Inouye S K, Foreman M D, Mion L C, Katz K H, Cooney L M
Yale University School of Medicine, Yale-New Haven Hospital, 20 York St, Tompkins 15, New Haven, CT 06504, USA.
Arch Intern Med. 2001 Nov 12;161(20):2467-73. doi: 10.1001/archinte.161.20.2467.
Nurses play a key role in recognition of delirium, yet delirium is often unrecognized by nurses. Our goals were to compare nurse ratings for delirium using the Confusion Assessment Method based on routine clinical observations with researcher ratings based on cognitive testing and to identify factors associated with underrecognition by nurses.
In a prospective study, 797 patients 70 years and older underwent 2721 paired delirium ratings by nurses and researchers. Patient-related factors associated with underrecognition of delirium by nurses were examined.
Delirium occurred in 239 (9%) of 2721 observations or 131 (16%) of 797 patients. Nurses identified delirium in only 19% of observations and 31% of patients compared with researchers. Sensitivities of nurses' ratings for delirium and its key features were generally low (15%-31%); however, specificities were high (91%-99%). Nearly all disagreements between nurse and researcher ratings were because of underrecognition of delirium by the nurses. Four independent risk factors for underrecognition by nurses were identified: hypoactive delirium (adjusted odds ratio [OR], 7.4; 95% confidence interval [CI], 4.2-12.9), age 80 years and older (OR, 2.8; 95% CI, 1.7-4.7), vision impairment (OR, 2.2; 95% CI, 1.2-4.0), and dementia (OR, 2.1; 95% CI, 1.2-3.7). The risk for underrecognition by nurses increased with the number of risk factors present from 2% (0 risk factors) to 6% (1 risk factor), 15% (2 risk factors), and 44% (3 or 4 risk factors; P(trend)<.001). Patients with 3 or 4 risk factors had a 20-fold risk for underrecognition of delirium by nurses.
Nurses often missed delirium when present, but rarely identified delirium when absent. Recognition of delirium can be enhanced with education of nurses in delirium features, cognitive assessment, and factors associated with poor recognition.
护士在谵妄的识别中起着关键作用，但谵妄常常未被护士识别出来。我们的目标是比较护士根据常规临床观察使用意识错乱评估法对谵妄的评分与研究人员基于认知测试的评分，并确定与护士识别不足相关的因素。
在一项前瞻性研究中，797名70岁及以上的患者接受了护士和研究人员对谵妄的2721次配对评分。研究了与护士未识别出谵妄相关的患者相关因素。
在2721次观察中有239例（9%）发生谵妄，797例患者中有131例（16%）发生谵妄。与研究人员相比，护士仅在19%的观察和31%的患者中识别出谵妄。护士对谵妄及其关键特征评分的敏感性普遍较低（15%-31%）；然而，特异性较高（91%-99%）。护士和研究人员评分之间几乎所有的差异都是因为护士未识别出谵妄。确定了护士识别不足的四个独立危险因素：活动减退型谵妄（校正比值比[OR]，7.4；95%置信区间[CI]，4.2-12.9）、80岁及以上（OR，2.8；95%CI，1.7-4.7）、视力障碍（OR，2.2；95%CI，1.2-4.0）和痴呆（OR，2.1；95%CI，1.2-3.7）。随着存在的危险因素数量增加，护士识别不足的风险从2%（0个危险因素）增加到6%（1个危险因素）、15%（2个危险因素）和44%（3个或4个危险因素；P趋势<.001）。有3个或4个危险因素的患者被护士漏诊谵妄的风险高20倍。
护士经常在存在谵妄时漏诊，但在不存在谵妄时很少误诊。通过对护士进行谵妄特征、认知评估以及与识别不佳相关因素的教育，可以提高对谵妄的识别。
