Delirium detection instruments

Delirium is a neuropsychiatric condition characterized by altered consciousness and attention with cognitive, emotional and behavioural symptoms. The condition is common in inpatient care, especially in elderly and frail patients. The term delirium is often used synonymously with confusion, acute confusion, or temporary confusion. There are several assessment tools that can be used for the identification or screening of delirium.

Reading time approx. 10 minutes Published: March 4, 2020 Publication type:

SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Question

What systematic reviews are there on the diagnostic accuracy of delirium detection tools?

Identified literature

**Table 1** Systematic reviews with low/medium risk of bias.
AMT-4 = Abbreviated Mental Test 4; CAM = Confusion Assessment Method; CAM-ICU = Confusion Assessment Method for the ICU; DCT-2 = Digit Cancellation Test with a 2-digit matrix; DSM-III = Diagnostic and Statistical Manual of Mental Disorders-III; DSM-III-R =; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders-IV; FAM‐CAM = The Family Confusion Assessment Method; GAR = Global Attentiveness Rating; I‐AGeD = Informant Assessment of Geriatric Delirium Scale; OSLA = Observational Scale of Level of Arousal; OSLA = Observational Scale of Level of Arousal; SAVEAHAART = S-A-V-E-A-H-A-A-R-T; RASS = Richmond Agitation Sedation Scale; SQiD = Single Question in Delirium; SSQ‐Delirium = Single Screening Questions-Delirium; Sour Seven = Sour Seven Questionnaire; ICU = Intensive care unit
Included studies	Population/Intervention	Outcome
Rosgen et al [1]
Study design: Observational study design reporting on the validity of caregiver-centred delirium detection tools. Included studies: Search resulted in 6,076 unique studies whereof six were included in the systematic review.	Population: Adults (Above 18 years old) in any hospital setting. Intervention: Caregiver-centred delirium detection tools, defined as tools involving a family member’s or friend’s assessment of delirium symptoms.	Effect: Instrument validity, length of hospital stay, duration of mechanical ventilation, long-term cognitive impairment, death, caregiver anxiety, caregiver depression.
Authors' conclusion: “Caregiver‐informed tools, including the SQiD and SSQ‐Delirium, may be highly feasible for use in hospitals because they require no training and consist of 1 item each. Future research should evaluate the use of these tools in hospital settings where patients are likely to remain for a short period of time (<24 hours), such as emergency departments (EDs).” “Caregiver‐administered delirium detection tools, including the FAM‐CAM, I‐AGeD, and Sour Seven, require minimal effort from the care team and no preliminary training. Using these tools, caregivers can independently detect symptoms of delirium and notify healthcare professionals accordingly”
Quispel-Aggenbach et al [2]
Study design: Studies assessing the test accuracy of rapid screening instruments. Included studies: Search resulted in 6,077 unique studies, whereof 27 studies were included.	Population: Patients aged 60 years or older. Intervention: Bedside screening instrument with an administration time less than three minutes.	Effect: Instrument sensitivity and specificity. Tests designed to diagnose delirium or delirium tremens, or rate the severity of delirium or cognitive impairments were excluded.
Authors' conclusion: “We performed a systematic review of rapid and easy-to-administer screening instruments for delirium in older patients. The tools took 3 min or less to administer. The AMT-4, DCT-2, GAR, OSLA, RASS and ‘writing name and address’ had sensitivity above 90% and specificity above 80% in older patients in general. The OSLA + SAVEAHAART performed well in those with dementia.”
Wong et al [3]
Study design: Studies describing the use of an appropriate reference standard (DSM-III, DSM-III-R, or DSM-IV) and had the reference standard performed by a specialist physician Included studies: Search resulted in 6,570 unique studies, whereof 25 studies were included.	Population: Hospitalized patients not in the intensive care unit. Studies involving alcohol-related delirium or a paediatric population were also excluded. Intervention: A bedside instrument that is feasible to use in a clinical setting, without requiring special equipment, and may be performed by a non-expert.	Effect: Instrument sensitivity and specificity, delirium prevalence.
Authors' conclusion: “The choice of instrument may be dictated by the amount of time available and the discipline of the examiner; however, the best evidence supports use of the CAM, which takes 5 minutes to administer.”
Morandi et al [4]
Study design: Validation studies which had evaluated delirium with tools using the DSM-IV OR DSM-III criteria as a gold standard. Included studies: Search resulted in 10,273 unique studies, whereof 9 studies were included.	Population: Patients with dementia. Studies assessing solely alcohol-related delirium or had a study population with age <18 years were excluded. Intervention: Standardised tool to detect delirium.	Effect: Instrument sensitivity and specificity.
Authors' conclusion: “This is the first systematic review of the literature on the performance of existing tools for delirium detection in patients with dementia. We found that the CAM and the derived CAM-ICU both had preliminary data supporting their use in the general ward and ICU settings, respectively. Nonetheless, the overall evidence base is small.”

