Detecting Delirium and Subsyndromal Delirium Using Different Diagnostic Criteria among Demented Long-Term Care Residents

doi:10.1016/j.jamda.2008.09.006

Journal of the American Medical Directors Association

Volume 10, Issue 3, March 2009, Pages 181-188

https://doi.org/10.1016/j.jamda.2008.09.006 Get rights and content

Objectives

To evaluate the impact of using different diagnostic criteria on prevalence rates of delirium and subsyndromal delirium (SSD) among demented long-term care (LTC) residents.

Design

Descriptive study.

Setting

LTC settings in Quebec City, Canada.

Participants

Participants were 155 individuals aged 65 and older, with dementia.

Measurements

(1) Prevalence rates of delirium according to: (a) the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-III-R, and DSM-IV) and (b) the Confusion Assessment Method (CAM) algorithms for definite and probable delirium; and (2) prevalence rates of SSD employing 2 definitions described in previous studies.

Results

Prevalence rates of delirium according to each set of criteria were 26.5% for DSM-III; 29% for DSM-IV-TR; 41.3% for DSM-III-R; 45.8% for CAM algorithm for definite delirium; and 70.3% for CAM algorithm for probable delirium. A total of 109 subjects (70.3%) were identified as delirious consistent with at least one classification and 37 (23.9%) met all the sets of criteria considered. Prevalence rates for SSD were 75 (48.4%) and 78 (50.3%) depending on the definition employed.

Conclusion

Prevalence rates for delirium are much affected by the diagnostic formulations used. The use of DSM-IV-TR among this population could result in fewer cases being identified as delirious and thus compromise proper care for those individuals. Considering that SSD was prevalent among this population, a systematic implementation of protocols targeting risk factors of delirium might be beneficial among demented LTC residents.

Section snippets

Study Settings and Selection of Participants

Subjects were recruited in 3 LTC facilities and 1 LTC unit of a large regional hospital, all located within the Quebec City region of Canada. A convenience sampling procedure was used. All patients aged 65 years and older with dementia and no history of psychiatric illness were eligible for this study. Following clearances from all appropriate institutional ethics committees, a study nurse met with the head nurse of every unit in each participating facility to identify eligible patients.

Results

Baseline characteristics of the 155 residents are presented in Table 1. The mean age of the participants was 86.3 ± 6.9 (mean ± SD) and most of them were female (73.6%). The mean time since admission to their LTC facility was 2.6 years (SD: 2.3). The degree of cognitive impairment in this population was important, with a mean score of 91.0 (SD: 49.0) on the HDS Scale. About 41% of participants had a high level of comorbidity (score ≥8 on the Charlson Comorbidity Index) and the mean number of

Discussion

This study investigated the effect that using different classification systems had on prevalence rates (detection rates) of delirium among demented elderly residents in LTC settings. It also aimed at describing the frequency of subsyndromal delirium among this same population according to 2 different definitions.28, 29 As far as the authors are aware, the present study is the first to address these particular issues among this distinctive population.

The first observation that can be made from

Acknowledgment

The authors would thank Dr Martin G. Cole and Dr Jane McCusker for their constructive comments on an earlier version of the manuscript and Christine Danjou, Sophie Dufort, Christine Noebert, and Marie-Pierre Poulin for their dedicated work.

