method ◽

Diagnostic Tools ◽

Health Providers ◽

Survey Period ◽

Italian Survey ◽

Multicenter Survey ◽

Patients At Risk ◽

Case Vignettes

ABSTRACTBackground:There are no studies that have identified the ability to recognize and manage delirium among Italian health providers caring for patients at risk. Therefore, the Italian Association of Psychogeriatrics (AIP) conducted a multicenter survey among doctors, nurses, psychologists and physiotherapists to assess their competence regarding the theme of delirium and its management in the everyday clinical practice.Methods:The survey period was 1st June 2013 to 30th November 2013. The invitation to participate was sent via email, with publication on the AIP website. The survey included 14 questions and two case vignettes.Results:A total of 648/1,500 responses were collected. Most responders were doctors (n= 322/800), followed by nurses (n= 225/500), psychologists (n= 51/100), and physiotherapists (n= 30/100). Generally, doctors and psychologists correctly defined delirium, while nurses and physiotherapists did not. The most frequently used diagnostic tools were the Confusion Assessment Method (CAM) and the Diagnostic and Statistical Manual of Mental Disorders-IV. Delirium intensity was rarely assessed. Hypoactive delirium was generally managed with non-pharmacological approaches, while hyperactive delirium with a combination of non-pharmacological and pharmacological approaches. However, possible causes of delirium were under-assessed by half of doctors and by the majority of other professionals. Nurses, psychologists and physiotherapists did not answer the case vignettes, while doctors identified the correct answer in most cases.Conclusions:This is the first Italian survey among health providers caring for patients at risk of delirium. This is also the first survey including doctors, nurses, psychologists and physiotherapists. The results emphasize the importance of training to improve knowledge of this relevant unmet medical need.

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Validation of a Dysphagia Screening Tool in Acute Stroke Patients

American Journal of Critical Care ◽

10.4037/ajcc2009961 ◽

2010 ◽

Vol 19 (4) ◽

pp. 357-364 ◽

Cited By ~ 63

Author(s):

Jeff Edmiaston ◽

Lisa Tabor Connor ◽

Lynda Loehr ◽

Abdullah Nassief

Keyword(s):

Acute Stroke ◽

Health Care Professionals ◽

Screening Tool ◽

Tertiary Care ◽

Screening Tools ◽

Care Hospital ◽

Stroke Patients ◽

Aspiration Risk ◽

The Mean ◽

Mean Time

Background Although many dysphagia screening tools exist, none has high sensitivity and reliability or can be administered quickly with minimal training. Objective To design and validate a swallowing screening tool to be used by health care professionals who are not speech language pathologists to identify dysphagia and aspiration risk in acute stroke patients. Methods In a prospective study of 300 patients admitted to the stroke service at an urban tertiary care hospital, interrater and test-retest reliabilities of a new tool (the Acute Stroke Dysphagia Screen) were established. The tool was administered by nursing staff when patients were admitted to the stroke unit. A speech language pathologist blinded to the results with the new tool administered the Mann Assessment of Swallowing Ability, a clinical bedside evaluation, with dysphagia operationally defined by a score less than 178. Results The mean time from admission to screening with the new tool was 8 hours. The mean time between administration of the new tool and the clinical bedside evaluation was 32 hours. For the new tool, interrater reliability was 93.6% and test-retest reliability was 92.5%. The new tool had a sensitivity of 91% and a specificity of 74% for detecting dysphagia and a sensitivity of 95% and a specificity of 68% for detecting aspiration risk. Conclusions The Acute Stroke Dysphagia Screen is an easily administered and reliable tool that has sufficient sensitivity to detect both dysphagia and aspiration risk in acute stroke patients.

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