Improving recognition of delirium in clinical practice: a call for action

The purpose of this correspondence article is to report opinion amongst experts in the delirium field as to why, despite on-going training for all health professionals, delirium continues to be under recognised. Consensus was obtained by means of two conference workshops and an online survey of members of the European Delirium Association. Major barriers to recognition at an individual level include ignorance about the benefit of treating delirium. At an organisational level, reflecting socio-cultural attitudes, barriers include a low strategic and financial priority and the fact that delirium is an orphan condition falling between specialties

Validation of the 4AT tool for delirium assessment in specialist palliative care settings: protocol of a prospective diagnostic test accuracy study [version 1; peer review: 2 approved]

BACKGROUND: Delirium is a serious and distressing neuropsychiatric condition, which is prevalent across all palliative care settings. Hypoactive delirium is particularly common, but difficult to recognize, partly due to overlapping symptoms with depression and dementia. Delirium screening tools can lead to earlier identification and hence better management of patients. The 4AT (4 ‘A’s Test) is a brief tool for delirium detection, designed for use in clinical practice. It has been validated in 17 studies in over 3,700 patients. The test is currently used in specialist palliative care units, but has not been validated in this setting. The aim of the study is to determine the diagnostic accuracy of the 4AT for delirium detection against a reference standard, in hospice inpatients. METHODS: 240 participants will be recruited from the inpatient units of two hospices in Scotland. If a patient lacks capacity to consent, agreement will be sought from a legal proxy. Each participant will complete the 4AT and a reference standard assessment based on the diagnostic delirium criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This will be supplemented by tests of cognition and attention, including reverse days of the week, counting down from 20 to 1, Vigilance 'A', the Observational Scale for Level of Arousal, the modified Richmond Agitation Sedation Scale and the Delirium Rating Scale-Revised-98. The assessments will be conducted in a randomized order by two independent clinicians, who will be blinded to the results until both are complete. Primary outcomes will be the sensitivity and specificity of the 4AT in detecting delirium. DISCUSSION: The findings will inform clinical practice regarding delirium assessment in palliative care settings. TRIAL REGISTRATION: ISRCTN ISRCTN97417474 (21/02/2020)

The DSM-5 criteria, level of arousal and delirium diagnosis: Inclusiveness is safer

© 2014 European Delirium Association et al.; licensee BioMed Central Ltd. Background: Delirium is a common and serious problem among acutely unwell persons. Alhough linked to higher rates of mortality, institutionalisation and dementia, it remains underdiagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) provides an opportunity to examine the constructs underlying delirium as a clinical entity.Discussion: Altered consciousness has been regarded as a core feature of delirium; the fact that consciousness itself should be physiologically disrupted due to acute illness attests to its clinical urgency. DSM-5 now operationalises 'consciousness' as 'changes in attention'. It should be recognised that attention relates to content of consciousness, but arousal corresponds to level of consciousness. Reduced arousal is also associated with adverse outcomes. Attention and arousal are hierarchically related; level of arousal must be sufficient before attention can be reasonably tested.Summary: Our conceptualisation of delirium must extend beyond what can be assessed through cognitive testing (attention) and accept that altered arousal is fundamental. Understanding the DSM-5 criteria explicitly in this way offers the most inclusive and clinically safe interpretation

Klinisch management van delier bij ouderen

status: publishe

Management of delirium on acute geriatric wards: A survey in Belgian hospitals

This survey shows the need for a uniform practice guideline on the prevention, detection and management of delirium. There are currently no studies available, which show that the implementation of a guideline for delirium improves the quality of care [27]. However, the implementation of guidelines for other diseases, as acute myocardial infarction, has already proven their effect on quality of care [28]. The College of Geriatrics aims to develop a practice guideline based on the best evidence currently available and on international guidelines, such as National Institute for Health and Clinical Excellence (NICE) Guideline [1]. In this way, hospitals can implement evidence-based prevention, screening and standard intervention care plans to maintain uniformity and quality of care in delirium management. In doing so, the challenge will be to provide strategic education at individual and organizational level, and to take into account barriers and facilitators for implementation in daily care. Examples of action strategies to address difficulties in implementing delirium prevention and management strategies and examples to a related geriatric syndrome (e.g. falls) are reported elsewhere [29] and [30]

Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings.

PURPOSE:Understanding the quality of evidence of delirium education studies will assist in designing future education interventions that seek to improve the well-known deficits in delirium prevention, detection and care. The aim of this study is to systematically review the methodological strengths and limitations, as well as the impact of delirium educational interventions for healthcare professionals working in inpatient settings. METHODS:MEDLINE, EMBASE, The Cochrane Library, PsychINFO and CINAHL databases were searched according to PRISMA guidelines for delirium educational interventions in hospital inpatient settings from 2007 to 2017. Identified studies were rated using a standardised quality assessment criteria checklist (Kmet). Reported outcomes were organised by level on the Kirkpatrick model for educational outcomes. The search was repeated in March 2018. RESULTS:1354 papers were screened, of which 42 studies met the inclusion criteria. Interventions delivered included face-to-face education (n = 34), e-learning (n = 8) and interprofessional education (n = 8). Quality of studies varied in Kmet score (14-96%). There were 17 high-quality studies (Kmet > 80%) and 4 very high-quality studies (Kmet over > 90%). Thirty-eight studies (90%) reported improved outcomes post-intervention. In terms of Kirkpatrick level of educational outcomes, 6 studies were rated at level 1; 13 studies at level 2; 15 studies at level 3; and 8 studies at level 4. Thirteen studies measured intervention sustainability with variable impacts. CONCLUSIONS:Healthcare professional education has benefits for inpatient delirium care, as shown by the high number of good-quality studies and the majority demonstrating improved outcomes post-intervention. The sustainability of educational interventions warrants further exploration

Resolution of diffuse skin and systemic Kaposi's sarcoma in a renal transplant recipient after introduction of everolimus: A case report

We present a case report of a patient with diffuse skin and systemic Kaposi's sarcoma (KS), 1 year after renal transplantation. A concomitant Pyrenochaeta romeroi granuloma of the right hallux was diagnosed and illustrated an important immunodysfunction in our patient. Four months after reduction in immunosuppression and switch to everolimus, a total regression of the KS was observed. Reduction in the immunosuppression and treatment with terbinafine cleared the P. romeroi infection, while lowering immunosuppression and changing the type of immunosuppressive therapy were important steps in the successful management of the KS. In recent years, evidence of the antitumor effects of everolimus is increasing: total regression of KS in combination with renal function preservation in renal graft recipients is possible with mammalian target of rapamycin (mTOR) inhibitor-based regimens. In addition, with increasing numbers of human immunodeficiency virus-positive transplant recipients, mTOR inhibitors may play a more crucial role in the management of KS.SCOPUS: ar.jFLWINinfo:eu-repo/semantics/publishe