Attention! A good bedside test for delirium?
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ABSTRACT: Background
Routine delirium screening could improve delirium detection, but it remains unclear as to which screening tool is most suitable. We tested the diagnostic accuracy of the following screening methods (either individually or in combination) in the detection of delirium: MOTYB (months of the year backwards); SSF (Spatial Span Forwards); evidence of subjective or objective 'confusion'.Methods
We performed a cross-sectional study of general hospital adult inpatients in a large tertiary referral hospital. Screening tests were performed by junior medical trainees. Subsequently, two independent formal delirium assessments were performed: first, the Confusion Assessment Method (CAM) followed by the Delirium Rating Scale-Revised 98 (DRS-R98). DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) criteria were used to assign delirium diagnosis. Sensitivity and specificity ratios with 95% CIs were calculated for each screening method.Results
265 patients were included. The most precise screening method overall was achieved by simultaneously performing MOTYB and assessing for subjective/objective confusion (sensitivity 93.8%, 95% CI 82.8 to 98.6; specificity 84.7%, 95% CI 79.2 to 89.2). In older patients, MOTYB alone was most accurate, whereas in younger patients, a simultaneous combination of SSF (cut-off 4) with either MOTYB or assessment of subjective/objective confusion was best. In every case, addition of the CAM as a second-line screening step to improve specificity resulted in considerable loss in sensitivity.Conclusions
Our results suggest that simple attention tests may be useful in delirium screening. MOTYB used alone was the most accurate screening test in older people.
SUBMITTER: O'Regan NA
PROVIDER: S-EPMC4173985 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Delirium is common, morbid, and costly, yet is greatly under-recognized among hospitalized older adults.To identify the best single and pair of mental status test items that predict the presence of delirium.Diagnostic test evaluation study that enrolled medicine inpatients aged 75 years or older at an academic medical center.Patients underwent a clinical reference standard assessment involving a patient interview, medical record review, and interviews with family members and nurses to determine the presence or absence of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition defined delirium. Participants also underwent the three-dimensional Confusion Assessment Method (3D-CAM), a brief, validated assessment for delirium. Individual items and pairs of items from the 3D-CAM were evaluated to determine sensitivity and specificity relative to the reference standard delirium diagnosis.Of the 201 participants (mean age 84 years, 62% female), 42 (21%) had delirium based on the clinical reference standard. The single item with the best test characteristics was "months of the year backwards" with a sensitivity of 83% (95% confidence interval [CI]: 69%-93%) and specificity of 69% (95% CI: 61%-76%). The best 2-item screen was the combination of "months of the year backwards" and "what is the day of the week?" with a sensitivity of 93% (95% CI: 81%-99%) and specificity of 64% (95% CI: 56%-70%).We identified a single item with >80% and pair of items with >90% sensitivity for delirium. If validated prospectively, these items will serve as an initial innovative screening step for delirium identification in hospitalized older adults.
| S-EPMC4665114 | biostudies-literature
Project description:ObjectivesClinicians performing a horizontal head impulse test (HIT) are looking for a corrective saccade. The detection of such saccades is a challenge. The aim of this study is to assess an expert's likelihood of detecting corrective saccades in subjects with vestibular hypofunction.DesignIn a prospective cohort observational study at a tertiary referral hospital, we assessed 365 horizontal HITs performed clinically by an expert neurootologist from a convenience sample of seven patients with unilateral or bilateral deficient vestibulo-ocular reflex (VOR). All HITs were recorded simultaneously by video-oculography, as a gold standard. We evaluated saccades latency and amplitude, head velocity, and gain.ResultsSaccade amplitude was statistically the most significant parameter for saccade detection (p < 0.001).The probability of saccade detection was eight times higher for HIT toward the pathological side (p = 0.029). In addition, an increase in saccade amplitude resulted in an increased probability of detection (odds ratio [OR] 1.77 [1.31 to 2.40] per degree, p < 0.001). The sensitivity to detect a saccade amplitude of 1 degree was 92.9% and specificity 79%. Saccade latency and VOR gain did not significantly influence the probability of the physician identifying a saccade (OR 1.02 [0.94 to 1.11] per 10-msec latency and OR 0.84 [0.60 to 1.17] per 0.1 VOR gain increase).ConclusionsThe saccade amplitude is the most important factor for accurate saccade detection in clinically performed head impulse tests. Contrary to current knowledge, saccade latency and VOR gain play a minor role in saccade detection.
