Cerejeira, J

Jay, R

Mukaetova-Ladinska, EB

Stanley, N

Yates, C

Name not available

Screening instruments for delirium in older people with an acute medical illness.

CHUC Institutional Repository

Repositório Institucional dos Hospitais da Universidade de Coimbra

Research lettersthereby increasing the risk of cholangitis and thus the overallmorbidity.Both cholangiocarcinoma and pancreatic cancers werefound more commonly in the elderly group. Metal stentingis performed in cases where surgery is not an option andthis is reflected in the higher number of these stents in theelderly populationwithmalignant strictures. In contrast, plas-tic stenting provides temporary relief of obstructive symp-toms prior to more definitive surgical intervention. This isreflected in more frequent insertion of these stents in theyounger population.ERCP is being increasingly utilised in the elderly popula-tion at high risk undergoing invasive procedures. It remainsa technically feasible and safe procedure with a low rate ofcomplications in this population.Key points ERCP is being increasingly utilised in the elderly popula-tion. ERCP in the elderly is a technically feasible procedurewith a high success rate, comparable with a younger pop-ulation. ERCP in the elderly is a safe procedure with a low com-plication risk, comparable with a younger population.Conflicts of interestThere are no conflicts of interest.Supplementary dataSupplementary data are available at Age and Ageing online.A. R. AFTAB∗, F. DONNELLAN, F. ZEB, G. COURTNEYDepartment of Gastroenterology, St. Luke’s Hospital, Kilkenny,IrelandEmail: aftabar@hotmail.com∗To whom correspondence should be addressedReferences1. Siegel JH, Kasmin FE. Biliary tract diseases in the elderly: man-agement and outcomes. Gut 1997; 41: 433–5.2. Nagenthiraja K, Ewertz M, Engholm G, Storm HH. Incidenceand mortality of pancreatic cancer in the Nordic countries1971–2000. Acta Oncol 2007; 46(8): 1064–9.3. Patel T. Increasing incidence and mortality of primary intra-hepatic cholangiocarcinoma in the United States. Hepatology2001; 33: 1353–7.4. ThomopoulosKC,VagenasK,Assimakopoulos SF et al.Endo-scopic retrogade cholangiopancreatography is safe and effec-tive method for diagnosis and treatment of biliary and pancre-atic disorders in octogenarians. Acta Gastroenterol Belg 2007;70: 199–202.5. Katsinelos P, Paroutoglou G, Kountouras J, Zavos C, BeltsisA, Tzovaras G. Efficacy and safety of therapeutic ERCP inpatients 90 years of age and older. Gastrointest Endosc 2006;63: 417–23.6. McCuneWS, ShorbPE,MoscovitzH.Endoscopic cannulationof the ampulla of Vater: a preliminary report. Ann Surg 1968;167: 752–56.7. Health in Ireland, Key Trends. 2007. www.dohc.ie/statistics.8. PopulationEstimates (Thousand) byAgeGroup, Year and Sex.www.cso.ie.9. Deans GT, Sedman P, Martin DF et al. Are complications ofendoscopic sphincterotomy age related? Gut 1997; 41: 545–8.10. Agarwal N, Sharma BC, Sarin SK. Endoscopic managementof acute cholangitis in elderly patients. World J Gastroenterol2006; 12: 6551–5.11. Mitchell RM, O’Connor F, Dickey W. Endoscopic retrogradecholangiopancreatography is safe and effective in patients90 years of age and older. Clin Gastroenterol 2003; 36: 72–4.12. Clarke GA, Jacobson BC, Hammett RJ, Carr-Locke DL. Theindications, utilization and safety of gastrointestinal endoscopyin an extremely elderly patient cohort. Endoscopy 2001; 33:580–4.13. Fritz E, Kirchgatterer A, Hubner D et al. ERCP is safe andeffective in patients 80 years of age and older compared withyounger patients. Gastrointest Endosc 2006; 64: 899–905.14. Ashton CE, McNabb WR, Wilkinson ML, Lewis RR. Endo-scopic retrograde cholangiopancreatography in elderly patients.Age Ageing 1998; 27: 683–8.15. O’ConnorHJ,BhuttaAS,RedmondPL,CarruthersDA. Supra-papillary fistulosphincterotomy at ERCP: a prospective study.Endoscopy 1997; 29: 266–70.doi: 10.1093/ageing/afn280Published electronically 23 December 2008Screening instruments for delirium in olderpeople with an acute