Informant single screening questions for delirium and dementia in acute care – a cross-sectional test accuracy pilot study

Background Cognitive impairment often goes undetected in older people in hospital. Efficient screening tools are required to improve detection.<p></p> To determine diagnostic properties of two separate informant-based single screening questions for cognitive impairment (dementia and delirium) in hospitalised older people.<p></p> Methods Patients over 65 years non-electively admitted to medical or geriatric wards within a teaching hospital. Our index tests were single screening questions (SSQ), one for dementia (“How has your relative/friend’s memory changed over the past 5 years (up to just before their current illness)?”) and one for delirium (“How has your relative/friend’s memory changed with his/her current illness?”), which were assessed with informant response given on a five point Likert scale.<p></p> Any deterioration on our index tests of SSQ-dementia and SSQ-delirium was accepted as a positive screen for cognitive impairment. Scores were compared to the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) >3.38 accepted as dementia, and Confusion Assessment Method (CAM) diagnosis of delirium. We also collected direct cognitive screening data using Mini Mental Status Examination (MMSE).<p></p> Results Informant responses were obtained in 70/161 (43.5%) patients, median age 80.8 (range:67–97) years; mean MMSE score 18.5 (SD: 8.1). The SSQ-dementia when compared to the IQCODE had a sensitivity of 83.3% and specificity of 93.1%. The SSQ-delirium when compared to CAM diagnosis had sensitivity of 76.9% and a specificity of 56.1%.<p></p> Conclusions These findings show promise for use of an informant single screening question tool as the first step in detection of dementia in older people in acute hospital care, although this approach appears to be less accurate in screening for delirium.<p></p&gt

