Diagnostic Criteria For Delirium Research Articles

Main features of diagnosis and treatment of delirium in icu patients: a systematic review

Relevance. Delirium is a severe neuropsychiatric syndrome, which is a common problem in patients in the intensive care unit (ICU). Recently published works indicate a insufficiency of awareness about the key principles of diagnosis and treatment of this condition. The aim of the study is to analyze and summarize data on algorithms that allow the identification and correction of delirium in patients in the intensive care unit. Materials and methods. A comprehensive search was conducted in the electronic databases PubMed and eLIBRARY. The review includes searchable publications for May 2023. Results. A literature review identified five adult delirium screening tools that have been validated against The Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria for delirium. Prospects for improving clinical outcomes are multi-component programs with a large number of strategies aimed at assessing, preventing and treating delirium in the ICU. Conclusion. It is necessary to use validated screening tools, as well as implement preventive strategies such as ABCDEF. Prevention of delirium in the ICU by determining the level of risk, eliminating etiological development factors and early multimodal therapy should be included in the standard algorithm from the moment the patient is admitted to the hospital in order to reduce hospital mortality.

Accuracy of delirium assessments in critically ill children: A prospective, observational study during routine care

ObjectivesThe objectives of this study was to explore the accuracy of the Cornell Assessment for Pediatric Delirium (CAP-D), Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU), and Preschool Confusion Assessment Method for the Intensive Care Unit (psCAM-ICU) when implemented in routine care as delirium screening tools, and to assess patient characteristics and clinical variables that may affect their validity. DesignThis is a prospective observational study. SettingThe study was conducted in a 36-bed, mixed paediatric intensive care unit (PICU) at an Australian tertiary hospital. PatientsThe study included critically ill children developmentally aged 6 months to 17 years, with a PICU length of stay >18 h. InterventionsNo interventions were provided in the study. Measurements and main resultsPatients were screened for delirium by their bedside nurse (CAP-D and pCAM-ICU/psCAM-ICU) once daily, for up to 5 d. Delirium status identified using screening instruments was compared with delirium diagnosis using the diagnostic criteria for delirium (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition). In this sample, the CAP-D retained its high sensitivity (91.3%) and good specificity (75.2%), whereas the psCAM-ICU and pCAM-ICU had moderate sensitivity (58.8% and 75.0%, respectively) and excellent specificity (89.8% and 84.9%, respectively). There was moderate agreement between the CAP-D and the psCAM-ICU (κ = 0.52, p < .001) and good agreement between the CAP-D and the pCAM-ICU (κ = 0.80, p < .01). ConclusionsAlthough the CAP-D, psCAM-ICU, and pCAM-ICU all appear promising in their validation studies, when implemented in routine care, their performance can be variable. The CAP-D performed well in routine clinical practice, but follow-up diagnosis is required to confirm delirium. The psCAM-ICU and pCAM-ICU both provide valuable, objective assessments of delirium in critically ill children; however, further evaluation of their implementation in routine clinical practice is needed.

A systematic review and meta-analysis of the accuracy of the clock drawing test (CDT) in the identification of delirium in older hospitalised patients

Objective: Delirium is a common neurocognitive syndrome among hospitalised older adults. The clock drawing test (CDT) is a relatively simple bedside test of cognitive function. This systematic review and meta-analysis examine the accuracy of the CDT in identifying delirium in hospitalised older adults.Methods: PRISMA guidelines were used to report the identified studies. Pubmed, SCOPUS, and Ovid and EBSCO platforms (including MEDLINE ®, PsycINFO, PsycEXTRA, EMCARE, CINAHL and EMBASE databases) were searched. Studies were assessed for methodological quality using the Downs and Black Tool. Data were extracted regarding the number of delirious/not delirious, number with normal and abnormal CDT, age, and MMSE scores, and information regarding CDT scoring, criteria for diagnosis of delirium and setting of the study. Analysis was carried out with the “Mada” and “Metatron” packages of R software.Results: Fifteen studies were examined. The number of participants was 2199, of whom 597 (27.15%) were diagnosed with delirium. The overall sensitivity of CDT in the absence of any formal cognitive test was 0.76 (0.58–0.87) with specificity of 0.70 (0.51–0.83). When the MMSE was taken into account, the specificity and sensitivity reduced to 0.51. Diagnostic criteria for delirium, scoring method of CDT, age of participants and setting significantly (p < 0.05) affect the sensitivity and specificity of the CDT.Conclusion: Although, the CDT is generally considered to be a simple and easy to administer screening tool for cognitive impairment in older hospitalised adults, when a more formal cognitive test is used its sensitivity and specificity to detect delirium is low.

