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      Using the Mini-Mental State Examination to Screen for Delirium in Elderly Patients with Hip Fracture

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          Abstract

          Background: The main aim of this paper was to examine the usefulness of the Mini-Mental State Examination (MMSE) for screening delirium in elderly patients with hip fracture. Methods: The sample included 364 elderly patients with hip fracture admitted to two hospitals in Oslo. Delirium was assessed by the Confusion Assessment Method (CAM) as an approximation of the gold standard, DSM-IV. To evaluate the psychometric properties of the MMSE scale, we used the Mokken nonparametric latent trait model for unidimensional scaling. Results: In total, 76 (21%) patients were diagnosed with delirium based on the CAM, and 141 (43%) had preexisting cognitive impairment. As a screening tool, the recommended MMSE cut-point of 24 showed an acceptable sensitivity of 88% with a specificity of 54%. The prediction of delirium, based on logistic regression on the MMSE total score and on the 5 items selected by the stepwise logistic regression procedure, gave clearly less acceptable results. Conclusions: Our study indicates that the MMSE may be useful in screening for delirium, but the high percentage of false positives shows that it does not have diagnostic potential in patients with hip fracture.

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          A chart-based method for identification of delirium: validation compared with interviewer ratings using the confusion assessment method.

          Sharon Inouye, Sidney T Bogardus, Jin-ying Zhang … (2005)
          To validate a chart-based method for identification of delirium and compare it with direct interviewer assessment using the Confusion Assessment Method (CAM). Prospective validation study. Teaching hospital. Nine hundred nineteen older hospitalized patients. A chart-based instrument for identification of delirium was created and compared with the reference standard interviewer ratings, which used direct cognitive assessment to complete the CAM for delirium. Trained nurse chart abstractors were blinded to all interview data, including cognitive and CAM ratings. Factors influencing the correct identification of delirium in the chart were examined. Delirium was present in 115 (12.5%) patients according to the CAM. Sensitivity of the chart-based instrument was 74%, specificity was 83%, and likelihood ratio for a positive result was 4.4. Overall agreement between chart and interviewer ratings was 82%, kappa=0.41. By contrast, using International Classification of Diseases, Ninth Revision, Clinical Modification, administrative codes, the sensitivity for delirium was 3%, and specificity was 99%. Independent factors associated with incorrect chart identification of delirium were dementia, severe illness, and high baseline delirium risk. With all three factors present, the chart instrument was three times more likely to identify patients incorrectly than with none of the factors present. A chart-based instrument for delirium, which should be useful for patient safety and quality-improvement programs in older persons, was validated. Because of potential misclassification, the chart-based instrument is not recommended for individual patient care or diagnostic purposes.
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            Delirium predicts 12-month mortality.

            Jane McCusker, Martin Cole, Michal Abrahamowicz … (2002)
            Delirium has not been found to be a significant predictor of postdischarge mortality, but previous research has methodologic limitations including small sample sizes and inadequate control of confounding. This study aimed to determine the independent effects of presence of delirium, type of delirium (incident vs prevalent), and severity of delirium symptoms on 12-month mortality among older medical inpatients. A prospective, observational study of 2 cohorts of medical inpatients was conducted with patients 65 years or older: 243 patients had prevalent or incident delirium, and 118 controls had no delirium. Baseline measures included presence of delirium and/or dementia, severity of delirium symptoms, physical function, comorbidity, and physiological and clinical severity of illness. Mortality during the 12 months after enrollment was analyzed with the Cox proportional hazards model with adjustment for covariates. The unadjusted hazard ratio of delirium with mortality was 3.44 (95% confidence interval, 2.05-5.75); the adjusted hazard ratio was 2.11 (95% confidence interval, 1.18-3.77). The effect of delirium was sustained over the entire 12-month period after adjustment for covariates and was stronger among patients without dementia. Among patients with dementia, there was a weak, nonsignificant effect of delirium on survival. After adjustment for covariates, mortality did not differ between patients with incident and prevalent delirium, but among patients with delirium without dementia, greater severity of delirium symptoms was associated with higher mortality. Delirium is an independent marker for increased mortality among older medical inpatients during the 12 months after hospital admission. It is a particularly important prognostic marker among patients without dementia.
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              Does this patient have delirium?: value of bedside instruments.

