“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)

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

ISRN Stroke ◽

10.1155/2013/620186 ◽

2013 ◽

Vol 2013 ◽

pp. 1-7 ◽

Cited By ~ 1

Author(s):

Gail Carin-Levy ◽

Kath Nicol ◽

Frederike van Wijck ◽

Gillian E. Mead

Keyword(s):

Acute Stroke ◽

Clinical Judgment ◽

Confusion Assessment Method ◽

Assessment Method ◽

Screening Tools ◽

Diagnostic Tools ◽

Free Text ◽

Stroke Patients ◽

Nominal Data ◽

Doctors And Nurses

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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Delirium

10.2310/psych.13089 ◽

2019 ◽

Author(s):

Sarah Wagner ◽

Robert Gerstman

Keyword(s):

Health Care Cost ◽

Length Of Hospital Stay ◽

Altered Mental Status ◽

Confusion Assessment Method ◽

Assessment Method ◽

Medical Illness ◽

Richmond Agitation Sedation Scale ◽

The Past ◽

Short Period ◽

Brain Failure

Delirium is a disturbance of attention and awareness, which develops over a short period of time. It is a change in a person’s baseline and fluctuates throughout the course of the day.1 Delirium can accompany almost any serious medical illness. It is an independent risk factor for increasing a person’s morbidity and mortality. Delirium is associated with an increased length of hospital stay and an increase in health care cost.2 There is growing literature to assist in the diagnosing and treatment of patients with delirium. This article dives into the recent research addressing the pharmacologic and nonpharmacologic methods to treat delirium. Various pharmacologic interventions have been studied over the past several years including the use of melatonin, ramelteon, dexmedetomidine, and antipsychotics. This review contains 2 tables and 17 references. Key Words: acute brain failure, altered mental status, Confusion Assessment Method, critical care, delirium, encephalopathy, ICU, RASS, Richmond Agitation-Sedation Scale

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Time of delirium onset and prognosis amongst Southern Brazilian hospitalized elderly patients

Dementia & Neuropsychologia ◽

10.1590/s1980-57642009dn30400007 ◽

2009 ◽

Vol 3 (4) ◽

pp. 303-307

Author(s):

André Luiz Moschetta ◽

Carine Volkweis Silveira ◽

Roberta Rigo Dalacorte ◽

Rodolfo Herberto Schneider ◽

Irênio Gomes da Silva Filho

Keyword(s):

Protective Factor ◽

Average Length ◽

Prognostic Significance ◽

Length Of Hospital Stay ◽

Confusion Assessment Method ◽

Assessment Method ◽

Historical Cohort ◽

Hospitalized Elderly ◽

Hospitalized Elderly Patients ◽

The Relationship

Abstract The prognostic significance of delirium in hospitalized elderly has not yet been fully clarified. Objectives: The present study was designed to evaluate the relationship between prevalent delirium (PrD), incident delirium (InD) and final outcome. Methods: A historical cohort of 261 patients was selected. delirium was diagnosed using the Confusion Assessment Method. Results: The total frequency of delirium detected was 42.5%-31.4% PrD and 16.2% InD. Among patients with InD, the average length of hospital stay was 9.1 days longer than for patients without delirium (p=0.002), and the hospital mortality associated with InD was 48% versus 2.7% for those without delirium (p<0.001). However, no difference was observed between patients with PrD and those without delirium. Conclusions: These results suggest that, when investigating delirium and prognosis amongst hospitalized elderly, it is fundamental to differentiate in terms of time of onset. Furthermore, the absence of delirium seems to be an important protective factor.

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LO14: Unrecognized delirium in a cohort of older ED patients assessed at a tertiary care center: signs of improvement?