medical illnessSIR—As a medical professional we are not especially goodat diagnosing delirium in older people, with up to two-thirdsof cases being either misdiagnosed or undetected [1]. Thisis largely due to many of the older people having dementia,with the features of delirium often difficult to distinguish.Delirium is associated with significant morbidity and mor-tality in older people, and their protracted hospital stays [2]have implications for finances and bed availability within ourhealthcare service. Any steps taken to improve the diagnosisand management of this syndrome would be of great benefitto both patients and the NHS.The British Geriatrics Society (BGS) recently producedclinical guidelines to improve prevention, diagnosis andman-agement of delirium in older people in hospital [3]. In theseguidelines, diagnosis of delirium is aided by screening forcognitive impairment on admission using the AbbreviatedMental Test (AMT) or Mini-Mental State Examination(MMSE), followed by the CAM screening instrument to con-firm delirium [4, 5].235 by guest on November 23, 2011http://ageing.oxfordjournals.org/Downloaded from Research lettersTable 1. Sensitivity, specificity and predictive values of the screening tools for delirium in relation to DSM-IV criteriaDelirium rating scales items Sensitivity (no.) Specificity (no.) Positive predictive value (no.) Negative predictive value (no.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CAM 0.909 (10/11) 0.961 (49/51) 0.833 (10/12) 0.980 (49/50)Inattention 0.909 (10/11) 0.745 (38/51) 0.476 (10/21) 1.000 (38/38)Disorganised thinking 0.818 (9/11) 0.784 (40/51) 0.562 (9/16) 1.000 (40/40)Altered consciousness 0.545 (6/11) 0.863 (44/51) 0.461 (6/13) 0.898 (44/49)Disorientation 0.818 (9/11) 0.627 (32/51) 0.391 (9/23) 1.000 (32/32)Memory impairment 0.909 (10/11) 0.412 (21/51) 0.294 (10/34) 1.000 (21/21)Perceptual disturbances 0.091 (1/11) 0.980 (50/51) 1.000 (1/1) 0.847 (50/59)Psychomotor agitation 0.273 (3/11) 0.980 (50/51) 0.750 (3/4) 0.862 (50/58)Psychomotor retardation 0.182 (2/11) 0.882 (45/51) 0.250 (2/8) 0.849 (45/53)Altered sleep–wake cycle 0.454 (5/11) 0.941 (48/51) 0.833 (5/6) 0.906 (48/53)Fluctuation 0.636 (7/11) 0.922 (47/51) 0.636 (7/11) 0.922 (47/51)DSI 0.909 (10/11) 0.804 (41/51) 0.500 (10/20) 0.9854 (41/42)Disorientation 1.000 (11/11) 0.784 (40/51) 0.524 (11/21) 1.000 (40/40)Sleep disturbance 0.545 (6/11) 0.922 (47/51) 0.667 (6/9) 0.922 (47/51)Perceptual disturbance 0.454 (5/11) 0.961 (49/51) 0.833 (5/6) 0.891 (49/55)Psychomotor activity 0.454 (5/11) 1.000 (51/51) 1.000 (5/5) 0.895 (51/57)Activity/disturbance of consciousness 0.454 (5/11) 0.941 (48/51) 0.625 (5/8) 0.889 (48/54)General behaviour 0.727 (8/11) 0.961 (49/51) 0.889 (8/9) 0.942 (49/52)Fluctuating behaviour 0.454 (5/11) 0.980 (50/51) 0.833 (5/6) 0.893 (50/56)Every acute older people admission (62 in total) to a careof the elderly ward and a mixed general medical ward over a6-week period in a teaching hospital in Newcastle upon Tynewas assessed for delirium using DSM-IV [6], the DeliriumSymptom Interview (DSI) [7] and the Confusion AssessmentMethod (CAM) [5]. All the interviews were carried out by oneof twomedical SHOs (CY andNS). All patientswere assessedwith MMSE [8]. ‘Delirium’ was defined if patients fulfilledthe DSM-IV criteria.Twenty patients (32%)met the screening criteria for delir-ium on at least one of the three diagnostic instruments. Ofthese, only 11 met the diagnostic criteria for delirium accord-ing to DSM-IV; 10 were identified using either the CAM orDSI. However, each delirium rating scale failed to detect onecase of DSM-IV-defined delirium. An additional two caseswere CAM positive, and ten were DSI positive when DSM-IV criteria were not fulfilled. All the tools were in diagnosticagreement with only nine (81.8%) delirium patients. Com-pared with patients without delirium, patients with deliriumhad similar age (81.39 vs. 83.09, P = 0.518) but significantlylower MMSE scores (14.94 vs. 4.64, P = 0.003).Both DSI and CAM