References

Rosgen B, Krewulak K, Demiantschuk D, Ely EW, Davidson JE, Stelfox HT, et al. Validation of Caregiver‐Centered Delirium Detection Tools: A Systematic Review. Journal of the American Geriatrics Society 2018;66:1218-1225.
Quispel-Aggenbach DWP, Holtman GA, Zwartjes H, Zuidema SU, Luijendijk HJ. Attention, arousal and other rapid bedside screening instruments for delirium in older patients: a systematic review of test accuracy studies. Age & Ageing 2018;47:644-653.
Wong CL, Holroyd-Leduc J, Simel DL, Straus SE. Does this patient have delirium?: Value of bedside instruments. JAMA - Journal of the American Medical Association 2010;304:779-786.
Morandi A, McCurley J, Vasilevskis EE, Fick DM, Bellelli G, Lee P, et al. Tools to detect delirium superimposed on dementia: a systematic review. Journal of the American Geriatrics Society 2005;60:2005-2013.

Literature search

MedLINE via OVID 2019-12-10
Delirium detection instruments
The search result, usually found at the end of the documentation, forms the list of abstracts.; [MeSH] = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy; [MeSH:NoExp] = Does not include terms found below this term in the MeSH hierarchy; [MAJR] = MeSH Major Topic; [TIAB] = Title or abstract; [TI] = Title; [AU] = Author; [TW] = Text Word; Systematic[SB] = Filter for retrieving systematic reviews; * = Truncation
Search terms		Items found
Population:
1.	Exp delirium/ OR Deliri*.ti,ab,kw.	16,623
2.	Exp confusion/ OR confus*.ti,ab,kw.	66,298
3.	disorient*.ti,ab,kw.	4,647
4.	acute confusion/ OR Exp acute brain disease/	0
5.	(Acute ADJ3 (Brain syndrome OR Organic psychosyndrome OR Psycho-organic syndrome OR Encephalopathy)).ti,ab,kw.	2,713
6.	(metabolic encephalopathy OR exogenous psychosis).ti,ab,kw	470
7.	(clouded state OR clouding of consciousness).ti,ab,kw	183
8.	(Toxic confusion OR toxic psychos*).ti,ab,kw	201
9.	obnubilat*.ti,ab,kw	54
10.	1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9	80,007
Intervention:
11.	Exp risk assessment/	255,574
12.	(4AT OR 4 AT OR 4 A T OR 4A T).ti,ab,kw	8,512
13.	((risk OR rapid OR predict* OR diag* OR screen* OR clinical) ADJ3 (model? OR tool? OR instrument OR scale? OR test? OR assessment OR method?)).ti,ab,kw	747,631
14.	11 OR 12 OR 13	963,646
Study types:
15.	Exp systematic review/ OR cochrane library.mp OR exp meta analysis/	188,595
16.	((systematic* ADJ3 review) OR meta analy* OR metaanaly*).ab,ti,kw	251,727
17.	15 OR 16	278,318
Combined sets:
18.	10 AND 14	4,947
Final	17 AND 18	224

Embase via embase.com 2019-12-10
Delirium detection instruments
/de = Term from the EMTREE controlled vocabulary; /exp = Includes terms found below this term in the EMTREE hierarchy; /mj = Major Topic; :ab = Abstract; :au = Author; :ti = Article Title; :ti,ab = Title or abstract; * = Truncation; ’ ’ = Citation Marks; searches for an exact phrase
Search terms		Items found
Population:
1.	'delirium'/exp OR Deliri*:ti,ab,kw	34,747
2.	'confusion' OR confus*:ti,ab,kw	101,374
3.	'disorientation'/exp OR disorient*:ti,ab,kw	15,116
4.	'acute confusion'/de OR 'acute brain disease'/exp	1,976
5.	(Acute NEAR/3 (‘Brain syndrome’ OR ‘Organic psychosyndrome’ OR ‘Psycho-organic syndrome’ OR Encephalopathy)):ti,ab,kw	3,934
6.	(‘metabolic encephalopathy’ OR 'exogenous psychosis'):ti,ab,kw	806
7.	(‘clouded state’ OR ‘clouding of consciousness’):ti,ab,kw	291
8.	(‘Toxic confusion’ OR ‘toxic psychos*’):ti,ab,kw	271
9.	obnubilat*:ti,ab,kw	111
10.	1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9	146,846
Intervention:
11.	'risk assessment'/exp	535,560
12.	(‘4AT’ OR ‘4 AT’ OR ‘4 A T’ OR ‘4A T’):ti,ab,kw	31,560
13.	((risk OR rapid OR predict* OR diag* OR screen* OR clinical) NEAR/3 (model$ OR tool$ OR instrument OR scale$ OR test$ OR assessment OR method$)):ti,ab,kw	1,205,219
14.	11 OR 12 OR 13	1,654,969
Study types:
15.	'systematic review'/exp OR 'cochrane library'/exp OR 'meta analysis'/exp	322,360
16.	((systematic* NEAR/3 review) OR ‘meta analy’ OR metaanaly):ab,ti,kw	325,157
17.	15 OR 16	414,055
Combined sets:
18.	10 AND 14	11,685
Final	17 AND 18	640