              Daniel S Straus, D L Simel, Camilla Wong … (2010)
              Delirium occurs in many hospitalized older patients and has serious consequences including increased risk for death and admission to long-term care. Despite its importance, health care clinicians often fail to recognize delirium. Simple bedside instruments may lead to improved identification. To systematically review the evidence on the accuracy of bedside instruments in diagnosing the presence of delirium in adults. Search of MEDLINE (from 1950 to May 2010), EMBASE (from 1980 to May 2010), and references of retrieved articles to identify studies of delirium among inpatients. Prospective studies of diagnostic accuracy that compared at least 1 delirium bedside instrument to the Diagnostic and Statistical Manual of Mental Disorders-based diagnosis made by a geriatrician, psychiatrist, or neurologist. There were 6570 unique citations identified with 25 prospectively conducted studies (N = 3027 patients) meeting inclusion criteria and describing use of 11 instruments. Positive results that suggested delirium with likelihood ratios (LRs) greater than 5.0 were present for the Global Attentiveness Rating (GAR), Memorial Delirium Assessment Scale (MDAS), Confusion Assessment Method (CAM), Delirium Rating Scale Revised-98 (DRS-R-98), Clinical Assessment of Confusion (CAC), and Delirium Observation Screening Scale (DOSS). Normal results that decreased the likelihood of delirium with LRs less than 0.2 were calculated for the GAR, MDAS, CAM, DRS-R-98, Delirium Rating Scale (DRS), DOSS, Nursing Delirium Screening Scale (Nu-DESC), and Mini-Mental State Examination (MMSE). The Digit Span test and Vigilance "A" test in isolation have limited utility in diagnosing delirium. Considering the instrument's ease of use, test performance, and clinical importance of the heterogeneity in the confidence intervals (CIs) of the LRs, the CAM has the best available supportive data as a bedside delirium instrument (summary-positive LR, 9.6; 95% CI, 5.8-16.0; summary-negative LR, 0.16; 95% CI, 0.09-0.29). Of all scales, the MMSE (score <24) was the least useful for identifying a patient with delirium (LR, 1.6; 95% CI, 1.2-2.0). 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.
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                Author and article information

                Journal
                Journal ID (publisher-id): DEM
                Journal ID (nlm-ta): Dement Geriatr Cogn Disord
                Journal ID (doi): 10.1159/issn.1420-8008
                Title: Dementia and Geriatric Cognitive Disorders
                Publisher: S. Karger AG
                ISSN (Print): 1420-8008
                ISSN (Electronic): 1421-9824
                Publication date Subscription-year: 2011
                Publication date (Print): February 2012
                Publication date (Electronic): 01 February 2012
                Volume: 32
                Issue: 6
                Pages: 394-400
                Affiliations
                Departments of aPsychology, bSociology and Political Science and cCancer Research and Molecular Medicine (European Palliative Care Research Centre, Faculty of Medicine), St. Olavs University Hospital, Norwegian University of Science and Technology, Trondheim, Departments of dGeriatric Medicine, Institute of Clinical Medicine and eBehavioural Sciences, National Resource Centre for Late Effects after Cancer Treatment, Oslo University Hospital and University of Oslo, and fDepartment of Oncology, Regional Centre for Excellence in Palliative Care, Oslo University Hospital, Ullevål, Oslo, Norway
                Author notes
                *G.I. Ringdal, Department of Psychology, Norwegian University of Science and Technology (NTNU), NO–7491 Trondheim (Norway), Tel. +47 7359 1960, E-Mail gerd.inger.ringdal@svt.ntnu.no
                Article
                Publisher ID: 335743 Other ID: Dement Geriatr Cogn Disord 2011;32:394–400
                DOI: 10.1159/000335743
                PubMed ID: 22301509
                SO-VID: 4d1bdbb8-ca34-47f5-aa35-9af1efb7dacb
                Copyright © © 2012 S. Karger AG, Basel
                License:

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                Date accepted : 09 December 2011
                Page count
                Figures: 2, Tables: 4, Pages: 7
                Categories
                Subject: Original Research Article

                ScienceOpen disciplines: Geriatric medicine,Neurology,Cardiovascular Medicine,Neurosciences,Clinical Psychology & Psychiatry,Public health
                Keywords: Delirium,Mini-Mental State Examination,Elderly patients,Confusion Assessment Method,Hip fracture
                Data availability:
                ScienceOpen disciplines: Geriatric medicine, Neurology, Cardiovascular Medicine, Neurosciences, Clinical Psychology & Psychiatry, Public health
                Keywords: Delirium, Mini-Mental State Examination, Elderly patients, Confusion Assessment Method, Hip fracture

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