Department of Nursing and Allied Health Professions, University Hospital Basel, Hebelstrasse 2, Basel, 4031, Switzerland.
Emergency Department, University Hospital Basel, Basel, Switzerland.
Intern Emerg Med. 2018 Sep;13(6):915-922. doi: 10.1007/s11739-017-1781-y. Epub 2017 Dec 30.
Delirium is frequent in older Emergency Department (ED) patients, but detection rates for delirium in the ED are low. To aid in identifying delirium, we developed and implemented a two-step systematic delirium screening and assessment tool in our ED: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Components of the mCAM-ED include: (1) screening for inattention, the main feature of delirium, which was performed with the Months Backwards Test (MBT); (2) delirium assessment based on a structured interview with questions from the Mental Status Questionnaire by Kahn et al. and the Comprehension Test by Hart et al. The aims of our study are (1) to investigate the performance criteria of the mCAM-ED tool in a consecutive sample of older ED patients, (2) to evaluate the performance of the mCAM-ED in patients with and without dementia and (3) to test whether this tool is efficient in keeping evaluation time to a minimum and reducing screening and assessment burden on the patient. For this prospective validation study, we recruited a consecutive sample of ED patients aged 65 and older during an 11-day period in November 2015. Trained nurses assessed patients with the mCAM-ED. Results were compared to the reference standard [i.e. the geriatricians' delirium diagnosis based on the criteria of the Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)]. Performance criteria were computed. We included 286 consecutive ED patients aged 65 and older. The median age was 80.02 (Q = 72.15; Q = 86.76), 58.7% of included patients were female, 14.3% had dementia. We found a delirium prevalence of 7.0%. In patients with dementia, specificity and positive likelihood ratio were lower. When compared to the reference standard, delirium assessment with the mCAM-ED has a 0.98 specificity and a 39.9 positive likelihood ratio. In 80.0% of all cases, the first step of the mCAM-ED, i.e. screening for inattention with the MBT, took less than 30 s. On average, the complete mCAM-ED assessment required 3.2 (SD 2.0), 5.6 (SD 3.2), and 6.2 (SD 2.3) minutes in cognitively unimpaired patients, patients with dementia and patients with dementia or delirium, respectively. The mCAM-ED is able to efficiently rule out delirium as well as confirm the diagnosis of delirium in elderly patients with and without dementia and applies minimal screening and assessment burden on the patient.
谵妄在老年急诊科患者中很常见，但急诊科对谵妄的检测率很低。为了帮助识别谵妄，我们在急诊科开发并实施了一个两步系统的谵妄筛查和评估工具：改良的急诊谵妄评估方法（mCAM-ED）。mCAM-ED 的组成部分包括：（1）使用月份倒推测试（MBT）对注意力不集中进行筛查，这是谵妄的主要特征；（2）根据 Kahn 等人的精神状态问卷和 Hart 等人的理解测试进行结构化访谈进行谵妄评估。我们研究的目的是：（1）调查 mCAM-ED 工具在连续的老年急诊科患者样本中的性能标准；（2）评估 mCAM-ED 在痴呆症和非痴呆症患者中的表现；（3）测试该工具是否能够有效地将评估时间最小化，并减轻患者的筛查和评估负担。在这项前瞻性验证研究中，我们在 2015 年 11 月的 11 天内连续招募了急诊科年龄在 65 岁及以上的患者。经过培训的护士使用 mCAM-ED 对患者进行评估。结果与参考标准（即老年医生根据《精神障碍诊断与统计手册（DSM-IV-TR）》修订版的标准诊断的谵妄）进行比较。计算了性能标准。我们纳入了 286 名年龄在 65 岁及以上的连续急诊科患者。中位年龄为 80.02 岁（Q=72.15；Q=86.76），58.7%的患者为女性，14.3%的患者患有痴呆症。我们发现谵妄的患病率为 7.0%。在痴呆症患者中，特异性和阳性似然比较低。与参考标准相比，使用 mCAM-ED 进行的谵妄评估具有 0.98 的特异性和 39.9 的阳性似然比。在所有病例中，mCAM-ED 的第一步，即使用 MBT 对注意力不集中进行筛查，不到 30 秒即可完成。平均而言，认知无障碍患者、痴呆症患者和痴呆症或谵妄患者完成完整的 mCAM-ED 评估分别需要 3.2（SD 2.0）、5.6（SD 3.2）和 6.2（SD 2.3）分钟。mCAM-ED 能够有效地排除谵妄，并在有和没有痴呆症的老年患者中确认谵妄的诊断，并且对患者的筛查和评估负担最小。