Screening for delirium and cognitive impairment in older, acute care in-patients

Background: Delirium, an acute neurobehavioral syndrome, occurs across all healthcare settings and is suggested to be the most common psychiatric condition experienced by older hospitalised patients. It affects around a fifth of those in general medical wards with higher prevalence in surgical and intensive care unit patients. Delirium and chronic cognitive impairment share a complicated two-way relationship. Those with dementia are at greater risk of developing delirium while length of delirium episode is also associated with increased risk of long-term cognitive decline. Delirium is associated with a number of other serious negative outcomes including increased risk of falls, institutionalisation and mortality. Identification of delirium in hospitalised older patients is necessary to facilitate good patient care as well as to allow for the appropriate support for concerned relatives and carers. Guidelines are in general agreement that screening for delirium and cognitive impairment is important in hospitalised, older patients. Identification of delirium is the first necessary step to then allow for the management of this syndrome. However, there are a wide range of screening tools available for cognitive impairment and delirium with limited research evidence or validation of these tools in large, representative cohorts. Furthermore, clinical awareness of delirium is low compared to many other conditions; this may be improved by implementing clear delirium screening guidelines along-side the necessary training. Methodology: Before delirium screening tools can be implemented in routine practice, an evidence-based approach should be followed to assess feasibility and diagnostic accuracy within older in-patient cohorts. In this thesis, I investigate screening for cognitive impairment systematically in a series of linked studies. I review the existing published evidence as well as investigating screening for delirium in older, acute medical units locally and nationwide. I collate existing evidence for the use of brief screening tools for delirium, dementia and mild cognitive impairment (MCI) across healthcare settings. I also carry out analysis of an existing data set looking at the feasibility and accuracy of two single questions for delirium and dementia, separately. Furthermore I gather data relating to cognitive screening from lead clinicians across hospital sites within elderly acute care units in Scotland. I also carry out a local service evaluation to determine documented delirium prevalence as well as what tools were being used to screen for cognitive impairment and delirium. These results inform a diagnostic test accuracy evaluation of delirium and cognitive impairment screening tools recommended for routine clinical use with acute care in-patients. This evaluation is in a relatively large-scale, representative sample and assesses the feasibility as well as accuracy of these tools against a gold standard clinician diagnosis of delirium. My diagnostic test accuracy evaluation was based on a clear local problem of lack of routine delirium screening in older in-patients and aimed to inform future recommendation policy by examining which tools are feasible and accurate within this setting. I also aimed to add to the existing delirium screening evidence base by examining a range of recommended tools within a large, consecutive patient cohort. This was contrary to much of the published literature which generally examine one screening tool and often within small or case-controlled patient samples. This evaluation of screening tools for the assessment of possible delirium within the acute care setting examined the feasibility and test accuracy of cognitive tests which were recommended by clinical guidelines for both delirium and cognitive impairment. The tests evaluated were the Abbreviated Mental Test (AMT 10/4), the 4 A’s Test (4AT), the brief Confusion Assessment Method (bCAM) (a rapid, operationalised version of the Confusion Assessment Method (CAM)) and the Single Screening Question in Delirium (SQiD). I also explored the performance of reciting months of the year backwards (MOTYB), present as part of both the 4AT and bCAM. All screening tests were compared to gold standard diagnosis using delirium criteria from the Diagnostic and Statistical Manual of Mental Disorders – fifth revision (DSM 5) which was completed by senior geriatricians. Findings: My systematic literature review revealed heterogeneity of methods in the published evidence for very brief, single item cognitive screening tools. However my secondary data analysis revealed high sensitivity for a single informant question for dementia and reasonable sensitivity for a single question for delirium. The clinician survey showed a lack of consensus regarding the choice of screening tools used for delirium and dementia at a national (Scottish) level. Within geriatric units in Scotland there appears to be notable variability in the way delirium screening is carried out. The clinician survey revealed a particular issue for delirium screening in the West of Scotland where there appears to be a lack of standardised tools used to screen for delirium. Furthermore, local ward service evaluation revealed a lack of documentation of delirium diagnosis with little awareness of delirium across acute elderly wards within a large teaching hospital in Glasgow. Evaluation of cognitive impairment screening tools found that the AMT 10, AMT 4, 4AT and MOTYB were feasible and accurate tools for the assessment of delirium within a cohort of 500 acute in-patients age > 65 years. The AMT 10 was found to have reasonable sensitivity at a cut point of <4/10 and the AMT 4 was found to have good sensitivity at a cut point of <3/4; use of the full 10-point AMT seemed to carry no substantial advantage over the shorter AMT 4. The bCAM was found to have poor sensitivity, missing 3 in 10 cases of delirium. I did not find the informant-based SQiD to be feasible in this population, with a return rate of 28%, but displaying a sensitivity of over 90%. These results suggest that a range of tools exist which display good diagnostic test accuracy and feasibility in an older, acute care in-patient cohort. These can all be completed quickly and are simple to administer. Informant information using a standardised single screening question (SSQ) such as the SQiD may still hold value in aiding the diagnosis of delirium when this can be obtained. Conclusions: In conclusion, the studies in this thesis aim to add to the pool of literature available for the screening of delirium and cognitive impairment. I used a logical and informed ordering of the research conducted. The results from my systematic review, secondary data analysis, clinician survey and service evaluation all fed in to the planning of my clinical patient evaluation of delirium screening. Results from my literature review and data analysis did not discount the use of a single question to screen for delirium but did suggest a need for further research with a gold standard clinician diagnosis for comparison. My clinical evaluation results revealed that relatively accurate screening of delirium is possible using existing, simple and brief screening tools which are already suggested in guidelines for routine clinical use. Screening for delirium should be regarded as a first step in the care pathway for those who are identified as having possible delirium. The value of delirium screening depends on the implementation of specific care pathways for those who then go on to receive a clinical diagnosis of delirium. Patients with delirium have an increased risk of falls, dehydration and infection alongside the associated long-term complications. Good patient care should aim to cater to these patients’ specific needs in the same way it does with other medical conditions. Healthcare Improvement Scotland (HIS) recommends all older patients should be routinely screened for delirium but acknowledges that this is not the case, with delirium being ‘frequently overlooked or misdiagnosed’. It may not be enough to make these recommendations without implementing a system of education to promote and raise awareness for the importance of screening for delirium. I suggest that further research is needed to assess the accuracy and feasibility of delirium screening tools for older, acute care in-patients while implementing a care pathway for patients who are then diagnosed with delirium. This would inform the best possible future care for patients with delirium. The potential for improved outcomes for these patients is also of interest. Evaluation of interventions in large scale, representative patient samples are needed to further progress our knowledge of treatment of delirium as a serious and often overlooked disorder of the brain caused by physical illness

The challenges of measuring physical activity and sedentary behaviour in people with rheumatoid arthritis