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Prevalence, risk factors, and outcomes of subsyndromal delirium in older adults in hospital or long-term care settings: A systematic review and meta-analysis
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Citation Excerpt :
In the ‘outcome’ criteria, nine studies achieved the maximum of three points. According to the NOS scale, 11 articles10,26,27,30,32,33,35-37,40,43 were of HQ (median 7 points) and 5 articles18,19,28,29,31 were of MQ (median 6 points), which shows that the overall quality of these articles was moderate to high. six articles17,34,38,39,41,42 used the AHRQ checklist with a range of scores from 4 to 7 points (median 6 points).
Subsyndromal delirium (SSD) refers to the presence of one or more delirium criteria without a diagnosis of delirium, and it is common in older patients. The prevalence, risk factors, and outcomes of SSD are explored herein.
A systematic review and meta-analysis.
PubMed, Web of Science, OVID, PsycINFO, CINAHL, Cochrane Library, CNKI, CBM, Chongqing VIP, and Wanfang databases were searched for studies published from inception to 2021, without language restrictions. Independent reviewers performed quality assessments, data extraction and analysis for all included studies.
A total of 2,426 titles were initially identified, and 22 studies (5,125 individuals) were included in the systematic review. The prevalence of SSD in older adults was 36.4% (95%CI:0.28 to 0.44). Significant risk factors were dementia (OR 5.061, 95%CI:2.320 to 11.043), lower ADL scores (OR 1.706, 95%CI:1.149 to 2.533), lower hemoglobin (SMD -0.21, 95%CI: -0.333 to -0.096), and advanced age (SMD 0.358, 95% CI:0.194 to 0.522), and SSD was associated with poor outcomes, including cognitive and functional decline, increased length of hospital stay, and a higher mortality rate.
SSD has a high prevalence and is associated with many risk factors and poor outcomes. Clinical oversight of patients with SSD should be increased.
The systematic review was registered on the International Prospective Register of Systematic Review (CRD42021276070).
Subsyndromal delirium has a high prevalence and an association with many risk factors and poor outcomes.
Delirium in the elderly
2021, NPG Neurologie - Psychiatrie - Geriatrie
La confusion est un événement sévère, annonciateur d’une urgence médicale. Chez la personne âgée, elle est associée à une morbidité et à une mortalité significatives. Elle se définit comme une perturbation cérébrale de début soudain et fluctuante. S’y associent des troubles de l’attention et de la fonction cognitive. Cette revue narrative explore les éléments d’épidémiologie, de physiopathologie, de diagnostic et de surveillance. Elle alerte sur les liens identifiés entre la Covid-19 et la confusion. Elle appelle à une prise en charge majoritairement non pharmacologique et multidimensionnelle, ainsi qu’à un renforcement des formations ciblées et des équipes mobiles de gériatrie qualifiées en psychogériatrie. De façon générale, l’approche thérapeutique de la confusion est holistique et humaniste plus qu’orientée sur l’organe.
Delirium is a severe condition that can herald a medical emergency. In the elderly, it is associated with significant morbidity and mortality. It is defined as a brain disturbance with a sudden, fluctuating onset. These disturbances are associated with disruptions in attention and cognitive function. This narrative review explores elements of epidemiology, pathophysiology, diagnosis and surveillance. It alerts on the links identified between Covid-19 and confusional states. It calls for a predominantly non-pharmacological and multidimensional management, and a reinforcement of targeted training and the promotion of mobile geriatric teams qualified in psychogeriatrics. In general, the therapeutic approach to delirium is holistic and humanistic rather than being oriented towards the organ.
A Decade of JAMDA
2017, Journal of the American Medical Directors Association
Radar: New empirical evidence that supports its validity and relevance for delirium screening
2017, NPG Neurologie - Psychiatrie - Geriatrie
Le delirium est un grave syndrome gériatrique fréquemment sous-détecté dans les milieux cliniques. Cette étude avait pour objectif de tester la validité de l’outil Repérage actif du delirium au cours de la routine (Radar) lorsqu’il est utilisé par des préposés aux bénéficiaires (PAB) en résidence intermédiaire auprès d’aînés atteints de déficits cognitifs (n = 31). Les résultats de la sensibilité et la spécificité sont respectivement de 100 % et 77 %. De tous les aînés ayant obtenu un résultat positif au Radar mais qui n’étaient pas atteints d’un delirium, 88 % présentaient des changements cognitifs préoccupants. Les résultats de la fidélité inter-juge présentent des pourcentages d’accord variant de 94,2 % à 99 %. En conclusion, l’outil Radar est valide lorsqu’il est utilisé par des PAB en résidence intermédiaire.
Delirium is a serious geriatric syndrome that is frequently under-detected in clinical settings. The purpose of this study was to test the validity of Recognizing acute delirium as part of your routine (Radar) when used by nursing-assistants in residential care homes for cognitively impaired residents (n = 31). The results support the validity of the tool in this environment with acceptable sensitivity and specificity of 100 % and 77 %, respectively. Furthermore, of all the residents who scored positive on Radar but who did not meet the criteria for delirium, 88 % nevertheless presented serious cognitive impairment. Inter-rater reliability of Radar when used by assistant-nurses is excellent with percentage of agreement between 94.2 % and 99 %. Given these results, it would be appropriate to integrate Radar as a routine assessment in residential care.
Delirium diagnostic and classification challenges in palliative care: Subsyndromal delirium, comorbid delirium-dementia, and psychomotor subtypes
2014, Journal of Pain and Symptom Management
Delirium often presents difficult diagnostic and classification challenges in palliative care settings.
To review three major areas that create diagnostic and classification challenges in relation to delirium in palliative care: subsyndromal delirium (SSD), delirium in the context of comorbid dementia, and classification of psychomotor subtypes, and to identify knowledge gaps and research priorities in relation to these three areas of focus.
We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant PubMed literature searches as the knowledge synthesis strategy in this review.
We identified six (SSD), 33 (dementia), and 44 (psychomotor subtypes) articles of relevance in relation to the focus of our review. Recent literature data highlight the frequency and impact of SSD, the relevance of comorbid dementia, and the propensity for a hypoactive presentation of delirium in the palliative population. The differential diagnoses to consider are wide and include pain, fatigue, mood disturbance, psychoactive medication effects, and other causes for altered consciousness.
Challenges in the diagnosis and classification of delirium in people with advanced disease are compounded by the generalized disturbance of central nervous system function that occurs in the seriously ill, often with comorbid illness, including dementia. Further research is needed to delineate the pathophysiological and clinical associations of these presentations and thus inform therapeutic strategies. The expanding aged population and growing focus on dementia care in palliative care highlight the need to conduct this research.
Latent class analysis of the multivariate Delirium Index in long-term care settings
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: Funding for this work was through an Investigator Award to Philippe Voyer from the Quebec Health Research Funds (Fonds de la recherche en santé du Québec) and the Quebec Nursing Research Funds (Fonds de la recherche en sciences infirmières du Québec). Financial support also came from the Saint-Sacrement Hospital Foundation.

