Evaluation of delirium screening tools in geriatric medical inpatients: a diagnostic test accuracy study

Introduction: screening all unscheduled older adults for delirium is recommended in national guidelines, but there is no consensus on how to perform initial assessment. Aim: to evaluate the test accuracy of five brief cognitive assessment tools for delirium diagnosis in routine clinical practice. Methods: a consecutive cohort of non-elective, elderly care (older than 65 years) hospital inpatients admitted to a geriatric medical assessment unit of an urban teaching hospital. Reference assessments were clinical diagnosis of delirium performed by elderly care physicians. Routine screening tests were: Abbreviated Mental Test (AMT-10, AMT-4), 4 A's Test (4AT), brief Confusion Assessment Method (bCAM), months of the year backwards (MOTYB) and informant Single Question in Delirium (SQiD). Results: we assessed 500 patients, mean age 83 years (range = 66−101). Clinical diagnoses were: 93 of 500 (18.6%) definite delirium, 104 of 500 (20.8%) possible delirium and 277 of 500 (55.4%) no delirium; 266 of 500 (53.2%) were identified as definite or possible dementia. For diagnosis of definite delirium, AMT-4 (cut-point < 3/4) had a sensitivity of 92.7% (95% confidence interval (CI): 84.8–97.3), with a specificity of 53.7% (95% CI: 48.1–59.2); AMT-10 (<4/10), MOTYB (<4/12) and SQiD showed similar performance. bCAM had a sensitivity of 70.3% (95% CI: 58.5–80.3) with a specificity of 91.4% (95% CI: 87.7–94.3). 4AT (>4/12) had a sensitivity of 86.7% (95% CI: 77.5–93.2) and specificity of 69.5% (95% CI: 64.4–74.3). Conclusions: short screening tools such as AMT-4 or MOTYB have good sensitivity for definite delirium, but poor specificity; these tools may be reasonable as a first stage in assessment for delirium. The 4AT is feasible and appears to perform well with good sensitivity and reasonable specificity

Vascular neurocognitive disorders and the vascular risk factors

Dementias are clinical neurodegenerative diseases characterized by permanent and progressive transformation of cognitive functions such as memory, learning capacity, attention, thinking, language, passing judgments, calculation or orientation. Dementias represent a relatively frequent pathology, encountered at about 10% of the population of 65-year olds and 20% of the population of 80-year olds. This review presents the main etiological forms of dementia, which include Alzheimer form of dementia, vascular dementia, dementia associated with alpha-synucleionopathies, and mixed forms. Regarding vascular dementia, the risk factors are similar to those for an ischemic or hemorrhagic cerebrovascular accident: arterial hypertension, diabetes mellitus, dyslipidemia, smoking, obesity, age, alcohol consumption, cerebral atherosclerosis/ arteriosclerosis. Several studies show that efficient management of the vascular risk factors can prevent the expression and/ or progression of dementia. Thus, lifestyle changes such as stress reduction, regular physical exercise, decreasing dietary fat, multivitamin supplementation, adequate control of blood pressure and serum cholesterol, and social integration and mental stimulation in the elderly population are important factors in preventing or limiting the symptoms of dementia, a disease with significant individual, social, and economic implications

Standardizing the Process for Diagnosing Attention Deficit Hyperactivity Disorder (ADHD) in the Primary Care Setting

Standardizing the Process for Diagnosing Attention Deficit Hyperactivity Disorder (ADHD) in the Primary Care Setting Louise Moon Rosales, MSN, APRN Purpose. Attention deficit hyperactivity disorder (ADHD) is a common problem that primary care providers diagnose and treat. Yet, there is a current lack of standardization to diagnose ADHD in many primary care settings. This purpose of this project was to standardize the process of diagnosing ADHD through introduction of screening instruments. Objectives included: assessment of clinician knowledge and attitudes about ADHD, implementation of a clinician-directed educational intervention, and development of a work flow procedure to standardize the diagnostic process. Methods. Clinicians at a family practice participated in a project to standardize the ADHD diagnostic process. Knowledge and attitude assessments via informal interviews and pre-intervention surveys were conducted with the five practice clinicians; three physicians and two nurse practitioners. An ADHD educational intervention was implemented followed by post-intervention surveys. A work flow procedure was implemented to assist in diagnosing ADHD through the use of psychometrically proven instruments embedded into the electronic health record (EHR). The scales used were the Vanderbilt ADHD Assessment Scale and Wender Utah Rating Scale. To measure clinician and subsequent patient outcomes, a data collection plan was created. Results. All five clinicians completed the pre and post knowledge and attitudinal surveys. The results demonstrated increased provider knowledge and confidence in diagnosing ADHD. A standardized process to diagnose ADHD was successfully developed, and scales to aid in the diagnosis of ADHD were embedded into the EHR. A data collection plan to monitor ongoing clinician and patient outcomes was implemented. Conclusions. An educational intervention and standardized workflow procedure by which to diagnose ADHD were successfully implemented in a family practice, thereby laying the foundation for continued quality improvement in the diagnosis of ADHD. To refine the process and gain a better appreciation of the impact of the intervention on clinicians and patients, data collection on established outcome measures continues. Keywords. Attention deficit hyperactivity disorder, ADHD, diagnosis, rating scales, primary care

