Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments.

Autor: Carpenter CR; Mayo Clinic, Rochester, Minnesota, USA., Lee S; University of Iowa, Iowa City, Iowa, USA., Kennedy M; Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA., Arendts G; Medical School, University of Western Australia, Perth, Western Australia, Australia., Schnitker L; Bolton Clarke Research Institute, Bolton Clarke School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia., Eagles D; University of Ottawa, Ottawa, Ontario, Canada., Mooijaart S; Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands.; LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, The Netherlands., Fowler S; University of Connecticut Health Sciences, Farmington, Connecticut, USA., Doering M; Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA., LaMantia MA; Portland Veterans Affairs Medical Center, Portland, Oregon, USA., Han JH; Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA., Liu SW; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.; Harvard Medical School, Boston, Massachusetts, USA.
Jazyk: angličtina
Zdroj: Academic emergency medicine : official journal of the Society for Academic Emergency Medicine [Acad Emerg Med] 2024 Oct; Vol. 31 (10), pp. 1014-1036. Date of Electronic Publication: 2024 May 16.
DOI: 10.1111/acem.14935
Abstrakt: Introduction: Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening.
Methods: We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds.
Results: Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%.
Conclusions: The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.
(© 2024 Society for Academic Emergency Medicine.)
Databáze: MEDLINE
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