Attention! A good bedside test for delirium?

peer-reviewedBackground Routine delirium screening could improve delirium detection, but it remains unclear as to which screening tool is most suitable. We tested the diagnostic accuracy of the following screening methods (either individually or in combination) in the detection of delirium: MOTYB (months of the year backwards); SSF (Spatial Span Forwards); evidence of subjective or objective 'confusion'.Methods We performed a cross-sectional study of general hospital adult inpatients in a large tertiary referral hospital. Screening tests were performed by junior medical trainees. Subsequently, two independent formal delirium assessments were performed: first, the Confusion Assessment Method (CAM) followed by the Delirium Rating Scale-Revised 98 (DRS-R98). DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) criteria were used to assign delirium diagnosis. Sensitivity and specificity ratios with 95% CIs were calculated for each screening method.Results 265 patients were included. The most precise screening method overall was achieved by simultaneously performing MOTYB and assessing for subjective/objective confusion (sensitivity 93.8%, 95% CI 82.8 to 98.6; specificity 84.7%, 95% CI 79.2 to 89.2). In older patients, MOTYB alone was most accurate, whereas in younger patients, a simultaneous combination of SSF (cutoff 4) with either MOTYB or assessment of subjective/objective confusion was best. In every case, addition of the CAM as a second-line screening step to improve specificity resulted in considerable loss in sensitivity.Conclusions Our results suggest that simple attention tests may be useful in delirium screening. MOTYB used alone was the most accurate screening test in older people.PUBLISHEDpeer-reviewe

Cumulative effects of early poverty on cortisol in young children: Moderation by autonomic nervous system activity

The relation of the cumulative experience of poverty in infancy and early childhood to child cortisol at age 48 months was examined in a prospective longitudinal sample of children and families (N=1,292) in predominantly low-income and rural communities in two distinct regions of the United States. Families were seen in the home for data collection and cumulative experience of poverty was indexed by parent reported income-to-need ratio and household chaos measures collected between child ages 2mos and 48mos. For the analysis presented here, three saliva samples were also collected over an approximate 90 minute interval at child age 48mos and were assayed for cortisol. ECG data were also collected during a resting period and during the administration of a mildly challenging battery of cognitive tasks. Mixed model analysis indicated that child cortisol at 48 months decreased significantly over the sampling time period and that cumulative time in poverty (number of years income-to-need less than or equal to 1) and cumulative household chaos were significantly related to a flatter trajectory for cortisol change and to an overall higher level of cortisol, respectively. Findings also indicated that respiratory sinus arrhythmia derived from the ECG data moderated the association between household chaos and child cortisol and that increase in respiratory sinus arrhythmia during the cognitive task was associated with an overall lower level of cortisol at 48 months