Attention! A good bedside test for delirium?

Abstract

BackgroundRoutine 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’.MethodsWe 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.Results265 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.ConclusionsOur results suggest that simple attention tests may be useful in delirium screening. MOTYB used alone was the most accurate screening test in older people.

Delirium: a guide for the general physician

“…Failure to reach July on this test has a sensitivity of 83% and specificity of 91% for picking up delirium although specificity is reduced in patients with background dementia. 16 Delirium is a syndrome, therefore it is not usefully reducible to a single deficit, and a combination of tests demonstrates higher discrimination. The 4 As test (4AT) presents one such battery: it is well validated across different settings, brief and requires no training (Fig 1 ).…”

Evaluation of delirium screening tools in geriatric medical inpatients: a diagnostic test accuracy study

“…We determined the patient's score out of a maximum possible 12 dependent on how many months they could recite backwards in the correct order. A validation study evaluating MOTYB as a screening test in general in-patient wards cited a optimal threshold of <5 out of 12 for detection of delirium [14].…”

The utility of the clock drawing test in detection of delirium in elderly hospitalised patients

“…Moreover, although we used a simplified system for scoring the CDT, it may be that particular aspects of performance are affected in different clinical states. Recent detailed studies of the neurocognitive profile of delirium indicate that disturbances of attention and visuospatial function are especially relevant to identification of this complex syndrome (Meagher et al, 2007;O'Regan et al, 2014) but this has been based upon studies that have used the interlocking pentagons(IP) as the principal measure of constructional praxis. Both the IP and CDT suffer from limitations due to inherent physical and motor demands and it may be that alternate bedside tests of visuospatial ability with performance less predicated upon motor skills and which test a wider range of ability (including the highly impaired performance typical of delirium) may have better discerning ability for more severely unwell populations.…”