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Detecting delirium superimposed on dementia: diagnostic accuracy of a simple combined arousal and attention testing procedure

Published online by Cambridge University Press:  31 May 2017

Sarah J. Richardson ,
Daniel H. J. Davis ,
Giuseppe Bellelli ,
Wolfgang Hasemann ,
David Meagher ,
Stefan H. Kreisel ,
Alasdair M. J. MacLullich ,
Joaquim Cerejeira  and
Alessandro Morandi
Sarah J. Richardson*
Affiliation:
Institute of Neuroscience, 3rd floor Biomedical Research Building, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK
Daniel H. J. Davis
Affiliation:
University College London, MRC Unit for Lifelong Health and Ageing at UCL, London, UK
Giuseppe Bellelli
Affiliation:
School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
Wolfgang Hasemann
Affiliation:
Practice Development in Nursing, University Hospital Basel, Basel, Switzerland
David Meagher
Affiliation:
Graduate Entry Medical School, University of Limerick, Limerick, Ireland
Stefan H. Kreisel
Affiliation:
Department of Psychiatry and Psychotherapy Bethel, Evangelisches Krankenhaus Bielefeld, Division of Geriatric Psychiatry, Bielefeld, Germany
Alasdair M. J. MacLullich
Affiliation:
Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK
Joaquim Cerejeira
Affiliation:
Department of Psychiatry, Hospitais da Universidade de Coimbra, Coimbra, Portugal
Alessandro Morandi
Affiliation:
Ancelle Hospital, Cremona, Italy Geriatrics Research Group, Brescia, Italy
*
Correspondence should be addressed to: Institute of Neuroscience, 3rd floor Biomedical Research Building, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK. Phone: +44 0191 2081314. Email: Sarah.Richardson2@newcastle.ac.uk.
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Abstract

Background:

Detecting delirium superimposed on dementia (DSD) can be challenging because assessment partly relies on cognitive tests that may be abnormal in both conditions. We hypothesized that a combined arousal and attention testing procedure would accurately detect DSD.

Methods:

Patients aged ≥70 years were recruited from five hospitals across Europe. Delirium was diagnosed by physicians using DSM-5 criteria using information from nurses, carers, and medical records. Dementia was ascertained by the Informant Questionnaire on Cognitive Decline in the Elderly. Arousal was measured using the Observational Scale of Level of Arousal (OSLA), which assesses eye opening, eye contact, posture, movement, and communication. Attention was measured by participants signaling each time an “A” was heard when “S-A-V-E-A-H-A-A-R-T” was read out.

Results:

The sample included 114 persons (mean age 82 years (SD 7); 54% women). Dementia alone was present in 25% (n = 28), delirium alone in 18% (n = 21), DSD in 27% (n = 31), and neither in 30% (n = 34). Arousal and attention was assessed in n = 109 (96%). Using OSLA, 83% participants were correctly identified as having delirium (sensitivity 85%, specificity 82%, AUROC 0.92). The attention task correctly classified 76% of participants with delirium (sensitivity 90%, specificity 64%, AUROC 0.80). Combining scores correctly classified 91% of participants with delirium (sensitivity 84%, specificity 92%, AUROC 0.94). Diagnostic accuracy remained high in the subgroup with dementia (93% correctly classified, sensitivity 94%, specificity 92%, AUROC 0.98).

Conclusions:

This combined arousal–attention assessment to detect DSD was brief yet had high diagnostic accuracy. Such an approach could have clinical utility for diagnosing DSD.

Keywords

deliriumdementiadelirium superimposed on dementiadiagnosis
Type
Paper of the Month
Information
International Psychogeriatrics , Volume 29 , Issue 10 , October 2017 , pp. 1585 - 1593
Copyright
Copyright © International Psychogeriatric Association 2017 

