Delirium is common, leads to other adverse outcomes, and is costly. However, it often remains unrecognized in most clinical settings. The Confusion Assessment Method (CAM) is the most widely used ...diagnostic algorithm, and operationalizing its features would be a substantial advance for clinical care.
To derive the 3D-CAM, a new 3-minute diagnostic assessment for CAM-defined delirium, and validate it against a clinical reference standard.
Derivation and validation study.
4 general medicine units in an academic medical center.
201 inpatients aged 75 years or older.
20 items that best operationalized the 4 CAM diagnostic features were identified to create the 3D-CAM. For prospective validation, 3D-CAM assessments were administered by trained research assistants. Clinicians independently did an extensive assessment, including patient and family interviews and medical record reviews. These data were considered by an expert panel to determine the presence or absence of delirium and dementia (reference standard). The 3D-CAM delirium diagnosis was compared with the reference standard in all patients and subgroups with and without dementia.
The 201 participants in the prospective validation study had a mean age of 84 years, and 28% had dementia. The expert panel identified 21% with delirium, 88% of whom had hypoactive or normal psychomotor features. Median administration time for the 3D-CAM was 3 minutes (interquartile range, 2 to 5 minutes), sensitivity was 95% (95% CI, 84% to 99%), and specificity was 94% (CI, 90% to 97%). The 3D-CAM did well in patients with dementia (sensitivity, 96% CI, 82% to 100%; specificity, 86% CI, 67% to 96%) and without dementia (sensitivity, 93% CI, 66% to 100%; specificity, 96% CI, 91% to 99%).
Limited to single-center, cross-sectional, and medical patients only.
The 3D-CAM operationalizes the CAM algorithm using a 3-minute structured assessment with high sensitivity and specificity relative to a reference standard and could be an important tool for improving recognition of delirium.
National Institute on Aging.
Abstract Background Delirium is a common, morbid, and costly postoperative complication. We aimed to identify blood-based postoperative delirium markers in a nested case-control study of older ...surgical patients using a proteomics approach followed by enzyme-linked immunosorbent assay (ELISA) validation. Methods The Successful Aging after Elective Surgery study enrolled dementia-free adults ≥70 years old undergoing major scheduled noncardiac surgery ( N = 566; 24% delirium). Plasma was collected at four time points: preoperative, postanesthesia care unit, postoperative day 2, and 1 month postoperative. Matched pairs were selected for the independent discovery (39 pairs) and replication cohorts (36 pairs), which were subsequently combined into the pooled cohort (75 pairs). Isobaric tags for relative and absolute quantitation–based relative quantitation mass spectrometry proteomics were performed to identify the strongest delirium-related protein, which was selected for ELISA validation. Using the ELISA results, statistical analyses using nonparametric signed rank tests were performed in all cohorts examining the association between the identified protein and delirium. Results C-reactive protein emerged from the proteomics analysis as the strongest delirium-related protein. Validation by ELISA confirmed that compared with controls, cases had significantly higher C-reactive protein levels in the discovery, replication, and pooled cohorts at the preoperative (median paired difference MPD 1.97 mg/L p < .05, 0.29 mg/L, 1.56 mg/L p < .01), postanesthesia care unit (MPD 2.83 mg/L, 2.22 mg/L p < .05, 2.53 mg/L p < .01) and postoperative day 2 (MPD 71.97 mg/L p < .01, 35.18 mg/L p < .05, 63.76 mg/L p < .01) time points, but not 1 month postoperative (MPD 2.72 mg/L, −0.66 mg/L, 1.10 mg/L). Conclusions Elevated preoperative and postoperative plasma levels of C-reactive protein were associated with delirium, suggesting that a preinflammatory state and heightened inflammatory response to surgery are potential pathophysiologic mechanisms of delirium.
Review of video recorded sessions is a powerful teaching tool in medical education, helping students appreciate both spoken and unspoken communications not fully appreciated in the moment. For many ...years, the American Balint Society has used video review in its Leadership Training Intensive courses, however technical challenges around setting up and operating the equipment have led some faculty to question whether the benefits are worth the effort and anxiety. We describe here an approach to video review in Intensives with a focus on the case presentation. Close attention to the case presentation can uncover important clues about a presenter’s feelings and conflicts in a case, clues that may easily be missed on first pass. The Balint group leader listens for clues and cues to the patient’s state of mind, and how the clinician is being distracted or deflected from their authentic role. Focusing the video review at an Intensive on the case presentation highlights for novice leaders the importance of maintaining keen focus on this initial section of the Balint group process for information on “what this case is about.” Finally, we predict that Balint group leaders who emerge from an Intensive with this new appreciation for close listening to the presentation will not only be more effective Balint group leaders but will also be in a better position to serve as clinical role models, teaching by example to their Balint group members the importance of attending closely to the patient’s communications in the patient – clinician encounter.
