Aims. To survey the use of delirium screening and diagnostic tools in patients with acute stroke across Scotland and to establish whether doctors and nurses felt the tools used were suitable for stroke patients. Methods. An invitation to participate in a web-based survey was e-mailed to 217 doctors and nurses working in acute stroke across Scotland. Descriptive statistics were used to report nominal data, and content analysis was used to interpret free text responses. Results. Sixty-five responses were logged (30% return rate). 48% of the respondents reported that they routinely screened newly admitted patients for delirium. Following initial screening, 38% reported that they screened for delirium as the need arises. 43% reported using clinical judgment to diagnose delirium, and 32% stated that they combined clinical judgment with a standardised tool. 28% of the clinicians reported that they used the Confusion Assessment Method; however, only 13.5% felt that it was suitable for stroke patients. Conclusions. Screening for delirium is inconsistent in Scottish stroke services, and there is uncertainty regarding the suitability of screening tools with stroke patients. As the importance of early identification of delirium on stroke outcomes is articulated in recent publications, validating a screening tool to detect delirium in acute stroke is recommended. 1. Introduction Delirium is a common neuropsychiatric condition affecting 20–30% of elderly patients across most hospital settings [1]. In acute stroke, the incidence of delirium reported by individual studies ranges from 10% [2] to 48% [3], and meta analyses recently performed placed the incidence around 26%–28% [4, 5]. Delirium is associated with increased mortality, morbidity, and length of hospital stay [5–8], and it has been strongly associated with development of cognitive impairment in the long term in the general medical setting [9, 10]. In acute stroke, recent studies have clearly demonstrated that patients who develop delirium are more likely to die within 12 months, have poorer functional outcomes, and are at higher risk of developing dementia [4, 5, 11, 12]. There are calls in the literature for clinicians to place an emphasis on early identification of delirium in stroke patients, using a tool validated specifically for this population, as early intervention may minimise the aforementioned unfavourable outcomes [5, 13, 14]. The most recent guidance published in the United Kingdom (UK) by both the National Institute for Health and Clinical Excellence (NICE) and the Royal College of Physicians
References
[1]
N. Siddiqi, A. O. House, and J. D. Holmes, “Occurrence and outcome of delirium in medical in-patients: a systematic literature review,” Age and Ageing, vol. 35, no. 4, pp. 350–364, 2006.
[2]
M. H. Dahl, O. M. R？nning, and B. Thommessen, “Delirium in acute stroke—prevalence and risk factors,” Acta Neurologica Scandinavica, vol. 122, no. 190, pp. 39–43, 2010.
[3]
Y. Gustafson, T. Olsson, K. Asplund, and E. Hagg, “Acute confusional state (delirium) soon after stroke is associated with hypercortisolism,” Cerebrovascular Diseases, vol. 3, pp. 33–38, 1993.
[4]
G. Carin-Levy, G. E. Mead, K. Nicol, R. Rush, and F. van Wijck, “Delirium in acute stroke: screening tools, incidence rates and predictors: a systematic review,” Journal of Neurology, vol. 259, no. 8, pp. 1590–1599, 2012.
[5]
Q. Shi, R. Presutti, D. Selchen, and G. Saposnik, “Delirium in acute stroke: a sysaematic review and meta-analysis,” Stroke, vol. 43, no. 3, pp. 645–649, 2012.
[6]
J. McCusker, M. G. Cole, N. Dendukuri, and E. Belzile, “Does delirium increase hospital stay?” Journal of the American Geriatrics Society, vol. 51, no. 11, pp. 1539–1546, 2003.
[7]
National Institute for Clinical Excellence, Delirium: Diagnosis Prevention and Management, NICE, 2010.
[8]
J. Young and S. K. Inouye, “Delirium in older people,” British Medical Journal, vol. 334, no. 7598, pp. 842–846, 2007.
[9]
J. C. Jackson, S. M. Gordon, R. P. Hart, R. O. Hopkins, and E. W. Ely, “The association between delirium and cognitive decline: a review of the empirical literature,” Neuropsychology Review, vol. 14, no. 2, pp. 87–98, 2004.
