Predictive Ability of a Serious Game to Identify Emergency Patients With Unrecognized Delirium

Abstract

OBJECTIVES Recognition of delirium in the emergency department (ED) is poor. Our objectives were to assess: (1) the diagnostic accuracy of the Predicting Emergency department Delirium with an Interactive Computer Tablet (PrEDICT) “serious game” to identify older ED patients with delirium compared to clinical recognition and (2) the feasibility of the PrEDICT application compared to existing tests of attention. DESIGN Prospective observational study. SETTING ED of a Canadian tertiary care center. PARTICIPANTS We included ED patients, aged 70 years and older, with a minimum 4‐hour stay. We excluded anyone with critical illness, communication barriers, and visual impairment or those unable to use a computer tablet. None had prevalent delirium by ED clinicians' routine clinical assessment. MEASUREMENTS Participants were asked to tap targets on a tablet at four difficulty levels. Time and accuracy were automatically recorded. Other measures included the Confusion Assessment Method, the Delirium Severity Index, the Digit Vigilance Test (DVT), and the Choice Reaction Test (CRT). RESULTS We enrolled 203 patients. Their average age was 80.6 years, 49.8% were female, and their average ED length of stay was 15.9 hours. Sixteen subjects had clinically unrecognized delirium, and 14 of them completed the PrEDICT game (87.5%). We developed a threshold score with 100% sensitivity (95% confidence interval [CI] = 76.8%‐100.0%) and 59.7% specificity (95% CI = 52.3%‐66.6%) to identify patients with clinically unrecognized delirium. The area under the curve was 0.86 (95% CI = 0.77‐0.94). Completion rates were 196/203 (96.6%) for the PrEDICT serious game compared to 128/203 (63.1%) for the CRT and 51/203 (25.1%) for the DVT. CONCLUSION Older ED patients were able to use our serious game, including 87.5% of those with clinically unrecognized delirium. The PrEDICT application has potential to act as a sensitive screening tool to identify older ED patients with clinically unrecognized delirium. J Am Geriatr Soc 67:2370–2375, 2019

Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement

“…The most commonly evaluated stratification tool was clinician (nurse or physician) judgment (“gestalt”; studied in 12 papers) 11,12,27,28,30,32,34–39 . The next most commonly evaluated instruments were the Confusion Assessment Method for the Intensive Care Unit (CAM‐ICU; five), 39–43 Confusion Assessment Method (CAM; four), 27,29,44,45 Brief Confusion Assessment Method (bCAM; four), 46–49 Richmond Agitation Sedation Scale (RASS; four), 50–53 4AT (three), 29,54,55 and the tablet “serious game” (three) 56–58 …”

“…Patients were recruited from 1992 to 2016 and the manuscripts were published between 1995 and 2019. The majority of studies were prospective observational (35), 11,12,26,27,30,32,34–36,38,40–43,46–52,54–58,60–68 followed by chart review (three), 37,39,69 before/after (two), 31,70 case–control (one), 71 randomized controlled trial (one), 29 and a mixed prospective/retrospective study (one) 53 . Three studies failed to report their research design 28,33,44 …”

“…11,12,27,28,30,32,[34][35][36][37][38][39] The next most commonly evaluated instruments were the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU; five), [39][40][41][42][43] Confusion Assessment Method (CAM; four), 27,29,44,45 Brief Confusion Assessment Method (bCAM; four), [46][47][48][49] Richmond Agitation Sedation Scale (RASS; four), [50][51][52][53] 4AT (three), 29,54,55 and the tablet "serious game" (three). [56][57][58] Participant Characteristics. The sum of study populations totaled 15,860 patients and two systematic reviews of 12 ED-based studies.…”

“…53 Specificity of the instruments reported ranged from 27% for the Bergman-Paris question 67 to 100% for clinician gestalt. 12 The most commonly used reference standards were the CAM (18); 12,[26][27][28]30,32,33,36,38,54,[56][57][58]62,64,66,67,70 Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria applied by neurologist, geriatrician, or psychiatrist (16); 29,39,42,44,[46][47][48]50,51,53,55,60,61,65,68,69 and the CAM-ICU (three). 43,52,63 Two original data studies did not report their reference standard 31,37 (for a summary table of each included study's population, inclusion/exclusion criteria, study design, reference standard, and diagnostic accuracy outcomes, see Data Supplement S2, Appendix S2).…”

Transcending Distance in Long-Term Care: Can Serious Games Increase Resident Resilience?

“…BrainTagger is a suite of cognitive games designed to assess different cognitive functions based on standard psychological tasks (Figure 2). It can be used as a screening tool for detecting abnormal declines in cognitive status such as delirium onset (Tong et al, 2016, Lee et al, 2019.…”