The diagnosis of delirium among elderly patients presenting to the emergency department of an acute hospital

Press, Yan; Margulin, Tzila; Grinshpun, Yakov; Kagan, Ella; Snir, Yoram; Berzak, Alex; Clarfield, A. Mark

doi:10.1016/j.archger.2008.01.008

Cited by 37 publications

(31 citation statements)

References 21 publications

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“…In most EDs, delirium is not routinely screened for [9]. However, it is a form of organ failure (acute brain failure) and thus an important sign of severe illness [10].…”

Section: Introductionmentioning

confidence: 99%

Improved detection of delirium, implementation and validation of the CAM-ICU in elderly Emergency Department patients

Meeberg¹,

Festen

Kwant³

et al. 2017

European Journal of Emergency Medicine

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“…In most EDs, delirium is not routinely screened for [9]. However, it is a form of organ failure (acute brain failure) and thus an important sign of severe illness [10].…”

Section: Introductionmentioning

confidence: 99%

Improved detection of delirium, implementation and validation of the CAM-ICU in elderly Emergency Department patients

Meeberg¹,

Festen

Kwant³

et al. 2017

European Journal of Emergency Medicine

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“…Most healthcare professionals do not screen for delirium in their clinical practice, 13, 20 because there is a dearth of brief and easy to use assessments. Many existing assessments take more than 5 minutes to complete and may not be feasible to perform in busy clinical environments.…”

Section: Introductionmentioning

confidence: 99%

Diagnosing Delirium in Older Emergency Department Patients: Validity and Reliability of the Delirium Triage Screen and the Brief Confusion Assessment Method

Han

Wilson

Vasilevskis

et al. 2013

Annals of Emergency Medicine

265

261

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Background Delirium is a common form of acute brain dysfunction with prognostic significance. Health care professionals caring for older emergency department (ED) patients miss delirium approximately 75% of cases. This error results from a lack of available measures that can be performed rapidly enough to be incorporated into clinical practice. Therefore, we developed and evaluated a novel two-step approach to delirium surveillance for the ED. Methods This prospective observational study was conducted at an academic ED in patients ≥ 65 years old. A research assistant (RA) and physician performed the Delirium Triage Screen (DTS), designed to be a highly sensitive rule-out test, and the Brief Confusion Assessment Method (bCAM), designed to be a highly specific rule-in test for delirium. The reference standard for delirium was a comprehensive psychiatrist assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria. All assessments were independently conducted within 3 hours of each other. Sensitivities, specificities, and likelihood ratios with their 95% confidence intervals (95%CI) were calculated. Results Of 406 enrolled patients, 50 (12.3%) had delirium diagnosed by the psychiatrist reference standard. The DTS was 98.0% (95%CI: 89.5% – 99.5%) sensitive with an expected specificity of approximately 55% for both raters. The DTS’ negative likelihood ratio was 0.04 (95%CI: 0.01 – 0.25) in both raters. As the complement, the bCAM had a specificity of 95.8% (95%CI: 93.2% – 97.4%) and 96.9% (95%CI: 94.6% – 98.3%) and a sensitivity of 84.0% (95%CI: 71.5% – 91.7%) and 78.0% (95%CI: 64.8% – 87.2%) when performed by the physician and RA, respectively. The positive likelihood ratios for the bCAM were 19.9 (95%CI: 12.0 – 33.2) and 25.2 (95%CI: 13.9 – 46.0), respectively. If the RA DTS was followed by the physician bCAM, the sensitivity of this combination was 84.0% (95%CI: 71.5% – 91.7%) and the specificity was 95.8% (95%CI: 93.2% – 97.4%). If the RA performed both the DTS and bCAM, this combination was 78.0% (95%CI: 64.8% – 87.2%) sensitive and 97.2% (95%CI: 94.9% – 98.5%) specific. If the physician performed both the DTS and bCAM, this combination was 82.0% (95%CI: 69.2% – 90.2%) sensitive and 95.8% (95CI: 93.2% – 97.4%) specific. Conclusions In older ED patients, this two-step approach (highly sensitive DTS followed by highly specific bCAM) may enable healthcare professionals, regardless of clinical background, to efficiently screen for delirium. Larger, multi-centered trials are needed to confirm these findings and to determine the impact of these assessments on delirium recognition in the ED.

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“…Patient-related risk factors such as hypoactive delirium have been identified [12]. Further, mental status screening tools are complex, they are rarely used, and staff is inadequately trained in applying them [13,14]. Environmental factors such as ED crowding, rapid workflow, and high decision density may also contribute.…”

Section: Introductionmentioning

confidence: 99%

Screening, detection and management of delirium in the emergency department – a pilot study on the feasibility of a new algorithm for use in older emergency department patients: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED)

Grossmann

Hasemann

Graber

et al. 2014

Scand J Trauma Resusc Emerg Med

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BackgroundDelirium in emergency department (ED) patients occurs frequently and often remains unrecognized. Most instruments for delirium detection are complex and therefore unfeasible for the ED. The aims of this pilot study were first, to confirm our hypothesis that there is an unmet need for formal delirium assessment by comparing informal delirium ratings of ED staff with formal delirium assessments performed by trained research assistants. Second, to test the feasibility of an algorithm for delirium screening, detection and management, which includes the newly developed modified Confusion Assessment Method for the Emergency Department (mCAM-ED) at the ED bedside. Third, to test interrater reliability of the mCAM-ED.MethodsThis was a pilot study with a pre-post-test design with two data collection periods before and after the implementation of the algorithm. Consecutive ED patients aged 65 years and older were screened and assessed in the ED of a tertiary care center by trained research assistants. The delirium detection rate of informal ratings by nurses and physicians was compared with the standardized mCAM-ED assessment performed by the research assistants. To show the feasibility at the ED bedside, defined as adherence of ED staff to the algorithm, only post-test data were used. Additionally, the ED nurses’ assessments were analyzed qualitatively. To investigate the agreement between research assistants and the reference standard, the two data sets were combined.ResultsIn total, 207 patients were included in this study. We found that informal delirium assessment was inappropriate, even after a teaching intervention: Sensitivity of nurses to detect delirium without formal assessment was 0.27 pretest and 0.40 post-test, whilst sensitivity of physicians’ informal rating was 0.45 pre-test and 0.6 post-test. ED staff demonstrated high adherence to the algorithm (76.5%). Research assistants assessing delirium with the mCAM-ED demonstrated a high agreement compared to the reference standard (kappa = 0.729).ConclusionsInformal assessment of delirium is inadequate. The mCAM-ED proved to be useful at the ED bedside. Performance criteria need to be tested in further studies. The mCAM-ED may contribute to early identification of delirious ED patients.

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The diagnosis of delirium among elderly patients presenting to the emergency department of an acute hospital

Cited by 37 publications

References 21 publications

Improved detection of delirium, implementation and validation of the CAM-ICU in elderly Emergency Department patients

Improved detection of delirium, implementation and validation of the CAM-ICU in elderly Emergency Department patients

Diagnosing Delirium in Older Emergency Department Patients: Validity and Reliability of the Delirium Triage Screen and the Brief Confusion Assessment Method

Screening, detection and management of delirium in the emergency department – a pilot study on the feasibility of a new algorithm for use in older emergency department patients: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED)

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