Delirium remains underdetected as a result of its broad constellation of symptoms and the inadequate neuropsychiatric expertise of most medical-surgical clinicians. Brief, accurate tools are needed to enhance detection. Methods:The authors extended validation of the Delirium Diagnostic Tool-Provisional (DDT-Pro), originally validated in a study of inpatients with traumatic brain injury for diagnosis of delirium by nonexpert clinicians, for 200 general medical inpatients in Colombia. The three structured, quantitatively rated items in DDT-Pro represent the three core delirium domains.Results: High interrater reliability between physician and nurse (0.873) administrators, internal consistency (.0.81), and content validity were found. Compared with independent reference standard diagnosis with DSM-5 or the Delirium Rating Scale-Revised-98, the area under the receiver operating characteristic (ROC) curve (global diagnostic accuracy) range was 93.8%296.3%. ROC analysis revealed the same cutoff score (#6) as that for the original study, with somewhat lower sensitivities of 88.0%290.0% and specificities of 85.3%281.2% (independent expert physician or nurse ratings). Even when rated by a trained expert physician, the original version of the Confusion Assessment Method algorithm (CAM-A) performed moderately, with lower sensitivities (61.8%270.0%) than the DDT-Pro (88.0%2 100%) and somewhat higher specificities (84.8%295.3% versus 67.4%286.7%), with values depending on dementia status, reference standard, and rater type. Accuracies for the DDT-Pro and CAM-A were comparable (DDT-Pro: 83.0%2 87.5% versus CAM-A: 87.5%288.5%), although lower in the dementia subgroup, especially for CAM-A. However, these tools were significantly discordant, especially in negative cases, which suggests that they do not detect diagnosis of patients in the same way. Conclusions:The DDT-Pro had high validity and reliability in provisional delirium diagnosis by physicians and nonexpert clinicians, although further validation is warranted before widespread use can be recommended.

To evaluate the relationship between cognitive status and incident delirium, 291 geriatric patients on internal medicine wards were evaluated on admission with the Mini-Mental State Examination (MMSE) and Confusion Assessment Method-Spanish. Those with incident delirium were assessed using the Delirium Rating Scale-Revised-98 (DRS-R98). Delirium incidence was 11.7%, and 82 patients (28.2%) had cognitive deficits on MMSE. As cognitive impairment worsened, the risk for delirium increased linearly, and for each unit of MMSE worsening the DRS-R98 severity score worsened 0.4 points (F=5.39, df=1, p=0.027). Optimal MMSE cutoff score from receiver-operating characteristic curve analysis was 24.5. Even mild cognitive deficits increase delirium risk and severity.

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