Detecting delirium superimposed on dementia: diagnostic accuracy of a simple combined arousal and attention testing procedure

Richardson, Sarah; Davis, Daniel; Bellelli, Giuseppe; Hasemann, Wolfgang; Meagher, David; Kreisel, Stefan H.; MacLullich, Alasdair M.J.; Cerejeira, Joaquim; Morandi, Alessandro

doi:10.1017/s1041610217000916

Cited by 34 publications

(48 citation statements)

References 26 publications

(39 reference statements)

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“…In addition, as the current sample comprised patients with pre-existing cognitive impairment, there may have been diffi culty in diff erentiating between normal aging, dementia, and DSD. Richardson et al (2017) stated that the detection of DSD is usually achieved by collateral history. As the DOSS does not rely on collateral history information, there might be a weakness in detecting acute changes in cognition, as this criterion is not part of the DOSS.…”

Section: Discussionmentioning

confidence: 99%

“…As delirium detection via observation has limitations, the question arises of whether structured delirium assessment (i.e., asking patients questions about their cognitive status several times per day over several days) would provide a better alternative. Richardson et al (2017) suggested a combined arousal-attention assessment for diagnosing DSD. However, the current evidence reveals that nonadherence rates remain similar when nurses ask structured questions.…”

Section: Discussionmentioning

confidence: 99%

“…D elirium is an acute, severe neuropsychiatric syndrome characterized by disturbances in arousal, attention, and cognition (American Psychiatric Association [APA], 2013). Th ere is a signifi cant association between the development of incident dementia and the worsening of dementia after delirium (Davis et al, 2012;Davis et al, 2017). Th e non-detection of prevalent delirium in older patients presenting to emergency departments is associated with a 30.8% mortality rate within 6 months, which is double the mortality rate for patients with detected and treated delirium (Kakuma et al, 2003).…”

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Nurses' Recognition of Hospitalized Older Patients With Delirium and Cognitive Impairment Using the Delirium Observation Screening Scale: A Prospective Comparison Study

Hasemann¹,

Tolson²,

Godwin³

et al. 2018

J Gerontol Nurs

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The aim of the current study was to report fi ndings about delirium detection when ward nurses screened for delirium in patients with cognitive impairment using the Delirium Observation Screening Scale (DOSS) in comparison to the Confusion Assessment Method (CAM). A secondary analysis was performed of research data collected in 2010 at a Swiss tertiary university hospital. During the fi rst 5 days after admission, patients 70 and older with cognitive impairment were screened for delirium using the DOSS. Throughout patients' hospital stay, research assistants also completed the CAM on a daily basis. A total of 138 patients who did not have delirium initially participated in the study. Of these patients, 44 (32%) developed delirium with a median duration of 3 days (Q1 = 1.25; Q3 = 5.00). Ward nurses correctly identifi ed delirium using the DOSS in 56% of cases (sensitivity) and no delirium in 92% of cases (specifi city). Although the DOSS was 100% correct in detecting patients with hyperactive delirium, the identifi cation rate decreased to 60% for patients with mixed delirium subtype and 38% for patients with hypoactive delirium. Delirium screening using observational methods may be insuffi ciently sensitive and should be supplemented with a formal attention test.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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Nurses' Recognition of Hospitalized Older Patients With Delirium and Cognitive Impairment Using the Delirium Observation Screening Scale: A Prospective Comparison Study

Hasemann¹,

Tolson²,

Godwin³

et al. 2018

J Gerontol Nurs

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“…Some queries arose about the scoring of the cognitive test items. Cognitive tests used in hospital practice show variable diagnostic accuracy for dementia and delirium, 46,52,95,96 and no single test provides sufficiently good performance for it to be used in all contexts. In addition, cognitive tests performed in isolation inform clinical judgement, but cannot be performed as diagnostic tests alone.…”

Section: Survey Bmentioning

confidence: 99%

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

MacLullich

Shenkin

Goodacre

et al. 2019

Health Technol Assess

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Background Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 ‘A’s test (Arousal, Attention, Abbreviated Mental Test – 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. Methods Phase 1 – the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 – the 4AT’s diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. Results Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0–14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0–6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. Limitations Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. Conclusions These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. Future work Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. Trial registration Current Controlled Trials ISRCTN53388093. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.

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“…Delirium Superimposed on Dementia (DSD), has a prevalence ranging from 22 to 89% (Fick et al, 2002; and is associated with worse outcomes than each condition separately, including functional decline, institutionalization, mortality, and greater health care costs compared with patients with dementia alone (Bellelli et al, 2007;Fick et al, 2013;Morandi et al, 2014;Dani et al, 2017;Richardson et al, 2017).…”

Section: Introductionmentioning

confidence: 99%

Impairments in balance and mobility identify delirium in patients with comorbid dementia

Gual

Richardson

Davis

et al. 2018

Int. Psychogeriatr.

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Diagnosing delirium superimposed on dementia (DSD) remains challenging because of a lack of specific tools, though motor dysfunction in delirium has been relatively under-explored. This study aimed to use dysfunction in balance and mobility (with the Hierarchical Assessment of Balance And Mobility: HABAM) to identify DSD. This is a cross-sectional multicenter study, recruiting consecutive patients ≥70 years admitted to five acute or rehabilitation hospitals in Ireland, Italy, Portugal, and Switzerland. Delirium was diagnosed using DSM-5 criteria; dementia was determined by the Mini-Mental State Examination and the Questionnaire of Cognitive Decline in the Elderly. HABAM score was recorded at admission. Out of 114 patients (mean age ± SD = 82 ± 7; 54% female), dementia alone was present in 24.6% (n = 28), delirium alone in 18.4% (n = 21) and DSD in 27.2% (n = 31). Patients with DSD had a mean HABAM score 7 points greater than those with dementia alone (19.8 ± 8.7 vs 12.5 ± 9.5; p < 0.001); 70% of participants with DSD were correctly identified using the HABAM at a cut off of 22 (sensitivity 61%, specificity 79%, AUC = 0.76). Individuals with delirium have worse motor function than those without delirium, even in the context of comorbid dementia. Measuring motor function using the HABAM in older people at admission may help to diagnose DSD.

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Detecting delirium superimposed on dementia: diagnostic accuracy of a simple combined arousal and attention testing procedure

Abstract: This combined arousal-attention assessment to detect DSD was brief yet had high diagnostic accuracy. Such an approach could have clinical utility for diagnosing DSD.

Cited by 34 publications

References 26 publications

Nurses' Recognition of Hospitalized Older Patients With Delirium and Cognitive Impairment Using the Delirium Observation Screening Scale: A Prospective Comparison Study

Nurses' Recognition of Hospitalized Older Patients With Delirium and Cognitive Impairment Using the Delirium Observation Screening Scale: A Prospective Comparison Study

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

Impairments in balance and mobility identify delirium in patients with comorbid dementia

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