Delirium screening tools in the post-anaesthetic care unit: a systematic review and meta-analysis

Aldwikat, Rami Kamel; Manias, Elizabeth; Tomlinson, Emily; Amin, Mohammed; Nicholson, Patricia

doi:10.1007/s40520-021-02057-w

Cited by 10 publications

(10 citation statements)

References 28 publications

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“…The 3D-CAM has the highest reported specificity and sensitivity for detecting delirium; therefore, we used this metric as the primary outcome measure to which we compared other delirium assessments ( Jones et al, 2019 ; Motyl et al, 2020 ; Aldwikat et al, 2022 ). The mean time to delirium assessment was 26 min after arrival in PACU.…”

Section: Resultsmentioning

confidence: 99%

“…An adequate level of arousal is a perquisite to cognitive assessment, however, there is no consensus regarding a clear definition of the same for the PACU patient. Studies vary widely in their time (30 min after extubating or just prior to discharge from PACU) and method of assessment (RASS, Rikers Sedation Score, Aldrete Score; Lepousé et al, 2006 ; Radtke et al, 2008 ; Neufeld et al, 2013a ; Card et al, 2015 ; Aldwikat et al, 2022 ). Our results and observations suggest that a minimum RASS score of −1 and above could be considered an adequate level of arousal since it is sufficient to assess the most complex tasks like attention.…”

Section: Discussionmentioning

confidence: 99%

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Deconstructing delirium in the post anaesthesia care unit

Banerji

Sleigh

Voss

et al. 2022

Front. Aging Neurosci.

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The course of neuro-cognitive recovery following anaesthesia and surgery is distinctive and poorly understood. Our objective was to identify patterns of neuro-cognitive recovery of the domains routinely assessed for delirium diagnosis in the post anaesthesia care unit (PACU) and to compare them to the cognitive recovery patterns observed in other studies; thereby aiding in the identification of pathological (high risk) patterns of recovery in the PACU. We also compared which of the currently available tests (3D-CAM, CAM-ICU, and NuDESC) is the best to use in PACU. This was a post hoc secondary analysis of data from the Alpha Max study which involved 200 patients aged over 60 years, scheduled for elective surgery under general anaesthesia lasting more than 2 h. These patients were assessed for delirium at 30 min following arrival in the PACU, if they were adequately arousable (Richmond Agitation Sedation Score ≥ −2). All tests for delirium diagnosis (3D-CAM, CAM-ICU, and NuDESC) and the sub-domains assessed were compared to understand temporal recovery of neurocognitive domains. These data were also analysed to determine the best predictor of PACU delirium. We found the incidence of PACU delirium was 35% (3D-CAM). Individual cognitive domains were affected differently. Few individuals had vigilance deficits (6.5%, n = 10 CAM-ICU) or disorganized thinking (19% CAM-ICU, 27.5% 3D-CAM), in contrast attention deficits were common (72%, n = 144) and most of these patients (89.5%, n = 129) were not sedated (RASS ≥ −2). CAM-ICU (27%) and NuDESC (52.8%) detected fewer cases of PACU delirium compared to 3D-CAM. In conclusion, return of neurocognitive function is a stepwise process; Vigilance and Disorganized Thinking are the earliest cognitive functions to return to baseline and lingering deficits in these domains could indicate an abnormal cognitive recovery. Attention deficits are relatively common at 30 min in the PACU even in individuals who appear to be awake. The 3D CAM is a robust test to check for delirium in the PACU.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Deconstructing delirium in the post anaesthesia care unit

Banerji

Sleigh

Voss

et al. 2022

Front. Aging Neurosci.

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“…These scores were shown to have the greatest validity and reliability in a recent review of delirium screening methods for postoperative patients. 34 …”

Section: Cohort Descriptionmentioning

confidence: 99%

“…In addition to the DeltaScan measurement, the 4AT and the Confusion Assessment Method (CAM or CAM-intensive care unit (ICU) when the patient is admitted to the ICU) are recorded by the research staff to assess presence of clinically apparent delirium. These scores were shown to have the greatest validity and reliability in a recent review of delirium screening methods for postoperative patients 34…”