BACKGROUND/OBJECTIVES
Delirium manifests clinically in varying ways across settings. More than 40 instruments currently exist for characterizing the different manifestations of delirium. We evaluated ...all delirium identification instruments according to their psychometric properties and frequency of citation in published research.
DESIGN
We conducted the systematic review by searching Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Excerpta Medica Database (Embase), PsycINFO, PubMed, and Web of Science from January 1, 1974, to January 31, 2020, with the keywords “delirium” and “instruments,” along with their known synonyms. We selected only systematic reviews, meta‐analyses, or narrative literature reviews including multiple delirium identification instruments.
MEASUREMENTS
Two reviewers assessed the eligibility of articles and extracted data on all potential delirium identification instruments. Using the original publication on each instrument, the psychometric properties were examined using the Consensus‐based Standards for the Selection of Health Measurement Instruments (COSMIN) framework.
RESULTS
Of 2,542 articles identified, 75 met eligibility criteria, yielding 30 different delirium identification instruments. A count of citations was determined using Scopus for the original publication for each instrument. Each instrument underwent methodological quality review of psychometric properties using COSMIN definitions. An expert panel categorized key domains for delirium identification based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM)‐III through DSM‐5. Four instruments were notable for having at least two of three of the following: citation count of 200 or more, strong validation methodology in their original publication, and fulfillment of DSM‐5 criteria. These were, alphabetically, Confusion Assessment Method, Delirium Observation Screening Scale, Delirium Rating Scale‐Revised‐98, and Memorial Delirium Assessment Scale.
CONCLUSION
Four commonly used and well‐validated instruments can be recommended for clinical and research use. An important area for future investigation is to harmonize these measures to compare and combine studies on delirium.
Objectives
To examine associations between the inflammatory marker C‐reactive protein (CRP) measured preoperatively and on postoperative day 2 (POD2) and delirium incidence, duration, and feature ...severity.
Design
Prospective cohort study.
Setting
Two academic medical centers.
Participants
Adults aged 70 and older undergoing major noncardiac surgery (N = 560).
Measurements
Plasma CRP was measured using enzyme‐linked immunosorbent assay. Delirium was assessed from Confusion Assessment Method (CAM) interviews and chart review. Delirium duration was measured according to number of hospital days with delirium. Delirium feature severity was defined as the sum of CAM‐Severity (CAM‐S) scores on all postoperative hospital days. Generalized linear models were used to examine independent associations between CRP (preoperatively and POD2 separately) and delirium incidence, duration, and feature severity; prolonged hospital length of stay (LOS, >5 days); and discharge disposition.
Results
Postoperative delirium occurred in 24% of participants, 12% had 2 or more delirium days, and the mean ± standard deviation sum CAM‐S was 9.3 ± 11.4. After adjusting for age, sex, surgery type, anesthesia route, medical comorbidities, and postoperative infectious complications, participants with preoperative CRP of 3 mg/L or greater had a risk of delirium that was 1.5 times as great (95% confidence interval (CI) = 1.1–2.1) as that of those with CRP less than 3 mg/L, 0.4 more delirium days (P < .001), more‐severe delirium (3.6 CAM‐S points higher, P < .001), and a risk of prolonged LOS that was 1.4 times as great (95% CI = 1.1–1.8). Using POD2 CRP, participants in the highest quartile (≥235.73 mg/L) were 1.5 times as likely to develop delirium (95% CI = 1.0–2.4) as those in the lowest quartile (≤127.53 mg/L), had 0.2 more delirium days (P < .05), and had more severe delirium (4.5 CAM‐S points higher, P < .001).
Conclusion
High preoperative and POD2 CRP were independently associated with delirium incidence, duration, and feature severity. CRP may be useful to identify individuals who are at risk of developing delirium.
Objectives To document the extent and appropriateness of use of antipsychotics and benzodiazepines among nursing home residents using a nationally representative survey. Methods Cross-sectional ...analysis of the 2004 National Nursing Home Survey. Bivariate and multivariate analyses examined relationships between resident and facility characteristics and antipsychotic and benzodiazepine use by appropriateness classification among residents aged 60 years and older (N = 12,090). Resident diagnoses and information about behavioral problems were used to categorize antipsychotic and benzodiazepine use as appropriate, potentially appropriate, or having no appropriate indication. Results More than one quarter (26%) of nursing home residents used an antipsychotic medication, 40% of whom had no appropriate indication for such use. Among the 13% of residents who took benzodiazepines, 42% had no appropriate indication. In adjusted analyses, the odds of residents taking an antipsychotic without an appropriate indication were highest for residents with diagnoses of depression (odds ratio OR = 1.31; 95% confidence interval CI: 1.12–1.53), dementia (OR = 1.82; 95% CI: 1.52–2.18), and with behavioral symptoms (OR = 1.97, 95% CI: 1.56–2.50). The odds of potentially inappropriate antipsychotic use increased as the percentage of Medicaid residents in a facility increased (OR = 1.08, 95% CI: 1.02–1.15) and decreased as the percentage of Medicare residents increased (OR = 0.46, 95% CI: 0.25–0.83). The odds of taking a benzodiazepine without an appropriate indication were highest among residents who were female (OR = 1.44; 95% CI: 1.18–1.75), white (OR = 1.95; 95% CI: 1.47–2.60), and had behavioral symptoms (OR = 1.69; 95% CI: 1.41–2.01). Conclusion Antipsychotics and benzodiazepines seem to be commonly prescribed to residents lacking an appropriate indication for their use.
