A systematic review of studies reporting on neuropsychological and functional domains used for assessment of recovery from delirium in acute hospital patients.

OBJECTIVES: Assessing for recovery in delirium is essential in guiding ongoing investigation and treatment. Yet, there is little scrutiny and no research or clinical consensus on how recovery should be measured. We reviewed studies which used tests of neuropsychological domains and functional ability to track recovery of delirium longitudinally in acute hospital settings. METHODS/DESIGN: We systematically searched databases (MEDLINE, PsycInfo, CINAHL, Embase, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials), from inception to October 14th , 2022. Inclusion criteria were: adult acute hospital patients (≥18 years) diagnosed with delirium by a validated tool; 1+ repeat assessment using an assessment tool measuring domains of delirium/functional recovery ≤7 days from baseline. Two reviewers independently screened articles, performed data extraction, and assessed risk of bias. A narrative data synthesis was completed. RESULTS: From 6533 screened citations, we included 39 papers (reporting 32 studies), with 2370 participants with delirium. Studies reported 21 tools with an average of four repeat assessments including baseline (range 2-10 assessments within ≤7 days), measuring 15 specific domains. General cognition, functional ability, arousal, attention and psychotic features were most commonly assessed for longitudinal change. Risk of bias was moderate to high for most studies. CONCLUSIONS: There was no standard approach for tracking change in specific domains of delirium. The methodological heterogeneity of studies was too high to draw firm conclusions on the effectiveness of assessment tools to measure delirium recovery. This highlights the need for standardised methods for assessing recovery from delirium.

Three key areas in progressing delirium practice and knowledge: recognition and relief of distress, new directions in delirium epidemiology and developing better research assessments.

Delirium presents formidable challenges: it affects one in four of older hospitalised adults, greatly elevates the risk of multiple short- and long-term complications including dementia and causes significant distress. Delirium care remains generally poor. Yet, there are clear grounds for optimism; the last decade has seen impactful policy advances and a tripling of research output. Here, we highlight three linked areas which have strong potential to transform delirium practice and knowledge in the near term. Delirium-related distress is strikingly underrepresented in practice guidance and research. Proactive recognition combined with effective clinical responses based on good communication provides a critical and largely untapped opportunity to improve care. Delirium epidemiology research is well positioned to produce novel insights through advanced prospective designs in populations such as emergency medical patients with detailed pre-, intra- and post-delirium assessments allied with fluid, imaging and other biomarkers. Research-grade assessment of delirium currently involves a chaotic array of tools, methods and diagnostic algorithms. Areas for development: expand and analytically distinguish the range of features assessed (including distress), optimise feature assessment including use of validated neuropsychological tests where possible, produce standardised algorithms which articulate explicit pathways from features to diagnosis, and create new fine-grained approaches to the measurement of severity. Delirium practice and knowledge show accelerating growth. This is encouraging but much of the necessary progress is still to come. Innovation in these three highlighted areas, as well as many others, will open up exciting possibilities in enhancing the care of patients with this common and often devastating condition.

Early-Life Socioeconomic Position and the Accumulation of Health-Related Deficits by Midlife in the 1958 British Birth Cohort Study.

Reducing population levels of frailty is an important goal, and preventing its development in midadulthood could be pivotal. There is limited evidence on associations between childhood socioeconomic position (SEP) and frailty. Using data on the 1958 British birth cohort (followed from 1958 to 2016; n = 8,711), we aimed to 1) establish the utility of measuring frailty in midlife, by examining associations between a 34-item frailty index at age 50 years (FI50y) and mortality at ages 50-58 years, and 2) examine associations between early-life SEP and FI50y and investigate whether these associations were explained by adult SEP. Hazard ratios for mortality increased with increasing frailty; for example, the sex-adjusted hazard ratio for the highest quintile of FI50y versus the lowest was 4.07 (95% confidence interval (CI): 2.64, 6.25). Lower early-life SEP was associated with higher FI50y. Compared with participants born in the highest social class, the estimated total effect on FI50y was 42.0% (95% CI: 35.5, 48.4) for participants born in the lowest class, with the proportion mediated by adult SEP being 0.45% (95% CI: 0.35, 0.55). Mediation by adult SEP was negligible for other early-life SEP classes. Findings suggest that early-life SEP is associated with frailty and that adult SEP only partially explains this association. Results highlight the importance of improving socioeconomic circumstances across the life course to reduce inequalities in midlife frailty.