Delirium after a traumatic brain injury: predictors and symptom patterns.

BackgroundDelirium in traumatic brain injury (TBI) is common, may be predictable, and has a multifaceted symptom complex. This study aimed to examine: 1) the sum score of Glasgow Coma Scale (GCS) and if its component scores could predict delirium in TBI patients, and 2) the prominent symptoms and their courses over the first days after TBI.MethodsTBI patients were recruited from neurosurgical ward inpatients. All participants were hospitalized within 24 hours after their TBI. Apart from the sum score of GCS, which was obtained at the emergency department (ED), the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnostic criteria for delirium were applied daily. The severity of delirium symptoms was assessed daily using the Delirium Rating Scale – Revised-98 (DRS-R-98).ResultsThe participants were 54 TBI patients with a mean GCS score of 12.7 (standard deviation [SD] =2.9). A total of 25 patients (46.3%) met the diagnosis of delirium and had a mean age of 36.7 years (SD =14.8). Compared with 29 non-delirious patients, 25 delirious patients had a significantly lower mean GCS score (P=0.04), especially a significantly lower verbal component score (P=0.03). Among 18 delirious patients, four symptoms of the DRS-R-98 cognitive domain (orientation, attention, long-term memory, and visuospatial ability) were moderate symptoms (score ≥2) at the first day of admission. After follow-up, three cognitive (orientation, attention, and visuospatial ability) and two noncognitive symptoms (lability of affect and motor agitation) rapidly resolved.ConclusionAlmost half of patients with mild to moderate head injuries may develop delirium in the first 4 days after TBI. Those having a low GCS score, especially the verbal component score, at the ED were likely to have delirium in this period. Most cognitive domains of delirium described in the DRS-R-98 were prominent within the first 4 days of TBI with delirium. Three cognitive and two noncognitive symptoms of delirium decreased significantly.

The hinterland of delirium

The diagnostic criteria for delirium in the fi fth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) specify a disturbance in attention or change in cognition that is not better accounted for by a pre-existing, established, or evolving dementia; development over a short period; and evidence from the history, physical examination, or laboratory fi ndings that the disturbance is caused by the direct physiological consequences of a general medical condition, is due to an intoxicating substance or medication use, or has more than one cause. Although this defi nition seems unequivocal, delirium is still commonly under-recognised. Descriptions of what we would now know as delirium date back to Classical Greece, with references found in the works of Hippocrates to hyperactive and hypoactive symptoms, which he described with the terms phrenitis (mental abnormalities caused by fever, poisoning, or head trauma) and lethargy (inertia and dulling of the senses). Celus, in the 1st century AD, is generally credited with being the fi rst to use the term delirium to describe mental illness during fever or head trauma, although much debate remains about the etymology of the word. The medical literature throughout the Middle Ages and up to the 19th century is full of descriptions of delirium, although the terminology used varied widely throughout this period, with the designations phrenitis, phrensy, phrenesis, lethargy, paraphrensy, and paraphrenesis falling in and out of favour. During the 20th century, the focus moved away from looking at delirium as only a symptom and more towards understanding of the pathophysiology of the disorder itself. Engel and Romano led the way in this respect in 1959 by showing that delirium was a disturbance in the level of consciousness manifesting as cognitive attentional disturbances and was due to disruption of brain metabolism.

Do Surgical Trainees Believe They Are Adequately Trained to Manage the Ageing Population? A UK Survey of Knowledge and Beliefs in Surgical Trainees

Increasing numbers of older patients are undergoing surgery. Older surgical patients are at a higher risk of perioperative complications and mortality. Multimorbidity, frailty, and physiological changes of ageing contribute to adverse outcomes. These complications are predominantly medical, rather than directly surgical. Guidelines recommend preoperative assessment of comorbidity, disability, and frailty in older patients undergoing surgery and closer perioperative collaboration between surgeons and geriatricians. We conducted a survey to assess knowledge and beliefs of surgical trainees toward common perioperative problems encountered in older surgical patients. Paper-based survey. Unselected UK surgical training-grade physicians (CT1-ST8) attending the 2013 Congress of The Association of Surgeons of Great Britain and Ireland, Glasgow, UK, May 1-3, 2013. A total of 160 eligible UK surgical trainees attending the conference were invited to participate in the survey. Of them, 157 participated. Of the trainees, 68% (n = 107) reported inadequate training and 89.2% (n = 140) supported the inclusion of geriatric medicine issues in surgical curricula. Of the respondents, 77.2% (n = 122) were unable to correctly identify the key features required to demonstrate mental capacity, and only 3 of 157 respondents were familiar with the diagnostic criteria for delirium. Support from geriatric medicine was deemed necessary (84.7%, n = 133) but often inadequate (68.2%, n = 107). Surgical trainees support closer collaboration with geriatric medicine and shared care of complex, older patients (93.6%, n = 147). UK surgical trainees believe that they receive inadequate training in the perioperative management of complex, older surgical patients and are inadequately supported by geriatric medicine physicians. In this survey sample, trainee knowledge of geriatric issues such as delirium and mental capacity was poor. Surgical trainees support the concept of closer liaison and shared care of complex, older patients with geriatric medicine physicians. Changes to surgical training and service development are needed.

