Challenges and opportunities in understanding dementia and delirium in the acute hospital

Jackson, Thomas; Gladman, John; Harwood, Rowan H.; MacLullich, Alasdair M.J.; Sampson, Elizabeth L; Sheehan, Bart; Davis, Daniel

doi:10.1371/journal.pmed.1002247

Cited by 85 publications

(74 citation statements)

References 48 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Delirium is extremely common, affecting at least 15% of patients in acute hospitals, [3][4][5][6][7] and it is associated with many complications and poor outcomes. 4,[8][9][10][11][12][13][14][15] Delirium is both a marker of current dementia 4,[16][17][18] and associated with the acceleration of existing dementia. 19 In older patients without dementia, an episode of delirium strongly predicts future dementia risk.…”

Section: Delirium: Backgroundmentioning

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

Self Cite

View full text Add to dashboard Cite

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.

show abstract

Section: Delirium: Backgroundmentioning

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

Self Cite

View full text Add to dashboard Cite

show abstract

“…3,4 These (and various other conditions) are often associated with impairment of mental capacity to make decisions ( Box 2 ). Strictly, mental capacity should be assessed for every decision, about every examination, test, care procedure or treatment, but usually this will be informal and implicit, reserving formal assessment for important, or contentious, decisions.…”

Section: Application With Older Peoplementioning

confidence: 99%

Making difficult decisions with older patients on medical wards

Khizar

Harwood

2017

Clinical Medicine

View full text Add to dashboard Cite

How do we decide?Scientific knowledge, the law, professional regulation, the organisations within which we work and the political and social environment all influence how we practise medicine. Quite apart from law and regulation, and sometimes in contravention to it, people have expectations about healthcare: who should be consulted over decisions and how we should approach death ABSTRACTMaking diffi cult decisions with older patients on medical wards Key pointsOlder people are medically complex, the information needed to make decisions is often uncertain and the impact of cognitive impairment can make decision making difficult A systematic and thorough approach is required; the principlist approach of considering benefits, burdens, autonomy and justice can be applied, but principles often conflict

show abstract

“…Although the prevalence rates for dementia in the acute hospital setting vary in the literature, it is estimated that about 20-25% of hospital patients have dementia [1,2]. Thereby, about 56% of dementia cases are not diagnosed or recognised by healthcare staff [3]. The International Classification of Diseases (ICD-11) defines dementia as an 'acquired brain syndrome characterized by a decline from a previous level of cognitive functioning with impairment in two or more cognitive domains (such as memory, executive functions, attention, language, social cognition and judgment, psychomotor speed, visuoperceptual or visuospatial abilities)'.…”

Section: Introductionmentioning

confidence: 99%

A systematic review of interventions to improve acute hospital care for people with dementia

Karrer

Schnelli

Zeller

et al. 2020

Preprint

View full text Add to dashboard Cite

show abstract

Challenges and opportunities in understanding dementia and delirium in the acute hospital

Abstract: In an Essay, Andrew Jackson and colleagues discuss challenges in the diagnosis and management of older people with dementia and delirium in acute hospitals.

Cited by 85 publications

References 48 publications

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

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

Making difficult decisions with older patients on medical wards

A systematic review of interventions to improve acute hospital care for people with dementia

Contact Info

Product

Resources

About