Recurrent delirium over 12 months predicts dementia: results of the Delirium and Cognitive Impact in Dementia (DECIDE) study.

BACKGROUND: Delirium is common, distressing and associated with poor outcomes. Previous studies investigating the impact of delirium on cognitive outcomes have been limited by incomplete ascertainment of baseline cognition or lack of prospective delirium assessments. This study quantified the association between delirium and cognitive function over time by prospectively ascertaining delirium in a cohort aged ≥ 65 years in whom baseline cognition had previously been established. METHODS: For 12 months, we assessed participants from the Cognitive Function and Ageing Study II-Newcastle for delirium daily during hospital admissions. At 1-year, we assessed cognitive decline and dementia in those with and without delirium. We evaluated the effect of delirium (including its duration and number of episodes) on cognitive function over time, independently of baseline cognition and illness severity. RESULTS: Eighty two of 205 participants recruited developed delirium in hospital (40%). One-year outcome data were available for 173 participants: 18 had a new dementia diagnosis, 38 had died. Delirium was associated with cognitive decline (-1.8 Mini-Mental State Examination points [95% CI -3.5 to -0.2]) and an increased risk of new dementia diagnosis at follow up (OR 8.8 [95% CI 1.9-41.4]). More than one episode and more days with delirium (>5 days) were associated with worse cognitive outcomes. CONCLUSIONS: Delirium increases risk of future cognitive decline and dementia, independent of illness severity and baseline cognition, with more episodes associated with worse cognitive outcomes. Given that delirium has been shown to be preventable in some cases, we propose that delirium is a potentially modifiable risk factor for dementia.

Hospitalisation without delirium is not associated with cognitive decline in a population-based sample of older people-results from a nested, longitudinal cohort study.

BACKGROUND: Acute hospitalisation and delirium have individually been shown to adversely affect trajectories of cognitive decline but have not previously been considered together. This work aimed to explore the impact on cognition of hospital admission with and without delirium, compared to a control group with no hospital admissions. METHODS: The Delirium and Cognitive Impact in Dementia (DECIDE) study was nested within the Cognitive Function and Ageing Study II (CFAS II)-Newcastle cohort. CFAS II participants completed two baseline interviews, including the Mini-Mental State Examination (MMSE). During 2016, surviving participants from CFAS II-Newcastle were recruited to DECIDE on admission to hospital. Participants were reviewed daily to determine delirium status.During 2017, all DECIDE participants and age, sex and years of education matched controls without hospital admissions during 2016 were invited to repeat the CFAS II interview. Delirium was excluded in the control group using the Informant Assessment of Geriatric Delirium Scale (i-AGeD). Linear mixed effects modelling determined predictors of cognitive decline. RESULTS: During 2016, 82 of 205 (40%) DECIDE participants had at least one episode of delirium. At 1 year, 135 of 205 hospitalised participants completed an interview along with 100 controls. No controls experienced delirium (i-AGeD>4). Delirium was associated with a faster rate of cognitive decline compared to those without delirium (ß = -2.2, P < 0.001), but number of hospital admissions was not (P = 0.447). CONCLUSIONS: These results suggest that delirium during hospitalisation rather than hospitalisation per se is a risk factor for future cognitive decline, emphasising the need for dementia prevention studies that focus on delirium intervention.

The Dementias Platform UK (DPUK) Data Portal.

The Dementias Platform UK Data Portal is a data repository facilitating access to data for 3 370 929 individuals in 42 cohorts. The Data Portal is an end-to-end data management solution providing a secure, fully auditable, remote access environment for the analysis of cohort data. All projects utilising the data are by default collaborations with the cohort research teams generating the data. The Data Portal uses UK Secure eResearch Platform infrastructure to provide three core utilities: data discovery, access, and analysis. These are delivered using a 7 layered architecture comprising: data ingestion, data curation, platform interoperability, data discovery, access brokerage, data analysis and knowledge preservation. Automated, streamlined, and standardised procedures reduce the administrative burden for all stakeholders, particularly for requests involving multiple independent datasets, where a single request may be forwarded to multiple data controllers. Researchers are provided with their own secure 'lab' using VMware which is accessed using two factor authentication. Over the last 2 years, 160 project proposals involving 579 individual cohort data access requests were received. These were received from 268 applicants spanning 72 institutions (56 academic, 13 commercial, 3 government) in 16 countries with 84 requests involving multiple cohorts. Projects are varied including multi-modal, machine learning, and Mendelian randomisation analyses. Data access is usually free at point of use although a small number of cohorts require a data access fee.

