Journal of the American Medical Directors Association
Original StudyUltra-brief Screeners for Detecting Delirium Superimposed on Dementia
Section snippets
Study Sample and Design
We performed secondary data analysis of a prospective cluster randomized trial, Early Nurse Detection of Delirium Superimposed on Dementia (END-DSD), conducted between 2010 and 2014 across 3 acute care settings, 2 in Pennsylvania and 1 in Tennessee, as described elsewhere.19 Inclusion criteria for study participation included (1) prior history of dementia, (2) age 65 years or greater, (3) admission to a general medicine or surgery unit, and (4) enrollment within 24 hours of hospitalization.
Patient Characteristics
Three hundred ninety-one patients met the inclusion criteria and were enrolled. The mean age was 83.9 (SD = 6.1); 278 (71.1%) were female and 371 (94.9%) were white. Mild, moderate, and advanced dementia was present in 198 (50.6%), 134 (34.3%), and 59 (15.1%) of the patients, respectively. Ninety-two (23.5%) of the participants had less than a high school education, 179 (45.8%) completed high school, and 120 (30.7%) attended college and beyond. Depression was present in 101 (25.8%). Finally, 95
Discussion
Delirium is a common occurrence in people with underlying dementia, including nursing home residents experiencing an acute illness, and those recently hospitalized.28, 29 Despite this, DSD is frequently under-recognized by health care clinicians.1, 30 This study demonstrates that a brief 3-item screening test containing the items “days of the week backwards,” “What type of place is this,” and “Is the patient sleepy?” can detect more than 90% of DSD, while also effectively ruling out more than
Conclusion and Implications
In conclusion, we identified a 3-item screener that can effectively detect DSD. Once validated, this screener could assist clinicians in environments with a high prevalence of dementia to rapidly exclude patients without delirium and identify those who require further testing. Ultimately, our screener will facilitate the challenging process of identifying delirium in persons with dementia, with the potential to improve patient outcomes and decrease costs in this population of older adults.
Acknowledgments
We thank the older adult participants, unit champions, and staff members at the study hospitals, without whom the study would not have been possible. We also thank the research assistants and staff and dedicate this article in memory of Jane McDowell, the project director for END-DSD and a nurse champion of improving the care of older adults.
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Cited by (12)
Prevalence, Risk Factors, and Impact of Delirium on Hospitalized Older Adults With Dementia: A Systematic Review and Meta-Analysis
2022, Journal of the American Medical Directors AssociationThe 4-DSD: A New Tool to Assess Delirium Superimposed on Moderate to Severe Dementia
2021, Journal of the American Medical Directors AssociationCitation Excerpt :Future multicenter studies are necessary to further investigate this new tool to include a larger group of patients with severe dementia and to analyze if it could be created as a 2-step approach with one 4-DSD item considered as a screening step and then perform the full 4-DSD if the screening is positive. Recently, Steensma and colleagues39 proposed a screening test for DSD with 1-, 2-, and 3-item combinations, including various questions to be answered by the patient. They specifically looked at the performance of this approach in different stages of dementia, so one could use the 3-item combination screening and then perform the full 4-DSD evaluation.
Delirium Assessment in Critically Ill Older Adults: Considerations During the COVID-19 Pandemic
2021, Critical Care ClinicsCitation Excerpt :The CAM-ICU has an option to use a visual attention form to assess feature 2, the core feature of delirium, which can be useful in identifying delirium in patients with dementia. Other screening tools validated in larger populations of patients with dementia (the 4As test,49 6-Item Cognitive Impairment Test,50 3-Item Screener51) require patients to be verbal, which is often a barrier to implementation in the ICU. Hearing impairment can result in inappropriate answers to questions if an older adult does not correctly interpret the information communicated by the health care provider.
Delirium Superimposed Upon Dementia
2019, Journal of the American Medical Directors AssociationDelirium superimposed on dementia: Early detection and treatment
2023, Zeitschrift fur Gerontologie und GeriatrieDelirium in older patients
2022, Pathy's Principles and Practice of Geriatric Medicine
Funding sources: NIA and NINR Grants T35AG038027, R01AG030618, R01NR011042, and K24AG035075.
E.R. Marcantonio and D. Fick served in equal roles as senior investigators in this study.
The authors declare no conflicts of interest.