Section: Cohort Descriptionmentioning

confidence: 99%

Cohort profile of PLUTO: a perioperative biobank focusing on prediction and early diagnosis of postoperative complications

et al. 2023

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PurposeAlthough elective surgery is generally safe, some procedures remain associated with an increased risk of complications. Improved preoperative risk stratification and earlier recognition of these complications may ameliorate postoperative recovery and improve long-term outcomes. The perioperative longitudinal study of complications and long-term outcomes (PLUTO) cohort aims to establish a comprehensive biorepository that will facilitate research in this field. In this profile paper, we will discuss its design rationale and opportunities for future studies.ParticipantsPatients undergoing elective intermediate to high-risk non-cardiac surgery are eligible for enrolment. For the first seven postoperative days, participants are subjected to daily bedside visits by dedicated observers, who adjudicate clinical events and perform non-invasive physiological measurements (including handheld spirometry and single-channel electroencephalography). Blood samples and microbiome specimens are collected at preselected time points. Primary study outcomes are the postoperative occurrence of nosocomial infections, major adverse cardiac events, pulmonary complications, acute kidney injury and delirium/acute encephalopathy. Secondary outcomes include mortality and quality of life, as well as the long-term occurrence of psychopathology, cognitive dysfunction and chronic pain.Findings to dateEnrolment of the first participant occurred early 2020. During the inception phase of the project (first 2 years), 431 patients were eligible of whom 297 patients consented to participate (69%). Observed event rate was 42% overall, with the most frequent complication being infection.Future plansThe main purpose of the PLUTO biorepository is to provide a framework for research in the field of perioperative medicine and anaesthesiology, by storing high-quality clinical data and biomaterials for future studies. In addition, PLUTO aims to establish a logistical platform for conducting embedded clinical trials.Trial registration numberNCT05331118.

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“…There is a limited number of studies examining validated screening tools for delirium detection in the PACU. A recent systematic review examining diagnostic accuracy of screening tools found two tools (3D-CAM and 4AT) demonstrated high sensitivity and specificity values as potential suitable tools to detect delirium in this clinical setting [ 15 ]. However, those two tools were only examined among patients who underwent elective surgical procedures, excluding patients with cognitive impairment, dementia, and neurological disorders, making the sample less-representative of general surgical populations [ 7 , 16 ].…”

Section: Introductionmentioning

confidence: 99%

Validation of Two Screening Tools for Detecting Delirium in Older Patients in the Post-Anaesthetic Care Unit: A Diagnostic Test Accuracy Study

Aldwikat

Manias

Holmes

et al. 2022

IJERPH

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(1) Background: Delirium is a common complication among surgical patients after major surgery, but it is often underdiagnosed in the post-anaesthetic care unit (PACU). Valid and reliable tools are required for improving diagnoses of delirium. The objective of this study was to evaluate the diagnostic test accuracy of the Three-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM) and the 4A’s Test (4AT) as screening tools for detection of delirium in older people in the PACU. (2) Methods: A prospective diagnostic test accuracy study was conducted in the PACU and surgical wards of a university-affiliated tertiary care hospital in Victoria, Australia. A consecutive prospective cohort of elective and emergency patients (aged 65 years or older) admitted to the PACU were recruited between July 2021 and December 2021 following a surgical procedure performed under general anaesthesia and expected to stay in the hospital for at least 24 h following surgery. The outcome measures were sensitivity, specificity positive predictive value and negative predictive value for 3D-CAM and 4AT. (3) Results: A total of 271 patients were recruited: 16.2% (44/271) had definite delirium. For a diagnosis of definite delirium, the 3D-CAM (area under curve (AUC) = 0.96) had a sensitivity of 100% (95% CI 92.0 to 100.0) in the PACU and during the first 5 days post-operatively. Specificity ranged from 93% (95% CI 87.8 to 95.2) to 91% (95% CI 85.9 to 95.2) in the PACU and during the first 5 days post-operatively. The 4AT (AUC = 0.92) had a sensitivity of 93% (95% CI 81.7 to 98.6) in the PACU and during the first 5 days post-operatively, and specificity ranged from 89% (95% CI 84.6 to 93.1) to 87% (95%CI 80.9 to 91.8) in the PACU and during the first 5 days post-operatively. (4) Conclusions: The 3D-CAM and the 4AT are sensitive and specific screening tools that can be used to detect delirium in older people in the PACU. Screening with either tool could have an important clinical impact by improving the accuracy of delirium detection in the PACU and hence preventing adverse outcomes associated with delirium.

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Delirium screening tools in the post-anaesthetic care unit: a systematic review and meta-analysis

Cited by 10 publications

References 28 publications

Deconstructing delirium in the post anaesthesia care unit

Deconstructing delirium in the post anaesthesia care unit

Cohort profile of PLUTO: a perioperative biobank focusing on prediction and early diagnosis of postoperative complications

Validation of Two Screening Tools for Detecting Delirium in Older Patients in the Post-Anaesthetic Care Unit: A Diagnostic Test Accuracy Study

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