Clinical Features Associated with Delirium Motor Subtypes in Older Inpatients: Results of a Multicenter Study

Morandi, Alessandro; Santo, Simona Gabriella Di; Cherubini, Antonio; Mossello, Enrico; Meagher, David; Mazzone, Andrea; Bianchetti, Angelo; Ferrara, Nicola; Ferrari, Alberto; Musicco, Massimo; Trabucchi, Marco; Bellelli, Giuseppe; Boffelli, Stefano; Stefano, Fabio Di; Filippi, Francesco De; Guerini, Fabio; Bertoletti, Erik; March, Albert; Margiotta, Alessandro; Mecocci, Patrizia; Addesi, Desirée; Fantò, Fausto; Isaia, Gianluca; Dijik, Babette; Porrino, Paola; Cotroneo, Antonino Maria; Galli, G; Bruni, Amalia C.; Bernardini, Bruno; Corsini, Carla; Cagnin, Annachiara; Zurlo, Amedeo; Barbagallo, Giuseppe; Lunardelli, Maria Lia; Martini, Emilio; Battaglia, Giuseppe; Latella, Raffaele; Petritola, D.; Sinforiani, Elena; Cester, Alberto; Formilan, M.; Carbone, Pasqualina; Appollonio, Ildebrando; Cereda, Diletta; Tremolizzo, Lucio; Bottacchi, E.; Lucchetti, L.; Mariani, Claudio; Rapazzini, P; Romanelli, Giuseppe; Marengoni, Alessandra; Zuliani, Giovanni; Bianchi, Lara; Suardi, Teresa; Muti, Ettore; Bottura, Renato; Sgrò, Giovanni; Mandas, Antonella; Serchisu, Luca; Crippa, Patrizia; Ivaldi, Claudio; Ungar, Andrea; Villani, Daniele; Raimondi, Clara; Mussi, Chiara; Isaia, Giancarlo; Provenzano, G.; Mari, Daniela; Odetti, Patrizio; Monacelli, Fiammetta; Incalzi, Raffaele Antonelli; Pluderi, A.; Bellamoli, Claudio; Terranova, L.; Scarpini, Elio; D’Amico, Ferdinando; Guerrini, Gianbattista; Scotuzzi, A. M.; Chiarello, Antonino; Pilotto, Alberto; Tognini, Sara; Dell'Aquila, Giuseppina; Toigo, G.; Ceschia, Giuliano; Piccinini, M.; Fabbo, Andrea; Zoli, Marco; Forti, Paola; Wenter, Christian; Basile, Giorgio; Lasagni, Anna; Padovani, Alessandro; Rozzini, Luca; Cottino, Maria; Vitali, Silvia; Tripi, Gabriele; Avanzi, Stefano; Umidi, S.; Moretti, Daniela; Ruotolo, Giovanni; Boschi, Federica; Bonino, Paolo; Marchionni, Niccolò; Cavallini, Maria Chiara; Fascendini, Sara; Noro, Gabriele; Turco, Renato; Ubezio, Maria Chiara; Serrati, Carlo; Infante, María Teresa; Gentile, Simona; Pernigotti, L; Biagini, Carlo; Canonico, Enzo; Bonati, P; Gareri, Pietro; Caffarra, Paolo; Ceretti, Arcangelo; Castiglia, Rosanna; Gabelli, C.; Storto, Mario Lo; Putzu, P.; Santo, Simona Di; Rozzini, Renzo; Zanetti, Ermellina; Bo, Mario

doi:10.1016/j.jagp.2017.05.003

Cited by 46 publications

(34 citation statements)

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“…In addition to the 4AT being the subject of several diagnostic accuracy studies, it is in use as a tool in some other studies of delirium. [97][98][99] This brief chapter (1) provides an overview of current knowledge about the clinical use of the 4AT, including its presence in policy and guidelines documents, and (2) provides examples of clinical service evaluations, including field testing item 1 of the 4AT.…”

Section: Introductionmentioning

confidence: 99%

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

MacLullich

Shenkin

Goodacre

et al. 2019

Health Technol Assess

105

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Background Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 ‘A’s test (Arousal, Attention, Abbreviated Mental Test – 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. Methods Phase 1 – the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 – the 4AT’s diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. Results Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0–14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0–6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. Limitations Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. Conclusions These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. Future work Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. Trial registration Current Controlled Trials ISRCTN53388093. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.

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Section: Introductionmentioning

confidence: 99%

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

MacLullich

Shenkin

Goodacre

et al. 2019

Health Technol Assess

105

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“…The term comes from the Latin de "out" and lyre "rut"; the word therefore means "get out of the" rut, as if one were deviating from the usual state. Three different clinical forms are usually described [16]:…”

Section: Diagnostic Framework Of Delirium In Older Personsmentioning

confidence: 99%

“…According to a recent review, the hypoactive delirium phenotype has a higher prevalence when compared to the mixed and hyperactive forms of delirium [16].…”

Section: Diagnostic Framework Of Delirium In Older Personsmentioning

confidence: 99%

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Treatment of Delirium in Older Persons: What We Should Not Do!

