Accurate delirium screening when there is no carer available – impossible, right?

Suzanne Timmons is a geriatrician working in Mercy University hospital, Cork and a senior lecturer in University College Cork. She has a big clinical and research interest in delirium and dementia care in hospitals.

delirium-flatDelirium  is common in older people admitted to hospital, and is a serious condition that needs to be identified quickly on admission. But many busy hospital staff still don’t routinely screen older people for delirium, even when they have known dementia (dementia puts people at very high risk of delirium: see the Cork Dementia Study).

In this study, we tested out five simple cognitive tests to see if they could be used to screen for delirium. The tests were: the Six-item Cognitive Impairment Test (6-CIT; measuring attention, orientation to time, and short-term memory); the Clock-Drawing test; Spatial Span Forwards (pointing to a sequence of squares in a certain order); reciting the months of the year backwards (MOTYB); and copying a shape containing two intersecting pentagons. These particular tests were chosen as hospital staff are familiar with most of them, they test attention and/or visuospatial function (key problems in delirium), and are quick to perform. And most importantly, they don’t require the hospital staff member to contact a patient’s relatives and explore if any confusion is new, or worse than usual.

How did we do the study?

Within 36 hours of being admitted to two large hospitals in Cork city, Ireland, 470 medical patients (aged 70 years or older) were tested by a researcher using the five short cognitive tests. Patients were also assessed for delirium using a longer, highly accurate test, the Revised Delirium Rating Scale.

What were the results?

Almost 40% of the patients had delirium, highlighting that delirium is very common. The 6-CIT performed best. Only 9% of patients who screened “negative” actually had delirium and 60% screening “positive” had delirium. The 6-CIT has been studied in dementia screening (see our recent review paper) but this study is the first to show its promise as a delirium screening test. Also, some cognitive tests are too hard for people with dementia so they “fail” the test, even if they don’t have delirium. But 6-CIT did usefully distinguish delirium and dementia.

The MOTYB test also performed well. This extremely simple test takes less than one minute and it’s part of the 4AT delirium test (which you may be familiar with) and the 6-CIT. We’ve previously found that it also works very well on its own in detecting delirium in adults of any age in hospital.

 Where to from here?

The big question now is how does 6-CIT compare to the 4-AT test. 4AT was specifically developed to screen for delirium, unlike 6-CIT, which is a general cognitive test. The obvious advantage of 6-CIT is that it doesn’t need any extra information from family carers, whereas the 4-AT needs this for some patients. We know that busy hospital staff may not have time to ring families straight away to get this vital information. We have just completed another study comparing 4-AT and 6-CIT head-to-head in an emergency department, again using trained researchers. We now plan to compare the two tests when done by busy clinical staff, as a “real-life” test. We also plan to continue studying MOTYB as it’s so quick that we believe even the busiest staff could perform it every day. We’ll keep you posted!!

Read the full paper here.

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