Acute cognitive failure and delirium: screening

Transcription

1 Acute cognitive failure and delirium: screening instruments for research and clinical practice Augusto Caraceni Director Palliative Care, Pain therapy and rehabilitation Fondazione IRCCS National Cancer Institute Milan

2 In the beginning 29 April 1965 to Dr RobertTwycross... I hope we will continue to reduce this figure when we have St Christopher s s and when we learn more about the relief of mental suf fering and confusion, which as you see remain the big problem 16 August 1976 To Prof. Exton Smith the confusion which many patients experience we agreed that, all too often, this is and remains somewhat of a mistery David Clark: Cicely Saunders Founder of the Hospice movement selected letters Oxford University Press 2002

3 Epidemiology of delirium comparing oncology with palliative care with elderly populations Population Authors Prevalence Incidence 70 Francis (1990) Levfkoff (1992) Inouye (1993) Inouye (1996) 18.0 Oncology Ljubisavjevic (2003) 18.0 Oncology Gaudreau (2005) 16.5 Hospice Minagawa (1999) 28.0 PC Unit Lawlor (2000) Homecare Caraceni (2000) Dying patient Massie et al.(1983) 85 From Caraceni & Simonetti The Lancet Oncology 2009

4 Delirium DSM IV diagnostic criteria Disturbance of consciousness (i.e( reduced clarity of awareness of the environment) with reduced ability to focus, sustain and shift attention Change in cognition or the development of perceptual disturbances Develops in hours to days and fluctuates Is caused by the direct physiological consequence of a general medical condition Diagnostic and statistical manual of mental disorders (DSM) IV TR APA 2000

5 DSM IV criterion 1 A. Disturbance of consciousness (reduced clarity of awareness of the environment) B. With reduced ability to focus, sustain and shift attention Consciousness Awareness Attention

6 DSM IV criterion 2 A. A change in cognition (such as memory deficit, disorientation, language disturbance B. or perceptual disturbance C. that is not better accounted for by a preexisting, established or evolving dementia Cognition Perception

7 Clinical assessment Assessement of the level of consciousness Assessment of cognitive functions Hallucinations Delusions Incoherent thought Written and spoken language Neurologic signs

8 Delirium scales 1. DRS and DRS-revised revised-98 (Trzepacz et al 1988, 2001) 2. Memorial delirium assessment scale (Breitbart( et al 1997) 3. Confusional state evaluation (Robertson et al 1997) 4. Cognitive test for delirium (ICU) (Hart( et al 1996) 5. Delirium Index (Mc Cusker et al 1998) 6. Delirium writing test (Aakerlund( and Rosenberg 1994) 7. Communication capacity scale and Agitation distress scale (Morita et al 2001) (Morita( JPSM, 2003; 26: ) 834) 8. Delirium assessment scale (O Keefe( et al 1994) 9. Intensive care delirium screening checklist (Dubois( et al 2001) 10. Delirium severity scale (Bettin( et al 1998) Caraceni A and Grassi L, Delirium acute confusional states in palliative medicine OUP 2003 Second Edition IN PRESS 2010

9 Should specific delirium scales be used routinely in palliative care? Diagnostic instruments CAM (Confusion( Assessment Method) Inouye et al Ann Int Medicine 1999, Ryan et al Pall Med 2009) Delirium symptom interview (Albert et al, J Geriatr Psych Neurol 1992) Nursing delirium screening scale (Gaudreau et al J Pain Sympt Manage 2005) Descriptive, assessing severity, specific DRS, MDAS Non specific of delirium but assessing cognitive functions in general MMSE

10 Aim of test Screening = not losing any potential case, sensitivity has to be high, specificity may be low. It requires that after screening other tests are done to correctly identify cases to distiguish true positives from false positives Diagnosing = requires the best combination of sensitivity and specificity

11 MMSE In the MMSE 4 items over 20 are sufficient to screen for cognitive failure Orientation to year Orientation to date backward spelling copy design Fayers PM et al J Pain Sympt Manage 2005; 30: 41-50

12 MMSE - effects of age and education Normal lower limits Education middle school highscholl college/graduate Uhlmann et al JAGS 1991; 39:

13 MMSE - effects of age and education population based norms Median score Age Education > years Crum et al JAMA 1993; 269: 2386

14 MDAS, DRS, MMSE for diagnosis Cut-off DRS >/= 10 DRS >/= 12 MDS >/= 13 MMSE < 24 Sensitivity 95% 80% 68% 96% Specificity 61% 76% 94% 38% Negative PA 89% 69% 63% 88% Positive PA 80% 85% 95% 72% Grassi et al., J Pain Symp Manage 2001

15 Screening and diagnosing Confusion Assessment Method algorithm a. Acute onset and fluctuating course b. Inattention c. Disorganized thought d. Altered level of consciousness Delirium present if a and b are both present and c or d Inouye et al JAMA 1990

16 Diagnosing delirium with CAM Author Population Sensitivity Specificity Interrater reliability Leslie A JAGS 2008 Systhematic review of (91-97) 97) 89 (85-94) Ryan K Pall Med 2009 Pall care unit 52 with 17 cases Caraceni Glasgow 2010

17 Screening and diagnosing delirium Nu-DESC Disorientation 0-2 Inappropriate behaviour 0-2 Inappropriate communication 0-2 Illusion Hallucination 0-2 Psychomotor retardation 0-2 Gaudreau JD et al. The nursing delirium screening scale J Pain Sympt Manage 2005; 29:

18 Diagnosing delirium with Nu-DESC Author Population Comparator Sensitivity Specificity k Gaudreau 2005 oncology CAM 86 (65-95) 87 (72-94) - Radtke 2010 Post-op op DSM IV 97 (93-102) 92 (88-96) 0.83 Radtke 2008 Recovery room DSM IV Luetz 2010 ICU Psychiatry diagnosis Caraceni Glasgow 2010