Lauretani

Bellelli

Pelà

et al. 2020

IJMS

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The presentation of common acute diseases in older age is often referred to as “atypical”. Frequently, the symptoms are neither single nor tissue related. In most cases, the onset of symptoms and diseases is the expression of a diminished reserve with a failure of the body system and imbalance of brain function. Delirium is one of the main devastating and prevalent atypical symptoms and could be considered as a geriatric syndrome. It encompasses an array of neuropsychiatric symptoms and represents a disarrangement of the cerebral function in response to one or more stressors. The most recent definition, reported in the DSM-V, depicts delirium as a clear disturbance in attention and awareness. The deficit is to be developed in a relatively short time period (usually hours or days). The attention disorder must be associated with another cognitive impairment in memory, orientation, language, visual-spatial or perception abilities. For the treatment, it is imperative to remove the potential causes of delirium before prescribing drugs. Even a non-pharmacological approach to reducing the precipitating causes should be identified and planned. When we are forced to approach the pharmacological treatment of hyperactive delirium in older persons, we should select highly cost-effective drugs. High attention should be devoted to the correct balance between improvement of psychiatric symptoms and occurrence of side effects. Clinicians should be guided in the correct choice of drugs following cluster symptoms presentation, excluding drugs that could potentially produce complications rather than advantages. In this brief point-of-view, we propose a novel pharmacological flow-chart of treatment in relation to the basic clusters of diseases of an older patient acutely admitted to the hospital and, in particular, we emphasize “What We Should Not Do!”, with the intention of avoiding possible side effects of drugs used.

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“…Zu beachten ist, dass diese Medikamente vor allem bei einer hyperaktiven Delir-Symptomatik indiziert sind. Etwa ein Drittel der Patienten weist ein hypoaktives Delir auf [13,14], hier werden die medikamentöse Therapiestrategien jedoch uneinheitlich beurteilt [10,15]. Für die im ambulanten Versorgungssektor durchgeführte Psychopharmakotherapie des Delirs sind keine nationalen oder internationalen pharmako-epidemiologischen Studien bekannt.…”

Section: Introductionunclassified

Inzidenz und Behandlung des nicht stoffgebundenen Delirs in deutschen Haus- und Facharztpraxen

Bohlken

Hewer

Kostev³

2018

Fortschr Neurol Psychiatr

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Zusammenfassung Ziel Über die Häufigkeit und die medikamentöse Behandlung des nicht stoffgebundenen Delirs in deutschen Haus- (HA) und Facharzt-Praxen (FA) ist wenig bekannt. Ziel der Studie war die Bestimmung der Delir-Inzidenz und der Delir-Behandlung mit Neuroleptika und Benzodiazepinen in HA.- und FA-Praxen. Methoden In dem Zeitraum von 2012 bis 2015 wurden 2.999 Patienten > 65 Jahre in 1.262 HA- und 1.425 Patienten in 203 FA-Praxen mit erstmaliger Delir-Diagnose (ICD 10: F05) ausgewählt und hinsichtlich der Verordnung von Neuroleptika (EphMRA ATC: N05A) und Benzodiazepine (N06C) untersucht, die direkt nach der Diagnosestellung des Delirs erfolgte. Ergebnisse Die kumulative 1-Jahres-Inzidenz des Delirs betrug in HA-Praxen 0,6 und in FA-Praxen 1,9 Patienten pro Praxis. Keine Delir-Diagnose wurde in mehr als 40 % der Praxen gestellt. Im Heim erfolgte die Behandlung bei 31 % der HA- und 21 % der FA Patienten. Häufigste HA-Verordnung: Melperon (9,4 % zu Hause bzw. 13,7 % im Heim), FA: Risperidon (4,3 % zu Hause bzw. 13,4 % im Heim). Die antidelirante Medikation war positiv mit männlichem Geschlecht (OR = 1.26), Wohnen im Seniorenheim (OR = 1,74) Demenz (OR = 1.55) und Depression (OR = 1.32), und negativ mit FA-Behandlung (OR = 0.73) assoziiert. Schlussfolgerung Die Delir-Diagnose und seine medikamentöse Behandlung ist in deutschen Arzt-Praxen ein relativ seltenes Ereignis. Die Ursachen für die im internationalen Vergleich niedrige Prävalenzrate im ambulanten Versorgungsbereich sollte intensiver untersucht werden.

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Clinical Features Associated with Delirium Motor Subtypes in Older Inpatients: Results of a Multicenter Study

Cited by 46 publications

References 24 publications

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

Treatment of Delirium in Older Persons: What We Should Not Do!

Inzidenz und Behandlung des nicht stoffgebundenen Delirs in deutschen Haus- und Facharztpraxen

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