Background Delirium is a common form of acute brain dysfunction with prognostic significance. Health care professionals caring for older emergency department (ED) patients miss delirium approximately 75% of cases. This error results from a lack of available measures that can be performed rapidly enough to be incorporated into clinical practice. Therefore, we developed and evaluated a novel two-step approach to delirium surveillance for the ED. Methods This prospective observational study was conducted at an academic ED in patients ≥ 65 years old. A research assistant (RA) and physician performed the Delirium Triage Screen (DTS), designed to be a highly sensitive rule-out test, and the Brief Confusion Assessment Method (bCAM), designed to be a highly specific rule-in test for delirium. The reference standard for delirium was a comprehensive psychiatrist assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria. All assessments were independently conducted within 3 hours of each other. Sensitivities, specificities, and likelihood ratios with their 95% confidence intervals (95%CI) were calculated. Results Of 406 enrolled patients, 50 (12.3%) had delirium diagnosed by the psychiatrist reference standard. The DTS was 98.0% (95%CI: 89.5% – 99.5%) sensitive with an expected specificity of approximately 55% for both raters. The DTS’ negative likelihood ratio was 0.04 (95%CI: 0.01 – 0.25) in both raters. As the complement, the bCAM had a specificity of 95.8% (95%CI: 93.2% – 97.4%) and 96.9% (95%CI: 94.6% – 98.3%) and a sensitivity of 84.0% (95%CI: 71.5% – 91.7%) and 78.0% (95%CI: 64.8% – 87.2%) when performed by the physician and RA, respectively. The positive likelihood ratios for the bCAM were 19.9 (95%CI: 12.0 – 33.2) and 25.2 (95%CI: 13.9 – 46.0), respectively. If the RA DTS was followed by the physician bCAM, the sensitivity of this combination was 84.0% (95%CI: 71.5% – 91.7%) and the specificity was 95.8% (95%CI: 93.2% – 97.4%). If the RA performed both the DTS and bCAM, this combination was 78.0% (95%CI: 64.8% – 87.2%) sensitive and 97.2% (95%CI: 94.9% – 98.5%) specific. If the physician performed both the DTS and bCAM, this combination was 82.0% (95%CI: 69.2% – 90.2%) sensitive and 95.8% (95CI: 93.2% – 97.4%) specific. Conclusions In older ED patients, this two-step approach (highly sensitive DTS followed by highly specific bCAM) may enable healthcare professionals, regardless of clinical background, to efficiently screen for delirium. Larger, multi-centered trials are needed to confirm these findings and to determine the impact of these assessments on delirium recognition in the ED.

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PURPOSE Cognitive impairment after critical illness is common and debilitating. We developed a cognitive therapy program for critically ill patients and assessed the feasibility and safety of administering combined cognitive and physical therapy early during a critical illness. METHODS We randomized 87 medical and surgical ICU patients with respiratory failure and/or shock in a 1:1:2 manner to three groups: usual care, early once-daily physical therapy, or early once-daily physical therapy plus a novel, progressive, twice-daily cognitive therapy protocol. Cognitive therapy included orientation, memory, attention, and problem solving exercises, and other activities. We assessed feasibility outcomes of the early cognitive plus physical therapy intervention. At 3-months, we also assessed cognitive, functional and health-related quality of life outcomes. Data are presented as median [interquartile range] or frequency (%). RESULTS Early cognitive therapy was a delivered to 41/43 (95%) of cognitive plus physical therapy patients on 100% [92–100%] of study days beginning 1.0 [1.0–1.0] day following enrollment. Physical therapy was received by 17/22 (77%) of usual care patients, by 21/22 (95%) of physical therapy only patients and 42/43 (98%) of cognitive plus physical therapy patients on 17% [10–26%], 67% [46–87%] and 75% [59–88%] of study days, respectively. Cognitive, functional and health-related quality of life outcomes did not differ between groups at 3-month follow-up. CONCLUSIONS This pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy. Future work to determine optimal patient selection, intensity of treatment and benefits of cognitive therapy in the critically ill is needed.

A significant proportion of patients develop delirium signs in the immediate postoperative period, primarily manifesting with a hypoactive subtype. These signs often persist to PACU discharge, suggesting the need for structured delirium monitoring in the PACU to identify patients potentially at risk for worse outcomes in the postoperative period.

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