Impairments in balance and mobility identify delirium in patients with comorbid dementia.

ABSTRACTDiagnosing delirium superimposed on dementia (DSD) remains challenging because of a lack of specific tools, though motor dysfunction in delirium has been relatively under-explored. This study aimed to use dysfunction in balance and mobility (with the Hierarchical Assessment of Balance And Mobility: HABAM) to identify DSD. This is a cross-sectional multicenter study, recruiting consecutive patients ≥70 years admitted to five acute or rehabilitation hospitals in Ireland, Italy, Portugal, and Switzerland. Delirium was diagnosed using DSM-5 criteria; dementia was determined by the Mini-Mental State Examination and the Questionnaire of Cognitive Decline in the Elderly. HABAM score was recorded at admission. Out of 114 patients (mean age ± SD = 82 ± 7; 54% female), dementia alone was present in 24.6% (n = 28), delirium alone in 18.4% (n = 21) and DSD in 27.2% (n = 31). Patients with DSD had a mean HABAM score 7 points greater than those with dementia alone (19.8 ± 8.7 vs 12.5 ± 9.5; p < 0.001); 70% of participants with DSD were correctly identified using the HABAM at a cut off of 22 (sensitivity 61%, specificity 79%, AUC = 0.76). Individuals with delirium have worse motor function than those without delirium, even in the context of comorbid dementia. Measuring motor function using the HABAM in older people at admission may help to diagnose DSD.

Challenges and opportunities in understanding dementia and delirium in the acute hospital.

In an Essay, Andrew Jackson and colleagues discuss challenges in the diagnosis and management of older people with dementia and delirium in acute hospitals.

Detecting delirium superimposed on dementia: diagnostic accuracy of a simple combined arousal and attention testing procedure.

BACKGROUND: Detecting delirium superimposed on dementia (DSD) can be challenging because assessment partly relies on cognitive tests that may be abnormal in both conditions. We hypothesized that a combined arousal and attention testing procedure would accurately detect DSD. METHODS: Patients aged ≥70 years were recruited from five hospitals across Europe. Delirium was diagnosed by physicians using DSM-5 criteria using information from nurses, carers, and medical records. Dementia was ascertained by the Informant Questionnaire on Cognitive Decline in the Elderly. Arousal was measured using the Observational Scale of Level of Arousal (OSLA), which assesses eye opening, eye contact, posture, movement, and communication. Attention was measured by participants signaling each time an "A" was heard when "S-A-V-E-A-H-A-A-R-T" was read out. RESULTS: The sample included 114 persons (mean age 82 years (SD 7); 54% women). Dementia alone was present in 25% (n = 28), delirium alone in 18% (n = 21), DSD in 27% (n = 31), and neither in 30% (n = 34). Arousal and attention was assessed in n = 109 (96%). Using OSLA, 83% participants were correctly identified as having delirium (sensitivity 85%, specificity 82%, AUROC 0.92). The attention task correctly classified 76% of participants with delirium (sensitivity 90%, specificity 64%, AUROC 0.80). Combining scores correctly classified 91% of participants with delirium (sensitivity 84%, specificity 92%, AUROC 0.94). Diagnostic accuracy remained high in the subgroup with dementia (93% correctly classified, sensitivity 94%, specificity 92%, AUROC 0.98). CONCLUSIONS: This combined arousal-attention assessment to detect DSD was brief yet had high diagnostic accuracy. Such an approach could have clinical utility for diagnosing DSD.

Protocol for the Delirium and Cognitive Impact in Dementia (DECIDE) study: A nested prospective longitudinal cohort study.

