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Preliminary development of an ultrabrief two-item bedside test for delirium.

ABSTRACT: 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.

SUBMITTER: Fick DM

PROVIDER: S-EPMC4665114 | biostudies-literature | 2015 Oct

REPOSITORIES: biostudies-literature

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Preliminary development of an ultrabrief two-item bedside test for delirium.

Fick Donna M DM Inouye Sharon K SK Guess Jamey J Ngo Long H LH Jones Richard N RN Saczynski Jane S JS Marcantonio Edward R ER

Journal of hospital medicine 20150915 10

<h4>Background</h4>Delirium is common, morbid, and costly, yet is greatly under-recognized among hospitalized older adults.<h4>Objective</h4>To identify the best single and pair of mental status test items that predict the presence of delirium.<h4>Design, setting</h4>Diagnostic test evaluation study that enrolled medicine inpatients aged 75 years or older at an academic medical center.<h4>Methods</h4>Patients underwent a clinical reference standard assessment involving a patient interview, medic ...[more]

PMID: 26369992

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Project description:BackgroundDelirium screening instruments (DSIs) should be used to detect delirium, but they only show moderate sensitivity in patients with neurocritical illness. We explored whether, for these patients, DSI validity is impacted by patient-specific covariates.MethodsData were prospectively collected in a single-center quality improvement project. Patients were screened for delirium once daily using the Intensive Care Delirium Screening Checklist (ICDSC) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Reference was the daily assessment using criteria from the Diagnostic and Statistical Manual, 4th Edition, Text Revision (DSM-IV-TR). In a two-step receiver operating characteristics regression analysis adjusting for repeated measurements, the impact of acute diagnosis of stroke or transient ischemic attack (TIA), neurosurgical intervention, Richmond Agitation Sedation Scale, and ventilation status on test validity was determined.ResultsOf 181 patients screened, 101 went into final analysis. Delirium incidence according to DSM-IV-TR was 29.7%. For the first complete assessment series (CAM-ICU, ICDSC, and DSM-IV-TR), sensitivity for the CAM-ICU and the ICDSC was 73.3% and 66.7%, and specificity was 91.8% and 94.1%, respectively. Consideration of daily repeated measurements increased sensitivity for the CAM-ICU and ICDSC to 75.7% and 73.4%, and specificity to 97.3% and 98.9%, respectively. Receiver operating characteristics regression revealed that lower Richmond Agitation Sedation Scale levels significantly impaired validity of the ICDSC (p = 0.029) and the CAM-ICU in its severity scale version (p = 0.004). Neither acute diagnosis of stroke or TIA nor neurosurgical intervention or mechanical ventilation significantly influenced DSI validity.ConclusionsThe CAM-ICU and ICDSC perform well in patients requiring neurocritical care, regardless of the presence of acute stroke, TIA, or neurosurgical interventions. Yet, even very light or moderate sedation can significantly impair DSI performance.

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Preliminary development of an ultrabrief two-item bedside test for delirium.

Publications

Preliminary development of an ultrabrief two-item bedside test for delirium.

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