showed similar high internal con-sistency (Cronbach alpha of 0.857 and 0.841, respectively).In DSI, most affected symptom domains were disorienta-tion (33.9%), general behaviour (14.5%), sleep disturbances(14.5%) and psychomotor activity (12.9%). In CAM, mem-ory impairment (54.8%) and disorientation (37.1%) were themost frequent symptoms, followed by inattention (33.9%)and altered level of consciousness (21.0%) (Table 1). Highrates of memory impairment and disorientation may beattributed not only to delirium but also to underlying cog-nitive dysfunction in a significant proportion of the sample.Fifteen patients (24.2%) were unable to be assessed withMMSE because of their level of consciousness (coma or stu-por), inability to communicate or rapidly deteriorating med-ical condition. This significant figure suggests that MMSE,which is dependent on patient collaboration, may not be anadequate instrument to use in older people with an acutemedical illness.Our results have raised some interesting questions. First,what is the most useful tool to use in an acute medical settingwhen screening for delirium? In the older people populationwith multiple co-morbidities and poor medical and physicalcondition, levels of consciousness and/or communicationare frequently impaired, preventing the use of tools that relyon patient collaboration such asMMSE.Therefore, it appearsthat MMSE, although an efficient tool to exclude delirium, isnot as useful to screen for delirium when patients are unableto interact.So, which additional tool is best for screening for delir-ium? In reality, it is too time-consuming to consider a vastbattery of tests, since in routine clinical practice we needa quick and reliable method. Of the 20 patients positivelyscreened with delirium, 11 met the DSM-IV criteria, 20 mettheDSI criteria and 12met the CAM criteria. Although CAMand DSI seem to have high sensitivity to detect delirium,the biggest difference appears with respect to their positivepredictive values, with DSI being over-inclusive and substan-tially higher rates of false positivity (when DSM-IV criteriaare used as the gold standard for diagnosing delirium). Thissuggests that the screening procedure alone is not enough,and needs to be expanded to include more detailed clini-cal assessment incorporating clear and detailed items fromthe DSM-IV. When dealing with older people with an acutemedical illness, with high rates of underlying cognitive impair-ment as detected in our study, clinical diagnosis of deliriumis challenging, being difficult to distinguish from dementiaespecially if other sources of information are not available. A236 by guest on November 23, 2011http://ageing.oxfordjournals.org/Downloaded from Research lettersdetailed analysis of CAM and DSI (Table 1) shows that, asexpected, disorientation and memory problems are not use-ful for diagnosis of delirium given the low positive predictivevalue. On the other hand, inattention and disturbance of con-sciousness seem to be more reliable symptoms for diagnosisof delirium, having the advantage of not requiring prolongedassessment.Our studywas conducted on a real group of acutely admit-ted older people being assessed by juniormedical doctors.Weconfirmed that CAM,which is based onDSM-III-R, is a goodscreening instrument for delirium in this subset of patientsbecause of its simplicity, suitability for non-communicatingpatients and psychometric proprieties. We should highlightthe need for specific training to apply this scale, as recom-mended by Inouye [5], since it requires determining the levelof consciousness and attention which are often difficult toassess. Although we also found the DSI usefulness in routineclinical practice, it can easily lead to over-diagnosing deliriumwhen the DSM-IV criteria are used as the gold standard. Ourstudy revealed that MMSE could not be used in a quarter ofpatients. Similarly, AMT (suggested in the BGS guidelines),although less complex as it is purely verbal, may be difficultto use in clinical practice