BACKGROUND: Delirium is common, affecting at least 20% of older hospital inpatients. It is widely accepted that delirium is associated with dementia but the degree of causation within this relationship is unclear. Previous studies have been limited by incomplete ascertainment of baseline cognition or a lack of prospective delirium assessments. There is an urgent need for an improved understanding of the relationship between delirium and dementia given that delirium prevention may plausibly impact upon dementia prevention. A well-designed, observational study could also answer fundamental questions of major importance to patients and their families regarding outcomes after delirium. The Delirium and Cognitive Impact in Dementia (DECIDE) study aims to explore the association between delirium and cognitive function over time in older participants. In an existing population based cohort aged 65 years and older, the effect on cognition of an episode of delirium will be measured, independent of baseline cognition and illness severity. The predictive value of clinical parameters including delirium severity, baseline cognition and delirium subtype on cognitive outcomes following an episode of delirium will also be explored. METHODS: Over a 12 month period, surviving participants from the Cognitive Function and Ageing Study II-Newcastle will be screened for delirium on admission to hospital. At the point of presentation, baseline characteristics along with a number of disease relevant clinical parameters will be recorded. The progression/resolution of delirium will be monitored. In those with and without delirium, cognitive decline and dementia will be assessed at one year follow-up. We will evaluate the effect of delirium on cognitive function over time along with the predictive value of clinical parameters. DISCUSSION: This study will be the first to prospectively elucidate the size of the effect of delirium upon cognitive decline and incident dementia. The results will be used to inform future dementia prevention trials that focus on delirium intervention.

For Your Local Eyes Only: Culture-Specific Face Typicality Influences Perceptions of Trustworthiness.

Recent findings show that typical faces are judged as more trustworthy than atypical faces. However, it is not clear whether employment of typicality cues in trustworthiness judgment happens across cultures and if these cues are culture specific. In two studies, conducted in Japan and Israel, participants judged trustworthiness and attractiveness of faces. In Study 1, faces varied along a cross-cultural dimension ranging from a Japanese to an Israeli typical face. Own-culture typical faces were perceived as more trustworthy than other-culture typical faces, suggesting that people in both cultures employ typicality cues when judging trustworthiness, but that the cues, indicative of typicality, are culture dependent. Because perceivers may be less familiar with other-culture typicality cues, Study 2 tested the extent to which they rely on available facial information other than typicality, when judging other-culture faces. In Study 2, Japanese and Israeli faces varied from either Japanese or Israeli attractive to unattractive with the respective typical face at the midpoint. For own-culture faces, trustworthiness judgments peaked around own-culture typical face. However, when judging other-culture faces, both cultures also employed attractiveness cues, but this effect was more apparent for Japanese participants. Our findings highlight the importance of culture when considering the effect of typicality on trustworthiness judgments.

Integrative "-Omics" Analysis in Primary Human Hepatocytes Unravels Persistent Mechanisms of Cyclosporine A-Induced Cholestasis.

Cyclosporine A (CsA) is an undecapeptide with strong immunosuppressant activities and is used a lot after organ transplantation. Furthermore, it may induce cholestasis in the liver. In general, the drug-induced cholestasis (DIC) pathway includes genes involved in the uptake, synthesis, conjugation, and secretion of bile acids. However, whether CsA-induced changes in the cholestasis pathway in vitro are persistent for repeated dose toxicity has not yet been investigated. To explore this, primary human hepatocytes (PHH) were exposed to a subcytotoxic dose of 30 µM CsA daily for 3 and 5 days. To investigate the persistence of induced changes upon terminating CsA exposure after 5 days, a subset of PHH was subjected to a washout period (WO-period) of 3 days. Multiple -omics analyses, comprising whole genome analysis of DNA methylation, gene expression, and microRNA expression, were performed. The CsA-treatment resulted after 3 and 5 days, respectively, in 476 and 20 differentially methylated genes (DMGs), 1353 and 1481 differentially expressed genes (DEGs), and in 22 and 29 differentially expressed microRNAs (DE-miRs). Cholestasis-related pathways appeared induced during CsA-treatment. Interestingly, 828 persistent DEGs and 6 persistent DE-miRs but no persistent DMGs were found after the WO-period. These persistent DEGs and DE-miRs showed concordance for 22 genes. Furthermore, 29 persistent DEGs changed into the same direction as observed in livers from cholestasis patients. None of those 29 DEGs which among others relate to oxidative stress and lipid metabolism are yet present in the DIC pathway or cholestasis adverse outcome pathway (AOP) thus presenting novel findings. In summary, we have demonstrated for the first time a persistent impact of repeated dose administration of CsA on genes and microRNAs related to DIC in the gold standard human liver in vitro model with PHH.

Dynamic Interplay between the Transcriptome and Methylome in Response to Oxidative and Alkylating Stress.

