Under-detection of delirium and impact of neurocognitive deficits on in-hospital mortality among acute geriatric and medical wards

Bellelli, Giuseppe; Nobili, Alessandro; Annoni, Giorgio; Morandi, Alessandro; Djade, Codjo D.; Meagher, David; MacLullich, Alasdair M.J.; Davis, Daniel; Mazzone, Andrea; Tettamanti, Mauro; Mannucci, Pier Mannuccio

doi:10.1016/j.ejim.2015.08.006

Cited by 71 publications

(61 citation statements)

References 38 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…A definite increase in therapeutic duplicates of psychotropic drugs and drugs for peptic ulcer is also observed at hospital discharge, although duplication increases the risk of adverse drug events and costs [28]. Drugs with anticholinergic effects are associated with cognitive and functional impairment [29], and the recognition and management of delirium were rather inadequate in the internal medicine wards participating in the register [30]. Importantly, we recently observe that the 27 wards that had regularly participated in the different runs of REPOSI from its onset did improve the rate of polypharmacy compared with the 2010 run.…”

Section: Main Reposi Findingsmentioning

confidence: 99%

Polypharmacy in older people: lessons from 10 years of experience with the REPOSI register

2018

View full text Add to dashboard Cite

As a consequence of population aging, we have witnessed in internal medicine hospital wards a progressive shift from a population of in-patients relatively young and mainly affected by a single ailment to one of ever older and more and more complex patients with multiple chronic diseases, followed as out-patients by many different specialists with poor integration and inevitably treated with multiple medications. Polypharmacy (defined as the chronic intake of five or more drugs) is associated with increased risks of drug-drug interactions and related adverse effects, prescription and intake errors, poor compliance, re-hospitalization and mortality. With this background, the Italian Society of Internal Medicine chose to start in 2008 a prospective register called REPOSI (REgistro POliterapie SIMI, Società Italiana di Medicina Interna) in internal medicine and geriatric hospital wards. The country wide register is an ongoing observatory on multimorbidity and polypharmacy in the oldest old, with the goal to improve prescription appropriateness and, thus to avoid potentially inappropriate medications. The main findings of the register, that has accrued so far, 7005 older patients throughout a 10 year period, are summarized herewith, with special emphasis on the main patterns of poor prescription appropriateness and related risks of adverse events.

show abstract

Section: Main Reposi Findingsmentioning

confidence: 99%

Polypharmacy in older people: lessons from 10 years of experience with the REPOSI register

2018

View full text Add to dashboard Cite

show abstract

“…Although the severe impacts of delirium are becoming clear, 8,10,15,65,66 it has been amply documented that delirium remains substantially underdetected both in general settings and in the intensive care unit (ICU). 7,16,[31][32][33][67][68][69][70][71][72] There are many possible reasons for this, which surveys on practice and knowledge among professionals have helped to shed some light on. 34,36, The surveys vary considerably in the mix of professionals studied, the focus of the questions, the health-care setting, and so on.…”

Section: General Introductionmentioning

confidence: 99%

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

MacLullich

Shenkin

Goodacre

et al. 2019

Health Technol Assess

105

View full text Add to dashboard Cite

Background Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 ‘A’s test (Arousal, Attention, Abbreviated Mental Test – 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. Methods Phase 1 – the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 – the 4AT’s diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. Results Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0–14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0–6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. Limitations Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. Conclusions These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. Future work Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. Trial registration Current Controlled Trials ISRCTN53388093. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.

show abstract

“…Prevention of delirium represents the ideal, but, at best, a third of incident hospital delirium can be prevented, and prevalent delirium is an equal or greater problem. Clinical recognition of delirium remains poor (Kales et al, 2003;Saczynski et al, 2014;Bellelli et al, 2015). Brief screening tools help (Inouye, 2003;Bellelli et al, 2014), but depend on adequate training of staff who use them, and are inconsistently applied.…”

Section: Is There a Problem?mentioning

confidence: 99%

Where next for delirium research?

Harwood

Teale

2017

Int J Geriat Psychiatry

View full text Add to dashboard Cite

Clinicians who manage delirium must do so without key information required for evidence-based practice, not least lack of any clearly effective treatment for established delirium. Both the nature of delirium and the methods used to research it contribute to difficulties. Delirium is heterogeneous, with respect to motor subtype, aetiology, setting and the co-existence of dementia, and may be almost inevitable towards the end of life. Elements of assessment are subjective, so diagnosis can be uncertain or unreliable. Defining objectives of care and outcomes is sometimes unclear. Better identification and case definition, including seeking biomarkers, stratification by type, or aetiology, and application of more complex models of causation may help. This will likely require further observational epidemiology, imaging and laboratory-based research before further rounds of large-scale randomised controlled trials. Application of trial methodologies designed for drug treatments of better-defined conditions may have failed to take account of the complexities both of diagnosis and complex intervention in delirium. Both drug and complex intervention trials need sufficient preliminary work to ensure that the right dose, duration or intensity of treatment is delivered and a range of 'intermediate' and 'distal' outcome measures assessed. Re-purposing of established drugs may provide a source of investigational products. Greater use of alternative research methodologies (qualitative and realist), or adjuvants to trials (process evaluation), will help answer questions about focus, generalisability and why interventions succeed or fail. Delirium research will have to embrace both a 'back to basics' approach with increased breadth of methodologies to make progress.

show abstract

Under-detection of delirium and impact of neurocognitive deficits on in-hospital mortality among acute geriatric and medical wards

Cited by 71 publications

References 38 publications

Polypharmacy in older people: lessons from 10 years of experience with the REPOSI register

Polypharmacy in older people: lessons from 10 years of experience with the REPOSI register

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

Where next for delirium research?

Contact Info

Product

Resources

About