Diagnosing Delirium in Older Emergency Department Patients: Validity and Reliability of the Delirium Triage Screen and the Brief Confusion Assessment Method - 24/10/13
, Amanda Wilson, MD c, Eduard E. Vasilevskis, MD, MPH a, d, e, h, Ayumi Shintani, MPH, PhD g, John F. Schnelle, PhD a, d, e, h, Robert S. Dittus, MD, MPH d, e, h, Amy J. Graves, SM, MPH g, Alan B. Storrow, MD b, John Shuster, MD c, E. Wesley Ely, MD, MPH a, e, f, h
Address for correspondence: Jin H. Han, MD, MScSupervising editor: Timothy F. Platts-Mills, MD
Résumé |
Study objective |
Delirium is a common form of acute brain dysfunction with prognostic significance. Health care professionals caring for older emergency department (ED) patients miss delirium in approximately 75% of cases. This error results from a lack of available measures that can be performed rapidly enough to be incorporated into clinical practice. Therefore, we developed and evaluated a novel 2-step approach to delirium surveillance for the ED.
Methods |
This prospective observational study was conducted at an academic ED in patients aged 65 years or older. A research assistant and physician performed the Delirium Triage Screen (DTS), designed to be a highly sensitive rule-out test, and the Brief Confusion Assessment Method (bCAM), designed to be a highly specific rule-in test for delirium. The reference standard for delirium was a comprehensive psychiatrist assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. All assessments were independently conducted within 3 hours of one another. Sensitivities, specificities, and likelihood ratios with their 95% confidence intervals (95% CIs) were calculated.
Results |
Of 406 enrolled patients, 50 (12.3%) had delirium diagnosed by the psychiatrist reference standard. The DTS was 98.0% sensitive (95% CI 89.5% to 99.5%), with an expected specificity of approximately 55% for both raters. The DTS's negative likelihood ratio was 0.04 (95% CI 0.01 to 0.25) for both raters. As the complement, the bCAM had a specificity of 95.8% (95% CI 93.2% to 97.4%) and 96.9% (95% CI 94.6% to 98.3%) and a sensitivity of 84.0% (95% CI 71.5% to 91.7%) and 78.0% (95% CI 64.8% to 87.2%) when performed by the physician and research assistant, respectively. The positive likelihood ratios for the bCAM were 19.9 (95% CI 12.0 to 33.2) and 25.2 (95% CI 13.9 to 46.0), respectively. If the research assistant DTS was followed by the physician bCAM, the sensitivity of this combination was 84.0% (95% CI 71.5% to 91.7%) and specificity was 95.8% (95% CI 93.2% to 97.4%). If the research assistant performed both the DTS and bCAM, this combination was 78.0% sensitive (95% CI 64.8% to 87.2%) and 97.2% specific (95% CI 94.9% to 98.5%). If the physician performed both the DTS and bCAM, this combination was 82.0% sensitive (95% CI 69.2% to 90.2%) and 95.8% specific (95% CI 93.2% to 97.4%).
Conclusion |
In older ED patients, this 2-step approach (highly sensitive DTS followed by highly specific bCAM) may enable health care professionals, regardless of clinical background, to efficiently screen for delirium. Larger, multicenter trials are needed to confirm these findings and to determine the effect of these assessments on delirium recognition in the ED.
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| Author contributions: JHH, JFS, RDS, ABS, and EWE conceived the trial. JHH, AW, AS, JFS, RDS, ABS, and EWE participated in the study design. JHH, AW, and JS recruited patients and collected the data. JHH, AS, RDS, and AJG analyzed the data. All authors participated in the interpretation of results. JHH drafted the article and all authors contributed to its critical review and revision. JHH takes responsibility for the paper as a whole. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Dr. Han and this study were funded by the Emergency Medicine Foundation Career Development Award and National Institutes of Health K23AG032355. This project was also supported by the National Center for Research Resources, grant UL1 RR024975-01, and is now at the National Center for Advancing Translational Sciences, grant 2 UL1 TR000445-06. Dr. Vasilevskis was supported in part by the National Institutes of Health (K23AG040157). Dr. Ely was supported in part by the National Institutes of Health (R01AG027472 and R01AG035117), and a Veteran Affairs MERIT award. Drs. Vasilevskis, Schnelle, Dittus, and Ely are also supported by the Veteran Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC). The funders played no role in data collection, analysis, or interpretation of findings or the decision to submit the article. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, Emergency Medicine Foundation, and Veteran Affairs. |
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| Publication dates: Available online July 31, 2013. |
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| Please see page 458 for the Editor's Capsule Summary of this article. |
Vol 62 - N° 5
P. 457-465 - novembre 2013 Retour au numéro
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