In recent years, it has been shown that free radicals not only react directly with DNA but also regulate epigenetic processes such as DNA methylation, which may be relevant within the context of, for example, tumorigenesis. However, how these free radicals impact the epigenome remains unclear. We therefore investigated whether methyl and hydroxyl radicals, formed by tert-butyl hydroperoxide (TBH), change temporal DNA methylation patterns and how this interferes with genome-wide gene expression. At three time points, TBH-induced radicals in HepG2 cells were identified by electron spin resonance spectroscopy. Total 5-methylcytosine (5mC) levels were determined by liquid chromatography and tandem mass spectrometry and genome-wide changes in 5mC and gene expression by microarrays. Induced methylome changes rather represent an adaptive response to the oxidative stress-related reactions observed in the transcriptome. More specifically, we found that methyl radicals did not induce DNA methylation directly. An initial oxidative and alkylating stress-related response of the transcriptome during the early phase of TBH treatment was followed by an epigenetic response associated with cell survival signaling. Also, we identified genes of which the expression seems directly regulated by DNA methylation. This work suggests an important role of the methylome in counter-regulating primary oxidative and alkylating stress responses in the transcriptome to restore normal cell function. Altogether, the methylome may play an important role in counter-regulating primary oxidative and alkylating stress responses in the transcriptome presumably to restore normal cell function.

Increasing delirium skills at the front door: results from a repeated survey on delirium knowledge and attitudes.

BACKGROUND: delirium is under-recognised in comparison to other common and serious acute disorders. A 2006 survey of UK junior doctors (not undertaking specialist training) identified poor knowledge of the diagnostic criteria and treatment of delirium. We hypothesised that increased prominence accorded to delirium in the form of national initiatives and guidelines may have had an impact on understanding among junior doctors. OBJECTIVE: we repeated a multi-centre survey of knowledge of and attitudes to delirium in junior doctors (not undertaking specialist training) assessing unselected acute medical presentations (the 'medical take'). DESIGN: questionnaire-based survey in 48 acute hospitals in UK and Ireland. METHODS: we used questionnaires designed to test understanding of delirium, including prevalence, knowledge of the DSM-IV diagnostic criteria, use of specific screening tools, association with adverse outcomes and pharmacological management. RESULTS: one thousand two hundred and fifteen trainee physicians participated. Compared with the 2006 cohort, improvements were seen in 9 of 17 knowledge-based questions and overall score improved in the 2013 cohort. Nonetheless, significant deficits in knowledge, particularly for the diagnostic criteria for delirium, remained. CONCLUSIONS: despite improvements in some aspects of delirium knowledge, the diagnostic criteria for delirium remain poorly understood. Challenges remain in ensuring adequate training for junior doctors in delirium.

Delirium superimposed on dementia: a survey of delirium specialists shows a lack of consensus in clinical practice and research studies.

BACKGROUND: Despite advances in delirium knowledge and the publication of best practice guidelines, uncertainties exist regarding assessment of Delirium Superimposed on Dementia (DSD). An international survey of delirium specialists was undertaken to evaluate current practice. METHODS: Invitations to participate in an online survey were distributed by email among members of four international delirium associations with additional publication on their websites. The survey covered the assessment and diagnosis of DSD in clinical practice and research studies. Questions were structured around current practice and attitudes. RESULTS: The 205 responders were mostly confident that they could detect DSD with 60% rating their confidence at 7 or above on a likert scale of 0 (none) to 10 (excellent). Seventy-six percent felt that Dementia with Lewy Bodies (DLB) was the most challenging dementia subtype in which to diagnose DSD. Several scales were used to assess for the presence of DSD including the Confusion Assessment Method (CAM) (54%), DSM-5 criteria (25%) and CAM-ICU (15%). Responders stated that attention (71%), fluctuation in cognitive status (65%), and arousability (41%) were the most clinically useful features to assess when diagnosing DSD. Motor fluctuations were also deemed important but 61% had no specific test to monitor these. CONCLUSIONS: The largest survey of DSD practice to date demonstrates that despite good levels of confidence in recognizing DSD, there exists a lack of consensus concerning assessment and diagnosis globally. These findings suggest the need for the development of more research leading to precise diagnostic criteria and comprehensive guidelines regarding the assessment and diagnosis of DSD.

Disentangling neural processes of egocentric and allocentric mental spatial transformations using whole-body photos of self and other.