The importance of sufficient moderate-to-vigorous physical activity as a key component of a healthy lifestyle is well established, as are the health risks associated with high levels of sedentary behaviour. However, many people with RA do not undertake sufficient physical activity and are highly sedentary. To start addressing this, it is important to be able to carry out an adequate assessment of the physical activity levels of individual people in order that adequate steps can be taken to promote and improve healthy lifestyles. Different methods are available to measure different aspects of physical activity in different settings. In controlled laboratory environments, respiratory gas analysis can measure the energy expenditure of different activities accurately. In free-living environments, the doubly labelled water method is the gold standard for identifying total energy expenditure over a prolonged period of time (>10 days). To assess patterns of physical activity and sedentary behaviour in daily life, objective methods with body-worn activity monitors using accelerometry are superior to self-reported questionnaire- or diary-based methods

A novel computerized test for detecting and monitoring visual attentional deficits and delirium in the ICU

Objectives: Delirium in the ICU is associated with poor outcomes but is under-detected. Here we evaluated performance of a novel, graded test for objectively detecting inattention in delirium, implemented on a custom-built computerized device (Edinburgh Delirium Test Box–ICU). Design: A pilot study was conducted, followed by a prospective case-control study. Setting: Royal Infirmary of Edinburgh General ICU. Patients: A pilot study was conducted in an opportunistic sample of 20 patients. This was followed by a validation study in 30 selected patients with and without delirium (median age, 63 yr; range, 23–84) who were assessed with the Edinburgh Delirium Test Box–ICU on up to 5 separate days. Presence of delirium was assessed using the Confusion Assessment Method for the ICU. Measurements and Main Results: The Edinburgh Delirium Test Box–ICU involves a behavioral assessment and a computerized test of attention, requiring patients to count slowly presented lights. Thirty patients were assessed a total of 79 times (n = 31, 23, 15, 8, and 2 for subsequent assessments; 38% delirious). Edinburgh Delirium Test Box–ICU scores (range, 0–11) were lower for patients with delirium than those without at the first (median, 0 vs 9.5), second (median, 3.5 vs 9), and third (median, 0 vs 10.5) assessments (all p &lt; 0.001). An Edinburgh Delirium Test Box–ICU score less than or equal to 5 was 100% sensitive and 92% specific to delirium across assessments. Longitudinally, participants’ Edinburgh Delirium Test Box–ICU performance was associated with delirium status. Conclusions: These findings suggest that the Edinburgh Delirium Test Box–ICU has diagnostic utility in detecting ICU delirium in patients with Richmond Agitation and Sedation Scale Score greater than –3. The Edinburgh Delirium Test Box–ICU has potential additional value in longitudinally tracking attentional deficits because it provides a range of scores and is sensitive to change

Barriers and facilitators to physical activity in people with an inflammatory joint disease: a mixed methods study

BACKGROUND: Physical activity has been shown to be of great benefit to people with an inflammatory joint disease (IJD), however people with an IJD have been shown to be very inactive compared to the general population. The aims of this study were to explore 1) whether the transition from a National Health Service (NHS)-run exercise programme into exercising in the community could be achieved successfully; and 2) the barriers and facilitators during the transition period. METHODS: This study adopted a complementary mixed-methods study design including a qualitative approach using focus groups and a prospective cohort study. Descriptive statistics were used to summarise the cohort study data. All variables were assessed for normality of distribution using the Sharpiro-Wilk test. Paired t-tests or Wilcoxon tests were undertaken for two consecutive assessment timepoints; one-way repeated measures ANOVAs or Friedman’s tests for three consecutive assessment timepoints. Micro-interlocutor analysis was used to analyse the focus group data. Areas of congruence and incongruence were explored by confirming the statistical results against the qualitative results. The adapted ecological model of the determinants of physical activity was then used as a framework to describe the findings. RESULTS: A successful transition was defined as still exercising in the community 6-months post discharge from the NHS-run Inflammatory Arthritis Exercise Programme. This was self-reported to be 90% of the cohort. An individual barrier to physical activity in people with an IJD was found to be the unpredictable nature of their condition. Other barriers and facilitators found were similar to those found in the general population such as recreation facilities, locations, transportation and cost. Other facilitators were similar to those found in people living with other chronic long-term conditions such as the importance of peer support. CONCLUSIONS: 90% of the cohort data were defined as a successful transition. People with an IJD have similar barriers and facilitators to exercise as the general population and those living with other chronic long-term conditions. A barrier which appears to be unique to this population group is that of the unpredictable nature of their condition which needs to be considered whenever tailoring any intervention. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12891-022-05847-z

