Detecting Delirium: A Systematic Review of Identification Instruments for Non‐ICU Settings

Abstract

BACKGROUND/OBJECTIVES Delirium manifests clinically in varying ways across settings. More than 40 instruments currently exist for characterizing the different manifestations of delirium. We evaluated all delirium identification instruments according to their psychometric properties and frequency of citation in published research. DESIGN We conducted the systematic review by searching Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Excerpta Medica Database (Embase), PsycINFO, PubMed, and Web of Science from January 1, 1974, to January 31, 2020, with the keywords “delirium” and “instruments,” along with their known synonyms. We selected only systematic reviews, meta‐analyses, or narrative literature reviews including multiple delirium identification instruments. MEASUREMENTS Two reviewers assessed the eligibility of articles and extracted data on all potential delirium identification instruments. Using the original publication on each instrument, the psychometric properties were examined using the Consensus‐based Standards for the Selection of Health Measurement Instruments (COSMIN) framework. RESULTS Of 2,542 articles identified, 75 met eligibility criteria, yielding 30 different delirium identification instruments. A count of citations was determined using Scopus for the original publication for each instrument. Each instrument underwent methodological quality review of psychometric properties using COSMIN definitions. An expert panel categorized key domains for delirium identification based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM)‐III through DSM‐5. Four instruments were notable for having at least two of three of the following: citation count of 200 or more, strong validation methodology in their original publication, and fulfillment of DSM‐5 criteria. These were, alphabetically, Confusion Assessment Method, Delirium Observation Screening Scale, Delirium Rating Scale‐Revised‐98, and Memorial Delirium Assessment Scale. CONCLUSION Four commonly used and well‐validated instruments can be recommended for clinical and research use. An important area for future investigation is to harmonize these measures to compare and combine studies on delirium.

Inflammatory and blood gas markers of COVID-19 delirium compared to non-COVID-19 delirium: a cross-sectional study

“…Patients with no recording of a swab were excluded. The cohorts were retrospectively screened for delirium using the CHART-DEL (Chart-based Delirium Identification Instrument), a widely used and validated research tool for detecting the presence of delirium from analysis of patient notes (Helfand et al, 2021;Inouye et al, 2005). The CHART-DEL has a higher sensitivity than relying on clinical diagnosis, which is known to underestimate delirium prevalence and incidence in COVID-19 patients (Mcloughlin et al, 2020).…”

Delirium Item Bank: Utilization to Evaluate and Create Delirium Instruments

“…The expert panel also rated other delirium identification domains covered by DSM-diagnostic criteria from earlier versions of the DSM, including DSM-III (when delirium was first codified), DSM-III-R, DSM-IV, and DSM-IV-TR. In addition to the five domains already defined, there were five additional domains identified: level of consciousness, disorganized thinking, psychomotor agitation, psychomotor retardation, and hallucinations, perceptual disorder, or distortion [6]. Based on the previous expert panel process [6], each item of the CAM, DOSS, DRS-R-98, and MDAS items was matched to these domains.…”

“…In addition to the five domains already defined, there were five additional domains identified: level of consciousness, disorganized thinking, psychomotor agitation, psychomotor retardation, and hallucinations, perceptual disorder, or distortion [6]. Based on the previous expert panel process [6], each item of the CAM, DOSS, DRS-R-98, and MDAS items was matched to these domains.…”

“…A large number of instruments are used for the identification of delirium; their performance characteristics across different populations and their agreement with each other are largely unknown. In our systematic review, we identified that at least 30 instruments exist for identifying delirium (e.g., screening or diagnosis) and each assesses varying delirium domains [6]. Among these, the Confusion Assessment Method (CAM) [7], Delirium Observation Screening Scale (DOSS) [8], Delirium Rating Scale-Revised-98 (DRS-R-98) [9], and Memorial Delirium Assessment Scale (MDAS) [10] as the instruments that were most commonly used, with high-quality psychometric validation and best coverage of the domains in the Diagnostic and Statistical Manu-al of Mental Disorders fifth edition (DSM-5) [11] criteria.…”

Psychometric Properties of a Delirium Severity Score for Older Adults and Association With Hospital and Posthospital Outcomes

“…Our goal was to develop a new delirium severity measure, the DEL-S delirium-severity score, following state-of-the-art psychometric approaches, analogous to those used by the Patient-Reported Outcomes Measurement Information System initiative. 18 Accordingly, we pursued the following multistep process: (1) systematic review of the medical literature on delirium severity and evaluation of the quality of existing tools 19 ; (2) psychometric synthesis and harmonization of the 3 most commonly used delirium severity instruments using advanced psychometric methods to generate an item bank 20 of delirium severity measures; (3) in-depth qualitative interviews with patients, caregivers, and nurses to ensure comprehensive inclusion of key domains of delirium severity 21 ; (4) a modified Delphi process involving an interdisciplinary panel of delirium experts to define domains and subdomains of delirium severity that do not overweight hyperactive symptoms 22 ; and (5) a prospective study to evaluate new delirium severity items using advanced measurement methods including item response theory. 23 The resulting instrument includes cognitive test items, patient self-report, and observer-rated items.…”