Delirium, Dementia, and Dentistry for Medical Students Updated

This is the link to the most recent update to the Delirium and Major Neurocognitive Disorder powerpoint lecture for medical students or whoever is interested in the topic. On the date in July when I’m scheduled to give the talk, I’ll be at the dentist’s office getting some work done. In fact, I have several visits scheduled, including today.

I suppose some medical students think going to such lectures is about as painful as trips to the dentist. Well, you don’t have to go to mine–good luck on the test! I cover a fair amount of ground, including screening questions to detect delirium, one of which is called the SQiD. Consider the Silliest Question in Dentistry (SQiD): “Does this hurt?” The updated slides are below.

In order to see the picture galleries of photos or powerpoint slides, click on one of the slides, which will open up the presentation to fill the screen. Use the arrow buttons to scroll left and right through the slides or up and down to view any annotations.

The links and/or abstracts in the powerpoint are below. I saw an interesting article on another quick screening tool for delirium called the SQeeC which is new to me and which has been compared to the SQiD (Single Question in Delirium). The authors description of the SQeeC is below:

The SQeeC consists of two simple questions. The first question, ‘Name a place you would like to visit that you have never been before?’, examines the contemplative state or one’s ability to reflect, imagine and appreciate an experience which is hypothesised to draw on the default resting state of consciousness [6]. The second question, ‘How would you make the journey?’, assesses task positive cognition and the ability to problem solve [7]. A demonstration of consciousness is dependent upon the naming of a place that he/she wishes to go together with a mode of transport that logically fits with the destination. A complementary answer demonstrates co-operation between resting and task positive states and is evidence of intact consciousness at the level of network integrity. We hypothesised that, as disturbance of consciousness is integral to delirium, then successful demonstration of consciousness according to this test is inconsistent with a diagnosis of delirium.

The ICU Delirium link will take you to the Vanderbilit University site where cutting edge research is being done on delirium in the intensive care unit. Also take a look at the American Delirium Society website, recently updated and packed with practical and scientific pearls. The videos for how to administer the Mini-Cog, identifying hyperactive and hypoactive delirium and for the TADA method are below.

 

 

 

References:

Sands, M., et al. (2010). “Single Question in Delirium (SQiD): testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the Memorial Delirium Assessment Scale.” Palliative Medicine 24(6): 561-565.

In this study we address the research question; How sensitive is a single question in delirium case finding? Of 33 ‘target’ admissions, consent was obtained from 21 patients. The single question: ‘Do you think [name of patient] has been more confused lately?’ was put to friend or family. Results of the Single Question in Delirium (SQiD) were compared to psychiatrist interview (ΨI) which was the reference standard. The Confusion Assessment Method (CAM) and two other tools were also applied. Compared with ΨI, the SQiD achieved a sensitivity and specificity of 80% (95% CI 28.3—99.49%) and 71% (41.90—91.61%) respectively. The CAM demonstrated a negative predictive value (NPV) of 80% (51.91—95.67%) and the SQiD showed a NPV of 91% (58.72—99.77%). Kappa correlation of SQiD with the ΨI was 0.431 (p = 0.023). The CAM had a kappa value of 0.37 (p = 0.050). A further important finding in our study was that the CAM had only 40% sensitivity in the hands of minimally trained clinical users. Conclusion: The SQiD demonstrates potential as a simple clinical tool worthy or further investigation.

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. LINK

McCleary, E. and P. Cumming (2015). “Improving early recognition of delirium using SQiD (Single Question to identify Delirium): a hospital based quality improvement project.” BMJ Quality Improvement Reports 4(1).
Delirium is a serious condition associated with poor outcomes which can be prevented and treated if recognised early. Older people and people with dementia or severe illness are more at risk of delirium. SQiD is a simple prompt question which asks, “Is this patient more confused than before?” Focusing specifically on patients aged 75 and over, this project aimed to increase awareness and usage of SQiD to help improve early recognition of delirium, in accordance with the Healthcare Improvement Scotland national initiative. This project was carried out by two student nurses during an eight week clinical placement in the acute surgical receiving unit (ASRU) of Ninewells Hospital, Dundee, Scotland.Qualitative and quantitative methodology was used to establish baseline data which revealed that only 35% of the multidisciplinary team (MDT) were aware of SQiD, with only 15% using SQiD. Initial activities involved raising awareness of SQiD by means of information cards and posters. Once awareness was raised, the usage of the SQiD question by nurses was tested. Finally, the SQiD question was incorporated into the nursing care round forms and usage recorded. Following these awareness raising activities we noted an increase of 83% awareness and 20% use of SQiD. Incorporating the SQiD question into the hourly care round forms increased awareness to 100% and usage to 50%.Although this small scale project could be viewed as a success, the requirements for sustainability depend upon further implementation and spreading of the change. Sustained improvement is also dependent upon the implementation of the care rounds.As nursing students, undertaking this improvement project has provided valuable lessons in both quality improvement science and personal learning. The improved knowledge and understanding of effective communication and the intricacies of team working is transferrable and can be applied to future nursing practice. LINK

Lin, H.-S., et al. (2015). “Screening in delirium: A pilot study of two screening tools, the Simple Query for Easy Evaluation of Consciousness and Simple Question in Delirium.” Australasian Journal on Ageing 34(4): 259-264.
Aim Delirium is poorly recognised and inadequately treated in medical settings. This research aimed to determine the psychometric properties of a newly developed tool, SQeeC against another emergent instrument, SQiD, in the screening of delirium. Methods The SQeeC was administered to 100 patients and SQiD administered to their informants in the general medical wards of a General Hospital. Data were compared with the reference standard geriatric consultant assessment of delirium. Results Compared with the reference standard, the SQeeC was found to have a sensitivity of 83% (95% CI 52–98%) and a specificity of 81% (95% CI 72–89%) with a negative predictive value of 97% (95% CI 90–100%) while the SQiD was found to have a sensitivity of 77% (95% CI 56–91%), a specificity of 51% (95% CI 37–64%) and a negative predictive value of 83% (95% CI 66–93%). Conclusion The SQeeC and SQiD are simple and time efficient screening tools with encouraging psychometric properties.

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Comments

  1. I thought it was just teeth cleaning today.

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