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 &lt; 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 (&lt;4/10), MOTYB (&lt;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 (&gt;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

AD-8 for diagnosis of dementia across a variety of healthcare settings

This is a protocol for a Cochrane Review (Diagnostic test accuracy). The objectives are as follows: To determine the diagnostic accuracy of the informant‐based questionnaire AD‐8, in detection of all‐cause (undifferentiated) dementia in adults. We will present data for each healthcare setting where AD‐8 may be employed (community; primary care; secondary care)

AD-8 for detection of dementia across a variety of healthcare settings

BACKGROUND: Dementia assessment often involves initial screening, using a brief tool, followed by more detailed assessment where required. The AD-8 is a short questionnaire, completed by a suitable 'informant' who knows the person well. AD-8 is designed to assess change in functional performance secondary to cognitive change. OBJECTIVES: To determine the diagnostic accuracy of the informant-based AD-8 questionnaire, in detection of all-cause (undifferentiated) dementia in adults. Where data were available, we described the following: the diagnostic accuracy of the AD-8 at various predefined threshold scores; the diagnostic accuracy of the AD-8 for each healthcare setting and the effects of heterogeneity on the reported diagnostic accuracy of the AD-8. SEARCH METHODS: We searched the following sources on 27 May 2014, with an update to 7 June 2018: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), BIOSIS Previews (Thomson Reuters Web of Science), Web of Science Core Collection (includes Conference Proceedings Citation Index) (Thomson Reuters Web of Science), CINAHL (EBSCOhost) and LILACS (BIREME). We checked reference lists of relevant studies and reviews, used searches of known relevant studies in PubMed to track related articles, and contacted research groups conducting work on the AD-8 to try to find additional studies. We developed a sensitive search strategy and used standardised database subject headings as appropriate. Foreign language publications were translated. SELECTION CRITERIA: We selected those studies which included the AD-8 to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. We only included those studies where the AD-8 was used as an informant assessment. We made no exclusions in relation to healthcare setting, language of AD-8 or the AD-8 score used to define a 'test positive' case. DATA COLLECTION AND ANALYSIS: We screened all titles generated by electronic database searches, and reviewed abstracts of potentially relevant studies. Two independent assessors checked full papers for eligibility and extracted data. We extracted data into two-by-two tables to allow calculation of accuracy metrics for individual studies. We then created summary estimates of sensitivity, specificity and likelihood ratios using the bivariate approach and plotting results in receiver operating characteristic (ROC) space. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool. MAIN RESULTS: From 36 papers describing AD-8 test accuracy, we included 10 papers. We utilised data from nine papers with 4045 individuals, 1107 of whom (27%) had a clinical diagnosis of dementia. Pooled analysis of seven studies, using an AD-8 informant cut-off score of two, indicated that sensitivity was 0.92 (95% confidence interval (CI) 0.86 to 0.96); specificity was 0.64 (95% CI 0.39 to 0.82); the positive likelihood ratio was 2.53 (95% CI 1.38 to 4.64); and the negative likelihood ratio was 0.12 (95% CI 0.07 to 0.21). Pooled analysis of five studies, using an AD-8 informant cut-off score of three, indicated that sensitivity was 0.91 (95% CI 0.80 to 0.96); specificity was 0.76 (95% CI 0.57 to 0.89); the positive likelihood ratio was 3.86 (95% CI 2.03 to 7.34); and the negative likelihood ratio was 0.12 (95% CI 0.06 to 0.24).Four studies were conducted in community settings; four were in secondary care (one in the acute hospital); and one study was in primary care. The AD-8 has a higher relative sensitivity (1.11, 95% CI 1.02 to 1.21), but lower relative specificity (0.51, 95% CI 0.23 to 1.09) in secondary care compared to community care settings.There was heterogeneity across the included studies. Dementia prevalence rate varied from 12% to 90% of included participants. The tool was also used in various different languages. Among all the included studies there was evidence of risk of bias. Issues included the selection of participants, conduct of index test, and flow of assessment procedures. AUTHORS' CONCLUSIONS: The high sensitivity of the AD-8 suggests it can be used to identify adults who may benefit from further specialist assessment and diagnosis, but is not a diagnostic test in itself. This pattern of high sensitivity and lower specificity is often suited to a screening test. Test accuracy varies by setting, however data in primary care and acute hospital settings are limited. This review identified significant heterogeneity and risk of bias, which may affect the validity of its summary findings