The Epidemiology of Delirium: Challenges and Opportunities for Population Studies

Delirium is a serious and common acute neuropsychiatric syndrome that is associated with short- and long-term adverse health outcomes. However, relatively little delirium research has been conducted in unselected populations. Epidemiologic research in such populations has the potential to resolve several questions of clinical significance in delirium. Part 1 of this article explores the importance of population selection, case-ascertainment, attrition, and confounding. Part 2 examines a specific question in delirium epidemiology: What is the relationship between delirium and trajectories of cognitive decline? This section assesses previous work through two systematic reviews and proposes a design for investigating delirium in the context of longitudinal cohort studies. Such a design requires robust links between community and hospital settings. Practical considerations for case-ascertainment in the hospital, as well as the necessary quality control of these programs, are outlined. We argue that attention to these factors is important if delirium research is to benefit fully from a population perspective.

Detecting Delirium in Older Adults Living at Home

The aim of this study was to determine whether in-home care nurses had the necessary knowledge to detect delirium in older adults. To this end, 87 home care nurses from 2 sites in the greater Quebec City region in Canada answered a questionnaire. The results showed nurses had limited level of knowledge about the diagnostic criteria for delirium, the main signs and symptoms of delirium, and the tools for its detection. Moreover, 54.4% of the in-home care nurses were able to recognize delirium, from structured clinical vignettes.

Characterizing the behavior of children emerging with delirium from general anesthesia

Emergence delirium (ED) frequently occurs in young children awakening from general anesthesia (GA). To date, research is limited by scales that are unable to discriminate the condition from other forms of agitation. The primary aim of this study was to determine the core behaviors of ED that discriminate the condition from pain and tantrum in young children and to cluster these behaviors according to the DSM-IV/V core diagnostic criteria and associated behaviors of delirium. Children aged 18 months to 6 years (n=198) were observed upon awakening from GA following surgical or nonsurgical procedures to determine which behaviors categorize ED. Behaviors were recorded via a structured behavioral observation. Clinical opinion was sought to determine whether the child presented ED, pain, or tantrum. A chi-square analysis revealed children with ED were significantly more likely to display activity, nonpurposefulness, eyes averted, stared or closed, no language, and nonresponsivity. These behaviors were not significantly associated with pain or tantrum. A logistic regression showed eyes averted or stared and nonpurposefulness were significant predictors of ED, while no language and activity were not significant predictors of ED. Children with ED are significantly more likely to display nonpurposefulness, eyes averted, stared or closed, and nonresponsivity. These behaviors were not significantly associated with pain or tantrum and are believed to reflect the DSM-IV/V diagnostic criteria for delirium. Associated behaviors of ED identified by this research are irrelevant language, activity, and vocalization.

Falls in the General Hospital: Association With Delirium, Advanced Age, and Specific Surgical Procedures

Falls and delirium in general-hospital inpatients are related to increases in morbidity, mortality, and healthcare costs. Patients fall despite safeguards and programs to reduce falling. The authors sought to determine the prevalence of diagnosed and undiagnosed delirium in patients who fell during their hospital stay. The authors performed a retrospective electronic chart review of 252 patients who fell during their hospital stay. Falls were categorized by their severity (i.e., minor, moderate, and major). Demographic information, patient outcomes, and diagnostic criteria for delirium (per DSM-IV) were collected on the day of admission, the day of the fall, and the 2 days preceding the patient's fall. Falls in the general hospital were associated with delirium (both diagnosed and undiagnosed), advanced age, and specific surgical procedures. Improving the recognition of undiagnosed delirium may lead to sustainable and successful fall prevention programs. Detection of impairments in mental status can assist staff to create individualized patient care plans. Knowledge about which patients are at risk for injury from delirium and falls can lead to improvements in patient safety, functioning, and quality of life.