The discriminative capacity of CBCL/1½-5 -DSM5 scales to identify disruptive and internalizing disorders in preschool children

This paper studies the discriminative capacity of CBCL/1½-5 (Manual for the ASEBA Preschool-Age Forms & Profiles, University of Vermont, Research Center for Children, Youth, & Families, Burlington, 2000) DSM5 scales attention deficit and hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety and depressive problems for detecting the presence of DSM5 (DSM5 diagnostic and statistical manual of mental disorders, APA, Arlington, 2013) disorders, ADHD, ODD, Anxiety and Mood disorders, assessed through diagnostic interview, in children aged 3-5. Additionally, we compare the clinical utility of the CBCL/1½-5-DSM5 scales with respect to analogous CBCL/1½-5 syndrome scales. A large community sample of 616 preschool children was longitudinally assessed for the stated age group. Statistical analysis was based on ROC procedures and binary logistic regressions. ADHD and ODD CBCL/1½-5-DSM5 scales achieved good discriminative ability to identify ADHD and ODD interview's diagnoses, at any age. CBCL/1½-5-DSM5 Anxiety scale discriminative capacity was fair for unspecific anxiety disorders in all age groups. CBCL/1½-5-DSM5 depressive problems' scale showed the poorest discriminative capacity for mood disorders (including depressive episode with insufficient symptoms), oscillating into the poor-to-fair range. As a whole, DSM5-oriented scales generally did not provide evidence better for discriminative capacity than syndrome scales in identifying DSM5 diagnoses. CBCL/1½-5-DSM5 scales discriminate externalizing disorders better than internalizing disorders for ages 3-5. Scores on the ADHD and ODD CBCL/1½-5-DSM5 scales can be used to screen for DSM5 ADHD and ODD disorders in general populations of preschool childre

Application of PROMETHEE method for demand side management (DSM) options ranking

Demand Side Management (DSM) is a method used to modify the electrical load profile of a consumer to reduce its electricity bill. There are various types of DSM options available but mostly involve costs to be incurred by consumers. Moreover, the effectiveness of a DSM option depends on various factors including investment cost, saved energy, payback period and more. Multi Criteria Decision Analysis (MCDA) is a tool that can be applied to make decision when a lot of factors to be taken into account. In DSM, Analytical Hierarchy Process (AHP) is one MCDA technique that is widely used in ranking the DSM options. However, AHP requires additive aggregation that may cause lost in detailed information. This paper presents another MDCA method; Preference Ranking Organization Method for Enrichment Evaluation (PROMETHEE) to perform the ranking of DSM options. PROMETHEE (I and II) were used in a case study and the results shows that PROMETHEE give the same result as AHP. PROMETHEE has an advantage over AHP as it does not require additive aggregation even the problem is multi-dimensional and could provide visual analysis

Possible Causes of Increased Domestic Violence among Military Veterans: PTSD or Mefloquine Toxicity?

After more than a decade at war, our returning service members and their families are facing enormous amounts of difficulty when returning home. PTSD and TBI, the signature wounds of these wars, have been well covered in the media. The family struggles have remained hidden and mostly undiscussed. These families are facing very specific issues in military relationships like infidelity, substance misuse, and intimate partner violence; the latter of which military families are three times more likely to experience when compared to the civilian population. There is a potential effect on caregiver burden in the role of PTSD as a factor for relationship difficulties as well. Many times, spouses can struggle with no longer a being just a wife; they have become full-time, exclusive caregivers. This loss of personal identity is one of many things that can cause a cascade of mental health problems for the spouse. As much as spouses are excited to have their service member home, incorporating the service member back into the family can be stressful. Spouses may be taken off guard to find themselves experiencing deep sadness at the changes they perceive in their veteran. These are some of the more common relationship issues in a marriage where PTSD is present. Yet there seems to be a darker side to all of this. With the higher rates of domestic violence, this paper is researching the possibility of being wrong about PTSD or potentially there may be some previously unrecognized confounder that has not been looked at yet. Mefloquine is an anti-malaria pill given to our military members that is already known to confound the diagnoses of PTSD and TBI. This literature review will assess the difficulties that these veterans and family members are facing by looking at the different possibilities of what could be making veterans more violent

Impulsivity and Symptoms of Nicotine Dependence in a Young Adult Population

Introduction: Impulsivity is widely regarded as a risk factor for drug dependence. However, its relationship with the symptomatology of nicotine dependence is poorly understood. Methods: To examine the nature of these relationships, we recruited 404 daily and occasional smokers from a predominantly student population and assessed the association between impulsivity, as measured by the Barratt Impulsiveness Scale (BIS-11) and several self-reported measures of smoking rate and nicotine dependence, including the Diagnostic and Statistical Manual’s (DSM-IV) criteria. Results: Overall, impulsivity was high throughout the entire sample but only modestly associated with nicotine dependence. Within the diagnostic criteria of nicotine dependence, two symptoms, which reflect automatized or habitual smoking, were most strongly associated with impulsivity. Conclusion: These data support recent human and animal work, which suggests that impulsivity is linked to the formation of habitual drug use, and are discussed within the framework of a dual-system account of drug seeking