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Confusion Assessment Method (confusion + assessment_method)
Selected AbstractsSerum S100B in elderly patients with and without deliriumINTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, Issue 3 2010Barbara C. van Munster Abstract Objective Elevation of S100B has been shown after various neurologic diseases with cognitive dysfunction. The aim of this study was to compare the serum level of S100B of patients with and without delirium and investigate the possible associations with different subtypes of delirium. Methods Acutely admitted medical patients aged 65 years or more were included from 2005 through 2008. Delirium was diagnosed by Confusion Assessment Method, delirium subtype by Delirium Symptom Interview and preexistent global cognitive function by the ,Informant Questionnaire on Cognitive Decline-short form'. S100B levels were determined in serum by electrochemiluminescence immunoassay. Results Samples of 412 patients were included, 91 during delirium, 35 after delirium and 286 of patients without delirium. Patients with delirium (31%) were significantly older, 81.5 versus 76.6 years (p,<,0.001) and experienced significantly more often preexistent cognitive and functional impairment (p,<,0.001). S100B level differed significantly (p,=,0.004) between the three groups: median 0.07,,g/L (inter-quartile ranges: 0.05,0.14,,g/L) during delirium, 0.12,,g/L (0.05,0.29,,g/L) after delirium and 0.06,,g/L (0.03,0.10,,g/L) in patients without delirium. Combining the impact of cognitive impairment, infection and age on S100B, highest S100B was observed in the oldest patients after delirium with preexistent cognitive impaired and infection. Delirium subtype and S100B level were not significantly correlated. Conclusion Higher S100B levels were found in patients with delirium than in patients without delirium, with highest levels of S100B in samples taken after delirium. Future studies are needed to elucidate the mechanism responsible for the increase of S100B and the possible association with long term cognitive impairment. Copyright © 2009 John Wiley & Sons, Ltd. [source] Randomized Trial of a Delirium Abatement Program for Postacute Skilled Nursing FacilitiesJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 6 20100000], [See editorial comments by Dr. Steven A. Levenson on pp 0000 OBJECTIVES: To determine whether a delirium abatement program (DAP) can shorten duration of delirium in new admissions to postacute care (PAC). DESIGN: Cluster randomized controlled trial. SETTING: Eight skilled nursing facilities specializing in PAC within a single metropolitan region. PARTICIPANTS: Four hundred fifty-seven participants with delirium at PAC admission. INTERVENTION: The DAP consisted of four steps: assessment for delirium within 5 days of PAC admission, assessment and correction of common reversible causes of delirium, prevention of complications of delirium, and restoration of function. MEASUREMENTS: Trained researchers screened eligible patients. Those with delirium defined according to the Confusion Assessment Method were eligible for participation using proxy consent. Regardless of location, researchers blind to intervention status re-assessed participants for delirium 2 weeks and 1 month after enrollment. RESULTS: Nurses at DAP sites detected delirium in 41% of participants, versus 12% in usual care sites (P<.001), and completed DAP documentation in most participants in whom delirium was detected, but the DAP intervention had no effect on delirium persistence based on two measurements at 2 weeks (DAP 68% vs usual care 66%) and 1 month (DAP 60% vs usual care 51%) (adjusted P,.20). Adjusting for baseline differences between DAP and usual care participants and restricting analysis to DAP participants in whom delirium was detected did not alter the results. CONCLUSION: Detection of delirium improved at the DAP sites, but the DAP had no effect on the persistence of delirium. This effectiveness trial demonstrated that a nurse-led DAP intervention was not effective in typical PAC facilities. [source] The Overlap Syndrome of Depression and Delirium in Older Hospitalized PatientsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2009Jane L. Givens MD OBJECTIVES: To measure the prevalence, predictors, and posthospitalization outcomes associated with the overlap syndrome of coexisting depression and incident delirium in older hospitalized