in this context. Other assessmentapproaches, dependent more on clinical observation (e.g. ofinattention and disturbance of consciousness), may there-fore be more appropriate to screen for delirium without thenecessity for cognitive assessment, as demonstrated in ourstudy.Our study represents a practical clinical implementationof the BGS guidelines for delirium. Diagnosis of deliriumshould be done by skilled professionals, with good knowl-edge of this clinical syndrome and confidence in applyingreliable tools as part of routine clinical practice. Teachingthese skills needs to be an essential part of the medical cur-riculum, so that junior clinicians are empowered to thinkabout delirium and how to recognise it early. This in turnwill contribute to earlier diagnosis and treatment of thissyndrome.Key points Recognition of delirium should be done by skilled pro-fessionals. We confirm that CAM is a good screening instrumentfor delirium in elderly with dementia. However, there is afurther need for specific training to apply CAM, since itrequires assessment of level of consciousness and atten-tion. The usefulness of MMSE in elderly with delirium islimited, with one-quarter of the elderly not able tobe assessed because of altered level of consciousness,inability to communicate or rapidly deteriorating medicalcondition. Delirium symptom instrument (DSI), although useful indiagnosing delirium, can easily lead to over-diagnosingdelirium when DSM-IV criteria are used as a goldenstandard.CATHERINE YATES1, NEIL STANLEY2, JOAQUIM M. CEREJEIRA1,ROGER JAY3, ELIZABETA B. MUKAETOVA-LADINSKA1,∗1Institute for Ageing and Health, Newcastle University,Newcastle upon Tyne, NE4 6BE, UK,Email: Elizabeta.Mukaetova-Ladinska@ncl.ac.uk2University Hospital of North Durham, North Road, Durham,DH1 5TW, UK3Department of Geriatric Medicine, Royal Victoria Infirmary,Newcastle upon Tyne, NE1 4LP, UK∗To whom correspondence should be addressedReferences1. Foreman MD, Milisen K. Improving recognition of deliriumin the elderly. Prim Psychiatry 2004; 2: 46–50.2. Siddiqi N, House AO, Holmes JD. Occurrence and outcomeof delirium in medical inpatients: a systematic literature review.Age Ageing 2006; 35: 350–64.3. British Geriatrics Society. The prevention, diagnosis and man-agement of delirium in older people. RCP. June 20064. Inouye SK, Bogardus ST, Charpentier PA et al. A multicom-ponent intervention to prevent delirium in hospitalised olderpatients. N Engl J Med 1999; 340: 669–76.5. Inouye SK. The ConfusionAssessmentMethod (CAM): Train-ing Manual and Coding Guides 2003. Boston: Yale UniversitySchool of Medicine, 2003.6. American Psychiatric Association. Diagnostic and StatisticalManual of Mental Disorders, . Washington, DC: APA, 1994.7. Albert MS, Levkoff SE, Reilly C et al. The delirium symptominterview: an interview for the detection of delirium symptomsin hospitalized patients. J Geriatr Psychiatry Neurol 1992; 5:14–21.8. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State. Apractical method for grading the cognitive state of patients forthe clinician. J Psychiatr Res 1975; 12: 189–198.doi: 10.1093/ageing/afn285Published electronically 25 December 2008C-reactive protein and memory functionsuggest antagonistic pleiotropy in very oldnondemented subjectsSIR—A possible role of inflammation in the developmentof dementia [1] has led to investigations examining whetherC-reactive protein (CRP), a systemicmarker of inflammation,is associated with worse cognitive function and decline in oldage. Elevated CRP has been associated with worse global andspecific cognitive functioning [2–7], although other studieshave found no relationship between CRP and cognition [8–10].Most studies have examined samples averaging<75 years237 by guest on November 23, 2011http://ageing.oxfordjournals.org/Downloaded from 

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Screening instruments for delirium in older people with an acute medical illness.

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