Ethical Research in Delirium: Arguments for Including Decisionally Incapacitated Subjects

Adamis, Dimitrios; Treloar, Adrian; Martin, Finbarr C.; Macdonald, Alastair

doi:10.1007/s11948-009-9120-y

Cited by 19 publications

(47 citation statements)

References 12 publications

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“…Including only delirious subjects with capacity to consent can lead to selection bias with reduced generalisability of results. Such effects have been demonstrated in the Adamis et al sample, where exclusion from analysis of incapacitated participants showed that the significant association of IGF-I and delirium were no longer evident [125]. Thus, the informed consent process can be an important factor which has been underestimated in delirium studies and is an important source of bias.…”

Section: Methodological Critique Of the Studiesmentioning

confidence: 99%

Insulin-Like Growth Factor I and the Pathogenesis of Delirium: A Review of Current Evidence

Adamis

Meagher

2011

Journal of Aging Research

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Delirium is a frequent complication in medically ill elderly patients that is associated with serious adverse outcomes including increased mortality. Delirium risk is linked to older age, dementia, and illness that involves activation of inflammatory responses. IGF-I is increasingly postulated as a key link between environmental influences on body metabolism with a range of neuronal activities and has been described as the master regulator of the connection between brain and bodily well-being. The relationships between IGF-I and ageing, cognitive impairment and inflammatory illness further support a possible role in delirium pathogenesis. Five studies of IGF-I in delirium were identified by a systematic review. These conflicting findings, with three of the five studies indicating an association between IGF-1 and delirium occurrence, may relate to the considerable methodological differences in these studies. The relevance of IGF-I and related factors to delirium pathogenesis can be clarified by future studies which account for these issues and other confounding factors. Such work can inform therapeutic trials of IGF-I and/or growth hormone administration.

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Section: Methodological Critique Of the Studiesmentioning

confidence: 99%

Insulin-Like Growth Factor I and the Pathogenesis of Delirium: A Review of Current Evidence

Adamis

Meagher

2011

Journal of Aging Research

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“…Patients in agreement, but lacking capacity and with no available relatives, were entered in the study until they regained capacity or relatives were contactable. This was in accordance with previous research in delirium and the ethics committee approval …”

Section: Methodsmentioning

confidence: 99%

Evaluating attention in delirium: A comparison of bedside tests of attention

Adamis

Meagher

Murray

et al. 2015

Geriatrics Gerontology Int

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Aim: Impaired attention is a core diagnostic feature for delirium. The present study examined the discriminating properties for patients with delirium versus those with dementia and/or no neurocognitive disorder of four objective tests of attention: digit span, vigilance "A" test, serial 7s subtraction and months of the year backwards together with global clinical subjective rating of attention.Methods: This as a prospective study of older patients admitted consecutively in a general hospital. Participants were assessed using the Confusion Assessment Method, Delirium Rating Scale-98 Revised and Montreal Cognitive Assessment scales, and months of the year backwards. Pre-existing dementia was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders fourth edition criteria. Results:The sample consisted of 200 participants (mean age 81.1 ± 6.5 years; 50% women; pre-existing cognitive impairment in 126 [63%]). A total of 34 (17%) were identified with delirium (Confusion Assessment Method +). The five approaches to assessing attention had statistically significant correlations (P < 0.05). Discriminant analysis showed that clinical subjective rating of attention in conjunction with the months of the year backwards had the best discriminatory ability to identify Confusion Assessment Method-defined delirium, and to discriminate patients with delirium from those with dementia and/or normal cognition. Both of these approaches had high sensitivity, but modest specificity. Conclusion:Objective tests are useful for prediction of non-delirium, but lack specificity for a delirium diagnosis. Global attentional deficits were more indicative of delirium than deficits of specific domains of attention. Geriatr

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“…We used an informal capacity assessment to minimize such bias; however, it is possible that such selection or spectrum bias could falsely elevate PrEDICT specificity. 11,40 But other ethical approaches, including timing consent during lucid intervals, using plain language informed consent materials, and using proxies for consent when appropriate, could be considered. 12 Regardless, the PrEDICT application should be validated in a larger patient population prior to clinical use.…”

Section: Limitationsmentioning

confidence: 99%

Predictive Ability of a Serious Game to Identify Emergency Patients With Unrecognized Delirium

Lee

Tong

Tierney

et al. 2019

J American Geriatrics Society

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OBJECTIVES Recognition of delirium in the emergency department (ED) is poor. Our objectives were to assess: (1) the diagnostic accuracy of the Predicting Emergency department Delirium with an Interactive Computer Tablet (PrEDICT) “serious game” to identify older ED patients with delirium compared to clinical recognition and (2) the feasibility of the PrEDICT application compared to existing tests of attention. DESIGN Prospective observational study. SETTING ED of a Canadian tertiary care center. PARTICIPANTS We included ED patients, aged 70 years and older, with a minimum 4‐hour stay. We excluded anyone with critical illness, communication barriers, and visual impairment or those unable to use a computer tablet. None had prevalent delirium by ED clinicians' routine clinical assessment. MEASUREMENTS Participants were asked to tap targets on a tablet at four difficulty levels. Time and accuracy were automatically recorded. Other measures included the Confusion Assessment Method, the Delirium Severity Index, the Digit Vigilance Test (DVT), and the Choice Reaction Test (CRT). RESULTS We enrolled 203 patients. Their average age was 80.6 years, 49.8% were female, and their average ED length of stay was 15.9 hours. Sixteen subjects had clinically unrecognized delirium, and 14 of them completed the PrEDICT game (87.5%). We developed a threshold score with 100% sensitivity (95% confidence interval [CI] = 76.8%‐100.0%) and 59.7% specificity (95% CI = 52.3%‐66.6%) to identify patients with clinically unrecognized delirium. The area under the curve was 0.86 (95% CI = 0.77‐0.94). Completion rates were 196/203 (96.6%) for the PrEDICT serious game compared to 128/203 (63.1%) for the CRT and 51/203 (25.1%) for the DVT. CONCLUSION Older ED patients were able to use our serious game, including 87.5% of those with clinically unrecognized delirium. The PrEDICT application has potential to act as a sensitive screening tool to identify older ED patients with clinically unrecognized delirium. J Am Geriatr Soc 67:2370–2375, 2019

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Ethical Research in Delirium: Arguments for Including Decisionally Incapacitated Subjects

Cited by 19 publications

References 12 publications

Insulin-Like Growth Factor I and the Pathogenesis of Delirium: A Review of Current Evidence

Insulin-Like Growth Factor I and the Pathogenesis of Delirium: A Review of Current Evidence

Evaluating attention in delirium: A comparison of bedside tests of attention

Predictive Ability of a Serious Game to Identify Emergency Patients With Unrecognized Delirium

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