Augmenting Mental Health Support for Patients Accessing Different Degrees of Formal Psychiatric Care through a Supportive Text Messaging Program: Protocol for a Randomized Controlled Trial.

Patients feel more vulnerable when accessing community mental health programs for the first time or after being discharged from psychiatric inpatient units. Long wait times for follow-up appointments, shortage of mental health professionals, lack of service integration, and scarcity of tailored support can weaken their connection to the health care system. As a result, patients can present low adherence, dissatisfaction with treatment, and recurrent hospitalizations. Finding solutions to avoid unnecessary high-cost services and providing tailored and cost-effective mental health interventions may reduce the health system burden and augment patient support. We propose implementing an add-on, supportive text messaging service (Text4Support), developed using cognitive-behavioural therapy (CBT) principles to augment mental health support for patients attending to or being discharged from psychiatric care in Nova Scotia, Canada. This randomized controlled trial aims to investigate the effectiveness of Text4Support in improving mental health outcomes and overall mental well-being compared with usual care. We also will examine the intervention's impact on health services utilization and patient satisfaction. The results from this study will provide evidence on stepped and technology-based mental health care, which will contribute to generating new knowledge about mental health innovations in various clinical contexts, which is not only helpful for the local context but to other jurisdictions in Canada and abroad that are seeking to improve their health care.

A systematic review and meta-analysis of the accuracy of the clock drawing test (CDT) in the identification of delirium in older hospitalised patients.

Objective: Delirium is a common neurocognitive syndrome among hospitalised older adults. The clock drawing test (CDT) is a relatively simple bedside test of cognitive function. This systematic review and meta-analysis examine the accuracy of the CDT in identifying delirium in hospitalised older adults.Methods: PRISMA guidelines were used to report the identified studies. Pubmed, SCOPUS, and Ovid and EBSCO platforms (including MEDLINE ®, PsycINFO, PsycEXTRA, EMCARE, CINAHL and EMBASE databases) were searched. Studies were assessed for methodological quality using the Downs and Black Tool. Data were extracted regarding the number of delirious/not delirious, number with normal and abnormal CDT, age, and MMSE scores, and information regarding CDT scoring, criteria for diagnosis of delirium and setting of the study. Analysis was carried out with the "Mada" and "Metatron" packages of R software.Results: Fifteen studies were examined. The number of participants was 2199, of whom 597 (27.15%) were diagnosed with delirium. The overall sensitivity of CDT in the absence of any formal cognitive test was 0.76 (0.58-0.87) with specificity of 0.70 (0.51-0.83). When the MMSE was taken into account, the specificity and sensitivity reduced to 0.51. Diagnostic criteria for delirium, scoring method of CDT, age of participants and setting significantly (p < 0.05) affect the sensitivity and specificity of the CDT.Conclusion: Although, the CDT is generally considered to be a simple and easy to administer screening tool for cognitive impairment in older hospitalised adults, when a more formal cognitive test is used its sensitivity and specificity to detect delirium is low.

Comparison of novel tools with traditional cognitive tests in detecting delirium in elderly medical patients.

BACKGROUND: Efficient detection of delirium and comorbid delirium-dementia is a key diagnostic challenge. Development of new, efficient delirium-focused methods of cognitive assessment is a key challenge for improved detection of neurocognitive disorders in everyday clinical practice. AIM: To compare the accuracy of two novel bedside tests of attention, vigilance and visuospatial function with conventional bedside cognitive tests in identifying delirium in older hospitalized patients. METHODS: 180 consecutive elderly medical inpatients (mean age 79.6 ± 7.2; 51% female) referred to a psychiatry for later life consultation-liaison service with delirium, dementia, comorbid delirium-dementia and cognitively intact controls. Participants were assessed cross-sectionally with conventional bedside cognitive tests [WORLD, Months Backward test (MBT), Spatial span, Vigilance A and B, Clock Drawing test and Interlocking Pentagons test] and two novel cognitive tests [Lighthouse test, Letter and Shape Drawing test (LSD)-4]. RESULTS: Neurocognitive diagnoses were delirium (n = 44), dementia (n = 30), comorbid delirium-dementia (n = 60) and no neurocognitive disorder (n = 46). All conventional tests had sensitivity of > 70% for delirium, with best overall accuracy for the Vigilance-B (78.3%), Vigilance-A (77.8%) and MBT (76.7%) tests. The sustained attention component of the Lighthouse test was the most distinguishing of delirium (sensitivity 84.6%; overall accuracy 75.6%). The LSD-4 had sensitivity of 74.0% and overall accuracy 74.4% for delirium identification. Combining tests allowed for enhanced sensitivity (> 90%) and overall accuracy (≥ 75%) with the highest overall accuracy for the combination of MBT-Vigilance A and the combined Vigilance A and B tests (both 78.3%). When analyses were repeated for those with dementia, there were similar findings with the MBT-Vigilance A the most accurate overall combination (80.0%). Combining the Lighthouse-SA with the LSD-4, a fail in either test had sensitivity for delirium of 91.4 with overall accuracy of 74.4%. CONCLUSION: Bedside tests of attention, vigilance and visuospatial ability can help to distinguish neurocognitive disorders, including delirium, from other presentations. The Lighthouse test and the LSD-4 are novel tests with high accuracy for detecting delirium.

Attention, vigilance, and visuospatial function in hospitalized elderly medical patients: relationship to delirium syndromal status and motor subtype profile.

