The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts.

BACKGROUND: Quantifying the severity of delirium is essential to advancing clinical care by improved understanding of delirium effect, prognosis, pathophysiology, and response to treatment. OBJECTIVE: To develop and validate a new delirium severity measure (CAM-S) based on the Confusion Assessment Method. DESIGN: Validation analysis in 2 independent cohorts. SETTING: Three academic medical centers. PATIENTS: The first cohort included 300 patients aged 70 years or older scheduled for major surgery. The second included 919 medical patients aged 70 years or older. MEASUREMENTS: A 4-item short form and a 10-item long form were developed. Association of the maximum CAM-S score during hospitalization with hospital and posthospital outcomes related to delirium was evaluated. RESULTS: Representative results included adjusted mean length of stay, which increased across levels of short-form severity from 6.5 days (95% CI, 6.2 to 6.9 days) to 12.7 days (CI, 11.2 to 14.3 days) (P for trend < 0.001) and across levels of long-form severity from 5.6 days (CI, 5.1 to 6.1 days) to 11.9 days (CI, 10.8 to 12.9 days) (P for trend < 0.001). Representative results for the composite outcome of adjusted relative risk of death or nursing home residence at 90 days increased progressively across levels of short-form severity from 1.0 (referent) to 2.5 (CI, 1.9 to 3.3) (P for trend < 0.001) and across levels of long-form severity from 1.0 (referent) to 2.5 (CI, 1.6 to 3.7) (P for trend < 0.001). LIMITATION: Data on clinical outcomes were measured in an older data set limited to patients aged 70 years or older. CONCLUSION: The CAM-S provides a new delirium severity measure with strong psychometric properties and strong associations with important clinical outcomes. PRIMARY FUNDING SOURCE: National Institute on Aging.

The Language of Delirium: Keywords for Identifying Delirium from Medical Records.

Electronic medical records (EMRs) offer the opportunity to streamline the search for patients with possible delirium. The purpose of the current study was to identify words and phrases commonly noted in charts of patients with delirium. The current study included 67 patients (nested within a cohort study of 300 patients) ages 70 and older undergoing major elective surgery with evidence of confusion in their medical charts. Eight keywords or phrases had positive predictive values of 60% to 100% for delirium. Keywords were charted more often in nursing notes than physician notes. A brief list of keywords may serve as a building block for a methodology to screen for possible delirium from charts, with particular attention to nursing notes, for research and real-time clinical decision making.

Interprofessional Rounds Improve Timing of Appropriate Palliative Care Consultation on a Hospitalist Service.

Despite known benefits, palliative care (PC) consultation for hospitalized patients remains underutilized. The objective was to improve frequency and timeliness of appropriate inpatient PC consultation. On 2 of 11 hospitalist teams, a PC representative attended discharge rounds twice a week. Control teams' discharge rounds were unenhanced. Subjects were all patients admitted to a hospitalist service in a quaternary academic medical center. The primary outcome was change in provision of PC consultation over time; the secondary outcome was change in time-to-consult (days). Hospitalists were surveyed regarding the intervention. The unadjusted proportion of patients receiving PC consultation increased from 2.7% to 5.2% on the intervention teams. Compared to control teams over time and adjusting for multiple covariates, the intervention increased PC consultation (difference-in-difference [DID] = 1.0 percentage-point increase [95% CI = 0.3%-1.8%]) and decreased time to consult (DID = -5 days [95% CI = -11 to -1]) in patients admitted for noncancer diagnoses. Hospitalists thought the intervention facilitated effective patient care without increased burden.

Neuropsychological profiles of an elderly cohort undergoing elective surgery and the relationship between cognitive performance and delirium.

OBJECTIVES: To examine baseline (preoperative) neuropsychological test performance in a cohort of elderly individuals undergoing elective surgery and the association between specific neuropsychological domains and postoperative delirium. DESIGN: Ongoing prospective cohort study. SETTING: Successful Aging after Elective Surgery Study. PARTICIPANTS: Elderly adults (N=300) scheduled for elective (noncardiac) surgery. MEASUREMENTS: Neuropsychological testing, including standardized assessments of memory, divided and sustained attention, speed of mental processing, verbal fluency, working memory, language, and an overall measure of premorbid cognitive functioning, was performed 2 to 4 weeks before surgery. The relationship between the individual neuropsychological tests and delirium status was examined using linear regression, adjusting for age, sex, and education. RESULTS: Study participants were generally highly educated (mean years of education 15.0±2.9), with minimal or no cognitive impairment (mean Modified Mini-Mental State Examination score 93.2 out of 100). After adjustment, participants who developed postoperative delirium had performed significantly lower preoperatively on measures of speed of mental processing and divided attention (Trail-Making Test Part B, mean difference 17.55, P=.02), category fluency (animal naming, mean difference -1.94, P=.01), sustained visual attention (Visual Search and Attention, mean difference -3.19, P<.001), and working memory with new learning and recall (Hopkins Verbal Learning Test-Revised Total mean difference -0.53 to -0.79, P<.01). CONCLUSION: Individuals who later develop delirium have lower scores on tests evaluating the areas of complex attention, executive functioning, and rapid access to verbal knowledge or semantic networks at baseline. Future studies to better understand how the cognitive profiles identified may predispose individuals to developing delirium may help pave the way to greater understanding of the mechanisms of delirium.