[10]
D. H. J. Davis, G. M. Terrera, H. Keage et al., “delirium is a strong risk factor for dementia in the oldest old: a population based cohort study,” Brain, vol. 135, no. 9, pp. 2809–2816, 2012.
[11]
M. W. A. Van Rijsbergen, A. W. Oldenbeuving, R. E. Nieuwenhuis-Mark et al., “Delirium in acute stroke: a predictor of subsequent cognitive impairment? A two-year follow-up study,” Journal of the Neurological Sciences, vol. 306, no. 1-2, pp. 138–142, 2011.
[12]
S. Melkas, J. V. Laurila, R. Vataja et al., “Post-stroke delirium in relation to dementia and long-term mortality,” International Journal of Geriatric Psychiatry, vol. 27, no. 4, pp. 401–408, 2012.
[13]
J. Mcmanus, R. Pathansali, R. Stewart, A. Macdonald, and S. Jackson, “Delirium post-stroke,” Age and Ageing, vol. 36, no. 6, pp. 613–618, 2007.
[14]
A. Mitasova, M. Kostalova, J. Bednarik et al., “Poststroke delirium incidence and outcomes: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU),” Critical Care Medicine, vol. 40, no. 2, pp. 484–490, 2012.
[15]
National Institute for Health and Clinical Excellence, Stroke: National Clinical Guidelines for Treatment and Initial Management of Acute Stroke and Transient Ischaemic Attack (TIA), NICE, 2008.
[16]
Intercollegiate Stroke Wrking Party, National Clinical Guidelines for Stroke, Royal College of Physicians, London, UK, 4th edition, 2012.
[17]
Scottish Intercollegiate Guidelines Network, SIGN 118: Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications, and Discharge Planning. A National Clinical Guideline, 2010.
[18]
National Stroke Foundation, “Clinical Guidelines for Stroke Management,” Melbourne, Australia, 2010, http://strokefoundation.com.au/site/media/Clinical_Guidelines_Acute_Management_Recommendations_2010.pdf.
[19]
E. L. Miller, L. Murray, L. Richards et al., “Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American heart association,” Stroke, vol. 41, no. 10, pp. 2402–2448, 2010.
[20]
M. P. Lindsay, G. Gubitz, M. Bayley et al., Canadian Best Practice Recommendations for Stroke Care on Behalf of the Canadian Stroke Strategy Best Practices and Standards Writing Group, Canadian Stroke Network, Ottawa, Canada, 2010, http://www.strokebestpractices.ca/wp-content/uploads/2011/04/2010BPR_ENG.pdf.
[21]
J. W. Devlin, J. J. Fong, E. P. Howard et al., “Assessment of delirium in the intensive care unit: nursing practices and perceptions,” American Journal of Critical Care, vol. 17, no. 6, pp. 555–565, 2008.
[22]
Australian Health Ministers Advisory Council, Clinical Practice Guidelines for the Management of Delirium in Older People, Victorian Government Department of Human Services, Melbourne, Australia, 2006.
[23]
Canadian Coalition for Seniors' Mental Health, The Assessment and Treatment of Delirium, Canadian Coalition of Seniors' Mental Health, Toronto, Canada, 2006.
[24]
S. K. Inouye, C. H. Van Dyck, C. A. Alessi, S. Balkin, A. P. Siegal, and R. I. Horwitz, “Clarifying confusion: the confusion assessment method: a new method for detection of delirium,” Annals of Internal Medicine, vol. 113, no. 12, pp. 941–948, 1990.
[25]
P. T. Trzepacz, R. W. Baker, and J. Greenhouse, “A symptom rating scale for delirium,” Psychiatry Research, vol. 23, no. 1, pp. 89–97, 1988.
[26]
M. F. Folstein, S. E. Folstein, and P. R. McHugh, “Mini-mental state: a practical method for grading the cognitive state of patients for the clinician,” Journal of Psychiatric Research, vol. 12, pp. 189–198, 1975.