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References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edn, (DSM-5). Washington, DC: American Psychiatric Association.Google Scholar
Bellelli, G. et al. (2016). “Delirium Day”: a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool. BMC Medicine, 14, 1–12.Google Scholar
Bellelli, G., Speciale, S., Morghen, S., Torpilliesi, T., Turco, R. and Trabucchi, M. (2011). Are fluctuations in motor performance a diagnostic sign of delirium? Journal of the American Medical Directors Association, 12, 578–583.CrossRefGoogle ScholarPubMed
Brown, L. J. E. et al. (2011b). Differential effects of delirium on fluid and crystallized cognitive abilities. Archives of Gerontology and Geriatrics, 52, 153–158.Google Scholar
Brown, L. J., Fordyce, C., Zaghdani, H., Starr, J. M. and MacLullich, A. M. (2011a). Detecting deficits of sustained visual attention in delirium. Journal of Neurology, Neurosurgery and Psychiatry, 82, 1334–1340.CrossRefGoogle ScholarPubMed
Charlson, M. E., Pompei, P., Ales, K. L. and MacKenzie, C. R. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of Chronic Diseases, 40, 373–383.Google Scholar
Chester, J. G., Beth Harrington, M. and Rudolph, J. L. (2012). Serial administration of a modified Richmond Agitation and Sedation Scale for delirium screening. Journal of Hospital Medicine, 7, 450–453.Google Scholar
Collins, N., Blanchard, M. R., Tookman, A. and Sampson, E. L. (2010). Detection of delirium in the acute hospital. Age & Ageing, 39, 131–135.Google Scholar
Davis, H. J. et al. (2017). Association of delirium with cognitive decline in late life: A Neuropathologic Study of 3 Population-Based Cohort Studies. Journal of the American Medical Association Psychiatry, 74, 244–251.Google Scholar
Ely, E. W. et al. (2001). Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). Journal of the American Medical Association, 286, 2703–2710.Google Scholar
European Delirium Association and American Delirium Society (2014). The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer. BMC Medicine, 12, 141.CrossRefGoogle Scholar
Fick, D. M., Agostini, J. V. and Inouye, S. K. (2002). Delirium superimposed on dementia: a systematic review. Journal of the American Geriatrics Society, 50, 1723–1732.CrossRefGoogle ScholarPubMed
Gross, A. L. et al. (2012). Delirium and long-term cognitive trajectory among persons with dementia. Archives of Internal Medicine, 172, 1324–1331.CrossRefGoogle ScholarPubMed
Han, J. H. et al. (2015). The diagnostic performance of the richmond agitation sedation scale for detecting delirium in older emergency department patients. Academic Emergency Medicine, 22, 878–882.CrossRefGoogle ScholarPubMed
Jackson, T. A. et al. (2017). Challenges and opportunities in understanding dementia and delirium in the acute hospital. PLoS Medicine, 14, e1002247 Google Scholar
Jorm, A. F., Scott, R., Cullen, J. S. and MacKinnon, A. J. (1991). Performance of the informant questionnaire on cognitive decline in the elderly (IQCODE) as a screening test for dementia. Psychological Medicine, 21, 785–790.CrossRefGoogle ScholarPubMed
Kakuma, R. et al. (2003). Delirium in older emergency department patients discharged home: effect on survival. Journal of the American Geriatrics Society, 51, 443–450.Google Scholar
Leonard, M. et al. (2016). Comparison of cognitive and neuropsychiatric profiles in hospitalised elderly medical patients with delirium, dementia and comorbid delirium–dementia. BMJ Open, 6, e009212.CrossRefGoogle ScholarPubMed
Meagher, D. J., Leonard, M., Donnelly, S., Conroy, M., Saunders, J. and Trzepacz, P. T. (2010). A comparison of neuropsychiatric and cognitive profiles in delirium, dementia, comorbid delirium-dementia and cognitively intact controls. Journal of Neurology, Neurosurgery and Psychiatry, 81, 876–881.Google Scholar
Molloy, D. W. and Standish, T. I. (1997). A guide to the standardized mini-mental state examination. International Psychogeriatrics, 9, 87–94; discussion 143–150.Google Scholar
Morandi, A. et al. (2012). Tools to detect delirium superimposed on dementia: a systematic review. Journal of the American Geriatrics Society, 60, 2005–2013.Google Scholar
Morandi, A. et al. (2014). Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients. Journal of the American Medical Directors Association, 15, 349–354.Google Scholar
Morandi, A. et al. (2017). The diagnosis of delirium superimposed on dementia: an emerging challenge. Journal of the American Medical Directors Association, 18, 12–18.Google Scholar
Richardson, S. et al. (2016). Delirium superimposed on dementia: a survey of delirium specialists shows a lack of consensus in clinical practice and research studies. International Psychogeriatrics, 28, 853–861.Google Scholar
Tieges, Z. et al. (2015). Development of a smartphone application for the objective detection of attentional deficits in delirium. International Psychogeriatrics, 27, 1251–1262.Google Scholar
Tieges, Z., Brown, L. J. E. and MacLullich, A. M. J. (2014). Objective assessment of attention in delirium: a narrative review. International Journal of Geriatric Psychiatry, 29, 1185–1197.Google Scholar
Tieges, Z., McGrath, A., Hall, R. J. and Maclullich, A. M. (2013). Abnormal level of arousal as a predictor of delirium and inattention: an exploratory study. American Journal of Geriatric Psychiatry, 21, 1244–1253.Google Scholar
Voyer, P. et al. (2016). Assessment of inattention in the context of delirium screening: one size does not fit all! International Psychogeriatrics, 28, 1293– 1301.Google Scholar