Psychiatric symptomatology after delirium: a systematic review

Langan, Clare; Sarode, Deep P; Russ, Tom C.; Shenkin, Susan D.; Carson, Alan; MacLullich, Alasdair M.J.

doi:10.1111/psyg.12240

Cited by 33 publications

(19 citation statements)

References 25 publications

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“…13 Additionally, delirium is associated with a higher risk of long-term cognitive impairment 10,11,66 and other psychiatric comorbidities. 204,205 The prevention of delirium has been shown to be cost-effective. 4,206 However, the treatment of delirium is under-researched, so there remains a lack of unequivocal trial evidence that it is effective.…”

Section: Discussion Of the Cost Analysismentioning

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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Section: Discussion Of the Cost Analysismentioning

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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“…Delirium is often missed in the ED, because emergency staff are only 35% sensitive in detecting delirium 1,8–12 . Even when recognized, delirium may lead to prolonged hospital stay, functional decline, accelerated cognitive decline, and postdischarge depression 13–16 . When unrecognized in the ED, delirium is associated with increased 6‐month mortality 8 …”

mentioning

confidence: 99%

“…1,[8][9][10][11][12] Even when recognized, delirium may lead to prolonged hospital stay, functional decline, accelerated cognitive decline, and postdischarge depression. [13][14][15][16] When unrecognized in the ED, delirium is associated with increased 6-month mortality. 8 In 2007, the Society for Academic Emergency Medicine (SAEM) Geriatric Task Force identified cognitive impairment (including delirium) as one of three conditions with substantial quality gaps for geriatric ED patients.…”

mentioning

confidence: 99%

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

Carpenter

Hammouda

Linton

et al. 2020

Academic Emergency Medicine

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Background Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge‐to‐practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions. Methods GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci. Results In the scoping review, 27 delirium detection “instruments” were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common “instrument” evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research. Conclusions Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.

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“…Recent studies provided evidence that delirium in elderly patients is associated with various long-term sequelae, which include affective disturbances. A systematic review on neuropsychiatric symptoms after delirium found that the prevalence of depressive symptoms was almost three times higher in patients with delirium than in patients without delirium (22.2% vs 8.0%, risk ratio 2.79) [38]. Slor et al reported that in-hospital delirium is associated with an increased burden of depressive symptoms 3 months after discharge in elderly patients.…”

Section: Delirium As Predictor Of Depressionmentioning

confidence: 99%

Relationship between delirium and depression in old age

Eshmawey¹,

Zullino²,

Popp

2021

Swiss Arch Neurol Psychiatr Psychother

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BACKGROUND: Depression is the most prevalent affective syndrome in old age. Delirium is a common and serious adverse event in elderly patients and is associated with significant cognitive and functional decline and early institutionalisation. Both disorders have shared symptoms and signs. Recent studies suggest that depression is an independent risk factor for delirium, and depression symptoms may also represent sequels of delirium. It is important to identify patients at risk of delirium, in order to apply preventive strategies and to address the consequences of incident delirium. In this narrative review we discuss the complex relationship between depression and delirium in old age. METHODS: A literature search was conducted using following databases: PsycINFO, Embase, PubMed, Google scolar, Web of science and AgeLine using key words "delirium", "depression", "overlap" and "risk factor". MAIN FINDINGS: Delirium and depression are complex psychiatric syndromes that are common in old age and associated with poor outcomes. This study gives a general overview about the relationship between depression and delirium. Prior depression is not a rare finding in patients suffering from delirium, and depressive symptoms are frequently observed as sequel of delirium. If delirium occurs, differential diagnosis may be particularly challenging in people with depression. Studies suggest similar pathophysiology, such as disturbances in inflammatory and stress responses. Accurate detection of depression and delirium is a key target to achieve improvement of outcomes and to provide optimal healthcare. CONCLUSION: The literature suggests an inter-relationship between depression and delirium. Symptoms of depression may contribute an increased risk of delirium and delirium may be a predictor of depression. However, the relationships between the two conditions regarding common underlying pathomechanisms and clinical aspects remain imprecisely defined and requires more study.

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Psychiatric symptomatology after delirium: a systematic review

Cited by 33 publications

References 25 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

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

Relationship between delirium and depression in old age

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