Mental imagery of one's body moving through space is important for imagining changing visuospatial perspectives, as well as for determining how we might appear to other people. Previous neuroimaging research has implicated the temporoparietal junction (TPJ) in this process. It is unclear, however, how neural activity in the TPJ relates to the rotation perspectives from which mental spatial transformation (MST) of one's own body can take place, i.e. from an egocentric or an allocentric perspective. It is also unclear whether TPJ involvement in MST is self-specific or whether the TPJ may also be involved in MST of other human bodies. The aim of the current study was to disentangle neural processes involved in egocentric versus allocentric MSTs of human bodies representing self and other. We measured functional brain activity of healthy participants while they performed egocentric and allocentric MSTs in relation to whole-body photographs of themselves and a same-sex stranger. Findings indicated higher blood oxygen level-dependent (BOLD) response in bilateral TPJ during egocentric versus allocentric MST. Moreover, BOLD response in the TPJ during egocentric MST correlated positively with self-report scores indicating how awkward participants felt while viewing whole-body photos of themselves. These findings considerably advance our understanding of TPJ involvement in MST and its interplay with self-awareness.

What is typical is good: the influence of face typicality on perceived trustworthiness.

The role of face typicality in face recognition is well established, but it is unclear whether face typicality is important for face evaluation. Prior studies have focused mainly on typicality's influence on attractiveness, although recent studies have cast doubt on its importance for attractiveness judgments. Here, we argue that face typicality is an important factor for social perception because it affects trustworthiness judgments, which approximate the basic evaluation of faces. This effect has been overlooked because trustworthiness and attractiveness judgments have a high level of shared variance for most face samples. We show that for a continuum of faces that vary on a typicality-attractiveness dimension, trustworthiness judgments peak around the typical face. In contrast, perceived attractiveness increases monotonically past the typical face, as faces become more like the most attractive face. These findings suggest that face typicality is an important determinant of face evaluation.

Worsening cognitive impairment and neurodegenerative pathology progressively increase risk for delirium.

BACKGROUND: Delirium is a profound neuropsychiatric disturbance precipitated by acute illness. Although dementia is the major risk factor this has typically been considered a binary quantity (i.e., cognitively impaired versus cognitively normal) with respect to delirium risk. We used humans and mice to address the hypothesis that the severity of underlying neurodegenerative changes and/or cognitive impairment progressively alters delirium risk. METHODS: Humans in a population-based longitudinal study, Vantaa 85+, were followed for incident delirium. Odds for reporting delirium at follow-up (outcome) were modeled using random-effects logistic regression, where prior cognitive impairment measured by Mini-Mental State Exam (MMSE) (exposure) was considered. To address whether underlying neurodegenerative pathology increased susceptibility to acute cognitive change, mice at three stages of neurodegenerative disease progression (ME7 model of neurodegeneration: controls, 12 weeks, and 16 weeks) were assessed for acute cognitive dysfunction upon systemic inflammation induced by bacterial lipopolysaccharide (LPS; 100 µg/kg). Synaptic and axonal correlates of susceptibility to acute dysfunction were assessed using immunohistochemistry. RESULTS: In the Vantaa cohort, 465 persons (88.4 ± 2.8 years) completed MMSE at baseline. For every MMSE point lost, risk of incident delirium increased by 5% (p = 0.02). LPS precipitated severe and fluctuating cognitive deficits in 16-week ME7 mice but lower incidence or no deficits in 12-week ME7 and controls, respectively. This was associated with progressive thalamic synaptic loss and axonal pathology. CONCLUSION: A human population-based cohort with graded severity of existing cognitive impairment and a mouse model with progressing neurodegeneration both indicate that the risk of delirium increases with greater severity of pre-existing cognitive impairment and neuropathology.

Towards an understanding of why undergraduate teaching about delirium does not guarantee gold-standard practice--results from a UK national survey.