CINAHL via ebsco.com 2019-12-09
Delirium detection instruments
AB = Abstract; AU = Author; DE = Term from the thesaurus; MM = Major Concept; TI = Title; TX = All Text. Performs a keyword search of all the database's searchable fields; ZC = Methodology Index; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
Search terms		Items found
Population:
1.	(MH ”delirium”) OR (AB Deliri) OR (TI Deliri) OR (MW Deliri*)	8,760
2.	(MH “Confusion”) OR (AB confus) OR (Ti confus) OR (MW confus*)	17,069<
3.	(AB disorient) OR (TI disorient) OR (MW disorient*)	856
4.	(MH "Acute Confusion (NANDA)")	3
5.	(AB (Acute W3 (”Brain syndrome” OR ”Organic psychosyndrome” OR ”Psycho-organic syndrome” OR Encephalopathy))) OR (TI (Acute W3 (”Brain syndrome” OR ”Organic psychosyndrome” OR ”Psycho-organic syndrome” OR Encephalopathy))) OR (MW (Acute W3 (”Brain syndrome” OR ”Organic psychosyndrome” OR ”Psycho-organic syndrome” OR Encephalopathy)))	390
6.	(AB (”metabolic encephalopathy” OR ”exogenous psychosis”)) OR (TI (”metabolic encephalopathy” OR ”exogenous psychosis”)) OR (MW (”metabolic encephalopathy” OR ”exogenous psychosis”))	78
7.	(AB (”clouded state” OR ”clouding of consciousness”)) OR (TI (”clouded state” OR ”clouding of consciousness”)) OR (MW (”clouded state” OR ”clouding of consciousness”))	14
8.	(AB (”Toxic confusion” OR ”toxic psychos”)) OR (TI (”Toxic confusion” OR ”toxic psychos”)) OR (MW (”Toxic confusion” OR ”toxic psychos*”))	11
9.	AB obnubilat* OR TI obnubilat* OR MW obnubilat*	2
10.	1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9	25,561
Intervention:
11.	(MH ”risk assessment”)	89,045
12.	(AB (”4AT” OR ”4 AT” OR ”4 A T” OR ”4A T”) OR (TI (”4AT” OR ”4 AT” OR ”4 A T” OR ”4A T”) OR (MW (”4AT” OR ”4 AT” OR ”4 A T” OR ”4A T”)	247,648
13.	(AB (risk OR rapid OR predict* OR diag* OR screen* OR clinical) W3 (model# OR tool# OR instrument OR scale# OR test# OR assessment OR method#)) OR (TI (risk OR rapid OR predict* OR diag* OR screen* OR clinical) W3 (model# OR tool# OR instrument OR scale# OR test# OR assessment OR method#)) OR (MW (risk OR rapid OR predict* OR diag* OR screen* OR clinical) W3 (model# OR tool# OR instrument OR scale# OR test# OR assessment OR method#))	400,039
14.	11 OR 12 OR 13	617,867
Study types:
15.	(MH ”systematic review”) OR (MH ”cochrane library”) OR (MH ”meta analysis”)	100,963
16.	(AB ((systematic* W3 review) OR ”meta analy” OR metaanaly)) OR (TI ((systematic* W3 review) OR ”meta analy” OR metaanaly)) OR (MW ((systematic* W3 review) OR ”meta analy” OR metaanaly))	150,142
17.	15 OR 16	152,696
Combined sets:
18.	10 AND 14	4,261
Final	17 AND 18	253

Page published March 4, 2020