| S-EPMC7722467 | biostudies-literature
Project description:BackgroundDelirium is a common and serious acute neuropsychiatric syndrome which is often missed in routine clinical care. Inattention is the core cognitive feature. Diagnostic test accuracy (including cut-points) of a smartphone Delirium App (DelApp) for assessing attention deficits was assessed in older hospital inpatients.MethodsThis was a case-control study of hospitalised patients aged ≥65 years with delirium (with or without pre-existing cognitive impairment), who were compared to patients with dementia without delirium, and patients without cognitive impairment. Reference standard delirium assessment, which included a neuropsychological test battery, was based on Diagnostic and Statistical Manual of Mental Disorders-5 criteria. A separate blinded assessor administered the DelApp arousal assessment (score 0-4) and attention task (0-6) yielding an overall score of 0 to 10 (lower scores indicate poorer performance). Analyses included receiver operating characteristic curves and sensitivity and specificity. Optimal cut-points for delirium detection were determined using Youden's index.ResultsA total of 187 patients were recruited, mean age 83.8 (range 67-98) years, 152 (81%) women; n = 61 with delirium; n = 61 with dementia without delirium; and n = 65 without cognitive impairment. Patients with delirium performed poorly on the DelApp (median score = 4/10; inter-quartile range 3.0, 5.5) compared to patients with dementia (9.0; 5.5, 10.0) and those without cognitive impairment (10.0; 10.0, 10.0). Area under the curve for detecting delirium was 0.89 (95% Confidence Interval 0.84, 0.94). At an optimal cut-point of ≤8, sensitivity was 91.7% (84.7%, 98.7%) and specificity 74.2% (66.5%, 81.9%) for discriminating delirium from the other groups. Specificity was 68.3% (56.6%, 80.1%) for discriminating delirium from dementia (cut-point ≤6).ConclusionPatients with delirium (with or without pre-existing cognitive impairment) perform poorly on the DelApp compared to patients with dementia and those without cognitive impairment. A cut-point of ≤8/10 is suggested as having optimal sensitivity and specificity. The DelApp is a promising tool for assessment of attention deficits associated with delirium in older hospitalised adults, many of whom have prior cognitive impairment, and should be further validated in representative patient cohorts.
| S-EPMC6980392 | biostudies-literature
Project description:Postoperative delirium is a frequent and debilitating complication, especially amongst high risk procedures such as orthopedic surgery, and its pathogenesis remains unclear. Inattention is often reported in the clinical diagnosis of delirium, however limited attempts have been made to study this cognitive domain in preclinical models. Here we implemented the 5-choice serial reaction time task (5-CSRTT) to evaluate attention in a clinically relevant mouse model following orthopedic surgery. The 5-CSRTT showed a time-dependent impairment in the number of responses made by the mice acutely after orthopedic surgery, with maximum impairment at 24 h and returning to pre-surgical performance by day 5. Similarly, the latency to the response was also delayed during this time period but returned to pre-surgical levels within several days. While correct responses decreased following surgery, the accuracy of the response (e.g., selection of the correct nose-poke) remained relatively unchanged. In a separate cohort we evaluated neuroinflammation and blood-brain barrier (BBB) dysfunction using clarified brain tissue with light-sheet microscopy. CLARITY revealed significant changes in microglial morphology and impaired astrocytic-tight junction interactions using high-resolution 3D reconstructions of the neurovascular unit. Deposition of IgG, fibrinogen, and autophagy markers (TFEB and LAMP1) were also altered in the hippocampus 24 h after surgery. Together, these results provide translational evidence for the role of peripheral surgery contributing to delirium-like behavior and disrupted neuroimmunity in adult mice.