patients. DESIGN: Secondary analysis of prospective cohort data from the control group of the Delirium Prevention Trial. SETTING: General medical service of an academic medical center. Follow-up interviews at 1 month and 1 year post-hospital discharge. PARTICIPANTS: Four hundred fifty-nine patients aged 70 and older who were not delirious at hospital admission. MEASUREMENTS: Depressive symptoms assessed at hospital admission using the 15-item Geriatric Depression Scale (cutoff score of 6 used to define depression), daily assessments of incident delirium from admission to discharge using the Confusion Assessment Method, activities of daily living at admission and 1 month postdischarge, and new nursing home placement and mortality determined at 1 year. RESULTS: Of 459 participants, 23 (5.0%) had the overlap syndrome, 39 (8.5%) delirium alone, 121 (26.3%) depression alone, and 276 (60.1%) neither condition. In adjusted analysis, patients with the overlap syndrome had higher odds of new nursing home placement or death at 1 year (adjusted odds ratio (AOR)=5.38, 95% confidence interval (CI)=1.57,18.38) and 1-month functional decline (AOR=3.30, 95% CI=1.14,9.56) than patients with neither condition. CONCLUSION: The overlap syndrome of depression and delirium is associated with significant risk of functional decline, institutionalization, and death. Efforts to identify, prevent, and treat this condition may reduce the risk of adverse outcomes in older hospitalized patients. [source] Randomized, Placebo-Controlled Trial of the Cognitive Effect, Safety, and Tolerability of Oral Extended-Release Oxybutynin in Cognitively Impaired Nursing Home Residents with Urge Urinary IncontinenceJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 5 2008Thomas E. Lackner PharmD OBJECTIVES: Determine the cognitive effect, safety, and tolerability of oral extended-release oxybutynin in cognitively impaired older nursing home residents with urge urinary incontinence. DESIGN: Randomized, double-blinded, placebo-controlled trial. SETTING: Twelve skilled nursing homes. PARTICIPANTS: Fifty women aged 65 and older with urge incontinence and cognitive impairment. INTERVENTION: Four-week treatment with once-daily oral extended-release oxybutynin 5 mg or placebo. MEASUREMENTS: Withdrawal rates and delirium or change in cognition from baseline at 1, 3, 7, 14, 21, and 28 days after starting treatment using the Confusion Assessment Method (CAM), Mini-Mental State Examination (MMSE), and Severe Impairment Battery (SIB). The Brief Agitation Rating Scale, adverse events, falls incidence, and serum anticholinergic activity change with treatment were also assessed. RESULTS: Participants' mean age ±standard deviation was 88.6±6.2, and MMSE baseline score was 14.5±4.3. Ninety-six percent of subjects receiving oxybutynin (n=26) and 92% receiving placebo (n=24) completed treatment (P=.50). The differences in mean change in CAM score from baseline to all time points were equivalent between the oxybutynin and placebo groups. Delirium did not occur in either group. One participant receiving oxybutynin was withdrawn because of urinary retention, which resolved without treatment. Mild adverse events occurred in 38.5% of participants receiving oxybutynin and 37.5% receiving placebo (P=.94). CONCLUSION: Short-term treatment using oral extended-release oxybutynin 5 mg once daily was safe and well tolerated, with no delirium, in older female nursing home participants with mild to severe dementia. Future research should investigate different dosages and long-term treatment. [source] Preliminary Derivation of a Nursing Home Confusion Assessment Method Based on Data from the Minimum Data SetJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2007David Dosa MD OBJECTIVES: To develop a Nursing Home Confusion Assessment Method (NH-CAM) for diagnosing delirium using items found on the Minimum Data Set (MDS) and to compare its performance with that of the delirium Resident Assessment Protocol (RAP) trigger and to an additive score of six of the RAP items. DESIGN: Retrospective cohort study using MDS and Medicare claims data. SETTING: Free-standing NHs in urban markets in the 48 contiguous U.S. states. PARTICIPANTS: Long-stay residents who returned to their NHs after acute hospitalizations between April and September 2000 (N=35,721). MEASUREMENTS: Mortality and rehospitalization rates within 90 days of readmission to the NH from the hospital. RESULTS: Almost one-third (31.8%) of the residents were identified as having delirium according to the RAP; 1.4% had full delirium, 13.2% had Subsyndromal II delirium, and 17.2% had Subsyndromal I delirium. More-severe NH-CAM scores were associated with greater risks of mortality and rehospitalization. NH-CAM levels were strong independent risk factors for survival and rehospitalization in a Cox model (hazard ratios ranging from 1.5 to 1.9 for mortality and 1.1 to 1.3 for rehospitalization) adjusting for cognitive and physical function, diagnoses, inpatient care parameters, care preferences, and sociodemographic factors. CONCLUSION: The NH-CAM successfully stratified NH residents' risk of mortality and rehospitalization. If validated clinically, the NH-CAM may be useful in care planning and in further research on the determinants and consequences of delirium in the NH. [source] Detection of Delirium by Bedside Nurses Using the Confusion Assessment MethodJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 4 2006Joke Lemiengre RN A prospective, descriptive study was used to assess the diagnostic validity of the Confusion Assessment Method (CAM) administered at the bedside by nurses in daily practice. Two different scoring methods of the CAM (the specific (SPEC) and sensitive (SENS) methods) were compared with a criterion standard (CAM completed by trained research nurses). During a 5-month period, all patients consecutively admitted to an acute geriatric ward of the University Hospitals of Leuven (Belgium) were enrolled in the study. The 258 elderly inpatients who were included underwent 641 paired but independent ratings of delirium by bedside and trained research nurses. Delirium was identified in 36 of the 258 patients (14%) or in 42 of the 641 paired observations (6.5%). The SENS method of the CAM algorithm as administered by bedside nurses had the greatest diagnostic accuracy, with 66.7% sensitivity and 90.7% specificity; the SPEC method had 23.8% sensitivity and 97.7% specificity. Bedside nurses had difficulties recognizing the features of acute onset, fluctuation, and altered level of consciousness. For both scoring methods, bedside nurses had difficulties with the identification of elderly patients with delirium but succeeded in diagnosing correctly those patients without delirium in more than 90% of observations. Given these results, additional education about delirium with special attention to guided training of bedside nurses in the use of an assessment strategy such as the CAM for the recognition of delirium symptoms is warranted. [source] A Chart-Based Method for Identification of Delirium: Validation Compared with Interviewer Ratings Using the Confusion Assessment MethodJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2005Sharon K. Inouye MD Objectives: To validate a chart-based method for identification of delirium and compare it with direct interviewer assessment using the Confusion Assessment Method (CAM). Design: Prospective validation study. Setting: Teaching hospital. Participants: Nine hundred nineteen older hospitalized patients. Measurements: A chart-based instrument for identification of delirium was created and compared with the reference standard interviewer ratings, which used direct cognitive assessment to complete the CAM for delirium. Trained nurse chart abstractors were blinded to all interview data, including cognitive and CAM ratings. Factors influencing the correct identification of delirium in the chart were examined. Results: Delirium was present in 115 (12.5%) patients according to the CAM. Sensitivity of the chart-based instrument was 74%, specificity was 83%, and likelihood ratio for a positive result was 4.4. Overall agreement between chart and interviewer ratings was 82%, kappa=0.41. By contrast, using International Classification of Diseases, Ninth Revision, Clinical Modification, administrative codes, the sensitivity for delirium was 3%, and specificity was 99%. Independent factors associated with incorrect chart identification of delirium were dementia, severe illness, and high baseline delirium risk. With all three factors present, the chart instrument was three times more likely to identify patients incorrectly than with none of the factors present. Conclusion: A chart-based instrument for delirium, which should be useful for patient safety and quality-improvement programs in older persons, was validated. Because of potential misclassification, the