Serial administration of a modified richmond agitation and sedation scale for delirium screening

Chester, Jennifer G.; Harrington, Mary; Rudolph, James L.

doi:10.1002/jhm.1003

Cited by 138 publications

(124 citation statements)

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“…In 95 older medical inpatients, Chester et al observed that a mRASS other than 0 was 64% sensitive and 93% specific for delirium. 8 A mRASS > +1 or < −1 was 34% sensitive and 100% specific for delirium. 8 They reported a weighted kappa of 0.48.…”

Section: Discussionmentioning

confidence: 92%

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The Diagnostic Performance of the Richmond Agitation Sedation Scale for Detecting Delirium in Older Emergency Department Patients

et al. 2015

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Objectives Delirium is frequently missed in older emergency department (ED) patients. Brief (<2 minutes) delirium assessments have been validated for the ED, but some ED health care providers may consider them to be cumbersome. The Richmond Agitation Sedation Scale (RASS) is an observational scale that quantifies level of consciousness and takes less than 10 seconds to perform. The authors sought to explore the diagnostic accuracy of the RASS for delirium in older ED patients. Methods This was a preplanned analysis of a prospective observational study designed to validate brief delirium assessments for the ED. The study was conducted at an academic ED and enrolled patients who were 65 years or older. Patients who were non-English speaking, deaf, blind, comatose, or had end-stage dementia were excluded. A research assistant (RA) and a physician performed the RASS at the time of enrollment. Within 3 hours, a consultation-liaison psychiatrist performed his or her comprehensive reference standard assessment for delirium using Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision (DSM-IV-TR) criteria. Sensitivities, specificities, and likelihood ratios with their 95% confidence intervals (CIs) were calculated. Results Of 406 enrolled patients, 50 (12.3%) had delirium diagnosed by the consult-liaison psychiatrist reference rater. When performed by the RA, a RASS other than 0 (RASS > 0 or < 0) was 84.0% sensitive (95% CI = 73.8% to 94.2%), and 87.6% specific (95% CI = 84.2% to 91.1%) for delirium. When performed by physician, a RASS other than 0 was 82.0% sensitive (95% CI = 71.4% to 92.6%) and 85.1% specific (95% CI = 81.4% to 88.8%) for delirium. Using a RASS > +1 or < −1 as the cut-off, the specificity improved to approximately 99% for both raters at the expense of sensitivity; the sensitivities were 22.0% (95% CI = 10.5% to 33.5%) and 16.0% (95% CI = 5.8% to 25.2%) in the RAs and physician raters, respectively. The positive likelihood ratio was 19.6 (95% CI = 6.5 to 59.1) when performed by the RA, and 57.0 (95% CI = 7.3 to 445.9) when performed by the physician, indicating that a RASS > +1 or < −1 strongly increased the likelihood of delirium. The weighted kappa was 0.63, indicating moderate interobserver reliability. Conclusions In older ED patients, a RASS other than 0 has very good sensitivity and specificity for delirium as diagnosed by a psychiatrist. A RASS > +1 or < −1 is nearly diagnostic for delirium given the very high positive likelihood ratio.

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Section: Discussionmentioning

confidence: 92%

“…Previous studies have evaluated the RASS in hospitalized medical and hip fracture patients, but have limited generalizability to the older ED patient population, who include both admitted and discharged patients. 8,9 The purpose of this study was to determine the diagnostic accuracy of the RASS for delirium in older ED patients.…”

Section: Introductionmentioning

confidence: 99%

The Diagnostic Performance of the Richmond Agitation Sedation Scale for Detecting Delirium in Older Emergency Department Patients

et al. 2015

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“…The Modified Richmond Agitation and Sedation Scale (mRASS), which measures arousal, sedation and level of consciousness, has been advocated as a screening tool for delirium. However, the mRASS has a low sensitivity of 64% to70%, 42, 43 and the usefulness of the scale depends on the prevalence of decreased mental status in the population. In settings with high prevalence of sedation and depressed sensorium, such as the postoperative recovery room and ICU, this approach may be valuable; however, routine use of the mRASS is not recommended outside of these settings, since many cases of delirium will be missed.…”

Section: Resultsmentioning

confidence: 99%

Delirium in Older Persons

Fong

Hshieh

et al. 2017

JAMA

691

306

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Importance-Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual's function and quality of life, as well as broad societal effect with substantial health care costs.Objective-To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field.Evidence Review-We searched Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011 until March 16, 2017 using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded.Findings-Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment, 4 A's test, and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method-Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of

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“…The m-RASS has a sensitivity of 64% and a specificity of 93% for delirium. 1 However, its greatest value lies in its ability to monitor patients over time and identify changes; serial m-RASS measurements used to detect changes have a sensitivity of 85% and a specificity of 92% for incident delirium.…”

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confidence: 99%

Improving Delirium Care

Kostas

Zimmerman

Rudolph

2013

The Neurohospitalist

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Delirium is an acute change in awareness and attention and is common, morbid, and costly for patients and health care systems. While hyperactive delirium is easily identifiable, the hypoactive form is more common and carries a higher mortality. Hospital systems to address delirium should consist of 3 critical steps. First, hospitals must identify patients who develop or are at intermediate or high risk for delirium. Delirium risk may be assessed using known patient-based and illness-based risk factors, including preexisting cognitive impairment. Delirium diagnosis remains a clinical diagnosis that requires a clinical assessment that can be structured using diagnostic criteria. Hospital systems may be useful to efficiently allocate delirium resources to prevent and manage delirium. Second, it is crucial to develop a systematic approach to prevent delirium using multimodal nonpharmacologic delirium prevention methods and to monitor all high-risk patients for its occurrence. Tools such as the modified Richmond Agitation and Sedation Scale can aid in monitoring for changes in mental status that could indicate the development of delirium. Third, hospital systems can utilize established methods to assess and manage delirium in a standardized fashion. The key lies in addressing the underlying cause/causes of delirium, which often involve medical conditions or medications. With a sustained commitment, standardized efforts to identify and prevent delirium can mitigate the long-term morbidity associated with this acute change. In the face of changes in health care funding, delirium serves as an example of a syndrome where care coordination can improve short-term and long-term costs.

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Serial administration of a modified richmond agitation and sedation scale for delirium screening

Cited by 138 publications

References 13 publications

The Diagnostic Performance of the Richmond Agitation Sedation Scale for Detecting Delirium in Older Emergency Department Patients

The Diagnostic Performance of the Richmond Agitation Sedation Scale for Detecting Delirium in Older Emergency Department Patients

Delirium in Older Persons

Improving Delirium Care

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