| S-EPMC6918861 | biostudies-literature
Project description:BACKGROUND:Delirium is a common and serious clinical syndrome which is often missed in routine clinical care. The core cognitive feature is inattention. We developed a novel bedside neuropsychological test for assessing inattention in delirium implemented on a smartphone platform (DelApp). We aim to evaluate the diagnostic performance of the DelApp in a representative cohort of older hospitalised patients. METHODS:This is a prospective study of older non-scheduled hospitalised patients (target n?=?500, age ? 65), recruited from elderly care and acute orthopaedic wards. Exclusion criteria are: non-English speakers; severe vision or hearing impairment; photosensitive epilepsy. A structured reference standard delirium assessment based on DSM-5 criteria will be used, which includes a cognitive test battery administered by a trained assessor (Orientation-Memory-Concentration Test, Abbreviated Mental Test-10, Delirium Rating Severity Scale-Revised-98, digit span, months and days backwards, Vigilance A' test) and assessment of arousal (Observational Scale of Level of Arousal, Richmond Agitation Sedation Scale). Prior change in cognition will be documented using the Informant Questionnaire on Cognitive Decline in the Elderly. Patients will be categorized as delirium (with/without dementia), possible delirium, dementia, no cognitive impairment, or undetermined. A separate assessor (blinded to diagnosis and assessments) will administer the DelApp index test within 3 h of the reference standard assessment. The DelApp comprises assessment of arousal (score 0-4) and sustained attention (score 0-6), yielding a total score between 0 and 10 (higher score?=?better performance). Outcomes (length of stay, mortality and discharge location) will be collected at 12 weeks. We will evaluate a priori cutpoints derived from a previous case-control study. Measures of the accuracy of DelApp will include sensitivity, specificity, positive and negative predictive values, and area under the ROC curve. We plan repeat assessments on up to 4 occasions in a purposive subsample of 30 patients (15 delirium, 15 no delirium) to examine changes over time. DISCUSSION:This study evaluates the diagnostic test accuracy of a novel smartphone test for delirium in a representative cohort of older hospitalised patients, including those with dementia. DelApp has the potential to be a convenient, objective method of improving delirium assessment for older people in acute care. TRIAL REGISTRATION:Clinical trials.gov, NCT02590796 . Registered on 29 Oct 2015. Protocol version 5, dated 25 July 2016.
| S-EPMC6142423 | biostudies-literature
Project description:ObjectiveTo determine the accuracy of the bedside head impulse test (bHIT) by direct comparison with results from the quantitative head impulse test (qHIT) in the same subjects, and to investigate whether bHIT sensitivity and specificity changes with neuro-otological training.MethodsVideo clips of horizontal bHIT to both sides were produced in patients with unilateral and bilateral peripheral vestibular deficits (n = 15) and in healthy subjects (n = 9). For qHIT, eye and head movements were recorded with scleral search coils on the right eye and the forehead. Clinicians (neurologists or otolaryngologists) with at least 6 months of neuro-otological training ("experts": n = 12) or without this training ("non-experts": n = 45) assessed video clips for ocular motor signs of vestibular deficits on either side or of normal vestibular function.ResultsOn average, bHIT sensitivity was significantly (t test: p<0.05) lower for experts than for non-experts (63% vs 72%), while bHIT specificity was significantly higher for experts than non-experts (78% vs 64%). This outcome was a consequence of the experts' tendency to accept bHIT with corresponding borderline qHIT values as still being normal. Fitted curves revealed that at the lower normal limit of qHIT, 20% of bHIT were rated as deficient by the experts and 37% by the non-experts.ConclusionsWhen qHIT is used as a reference, bHIT sensitivity is adequate and therefore clinically useful in the hands of both neuro-otological experts and non-experts. We advise performing quantitative head impulse testing with search coils or high speed video methods when bHIT is not conclusive.
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Project description:BACKGROUND:The bedside head impulse test (bHIT) is a clinical method of assessing the vestibulo-ocular reflex (VOR). It is a critical component of the bedside assessment of dizzy patients, and can help differentiate acute stroke from vestibular neuritis. However, there is evidence showing the bHIT is often not performed in appropriate clinical settings or is performed poorly. To date, there have been no studies evaluating the bHIT competence of graduating physicians. METHODS:23 final year Otolaryngology -Head &Neck Surgery (OTL-HNS) residents in Canada were evaluated on the use of bHIT using a written multiple-choice examination, interpretation of bHIT videos, and performance of a bHIT. Ratings of subject bHIT performance were completed by two expert examiners (DT, DL) using the previously published Ottawa Clinic Assessment Tool (OCAT). RESULTS:Using a cut-off of an OCAT score of 4 or greater, only 22% (rater DT) and 39% (rater DL) of residents were found able to perform the bHIT independently. Inter-rater reliability was fair (0.51, interclass correlation). The mean scores were 65% (14.1% standard deviation) on the video interpretation and 71% (20.2% standard deviation) on the multiple-choice questions. The scores on multiple choice examination did not correlate with bHIT ratings (Pearson r?=?0.07) but there was fair correlation between video interpretation and bHIT ratings (Pearson r?=?0.45). CONCLUSION:Final year OTL-HNS residents in Canada are not adequately trained in performing the bHIT, though low interrater reliability may limit the evaluation of this bedside skill. Multiple choice examinations do not reflect bHIT skill. These findings have implications for development of competency-based curricula and evaluations in Canada in critical physical exam skills.
