Attention, Medical Students! Article on Bedside Test for Delirium

So this is really just an announcement to the medical students rotating through our psychiatry clerkship, although you’re all welcome to eavesdrop. I give the lecture on delirium and major neurocognitive disorder (the new DSM-5 term replacing “dementia”) and I recently learned of a new open-access article on a bedside screening test for delirium [1]. Niamh A. O’Regan and colleagues may be right on this one. I routinely use the months-of-the-year-backward (MOTYB) as a way to test for problems with attention as medical students readily learn when they’re on the psychiatry consultation service.

I’ve also had a chance to briefly try out the Edinburgh Delirium Test Box, which the authors give us an update on and about which I’ve posted before. It was developed by a brilliant colleague, Dr. Alasdair MacLullich, BSc(Hons), MB ChB, MRCP(UK), PhD, who is the current President of the European Delirium Association, an organization dedicated to research and clinical innovation in delirium. They’re a great group of professionals who work closely with the members of the American Delirium Society.

You can access the paper through the tweet below:

In my lecture, I usually mention the Confusion Assessment Method (CAM) and the Clock Drawing Task as part of the Mini-Cog (see Borson reference) which I think is a fairly quick and graphic way to demonstrate delirium, although it’s well to remember it’s actually a screen for dementia (whoops, I mean major neurocognitive disorder) [2].

And the problem with trying to use anything from the MMSE Folstein is the copyright restriction. I’m pretty sure I’m still right about that.

References:

1. O’Regan, N. A., et al. (2014). “Attention! A good bedside test for delirium?” Journal of Neurology, Neurosurgery & Psychiatry 85(10): 1122-1131.
Background Routine delirium screening could improve delirium detection, but it remains unclear as to which screening tool is most suitable. We tested the diagnostic accuracy of the following screening methods (either individually or in combination) in the detection of delirium: MOTYB (months of the year backwards); SSF (Spatial Span Forwards); evidence of subjective or objective ‘confusion’.Methods We performed a cross-sectional study of general hospital adult inpatients in a large tertiary referral hospital. Screening tests were performed by junior medical trainees. Subsequently, two independent formal delirium assessments were performed: first, the Confusion Assessment Method (CAM) followed by the Delirium Rating Scale-Revised 98 (DRS-R98). DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) criteria were used to assign delirium diagnosis. Sensitivity and specificity ratios with 95% CIs were calculated for each screening method.Results 265 patients were included. The most precise screening method overall was achieved by simultaneously performing MOTYB and assessing for subjective/objective confusion (sensitivity 93.8%, 95% CI 82.8 to 98.6; specificity 84.7%, 95% CI 79.2 to 89.2). In older patients, MOTYB alone was most accurate, whereas in younger patients, a simultaneous combination of SSF (cut-off 4) with either MOTYB or assessment of subjective/objective confusion was best. In every case, addition of the CAM as a second-line screening step to improve specificity resulted in considerable loss in sensitivity.Conclusions Our results suggest that simple attention tests may be useful in delirium screening. MOTYB used alone was the most accurate screening test in older people. http://jnnp.bmj.com/content/85/10/1122.long

2. Borson, S., et al. (2000). “The mini-cog: a cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly.” Int J Geriatr Psychiatry 15(11): 1021-1027.
OBJECTIVES: The Mini-Cog, a composite of three-item recall and clock drawing, was developed as a brief test for discriminating demented from non-demented persons in a community sample of culturally, linguistically, and educationally heterogeneous older adults. SUBJECTS: All 129 who met criteria for probable dementia based on informant interviews and 120 with no history of cognitive decline were included; 124 were non-English speakers. METHODS: Sensitivity, specificity, and diagnostic value of the Mini-Cog were compared with those of the Mini-Mental State Exam (MMSE) and Cognitive Abilities Screening Instrument (CASI). RESULTS: The Mini-Cog had the highest sensitivity (99%) and correctly classified the greatest percentage (96%) of subjects. Moreover, its diagnostic value was not influenced by education or language, while that of the CASI was adversely influenced by low education, and both education and language compromised the diagnostic value of the MMSE. Administration time for the Mini-Cog was 3 minutes vs 7 minutes for the MMSE. CONCLUSIONS: The Mini-Cog required minimal language interpretation and training to administer, and no test forms of scoring modifications were needed to compensate for the extensive linguistic and educational heterogeneity of the sample. Validation in clinical and population-based samples is warranted, as its brevity and ease of administration suggest that the Mini-Cog might be readily incorporated into general practice and senior care settings as a routine ‘cognitive vital signs’ measure.

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