[27]
S. Levkoff, B. Liptzin, P. Cleary, C. H. Reilly, and D. Evans, “Review of research instruments and techniques used to detect delirium,” International Psychogeriatrics, vol. 3, no. 2, pp. 253–271, 1991.
[28]
L. G. Wells, “Why don't intensive care nurses perform routine delirium assessment? A discussion of the literature,” Australian Critical Care, vol. 25, no. 3, pp. 157–161, 2012.
[29]
A. Teodorczuk, E. Reynish, and K. Milisen, “Improving recognition of delirium in clinical practice: a call for action,” BMC Geriatrics, vol. 2012, article 55, 2012.
[30]
Bristol Online Surveys, About BOS, http://www.survey.bris.ac.uk/support/about.
[31]
P. B. Doherty, “The context and culture of web as a research environment,” in Online Assessment Measurement and Evaluation, D. D. Williams, S. L. Howell, and M. Hericko, Eds., pp. 10–27, Information Science Publishing, London, UK, 2006.
[32]
H. M. Huang, “Do print and Web surveys provide the same results?” Computers in Human Behavior, vol. 22, no. 3, pp. 334–350, 2006.
[33]
M. D. Kaplowitz, T. D. Hadlock, and R. Levine, “A comparison of web and mail survey response rates,” Public Opinion Quarterly, vol. 68, no. 1, pp. 94–101, 2004.
[34]
W. Fan and Z. Yan, “Factors affecting response rates of the web survey: a systematic review,” Computers in Human Behavior, vol. 26, no. 2, pp. 132–139, 2010.
[35]
D. A. Dillman and J. D. Smyth, “Design effects in the transition to web-based surveys,” American Journal of Preventive Medicine, vol. 32, no. 5, pp. S90–S96, 2007.
[36]
F. J. Fowler and C. Cosenza, “Writing effective questions,” in International Handbook of Survey Methodology, E. D. de Leeuw, D. Hox, and D. D. A, Eds., chapter 8, pp. 136–159, Psychology Press, New York, NY, USA, 2008.
[37]
K. L. Manfreda and V. Vehovar, “Internet surveys,” in International Handbook of Survey Methodology, E. D. de Leeuw, J. J. Hox, and D. A. Dillman, Eds., chapter 14, pp. 264–284, Psychology Press, New York, NY, USA, 2008.
[38]
P. Naithani, “Guidelines for developing a robust web survey,” Advances in Information Technology and Management, vol. 1, pp. 20–23, 2012.
[39]
S. Elo and H. Kyngas, “The qualitative content analysis process,” Journal of Advanced Nursing, vol. 62, no. 1, pp. 107–115, 2008.
[40]
D. L. Morgan, “Qualitative content analysis: a guide to paths not taken,” Qualitative Health Research, vol. 3, no. 1, pp. 112–121, 1993.
[41]
K. Krippendorf, Content Analysis: An Introduction to Its Methodology, Sage Publications, Thousand Oaks, Calif, USA, 2004.
[42]
ISD Scotland, “Scottish stroke care audit 2010,” National Report, 2010.
[43]
A. MacLullich, T. Ryan, and H. Cash, “The 4A test: screening instrument for cognitive impairment and delirium,” http://www.the4at.com/.
[44]
H. M. Hodkinson, “Evaluation of a mental test score for assessment of mental impairment in the elderly,” Age and Ageing, vol. 1, no. 4, pp. 233–238, 1972.
[45]
B. Flagg, S. McDowell, and J. M. Beulow, “Nursing identification of delirium,” Clinical Nurse Specialist, vol. 24, no. 25, pp. 260–266, 2010.
[46]
L. M. Forsgren and M. Eriksson, “Delirium-Awareness, observation and interventions in intensive care units: a national survey of Swedish ICU head nurses,” Intensive and Critical Care Nursing, vol. 26, no. 5, pp. 296–303, 2010.
