Abstract
Backgroundrecognition of prevalent delirium and prediction of incident delirium may be difficult at first assessment. We therefore aimed to validate a pragmatic delirium susceptibility (for any, prevalent and incident delirium) score for use in front-line clinical practice in a consecutive cohort of older acute medicine patients.Methodsconsecutive patients aged ≥65 years over two 8-week periods (2010–12) were screened prospectively for delirium using the Confusion Assessment Method (CAM), and delirium was diagnosed using the DSM IV criteria. The delirium susceptibility score was the sum of weighted risk factors derived using pooled data from UK-NICE guidelines: age >80 = 2, cognitive impairment (cognitive score below cut-off/dementia) = 2, severe illness (systemic inflammatory response syndrome) = 1, infection = 1, visual impairment = 1. Score reliability was determined by the area under the receiver operating curve (AUC).Resultsamong 308 consecutive patients aged ≥65 years (mean age/SD = 81/8 years, 164 (54%) female), AUC was 0.78 (95% CI 0.71–0.84) for any delirium; 0.71 (0.64–0.79), for prevalent delirium; 0.81 (0.70–0.92), for incident delirium; odds ratios (ORs) for risk score 5–7 versus <2 were 17.9 (5.4–60.0), P < 0.0001 for any delirium, 8.1 (2.2–29.7), P = 0.002 for prevalent delirium, and 25.0 (3.0–208.9) P = 0.003 for incident delirium, with corresponding relative risks of 5.4, 4.7 and 13. Higher risk scores were associated with frailty markers, increased care needs and poor outcomes.Conclusionsthe externally derived delirium susceptibility score reliably identified prevalent and incident delirium using clinical data routinely available at initial patient assessment and might therefore aid recognition of vulnerability in acute medical admissions early in the acute care pathway.
Highlights
Effective delirium management requires recognition of prevalent delirium and identification of those at future risk to guide individualised patient care including targeted multicomponent interventions [1,2,3]
Recognition of prevalent delirium at initial patient assessment may be difficult owing to lack of available informant or because the fluctuating nature of the condition means that a period of Delirium susceptibility score for acute medicine observation is required: establishing the time course of behavioural change is a key component of validated screening tools such as the Confusion Assessment Method (CAM) [4] and the 4AT [5]
Imputation of missing cognitive data made little difference to the overall area under the receiver operating curve (AUC) for any delirium (0.77, 95% CI 0.71–0.82) but improved AUC for prevalent delirium (0.74, 95% CI 0.68–0.81) at the expense of incident delirium (0.74, 95% CI 0.63–0.85, Appendix Table 1)
Summary
Effective delirium management requires recognition of prevalent delirium and identification of those at future risk to guide individualised patient care including targeted multicomponent interventions [1,2,3]. A score to identify risk of any delirium that is present at first assessment (“prevalent”) as well as occurring during admission (“incident”) delirium would be helpful in enabling recognition of a vulnerable group with high care needs at the earliest point in the care pathway in busy clinical settings and would facilitate selection of appropriate care in the absence of a definite delirium diagnosis [1, 2]. Such a score would need to be pragmatic, simple and to use only routinely collected clinical data available at first assessment. We have previously examined existing delirium risk scores in older patients in acute general medicine [7], but these scores used factors obtained from single-institution–derived data sets, required simplification from their original published forms and reliability was only moderate
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