| S-EPMC6339336 | biostudies-other
Project description:BackgroundPleural fluid glucose (PFG) has diagnostic and therapeutic implications for the management of pleural effusion. The literature examining point-of-care testing of PFG is limited, and no studies exist for the bedside measurement of PFG using a glucometer (B-PFG). In this study, we compared the accuracy of B-PFG measurement to standard in-lab measurement (Lab-PFG).MethodsPatients undergoing thoracentesis or thoracostomy were enrolled. PFG was measured at the bedside with a finger stick blood glucometer (ACCU-CHEK® Inform II, Roche) and in the laboratory. Two consecutive measurements were taken using the glucometer, and their mean was compared to the glucose concentration measured in the laboratory. Pearson correlation coefficient and Bland-Altman Plot analysis were used to compare the two measurements.ResultsSixty patients were included. Mean age was 64.1 years. Forty-nine patients had exudative effusions (41% malignant, 26% parapneumonic, and 33% others). There was a significant correlation between the B-PFG and the Lab-PFG (r=0.98, 95% CI of 0.97 to 0.99; P<0.0001). There was good agreement between the B-PFG and the Lab-PFG with a mean difference of 14.8 mg/dL [95% limit of agreement (LOA) of -2.2 to 31.8 mg/dL]. This agreement was even better at glucose values less than 80 mg/dL.ConclusionsPFG measured at the bedside with a glucometer closely correlates with the laboratory measurement. Further studies are needed prior to incorporating this test in clinical practice.
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Project description:Background: Stress exacerbates symptoms of schizophrenia and attention deficit hyperactivity disorder, which are characterized by impairments in sustained attention. Yet how stress regulates attention remains largely unexplored. Here we investigated whether a 6-day variable stressor (VS) altered sustained attention and the cholinergic attention system in male and female rats. Methods: Sustained attention was tested with the sustained attention task (SAT). Successful performance on SAT relies on the release of acetylcholine (ACh) into the cortex from cholinergic neurons in the nucleus basalis of Meynert (NBM). Thus, we evaluated whether VS altered the morphology of these neurons with a novel approach using Cre-dependent virus in genetically modified ChAT::Cre rats, a species used for this manipulation only. Next, electrochemical recordings measured cortical ACh following VS. Finally, we used RNAseq to identify VS-induced transcriptional changes in the NBM. Results: VS impaired attentional performance in SAT and increased the dendritic complexity of NBM cholinergic neurons in both sexes. NBM cholinergic neurons are mainly under inhibitory control, so this morphological change could increase inhibition on these neurons, reducing downstream ACh release to impair attention. Indeed, VS decreased ACh release in the prefrontal cortex of males. Quantification of global transcriptional changes revealed that, although VS induced many sex-specific changes in gene expression, it increased several signaling molecules in both sexes.
2020-05-01 | GSE147806 | GEO
Project description:Negative affective states such as anxiety and depression pose a risk to animal welfare, however, practical tests for assessing these states in animals are limited. In humans, anxious individuals are shown to pay more attention toward threatening information than non-anxious individuals, known as an attention bias. Previously, an attention bias test was developed and validated as a measure of anxious states in sheep, where more anxious sheep showed increased attention toward a threat (dog) and were more vigilant than Control animals. Studies in humans suggest that attention biases also occur in depressed individuals, with observations of attention biases toward threats, as well as biases away from positive stimuli. Given these findings, we hypothesized that an attention bias test for sheep could also be used to assess states of depression. We predicted that Merino ewes in pharmacologically induced Depressed (para-chlorophenylalanine) and Anxious (m-chlorophenylpiperazine) states would show greater attention toward a threat than Control animals (saline), but that the Depressed sheep would show relatively less interest in a positive stimulus (photograph of a conspecific). During testing, Depressed sheep paid more attention toward the threat and less toward the photograph than Control animals as predicted (Analyses of Variance, P < 0.05, n = 16 per treatment). Interestingly, Anxious sheep showed an attention bias in the opposite direction, paying more attention toward the photograph and less toward the threat than Control animals (P < 0.05). Both Anxious and Depressed sheep were more vigilant than Control animals (P = 0.002). These results suggest the attention bias test can be used to measure and differentiate states of depression and anxiety in livestock. The bidirectional nature of the attention bias identified between treatments highlights the importance of measuring multiple behaviors in the test and considering the context in which the test is applied. This will enable a clearer characterization of the affective state of an animal, as an aspect of its welfare.
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