Increasing delirium skills at the front door: results from a repeated survey on delirium knowledge and attitudes

Jenkin, Rodric; Al-Attar, Adam; Richardson, Sarah; Myint, Phyo Kyaw; MacLullich, Alasdair M.J.; Davis, Daniel

doi:10.1093/ageing/afw066

Cited by 30 publications

(24 citation statements)

References 22 publications

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“…In a 2009 survey 34 of 784 UK trainee physicians, only 21% stated that they had a good knowledge of the diagnostic criteria for delirium, and only 8% reported using specific screening tools for delirium. A similar survey 35 recently repeated showed some improvements, but gave broadly similar results. A survey 36 in 2013-14 of undergraduate medical education found that, although delirium was included in teaching, the approach was highly heterogeneous and likely to lead to inconsistent knowledge.…”

Section: Underdetection Of Deliriummentioning

confidence: 55%

“…In the base-case analysis, the difference in costs between the 4AT and the CAM was -£90. 35, representing lower 12-week health-care costs for the 4AT. The difference in QALYs was -0.00053, representing very similar health outcomes using the 4AT to those using the CAM over 12 weeks.…”

Section: Cost-effectiveness Analysis Generated Through a Health Economentioning

confidence: 99%

“…74,78,83,89 Yet surveys frequently indicate that basic knowledge of delirium is inadequate. [34][35][36]77,90,91,93,94 In one study, 77 42% of nursing and medical staff working in one of three Scottish ICUs did not know that delirium was associated with an increased 6-month mortality rate and 44% had never received training on ICU delirium. In a survey of UK surgical training doctors, 90 only 2% were familiar with the diagnostic criteria for delirium.…”

Section: General Introductionmentioning

confidence: 99%

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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

102

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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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Section: Underdetection Of Deliriummentioning

confidence: 55%

Section: Cost-effectiveness Analysis Generated Through a Health Economentioning

confidence: 99%

Section: General Introductionmentioning

confidence: 99%

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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

102

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“…In some surveys, physicians were reported as the screening profession (Morandi et al, 2013;Jenkin et al, 2016;Richardson et al, 2016), in others nurses (Devlin et al, 2008;Elliott, 2014;Svenningsen, 2015), but this fact may be more related to the target profession within these surveys than reflecting current practice. The German guideline for Sedation, Agitation and Delirium recommends delirium screening thrice a day but does not mention a specific, responsible profession (DAS-Taskforce et al, 2015).…”

Section: Professions and Screening Deliriummentioning

confidence: 99%

Survey among critical care nurses and physicians about delirium management

Nydahl

Dewes

Dubb

et al. 2017

Nursing in Critical Care

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Background: Delirium is a serious complication in patients in intensive care units. Previous surveys on delirium management in daily practice showed low adherence to published guidelines. Aim: To evaluate delirium management in nurses and physicians working in intensive care units in German-speaking countries and to identify related differences between nurses and physicians. Design: The study used an open online survey with multiple-choice responses. Methods: An invitation for participation was spread via journals and electronic resources using a snowball system. Apart from recording socio-demographical characteristics, the survey collected data on delirium assessment, delirium-related processes, non-pharmacological prevention and treatment and barriers for implementation. Differences between nurses and physicians were tested by Fisher's exact test with sequential Bonferroni correction. Results: The survey was conducted in autumn 2016, and 559 clinicians participated. More nurses than physicians reported screening for delirium. The majority of clinicians reported screening for delirium when this was suspected; more than 50% used validated instruments. Half of the clinicians had delirium-related structures implemented, such as two thirds reporting delirium-related processes. Most cited barriers were lack of time and missing knowledge about delirium and its assessment. With significant difference, physicians recommended more than nurses early removal of catheters and daily interprofessional goals for patients. Conclusion: In German-speaking countries, assessment of delirium needs further improvement, leading to accurate assessment. Delirium-related structures and processes appear to be implemented widely, with only a few differences between nurses and physicians. Relevance to clinical practice: Nurses and physicians in this survey reported similar perceptions and attitudes towards management of delirium. Both professions need more knowledge and inter-professional training on when and how to use validated assessment instruments.

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“…It is therefore important for clinicians to be aware of factors that adversely influence outcomes in this group. One such emerging risk factor is delirium [4], which is being increasingly recognised [5].…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2019

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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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Increasing delirium skills at the front door: results from a repeated survey on delirium knowledge and attitudes

Abstract: despite improvements in some aspects of delirium knowledge, the diagnostic criteria for delirium remain poorly understood. Challenges remain in ensuring adequate training for junior doctors in delirium.

Cited by 30 publications

References 22 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

Survey among critical care nurses and physicians about delirium management

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

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