chart-based instrument is not recommended for individual patient care or diagnostic purposes. [source] Delirium Severity and Psychomotor Types: Their Relationship with Outcomes after Hip Fracture RepairJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 5 2002Edward Marcantonio MD OBJECTIVES: To validate the Memorial Delirium Assessment Scale (MDAS) as a measure of delirium severity in a cohort of patients aged 65 and older; to examine the association between severity of delirium and patient outcomes; and to examine the association between psychomotor variants of delirium and each of those outcomes. DESIGN: Prospective assessment of sample. SETTING: Hospital. PARTICIPANTS: One hundred twenty-two older patients (mean age ± standard deviation = 79 ± 8) who had undergone acute hip fracture surgery. MEASUREMENTS: We used standardized instruments to assess prefracture activities of daily living (ADLs), ambulatory status, cognition, and living situation. Postoperatively, each patient was interviewed daily. Delirium was diagnosed using the Confusion Assessment Method (CAM), and delirium severity was measured using the MDAS. The MDAS was also used to categorize the psychomotor types of delirium into "purely hypoactive" or "any hyperactivity." Telephone or face-to-face interviews were conducted at 1 and 6 months to assess survival, ADL function, ambulatory status, and living situation. RESULTS: Of 122 patients, 40% developed CAM-defined delirium. Delirious patients had higher average MDAS scores than nondelirious patients (11.7 vs 2.4, P <.0001). We used the median of the average MDAS score to classify patients into mild or severe delirium. Severe delirium was generally associated with worse outcomes than was mild delirium, and the associations reached statistical significance for nursing home placement or death at 6 months (52% vs 17%, P = .009). Additionally, patients who did not meet full CAM criteria for delirium experienced worse outcomes if they had some symptoms of delirium than if they had no or few symptoms (nursing home placement or death at 6 months: 27% vs 0%, P = .001). Surprisingly, these patients with subsyndromal delirium who did not fulfill CAM criteria for delirium but demonstrated significant delirium symptoms, had outcomes similar to or worse than those with mild CAM-defined delirium. Pure hypoactive delirium accounted for 71% (34/48) of cases and was less severe than was delirium with any hyperactivity (average MDAS score 10.6 vs 14.8, P = .007). In our cohort, patients with pure hypoactive delirium had better outcomes than did those with any hyperactivity (nursing home placement or death at 1 month: 32% vs 79%, P = .003); this difference persisted after adjusting for severity. CONCLUSION: In this study of delirium in older hip fracture patients, the MDAS, a continuous severity measure, was a useful adjunct to the CAM, a dichotomous diagnostic measure. In patients with CAM-defined delirium, severe delirium was generally associated with worse outcomes than was mild delirium. In patients who did not fulfill CAM criteria, subsyndromal delirium was associated with worse outcomes than having few or no symptoms of delirium. Patients with subsyndromal delirium had outcomes similar to patients with mild delirium, suggesting that a dichotomous approach to diagnosis and management may be inappropriate. Pure hypoactive delirium was more common than delirium with any hyperactive features, tended to be milder, and was associated with better outcomes even after adjusting for severity. Future studies should confirm our preliminary associations and examine whether treatment to reduce the severity of delirium symptoms can improve outcomes after hip fracture repair. [source] Factors associated with delirium severity among older patientsJOURNAL OF CLINICAL NURSING, Issue 5 2007Philippe Voyer PhD Aim., The goal of this study was to determine whether the factors associated with delirium varied according to the severity of the delirium experienced by the older patients. Background., Delirium among older patients is prevalent and leads to numerous detrimental effects. The negative consequences of delirium are worse among older adults with severe delirium compared with patients with mild delirium. There has been no study identifying those factors associated with delirium severity among long-term care older patients newly admitted to an acute care hospital. Design., This is a descriptive