ABSTRACTBackground:The early and effective detection of neurocognitive disorders poses a key diagnostic challenge. We examined performance on common cognitive bedside tests according to differing delirium syndromal status and clinical (motor) subtypes in hospitalized elderly medical inpatients. METHODS: A battery of nine bedside cognitive tests was performed on elderly medical inpatients with DSM-IV delirium, subsyndromal delirium (SSD), and no delirium (ND). Patients with delirium were compared according to clinical (motor) subtypes. RESULTS: A total of 198 patients (mean age 79.14 ± 8.26) were assessed with full syndromal delirium (FSD: n = 110), SSD (n = 45), and ND (n = 43). Delirium status was not associated with differences in terms of gender distribution, age, or overall medication use. Dementia burden increased with greater delirium status. Overall, the ability to meaningfully engage with the tests varied from 59% for the Vigilance B test to 85% for Spatial Span Forward test and was lowest in patients with FSD, where engagement ranged from 32% for the Vigilance B test to 77% for the Spatial Span Forwards test. The ND group was distinguished from SSD group for the Months of the year backwards, Vigilance B, global VSP, Clock Drawing test, and Interlocking Pentagons test. The SSD group was distinguished from the FSD group by Vigilance A, Spatial Span Forward, and Spatial Span Backwards. Regarding differences among motor subtypes in terms of percentage engagement and performance, the No subtype group had higher ratings across all tests. Delirious patients with no subtype had significantly lower scores on the DRS-R98 than for the other three subtype categories. CONCLUSIONS: Simple bedside tests of attention, vigilance, and visuospatial ability are useful in distinguishing neurocognitive disorders, including SSD from other presentations.

Development of the four-item Letter and Shape Drawing test (LSD-4): A brief bedside test of visuospatial function.

Conventional bedside tests of visuospatial function such as the Clock Drawing (CDT) and Intersecting Pentagons (IPT) lack consistency in delivery and interpretation. We compared performance on a novel test of visuospatial ability - the LSD - with the IPT, CDT and MMSE in 180 acute elderly medical inpatients [mean age 79.7±7.1 (range 62-96); 91 females (50.6%)]. 124 (69%) scored ≤23 on the MMSE; 60 with mild (score 18-23) and 64 with severe (score ≤17) impairment. 78 (43%) scored ≥6 on the CDT, while for the IPT, 87 (47%) scored ≥4. The CDT and IPT agreed on the classification of 138 patients (77%) with modest-strong agreement with the MMSE categories. Correlation between the LSD and visuospatial tests was high. A four-item version of the LSD incorporating items 1,10,12,15 had high correlation with the LSD-15 and strong association with MMSE categories. The LSD-4 provides a brief and easily interpreted bedside test of visuospatial function that has high coverage of elderly patients with neurocognitive impairment, good agreement with conventional tests of visuospatial ability and favourable ability to identify significant cognitive impairment. [181 words].

Attention, vigilance and visuospatial function in hospitalized elderly medical patients: Relationship to neurocognitive diagnosis.

OBJECTIVE: Efficient detection of neurocognitive disorders is a key diagnostic challenge. We explored how simple bedside tests of attention, vigilance and visuospatial function might assist in identifying delirium in hospitalized patients. METHODS: Performance on a battery of bedside cognitive tests was compared in elderly medical inpatients with DSM-IV delirium, dementia, comorbid delirium-dementia, and no neurocognitive disorder. RESULTS: 193 patients [mean age 79.9±7.3; 97 male] were assessed with delirium (n=45), dementia (n=33), comorbid delirium-dementia (n=65) and no neurocognitive disorder (NNCD) (n=50). The ability to meaningfully engage with the tests varied from 84% (Spatial Span Forwards) to 57% (Vigilance B test), and was especially problematic among the comorbid delirium-dementia group. The NNCD was distinguished from the delirium groups for most tests, and from the dementia group for the Vigilance B test and the Clock Drawing Test. The dementia group differed from delirium groups in respect of the Months Backward Test, Vigilance A and B tests, Global assessment of visuospatial ability and the Interlocking Pentagons Test. Overall, patients with delirium were best identified by three tests - the Months Backward Test, Vigilance A test and the Global Assessment of visuospatial function with failure to correctly complete any two of these predicting delirium status in 80% of cases. CONCLUSION: Simple bedside tests of attention, vigilance and visuospatial ability can help to distinguish neurocognitive disorders, including delirium, from other presentations. There is a need to develop more accurate methods specifically designed to assess patients with neurocognitive disorder who are unable to engage with conventional tests.

The Letter and Shape Drawing (LSD) test: An efficient and systematised approach to testing of visuospatial function.

The automation and systemisation of the next generation of cognitive assessment approaches have the potential to change how clinicians assess and interact with patients. This may be especially pertinent in the case of delirium, as current methods often rely on the subjective opinion of clinicians and specialists, with potential for the condition to be overlooked or misdiagnosed. Currently, one of the most commonly used tests, is the clock-drawing test, which has relatively wide appeal as a cognitive screening instrument due to its clinical utility and psychometric properties. However, there are a number of inconsistencies associated with its use and interpretation. In this paper, we describe a new assessment methodology that we have developed, facilitated by the advances in tablet technology. In trials, our "Letter and Shape Drawing (LSD)" tool, involving both an automated scoring capability and a simpler user interaction, has demonstrated correlation with other conventional cognitive test methods although some optimisation requirements remain.