BACKGROUND: delirium is common and serious, yet frequently missed by medical staff. It is known that delirium is widely taught and examined in UK medical schools; however, what is taught, and how such teaching is delivered, remains unknown. The primary aim of this study was to determine the content of UK undergraduate medical education about delirium and establish how it is delivered. A secondary aim was to highlight and share examples of gold-standard teaching on delirium. METHODS: all UK undergraduate medical schools were invited to complete a survey. Schools were asked to describe how delirium was taught and to provide delirium-related learning outcomes. Learning outcomes were mapped to the three overarching themes outlined in Tomorrow's Doctors (knowledge, skills and attitudes). RESULTS: 24/31 schools (77%) provided responses. In line with previous work, delirium was widely taught and examined. 18/24 schools reported at least one learning outcome that mapped to the knowledge domain, 19/24 for the skills domain and 2/24 for the attitudes domain. 4/24 evaluated the impact of sessions and 3/24 involved patients and the public in teaching. 13/24 schools were confident that exposure to delirium was guaranteed. Innovative teaching methods were reported by a number of schools; weblinks to examples are provided. DISCUSSION: there was widespread failure to address attitudes on delirium within teaching, to evaluate the impact of sessions, to involve patients and the public in teaching and to guarantee exposure to delirium. Future teaching interventions should be directed at attitudinal outcomes, using a synthesis of clinical experience with multidisciplinary interaction and supportive technologies.

Montreal Cognitive Assessment for the diagnosis of Alzheimer's disease and other dementias.

BACKGROUND: Dementia is a progressive syndrome of global cognitive impairment with significant health and social care costs. Global prevalence is projected to increase, particularly in resource-limited settings. Recent policy changes in Western countries to increase detection mandates a careful examination of the diagnostic accuracy of neuropsychological tests for dementia. OBJECTIVES: To determine the diagnostic accuracy of the Montreal Cognitive Assessment (MoCA) at various thresholds for dementia and its subtypes. SEARCH METHODS: We searched MEDLINE, EMBASE, BIOSIS Previews, Science Citation Index, PsycINFO and LILACS databases to August 2012. In addition, we searched specialised sources containing diagnostic studies and reviews, including MEDION (Meta-analyses van Diagnostisch Onderzoek), DARE (Database of Abstracts of Reviews of Effects), HTA (Health Technology Assessment Database), ARIF (Aggressive Research Intelligence Facility) and C-EBLM (International Federation of Clinical Chemistry and Laboratory Medicine Committee for Evidence-based Laboratory Medicine) databases. We also searched ALOIS (Cochrane Dementia and Cognitive Improvement Group specialized register of diagnostic and intervention studies). We identified further relevant studies from the PubMed 'related articles' feature and by tracking key studies in Science Citation Index and Scopus. We also searched for relevant grey literature from the Web of Science Core Collection, including Science Citation Index and Conference Proceedings Citation Index (Thomson Reuters Web of Science), PhD theses and contacted researchers with potential relevant data. SELECTION CRITERIA: Cross-sectional designs where all participants were recruited from the same sample were sought; case-control studies were excluded due to high chance of bias. We searched for studies from memory clinics, hospital clinics, primary care and community populations. We excluded studies of early onset dementia, dementia from a secondary cause, or studies where participants were selected on the basis of a specific disease type such as Parkinson's disease or specific settings such as nursing homes. DATA COLLECTION AND ANALYSIS: We extracted dementia study prevalence and dichotomised test positive/test negative results with thresholds used to diagnose dementia. This allowed calculation of sensitivity and specificity if not already reported in the study. Study authors were contacted where there was insufficient information to complete the 2x2 tables. We performed quality assessment according to the QUADAS-2 criteria.Methodological variation in selected studies precluded quantitative meta-analysis, therefore results from individual studies were presented with a narrative synthesis. MAIN RESULTS: Seven studies were selected: three in memory clinics, two in hospital clinics, none in primary care and two in population-derived samples. There were 9422 participants in total, but most of studies recruited only small samples, with only one having more than 350 participants. The prevalence of dementia was 22% to 54% in the clinic-based studies, and 5% to 10% in population samples. In the four studies that used the recommended threshold score of 26 or over indicating normal cognition, the MoCA had high sensitivity of 0.94 or more but low specificity of 0.60 or less. AUTHORS' CONCLUSIONS: The overall quality and quantity of information is insufficient to make recommendations on the clinical utility of MoCA for detecting dementia in different settings. Further studies that do not recruit participants based on diagnoses already present (case-control design) but apply diagnostic tests and reference standards prospectively are required. Methodological clarity could be improved in subsequent DTA studies of MoCA by reporting findings using recommended guidelines (e.g. STARDdem). Thresholds lower than 26 are likely to be more useful for optimal diagnostic accuracy of MoCA in dementia, but this requires confirmation in further studies.