Elsevier

General Hospital Psychiatry

Volume 27, Issue 3, May–June 2005, Pages 194-199
General Hospital Psychiatry

Impact on delirium detection of using a sensitive instrument integrated into clinical practice

https://doi.org/10.1016/j.genhosppsych.2005.01.002Get rights and content

Abstract

Early symptoms of delirium often go unnoticed. The Nursing Delirium Screening Scale (Nu-DESC) is a recently developed short, accurate and sensitive 24-h screening instrument. The Nu-DESC is more sensitive than the instrument from which it was derived, the Confusion Rating Scale (CRS). This study examined the impact on delirium detection of using the Nu-DESC over the CRS in 134 consecutive oncology patients. Expected false-negative rate (FNR) reductions at different delirium prevalence rates when using the Nu-DESC compared to the CRS and the number needed to screen (NNS) by the Nu-DESC were calculated. Kaplan–Meier survival analyses were used to study Nu-DESC–CRS divergences in delirium status and length of delirium-free survival. Ninety-nine patients were negative for delirium according to both tests. Of the remaining 35 patients, 16 had identical Nu-DESC–CRS delirium status and delirium-free survival, whereas 19 were detected later by the CRS (mean, 4.8 days). Among the 19 patients, 6 were still CRS negative upon hospital discharge. Integrating a continuous and sensitive delirium assessment instrument into usual care can facilitate its recognition, since more cases of delirium are diagnosed and patients are detected earlier.

Introduction

Delirium is a common and challenging psychiatric complication occurring during hospitalization in geriatrics, orthopedics, intensive care and oncology units [1], [2], [3], [4]. Although daily fluctuation is a cardinal symptom of delirium according to the Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV) [5], early delirium symptoms frequently go unnoticed [6] since, in general, only irregular or once-daily delirium clinical evaluations are performed. Promptly detecting delirium using continuous and sensitive assessment, thereby allowing immediate diagnosis and therapeutic actions [7], [8], can improve the efficiency of delirium screening, by decreasing the number of undetected patients and by reducing the delay in delirium recognition. The Nursing Delirium Screening Scale (Nu-DESC) is a simple observational instrument that can be used to assess delirium status on a continuous basis with a high level of sensitivity and accuracy [9]. The Nu-DESC was derived from the Confusion Rating Scale (CRS) [10] to improve its sensitivity to delirium without compromising its ease of use. We used this increased sensitivity to study how delirium detection can be improved. The objectives of this study were to determine delirium prevalence and incidence in oncology and to quantify the impact of using a continuous and sensitive delirium instrument on (1) the decrease in delirium underrecognition and (2) the reduction in time to delirium detection.

Section snippets

Method

This study is a secondary analysis of data collected in the validation study of a new delirium screening instrument, the Nu-DESC. The CRS comprises four items that are operationalized for on-site use: (1) disorientation (verbal or behavioral manifestation of not being oriented to time or place or of misperceiving persons in the environment), (2) inappropriate behavior (behavior inappropriate to place and/or for the person, e.g., pulling at tubes or dressings, attempting to get out of bed when

Results

Based on the validation study [9], the difference between Nu-DESC and CRS FNRs was 0.381 (95% CI, 0.173–0.589), for an absolute NNS of 2.6 (95% CI, 1.73–5.89). Relative NNS calculations for various overall delirium prevalences are presented in Table 1.

Overall prevalence of delirium based on the Nu-DESC was 35/134 (26.1%) and 29/134 (21.6%) based on the CRS. Nine cases were prevalent on admission according to the Nu-DESC compared to seven according to the CRS, and 26 patients were incident cases

Discussion

This study determined delirium prevalence and incidence in oncology and quantified the impact of using a continuous and sensitive delirium instrument on the decrease in delirium underrecognition and the reduction in time to delirium detection.

Acknowledgments

This research was supported by a grant from the Sociobehavioural Cancer Research Network (SCRN), funded through the National Cancer Institute of Canada's (NCIC) Centre for Behavioural Research and Program Evaluation, with funds from the Canadian Cancer Society. J.D. Gaudreau is the recipient of a Fonds d'Enseignement et de Recherche Award from the Faculty of Pharmacy, Laval University and of a Canadian Institutes of Health Research (CIHR) — NCIC award from the Strategic Training Program in

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