CJEM ◽

10.1017/cem.2019.57 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S12

Author(s):

J. Lee ◽

T. Tong ◽

M. Tierney ◽

A. Kiss ◽

M. Chignell

Keyword(s):

Cognitive Assessment ◽

Care Center ◽

Tertiary Care ◽

Confusion Assessment Method ◽

Assessment Method ◽

Clinical Staff ◽

Future Research ◽

Mini Mental Status Exam ◽

Observational Cohort ◽

Research Assistants

Introduction: BACKGROUND: Recognition rates of delirium in older ED patients were reported between 13 to 25% in studies conducted in the U.S in the 1990's. Recently, there has been increased attention to delirium in Emergency Medicine, with the development of Geriatric curriculums in Canada specifically focused on delirium. However rates of delirium recognition have not been reassessed in Canadian ED's. OBJECTIVES: To assess the rate of delirium recognition by ED staff in a cohort of older ED patients assessed at a tertiary care Canadian ED. Methods: STUDY DESIGN: Prospective observational cohort study at a Canadian teaching ED. PARTICIPANTS: Eligible patients were aged ≥70 years and older who had stayed in the ED for a minimum of 4 hours. We excluded patients who were critically ill, visually impaired or otherwise unable to communicate. DATA COLLECTION: Trained research assistants approached clinical staff prior to approaching patients to confirm that patients were delirium free. They then assessed demographics, ED length of stay (LOS) and cognition using the validated Montreal Cognitive Assessment scale (MOCA), mini-mental status exam (MMSE), delirium index and Richardson Agitation Scale (RASS) at baseline. Delirium was assessed using the validated Confusion Assessment Method (CAM). We report descriptive statistics and 95% confidence intervals (CI) where appropriate. Results: We enrolled 203 patients of which 102 (50.3%) were female. Their mean age was 81.0 years, mean LOS was 16.3 hours, mean MOCA was 23.4 and mean MMSE was 26.7. RA's detected delirium using the CAM in 16/203 patients (7.9%, 95% CI 4.6 to 12.5%). Mean MOCA and MMSE for delirious patients was 13.4 and 18.3 and their mean DI was 6.4. All CAM positive patients were deemed to be delirium free by clinical staff. RA alerted clinical staff in all cases where patients had delirium, but 3/16 were discharged home (18.8%, 95% CI 4.1 to 45.7%). Conclusion: Our findings confirm previous low delirium recognition rates in a Canadian Tertiary ED. Future research should explore barriers and facilitators to recognizing delirium in the ED.

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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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The Prevalence of Delirium in An Older Acute Surgical Population and Its Effect on Outcome

Geriatrics ◽

10.3390/geriatrics4040057 ◽

2019 ◽

Vol 4 (4) ◽

pp. 57 ◽

Cited By ~ 1

Author(s):

Hewitt ◽

Owen ◽

Carter ◽

Stechman ◽

Tay ◽

...

Keyword(s):

Older Adults ◽

Cognitive Impairment ◽

Hospital Stay ◽

Length Of Hospital Stay ◽

Confusion Assessment Method ◽

Assessment Method ◽

Ageing Population ◽

Multi Centre Study ◽

Logistic Regression Models ◽

Surgical Units

Background: With an ageing population, an increasing number of older adults are admitted for assessment to acute surgical units. Older adults have specific factors that may influence outcomes, one of which is delirium (acute cognitive impairment). Objectives: To establish the prevalence of delirium on admission in an older acute surgical population and its effect on mortality. Secondary outcomes investigated include hospital readmission and length of hospital stay. Method: This observational multi-centre study investigated consecutive patients, ≥65 years, admitted to the acute surgical units of five UK hospitals during an eight-week period. On admission the Confusion Assessment Method (CAM) score was performed to detect delirium. The effect of delirium on important clinical outcomes was investigated using tests of association and logistic regression models. Results: The cohort consisted of 411 patients with a mean age of 77.3 years (SD 8.1). The prevalence of admission delirium was 8.8% (95% CI 6.2–11.9%) and cognitive impairment was 70.3% (95% CI 65.6–74.7%). The delirious group were not more likely to die at 30 or 90 days (OR 1.1, 95% CI 0.2 to 5.1, p = 0.67; OR 1.4, 95% CI 0.4 to 4.1. p = 0.82) or to be readmitted within 30 days of discharge (OR 0.9, 95% CI 0.4 to 2.2, p = 0.89). Length of hospital stay was significantly longer in the delirious group (median 8 vs. 5 days respectively, p = 0.009). Conclusion: Admission delirium occurs in just under 10% of older people admitted to acute surgical units, resulting in significantly longer hospital stays.

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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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