IMPORTANCE: Measurement of delirium severity has been recognized as highly important for tracking prognosis, monitoring response to treatment, and estimating burden of care for patients both during ...and after hospitalization. Rather than simply rating delirium as present or absent, the ability to quantify its severity would enable development and monitoring of more effective treatment approaches for the condition. OBJECTIVES: To present a comprehensive review of delirium severity instruments, conduct a methodologic quality rating of the original validation study of the most commonly used instruments, and select a group of top-rated instruments. EVIDENCE REVIEW: This systematic review was conducted using literature from Embase, PsycINFO, PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature, from January 1, 1974, through March 31, 2017, with the key words delirium, severity, tests, measures, and intensity. Inclusion criteria were original articles assessing delirium severity and using a delirium-specific severity instrument. Final listings of articles were supplemented with hand searches of reference listings to ensure completeness. At least 2 reviewers independently completed each step of the review process: article selection, data extraction, and methodologic quality assessment of relevant articles using a validated rating scale. All discrepancies between raters were resolved by consensus. FINDINGS: Of 9409 articles identified, 228 underwent full text review, and we identified 42 different instruments of delirium severity. Eleven of the 42 tools were multidomain, delirium-specific instruments providing a quantitative rating of delirium severity; these instruments underwent a methodologic quality review. Applying prespecified criteria related to frequency of use, methodologic quality, construct or predictive validity, and broad domain coverage, an expert panel used an iterative modified Delphi process to select 6 final high-quality instruments meeting these criteria: the Confusion Assessment Method–Severity Score, Confusional State Examination, Delirium-O-Meter, Delirium Observation Scale, Delirium Rating Scale, and Memorial Delirium Assessment Scale. CONCLUSIONS AND RELEVANCE: The 6 instruments identified may enable accurate measurement of delirium severity to improve clinical care for patients with this condition. This work may stimulate increased usage and head-to-head comparison of these instruments.
OBJECTIVES
We examined the association between delirium severity and outcomes of delirium among persons with and without Alzheimer's disease and related dementias (ADRD).
DESIGN
Prospective cohort ...study.
SETTING
Academic tertiary medical center.
PARTICIPANTS
A total of 352 medical and surgical patients.
MEASUREMENTS
Delirium incidence and severity were rated daily using the Confusion Assessment Method (CAM) and CAM‐Severity (CAM‐S) score during hospitalization. Severe delirium was defined as a CAM‐S Short Form score in the highest tertile (3‐7 points out of 7). ADRD status was determined by a clinical consensus process. Clinical outcomes included prolonged length of stay (>6 d), discharge to post‐acute nursing facility, any decline in activities of daily living (ADLs) at 1 month from prehospital baseline, ongoing nursing facility stay, and mortality.
RESULTS
Patients with ADRD (n = 85 24%) had a significantly higher relative risk (RR) for incident delirium (RR = 2.31; 95% confidence interval CI = 1.64‐3.28) and higher peak CAM‐S scores (mean difference = 1.24 points; CI = .83‐1.65; P < .001). Among patients with ADRD, severe delirium significantly increased the RR for nursing facility stay (RR = 2.22; CI = 1.05‐4.69; P = .04) and increased the RR for mortality (RR = 2.10; CI = .89‐4.98; P = .09). Among patients without ADRD, severe delirium was associated with a significantly increased risk for all poor outcomes except mortality including prolonged length of stay in the hospital (RR = 1.47; CI = 1.18‐1.82) and discharge to a post‐acute nursing facility (RR = 2.17; CI = 1.58‐2.98) plus decline in ADLs (RR = 1.30; CI = 1.05‐1.60) and nursing facility stay at 1 month (RR = 1.93; CI = 1.31‐2.83).
CONCLUSION
Severe delirium is associated with increased risk for poor clinical outcomes in patients with and without ADRD. In both groups, severe delirium increased risk of nursing home placement. In patients with ADRD, delirium was more severe and associated with a trend toward increased mortality at 1 month. Although the increased risk remains substantial by RR, the study had limited power to examine the rarer outcome of death. J Am Geriatr Soc 68:1722‐1730, 2020.
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