Delirium occurs commonly in hospitalized older patients but is poorly recognized. Although there are a plethora of confirmed delirium screening tools, it’s unclear which tool best suits specific populations.
To assess validation studies of delirium screening programs in non–critically ill hospital inpatients and provide guidance on the selection of screening tool.
The MEDLINE, CINAHL, and PsychInfo databases were searched for studies comparing delirium bedside screening tools with either the Diagnostic and Statistical Manual or International Classification of Diseases characterized diagnosis of delirium in hospital inpatients. Information was also drawn from conference proceedings and discussion with delirium researchers.
Thirty-one studies describing 21 delirium screening tools were included in the systematic review. Nearly all studies were conducted across a broad variety of inpatient settings internationally in elderly inpatients, including patients with dementia but most excluded nonnative language speakers.
The Confusion Assessment Method was the most widely used instrument to identify delirium, however, specific training must ensure optimum performance. The Nurses’ Delirium Screening Checklist seems best suited to the surgical and recovery room setting. The Single Question in Delirium shows promise in oncology patients. The Memorial Delirium Assessment Scale, while demonstrating great measures of validity in the surgical and palliative care setting, may be used a measure of delirium severity. The 4As Test performed well when delirium was superimposed on dementia, but it requires additional study.
Delirium is a serious disorder of attention, cognition, and psychomotor activity that commonly affects older folks. The reported incidence of delirium during entrance in the hospitalized adult population is 3%–29% ( Siddiqi, House, & Holmes, 2006 ). The co-occurrence of delirium in patients with dementia is very high in hospitalized older adults (22%–89%, Fick, Agostini, & Inouye, 2002 ).
The total risk of adverse outcome because of hospitalization in the elderly people, particularly those from residential care centers, is currently high for functional decline and drops ( Friedman, Mendelson, Bingham, & McCann, 2008 ). The adverse outcomes for delirious patients may be even graver. They include multiple medical complications, greater lengths of stay, the chance of not returning to independent living, and death ( Cole et al., 2002; Elie et al., 2000; Inouye, 2006 ). Patients with dementia are particularly difficult to assess for delirium ( Powers et al., 2013 ). However, there are definite advantages to early detection and targeted therapy ( Chong, Chan, Tay, & Ding, 2014; Lundstrom et al., 2005; Mudge, Maussen, Duncan, & Denaro, 2013 ). It is thus imperative that delirium is properly identified and managed to decrease the significant morbidity and mortality, especially in elderly people.
Delirium was described more than 2000 years ago and is a prevalent condition in the hospitalized elderly population. It remains underrecognized ( Inouye, Westendorp, & Saczynski, 2014 ) and is often misdiagnosed ( Inouye, 2006; Voyer, Cole, McCusker, St-Jacques, & Laplante, 2008; Wand et al., 2013 ). By way of example, a recent Australian study revealed that detection of delirium by staff was poor, with staff properly identifying just 23 percent of cases with delirium despite a targeted multimodal educational intervention ( Wand et al., 2014 ). Delirium remains understudied with regard to the proportion of its disease burden ( MacLullich et al., 2013 ).
Delirium was only formally categorized by standardized diagnostic criteria, the Diagnostic and Statistical Manual (DSM) III, in 1980 ( American Psychiatric Association, 1980 ) and at the International Classification for Diseases 10th Edition (ICD-10) in 1992 ( World Health Organization, 1992 ). Prior to its inclusion in the DSM, delirium was described in the literature under different eponyms, such as acute confusional state, toxic encephalopathy, and toxic psychosis. Over the last three decades, there have been significant improvements in the understanding of delirium and with it, revisions in the delirium diagnostic criteria (American Psychiatric Association 1987, 1994, 2013).
There are now numerous screening tools validated for the evaluation of delirium. A recent review by Grover and Kate (2012) comprehensively identified and assessed 38 distinct instruments in use for screening, diagnosis, assessing cognitive function, assessing motor symptoms, risk factors, and grading severity of and quantifying the distress associated with delirium. The plethora of tools available can make it difficult for the clinicians to decide which instrument to use and in what context.
Therefore, the primary aim of this review was to identify, compare, and evaluate validation studies of delirium screening tools used in hospital inpatients. A secondary aim was to give guidance regarding the clinical applicability of the reviewed screening tools to certain patient populations.
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