An Exploratory Study of Diagnostic Criteria for Delirium in Older Medical Inpatients

The poor prognosis of delirium in older medical inpatients has generated controversy about the diagnostic criteria for delirium in this population. The goal of the present study was to explore the presenting symptoms of delirium among older medical inpatients who did or did not recover from delirium. Patients 65 years or older admitted from the emergency department to medical services were screened with the Confusion Assessment Method (CAM). Patients with delirium were assessed at enrollment, several times during the first week, then weekly for 4 weeks using the Delirium Index (DI). Measures at baseline included demographics, dementia and severity of physical illness. Recovery was defined as a decline of three points or more on the DI and a final DI score of less than 5 or 4 points in patients with or without dementia, respectively. Of 290 patients who met DSM-IV criteria for delirium, 65 recovered and 225 did not. Three symptoms (orientation to person, hyperactivity, and inattention) were associated with recovery from delirium in older medical inpatients. These results suggest it may be necessary to place increased emphasis on these presenting symptoms when diagnosing delirium in this population.

Delirium: Diagnosis, Neuropathogenesis, and Treatment

Delirium affects more than 2 million patients in the United States each year. The onset of delirium often occurs after hospitalization and in many cases is due to medications or procedures performed during the hospitalization. Unfortunately, delirium remains unrecognized in the majority of patients for several reasons. This review addresses the diagnostic criteria for delirium, the neurochemistry that is believed to be causative, risk factors, measures that may be taken to reduce the onset of delirium, and treatment options.

Outcome of delirium: Part 1. Outcome of delirium diagnosed by DSM-III-R, ICD-10 and CAMDEX and derivation of the Reversible Cognitive Dysfunction Scale among acute geriatric inpatients.

To study performance of DSM-III-R, ICD-10 and CAMDEX diagnoses of delirium as predictors of improvement in mental state in survivors, and to develop a brief rating scale which will predict reversibility of cognitive dysfunction. Prospective cohort study. Acute geriatric inpatient units. A random sample of consecutive acute admissions of patients over the age of 65 (N = 80). Serial assessments of mental state and cognitive function and observational data. Establishment of DSM-III-R, ICD-10, CAMDEX diagnoses. Patients with more than five points of 20% improvement in Mini Mental State Examination following the most severely impaired assessment operationally designated 'reversible cognitive dysfunction'. Diagnoses of delirium by DSM-III-R and ICD-10 do not predict improvement in cognitive function well; CAMDEX does rather better. Discriminant function analysis yielded the Reversible Cognitive Dysfunction Scale (RCDS), a simple clinical scale which accurately predicted improvement. This comprised reduced conscious level, poor attention, poor contact with the patient, incoherent speech, reduced psychomotor activity, lack of awareness of surroundings and poor orientation and memory. The concept of and diagnostic criteria for delirium should be reconsidered. The RCDS merits further evaluation.

A psychophysiological study of the development of delirium in coronary care units

This is a longitudinal investigation of the psychophysiological mechanism for the development of delirium in coronary care units (CCUs). Ten patients satisfying DSM-III-R diagnostic criteria for delirium (group D) and 10 controls (group C) were drawn from patients admitted to CCU. Electroencephalogram (EEG) and eye movement recordings were observed over the days that patients were admitted to CCU and on a control day of admission and compared for each group and between each day. In the D group, slowing of background EEG activity, particularly on day 2, and many R (rapid) group eye movements and RS type (rapid superimposed on slow) eye movements, particularly on day 3, were observed. That is, from days 2 to 3, EEG findings showed an improvement in consciousness, and eye movement recordings manifested signs of anxiety and tension. These psychophysiological findings can be used to explain the transition from prodromal delirium to obvious delirium, and are supported by clinical features.

Delirium

This article identifies the importance of delirium in general medical practice. Recent revisions in the diagnostic criteria for delirium are discussed, and the epidemiology of delirium is summarized, including the incidence and prevalence, risk factors, origins, course, and outcomes. Studies of the pathophysiological features of delirium are reviewed and recommendations are made for treatment of patients with delirium and future research.

Delirium in the Elderly: A Brief Overview

Organic mental disorders with cognitive impairment constitute an important medical and public health problem in elderly people. The emergence of severe acute psychiatric manifestations of delirium as a consequence of structural brain disease or cerebral dysfunction related to some other physical illness is well known in clinical practice. After a long period of nosological inconsistency, the DSM-111, and now the DSM-111-R, present operational diagnostic criteria for delirium emphasizing the cognitive symptoms of the disorder. At the same time different psychomotor symptoms in, for example, hyperkinetic, mixed, or silent delirium are also being recognized. In addition, many clinical studies have illustrated the wide variation in predisposing, precipitating, and sustaining factors for delirium, thus providing a basis for etiological hypotheses.