study. Methods., This is a secondary analysis study of institutionalized older patients newly admitted to an acute care hospital (n = 104). Upon admission, patients were screened for delirium with the Confusion Assessment Method and severity of delirium symptoms were determined by using the Delirium Index. Results., Of the 71 delirious older patients, 32 (45·1%) had moderate-severe delirium while 39 (54·9%) presented mild delirium. In univariate analyses, a significant positive relationship was observed between the level of prior cognitive impairment and the severity of delirium (p = 0·0058). Low mini-mental state examination (MMSE) scores (p < 0·0001), the presence of severe illness at the time of hospitalization (p = 0·0016) and low functional autonomy (BI: p = 0·0017; instrumental activities of daily living: p = 0·0003) were significantly associated with moderate-severe delirium. Older patients suffering from mild delirium used significantly more drugs (p = 0·0056), notably narcotics (p = 0·0017), than those with moderate-severe delirium. Results from the stepwise regression indicated that MMSE score at admission and narcotic medication use are the factors most strongly associated with the severity of delirium symptoms. Conclusions., This present study indicates that factors associated with moderate-severe delirium are different from those associated with mild delirium. Given the result concerning the role of narcotics, future studies should evaluate the role of pain management in the context of delirium severity. Relevance to Clinical Practice., As moderate-severe delirium is associated with poorer outcomes than is mild delirium, early risk factor identification for moderate-severe delirium by nurses may prove to be of value in preventing further deterioration of those older patients afflicted with delirium. [source] Predicting post-operative delirium in elderly patients undergoing surgery for hip fracturePSYCHOGERIATRICS, Issue 2 2006Gregory GOLDENBERG Abstract Background:, Delirium in elderly patients with hip fracture has a significant negative influence on the disease course. Awareness of risk factors for postoperative delirium (POD) may lead to the development of effective preventive strategies. The aims of this study were: to find patients' features that are predictors of POD, and; to develop a model predicting the risk for POD. Patients and methods:, Seventy-seven elderly patients (81.9 years of age, SD 7.5 years) were non-delirious prior to surgery and enrolled in the study. Delirium was diagnosed by Confusion Assessment Method and Algorrhithm. Patients' characteristics as potential predictors of POD were analyzed by logistic regression analysis on SAS software. Results:, Postoperative delirium was diagnosed in 37 patients. Use of multiple (>3) medications, lower scores on cognitive tests (<20 on Set Test and <24 on Mini-mental Status Exam), albumin level less than 3.5 g/dL, hematocrit level less than 33% and age over 81 years were predictors of POD. A logistic regression formula including these predictors weighed by their parameter estimates can be used to calculate the probability of POD. The model had a good fit and a good predictive power. A Delirium Predicting Scale was derived based on parameter estimates of these predictors. Patients can be classified as low-, intermediate- or high-risk for POD. Conclusions:, A logistic regression model, which includes patients' age, medication history, cognitive performance measured by Set Test and Mini-Mental Status Exam, albumin and hematocrit levels, can be used to predict risk for POD after surgical repair of fractured hip in elderly patients. [source] Delirium in Older Emergency Department Patients: Recognition, Risk Factors, and Psychomotor SubtypesACADEMIC EMERGENCY MEDICINE, Issue 3 2009Jin H. Han MD Abstract Objectives:, Missing delirium in the emergency department (ED) has been described as a medical error, yet this diagnosis is frequently unrecognized by emergency physicians (EPs). Identifying a subset of patients at high risk for delirium may improve delirium screening compliance by EPs. The authors sought to determine how often delirium is missed in the ED and how often these missed cases are detected by admitting hospital physicians at the time of admission, to identify delirium risk factors in older ED patients, and to characterize delirium by psychomotor subtypes in the ED setting. Methods:, This cross-sectional study was