NICE to HELP: operationalizing National Institute for Health and Clinical Excellence guidelines to improve clinical practice.

The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom developed guidelines for the diagnosis, prevention, and management of delirium in July 2010 that included 10 recommendations for delirium prevention. The Hospital Elder Life Program (HELP) is a targeted multicomponent strategy that has proven effective and cost-effective at preventing functional and cognitive decline in hospitalized older persons. HELP provided much of the basis for seven of the NICE recommendations. Given interest by new HELP sites to meet NICE guidelines, three new protocols addressing hypoxia, infection, and pain that were not previously included in the HELP program were developed. In addition, the NICE dehydration guideline included constipation, which was not specifically addressed in the HELP protocols. This project describes the systematic development of three new protocols (hypoxia, infection, pain) and the expansion of an existing HELP protocol (constipation and dehydration) to achieve alignment between the HELP protocols and NICE guidelines. Following the Institute of Medicine recommendations for developing trustworthy guidelines, an interdisciplinary group of experts conducted a systematic review of current literature, rated the quality of the evidence, developed intervention protocols based on the highest-quality evidence, and submitted the protocols first to internal review and then to external review by an interdisciplinary panel of experts. The protocols were revised based on the review process and incorporated into the HELP materials. Inclusion of these protocols enhances the scope of the HELP program and allows fulfillment of NICE guideline recommendations for delirium prevention. The rigorous process applied may provide a useful example for updating existing guidelines or protocols that may be applicable to a broad range of clinical applications.

A tale of two methods: chart and interview methods for identifying delirium.

OBJECTIVES: To compare chart- and interview-based methods for identification of delirium. DESIGN: Prospective cohort study. SETTING: Two academic medical centers. PARTICIPANTS: Individuals aged 70 and older undergoing major elective surgery (N = 300) (majority orthopedic surgery). MEASUREMENTS: Participants were interviewed daily during hospitalization for delirium using the Confusion Assessment Method (CAM; interview-based method), and their medical charts were reviewed for delirium using a validated chart-review method (chart-based method). Rate of agreement of the two methods and characteristics of those identified using each approach were examined. Predictive validity for clinical outcomes (length of stay, postoperative complications, discharge disposition) was compared. In the absence of a criterion standard, predictive value could not be calculated. RESULTS: The cumulative incidence of delirium was 23% (n = 68) according to the interview-based method, 12% (n = 35) according to the chart-based method, and 27% (n = 82) according to the combined approach. Overall agreement was 80%; kappa was 0.30. The methods differed in detection of psychomotor features and time of onset. The chart-based method missed delirium in individuals that the CAM identified who were lacking features of psychomotor agitation or inappropriate behavior. The CAM-based method missed chart-identified cases occurring during the night shift. The combined method had high predictive validity for all clinical outcomes. CONCLUSIONS: Interview- and chart-based methods have specific strengths for identification of delirium. A combined approach captures the largest number and broadest range of delirium cases.

EFFECT OF PREOPERATIVE PAIN AND DEPRESSIVE SYMPTOMS ON THE DEVELOPMENT OF POSTOPERATIVE DELIRIUM.

BACKGROUND: Preoperative pain and depression predispose patients to delirium. Our goal was to determine whether pain and depressive symptoms interact to increase delirium risk. METHODS: We enrolled 459 persons without dementia aged ≥70 years scheduled for elective orthopedic surgery. At baseline, participants reported their worst and average pain within seven days and current pain on a 0-10 scale. Depressive symptoms were assessed using the 15-item Geriatric Depression Scale and chart. Delirium was assessed with the Confusion Assessment Method and chart. We examined the relationship between preoperative pain, depressive symptoms and delirium using multivariable analysis of pain and delirium stratified by presence of depressive symptoms. FINDINGS: Delirium, occurring in 23% of the sample, was significantly higher in those with depressive symptoms at baseline than those without (relative risk, RR, 1·6, 95% confidence interval, CI, 1·2-2·3). Preoperative pain was associated with an increased adjusted risk for delirium across all pain measures (RR from 1·07-1·08 per point of pain). In stratified analyses, patients with depressive symptoms had a 21% increased risk for delirium for each one-point increase in worst pain score, demonstrating a significant interaction (P=0·049). Similarly, a significant 13% increased risk for delirium was demonstrated for a one-point increase in average pain score, but the interaction did not achieve statistical significance. INTERPRETATION: Preoperative pain and depressive symptoms demonstrated increased risk for delirium independently and with substantial interaction, suggesting a cumulative impact. Thus, pain and depression are vulnerability factors for delirium that should be assessed before surgery. FUNDING: U.S. National Institute on Aging.