Comparative Accuracy and Efficiency of Four Delirium Screening Protocols

Abstract

BACKGROUND/OBJECTIVES: Systematic screening can improve detection of delirium, but lack of time is often cited as why such screening is not performed. We investigated the time required to implement four screening protocols that use the Ultra-Brief two-item screener for delirium (UB-2) and the 3-Minute Diagnostic Interview for Confusion Assessment Method (CAM)-defined Delirium (3D-CAM), with and without a skip pattern that can further shorten the assessment. Our objective was to compare the sensitivity, specificity, and time required to complete four protocols: (1) full 3D-CAM on all patients, (2) 3D-CAM with skip on all patients, (3) UB-2, followed by the full 3D-CAM in "positives," and (4) UB-2, followed by the 3D-CAM with skip in "positives." DESIGN: Comparative efficiency simulation study using secondary data. SETTING: Two studies (3D-CAM and Researching Efficient Approaches to Delirium Identification (READI)) conducted at a large academic medical center (3D-CAM and READI) and a small community hospital (READI only). PARTICIPANTS: General medicine inpatients, aged 70 years and older (3D-CAM, n = 201; READI, n = 330). MEASUREMENTS: We used 3D-CAM data to simulate the items administered under each protocol and READI data to calculate median administration time per item. We calculated sensitivity, specificity, and total administration time for each of the four protocols. RESULTS: The 3D-CAM and READI samples had similar characteristics, and all four protocols had similar simulated sensitivity and specificity. Mean administration times were 3 minutes 13 seconds for 3D-CAM, 2 minutes 19 seconds for 3D-CAM with skip, 1 minute 52 seconds for UB-2 + 3D-CAM in positives, and 1 minute 14 seconds for UB-2 + 3D-CAM with skip in positives, which was 1 minute 59 seconds faster than the 3D-CAM (P < .001). CONCLUSION: The UB-CAM, consisting of the UB-2, followed in positives by the 3D-CAM with skip pattern, is a time-efficient delirium screening protocol that holds promise for increasing systematic screening for delirium in hospitalized older adults.

Comparison of delirium detection tools in acute care

“…MOTYB to identify inattention 2. If inattention present → SPMSQ for identifying cognitive impairment, Comprehension subtest of CTD for identifying disorganized thinking CAM algorithm: 1 + 2 + (3 or 4) positive = suspected delirium < 5 min Total sample: – DSM-IV criteria [ 18 , 22 ] Two-step approach; operationalization of core features 0.90 0.98 Patients with dementia: 0.91 0.87 Patients without dementia: 0.89 0.99 UB-CAM (Ultra-brief-CAM) General medicine patients ≥ 75 years ( n = 201) (+ collateral history) I: trained physician/nurse Screening 2–15 items UB‑2, in the case of an incorrect answer followed by a modified 3D-CAM (assessment of each CAM feature is stopped after one incorrect answer or positive observation item of that feature) CAM algorithm: 1 + 2 + (3 or 4) positive = suspected delirium 2 min 0.93 0.95 – 3D-CAM [ 4 , 25 , 40 ] Retrospective simulation based on 3D-CAM and UB‑2 data of two studies Other tools than CAM 4AT (4 As test) Acute care and rehabilitation patients ≥ 70 years ( n = 234) + collateral history I: untrained geriatrician Screening 4 items: alertness AMT‑4 Attention (MOTYB) Acute change or fluctuation Score 0–12 0 = no CI or delirium 1–3 = possible CI ≥ 4 = possible delirium < 5 min 0.90 0.84 AUC 0.89–0.93 DSM-IV criteria [ 5 ] Information on acute change/fluctuation not mandatory for delirium diagnosis; no special training required; includes MOTYB BCS (bedside confusion scale) Palliative patients ( n = 31) I: rater (no requirements) Screening Tool 2 items: psychomotor activity + MOTYB Score 0–5 Cut-off: ≥ 2 = suspected delirium 2 min 1.0 0.85 ...…”

“…Assessments like the UB-CAM or the delirium triage screen (DTS) address this limitation by combining a short screening with a focus on inattention, followed by a second assessment that includes collateral history [ 20 , 40 ]. The 4AT, that enjoys growing popularity, contains the item acute onset/fluctuating course but its presence is not mandatory for positive delirium screening [ 50 , 57 ].…”

Comparative salary‐related costs of a brief app‐directed delirium identification protocol by hospitalists, nurses, and nursing assistants

“…Finally, the patients in our study were not meant to be representative, but rather a purposefully challenged sample enriched for older age and dementia. Since patients with delirium and dementia take longer to assess, 16 the costs reported may represent an overestimate of hospital‐wide implementation, which would include younger, less impaired patients.…”

“…Our team developed and field tested the Ultra-brief CAM (UB-CAM), [15][16][17][18] a two-step delirium identification protocol that includes an ultra-brief 2-item screen (UB-2) paired with a validated diagnostic tool (3D-CAM). If hospitalized older adults answer both UB-2 questions correctly, the protocol ends and delirium is not present; otherwise, the 3D-CAM is administered.…”

Organinio Delyro Hipodiagnostika: Diagnostikos Perspektyvos Lietuvoje

“…CAM lengva naudoti, CAM skalė turi įvairių specifinių modifikacijų, leidžiančių šią priemonę taikyti skirtingose situacijose, pavyzdžiui, intensyviosios terapijos skyriuje ir kt. Vertintojai turi būti apmokyti naudotis CAM metodu [22]. Šis metodas validuotas ir išverstas į daugiau nei 20 kalbų.…”