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Original studyDetecting Delirium and Subsyndromal Delirium Using Different Diagnostic Criteria among Demented Long-Term Care Residents

Objectives

Design

Setting

Participants

Measurements

Results

Conclusion

Section snippets

Study Settings and Selection of Participants

Results

Discussion

Acknowledgment

Am J Geriatr Psychiatry

J Pain Symptom Manage

Am J Emerg Med

Clin Med

J Am Med Dir Assoc

Neurochem Int

J Chronic Dis

Older adults discharged from the hospital with delirium: 1-year outcomes

J Am Geriatr Soc

Does delirium contribute to poor hospital outcomes?A three-site epidemiologic study

J Gen Intern Med

Delirium symptoms in post-acute care: prevalent, persistent, and associated with poor functional recovery

J Am Geriatr Soc

The risk of dementia and death after delirium

Age Ageing

Delirium part one: Clinical features, risk factors and assessment

Nurs Stand

Multicomponent targeted intervention to prevent delirium in hospitalized older patients: what is the economic value?

Med Care

Prognosis of delirium in elderly hospital patients

CMAJ

Prevalence and detection of delirium in elderly emergency department patients

CMAJ

Detection of delirium by bedside nurses using the confusion assessment method

J Am Geriatr Soc

Delirium superimposed on dementia: A systematic review

J Am Geriatr Soc

Consequences of not recognizing delirium superimposed on dementia in hospitalized elderly individuals

J Gerontol Nurs

The impact of different diagnostic criteria on prevalence rates for delirium

Dement Geriatr Cogn Disord

An empirical study of different diagnostic criteria for delirium among elderly medical inpatients

J Neuropsychiatry Clin Neurosci

An empirical study of diagnostic criteria for delirium

Am J Psychiatry

A brief review of the history of delirium as a mental disorder

Hist Psychiatry

Diagnostic and Statistical Manual of Mental Disorders

Diagnostic and Statistical Manual of Mental Disorders

Diagnostic and Statistical Manual of Mental Disorders

Original study
Detecting Delirium and Subsyndromal Delirium Using Different Diagnostic Criteria among Demented Long-Term Care Residents