Real-world evaluation of an acceptance and commitment therapy–based group programme for breast cancer survivors with fear of cancer recurrence

Purpose: To evaluate the effectiveness and acceptability of a 6-week acceptance and commitment therapy (ACT)–based group programme on participants’ fear of cancer recurrence (FCR), quality of life (QoL), psychological distress and psychological flexibility at the end of the programme and 12-week follow-up. Methods: A one-group, post-test service evaluation of a real-world psychological programme was carried out to evaluate collected outcome measures and attendance for a total of 21 groups facilitated between 2017 and 2019. Participants were breast cancer survivors who attended a 6-week group programme led by NHS clinicians. Descriptive statistics and repeated measures ANOVA analyses were carried out for each outcome measure. Attendance levels were examined to assess acceptability. Results: A total of 97 group participants who had completed curative treatment for breast cancer took part. Of whom, 89% completed at least 4 of the 6 weekly group sessions and 76% attended the 12-week follow-up session. Eighty-four (87%) participants returned outcome measures at all three time points relative to group participation (T1 = pre, T2 = post T3 = 12-week follow-up). Group participants were female, mean age 51.9 years. FCR was highest at T1 (mean 25.2, SD 4.7), reduced T2 (mean 21.2, SD 5.4) and further lowered T3 (mean 19.5, SD 6.2). This difference was statistically significant (p &lt; 0.001). QoL was lowest at T1 (mean 62.4, SD 15.7), increased T2 (mean 71.7, SD 18.1) and further increased at T3 (mean 75.9, SD 17.5). This difference was statistically significant (p &lt; 0.001). Psychological distress measures were shown to reduce, and psychological flexibility increased. Conclusions: This real-world evaluation of an ACT-based group programme led to improvements in FCR, QoL, psychological distress and psychological flexibility in this population. This evaluation provides basis for further investigation to determine if these results can be replicated by controlled research design across diverse populations

Study protocol; thyroid hormone replacement for untreated older adults with subclinical hypothyroidism - a randomised placebo controlled trial (TRUST)

Background: Subclinical hypothyroidism (SCH) is a common condition in elderly people, defined as elevated serum thyroid-stimulating hormone (TSH) with normal circulating free thyroxine (fT4). Evidence is lacking about the effect of thyroid hormone treatment. We describe the protocol of a large randomised controlled trial (RCT) of Levothyroxine treatment for SCH. Methods: Participants are community-dwelling subjects aged ≥65 years with SCH, diagnosed by elevated TSH levels (≥4.6 and ≤19.9 mU/L) on a minimum of two measures ≥ three months apart, with fT4 levels within laboratory reference range. The study is a randomised double-blind placebo-controlled parallel group trial, starting with levothyroxine 50 micrograms daily (25 micrograms in subjects &lt;50Kg body weight or known coronary heart disease) with titration of dose in the active treatment group according to TSH level, and a mock titration in the placebo group. The primary outcomes are changes in two domains (hypothyroid symptoms and fatigue / vitality) on the thyroid-related quality of life questionnaire (ThyPRO) at one year. The study has 80% power (at p = 0.025, 2-tailed) to detect a change with levothyroxine treatment of 3.0% on the hypothyroid scale and 4.1% on the fatigue / vitality scale with a total target sample size of 750 patients. Secondary outcomes include general health-related quality of life (EuroQol), fatal and non-fatal cardiovascular events, handgrip strength, executive cognitive function (Letter Digit Coding Test), basic and instrumental activities of daily living, haemoglobin, blood pressure, weight, body mass index and waist circumference. Patients are monitored for specific adverse events of interest including incident atrial fibrillation, heart failure and bone fracture. Discussion: This large multicentre RCT of levothyroxine treatment of subclinical hypothyroidism is powered to detect clinically relevant change in symptoms / quality of life and is likely to be highly influential in guiding treatment of this common condition. Trial registration: Clinicaltrials.gov NCT01660126; registered 8th June 2012