a convenience sample of patients conducted at a tertiary care, academic ED. English-speaking patients who were 65 years and older and present in the ED for less than 12 hours at the time of enrollment were included. Patients were excluded if they refused consent, were previously enrolled, had severe dementia, were unarousable to verbal stimuli for all delirium assessments, or had incomplete data. Delirium status was determined by using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) administered by trained research assistants (RAs). Recognition of delirium by emergency and hospital physicians was determined from the medical record, blinded to CAM-ICU status. Multivariable logistic regression was used to identify independent delirium risk factors. The Richmond Agitation and Sedation Scale was used to classify delirium by its psychomotor subtypes. Results:, Inclusion and exclusion criteria were met in 303 patients, and 25 (8.3%) presented to the ED with delirium. The vast majority (92.0%, 95% confidence interval [CI] = 74.0% to 99.0%) of delirious patients had the hypoactive psychomotor subtype. Of the 25 patients with delirium, 19 (76.0%, 95% CI = 54.9% to 90.6%) were not recognized to be delirious by the EP. Of the 16 admitted delirious patients who were undiagnosed by the EPs, 15 (93.8%, 95% CI = 69.8% to 99.8%) remained unrecognized by the hospital physician at the time of admission. Dementia, a Katz Activities of Daily Living (ADL) , 4, and hearing impairment were independently associated with presenting with delirium in the ED. Based on the multivariable model, a delirium risk score was constructed. Dementia, Katz ADL , 4, and hearing impairment were weighed equally. Patients with higher risk scores were more likely to be CAM-ICU positive (area under the receiver operating characteristic [ROC] curve = 0.82). If older ED patients with one or more delirium risk factors were screened for delirium, 165 (54.5%, 95% CI = 48.7% to 60.2%) would have required a delirium assessment at the expense of missing 1 patient with delirium, while screening 141 patients without delirium. Conclusions:, Delirium was a common occurrence in the ED, and the vast majority of delirium in the ED was of the hypoactive subtype. EPs missed delirium in 76% of the cases. Delirium that was missed in the ED was nearly always missed by hospital physicians at the time of admission. Using a delirium risk score has the potential to improve delirium screening efficiency in the ED setting. [source] Delirium in acute stroke , prevalence and risk factorsACTA NEUROLOGICA SCANDINAVICA, Issue 2010M. H. Dahl Dahl MH, Rønning OM, Thommessen B. Delirium in acute stroke , prevalence and risk factors. Acta Neurol Scand: 2010: 122 (Suppl. 190): 39,43. © 2010 John Wiley & Sons A/S. Background,,, Delirium is frequently seen as a major complication among elderly stroke patients. Few studies have prospectively studied delirium as a complication of acute stroke. In these studies, the results are conflicting regarding risk factors and estimated prevalence. The aims of the present study are to assess the prevalence of delirium in patients with acute stroke treated in an acute Stroke Unit, identify characteristics of patients with delirium and important factors associated with the development of delirium. Methods,,, We conducted a prospective study of patients with delirium and acute stroke consecutively admitted to a Stroke Unit. The diagnosis of delirium was based on Confusion Assessment Method (CAM). CAM is devised from DSM-III-R criteria based on the diagnosis of delirium, and is a simple test with high sensitivity and specificity. Results,,, One hundred and seventy-eight patients with a diagnosis of stroke were eligible for the study. The prevalence of delirium in acute stroke in our study was 10% (18 of 178 patients). Patients with delirium had significantly longer length of stay in the Stroke Unit (12.3 vs 8.5 days, P < 0.004). Prestroke dementia [odds ratio (OR) 18.7], hemianopsia (OR 12.3), apraxia (OR 11.0), higher age (OR 5.5) and infection (UTI or pneumonia) (OR 4.9) during in-hospital stay were associated with increased risk of delirium. Conclusion,,, One of 10 stroke patients had delirium. This is the lowest prevalence of delirium shown in acute stroke patients. In our study, all patients were treated in a Stroke Unit. A Stroke Unit like the Scandinavian model may be beneficial in preventing delirium. [source] | ||||||||||