[47]
R. P. Patel, M. Gambrell, T. Speroff et al., “Delirium and sedation in the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals,” Critical Care Medicine, vol. 37, no. 3, pp. 825–832, 2009.
[48]
J. I. F. Salluh, F. Dal-Pizzol, P. V. C. Mello et al., “Delirium recognition and sedation practices in critically ill patients: a survey on the attitudes of 1015 Brazilian critical care physicians,” Journal of Critical Care, vol. 24, no. 4, pp. 556–562, 2009.
[49]
E. W. Ely, R. K. Stephens, J. C. Jackson et al., “Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: a survey of 912 healthcare professionals,” Critical Care Medicine, vol. 32, no. 1, pp. 106–112, 2004.
[50]
D. Davis and A. Maclullich, “Understanding barriers to delirium care: a multicentre survey of knowledge and attitudes amongst UK junior doctors,” Age and Ageing, vol. 38, no. 5, pp. 559–563, 2009.
[51]
S. T. O'Keeffe, E. C. Mulkerrin, K. Nayeem, M. Varughese, and I. Pillay, “Use of serial mini-mental state examinations to diagnose and monitor delirium in elderly hospital patients,” Journal of the American Geriatrics Society, vol. 53, no. 5, pp. 867–870, 2005.
[52]
J. Mc Manus, R. Pathansali, H. Hassan et al., “The evaluation of delirium post-stroke,” International Journal of Geriatric Psychiatry, vol. 24, no. 11, pp. 1251–1256, 2009.
[53]
A. Ni Chonchubhair, R. Valacio, J. Kelly, and S. O'Keeffe, “Use of the abbreviated mental test to detect postoperative delirium in elderly people,” British Journal of Anaesthesia, vol. 75, no. 4, pp. 481–482, 1995.
[54]
R. J. Hall, D. J. Meagher, and A. M. J. MacLullich, “Delirium detection and monitoring outside the ICU,” Best Practice & Research Clinical Anaesthesiology, vol. 26, no. 3, pp. 367–383, 2012.
[55]
E. W. Ely, R. Margolin, J. Francis et al., “Evaluation of delirium in critically ill patients: aalidation of the Confusion Assessment Method for the intensive care unit (CAM-ICU),” Critical Care Medicine, vol. 29, no. 7, pp. 1370–1379, 2001.
[56]
G. M. Eastwood, L. Peck, R. Bellomo, I. Baldwin, and M. C. Reade, “A questionnaire survey of critical care nurses' attitudes to delirium assessment before and after introduction of the CAM-ICU,” Australian Critical Care, vol. 25, no. 3, pp. 162–169, 2012.
[57]
M. Kostalova, J. Bednarik, A. Mitasova et al., “Towards a predictive model for post stroke delirium,” Brain Injury, vol. 26, pp. 962–971, 2012.
[58]
M. J. Schuurmans, “Early recognition of delirium: review of the literature,” Journal of Clinical Nursing, vol. 10, no. 6, pp. 721–729, 2001.
[59]
R. Eley, T. Fallon, J. Soar, E. Buikstra, and D. Hegney, “Barriers to use of information and computer technology by Australia's nurses: a national survey,” Journal of Clinical Nursing, vol. 18, no. 8, pp. 1151–1158, 2009.
[60]
C. Cook, F. Heath, and R. L. Thompson, “A meta-analysis of response rates in Web- or internet-based surveys,” Educational and Psychological Measurement, vol. 60, no. 6, pp. 821–836, 2000.
[61]
A. W. Oldenbeuving, P. L. M. de Kort, B. P. W. Jansen, L. J. Kappelle, and G. Roks, “A pilot study of rivastigmine in the treatment of delirium after stroke: a safe alternative,” BMC Neurology, vol. 8, article 34, 2008.
[62]
T. Ohta, K. Murao, K. Miyake, and K. Takemoto, “Melatonin receptor agonists for treating delirium in elderly patients with acute stroke,” Journal of Stroke and Cerebrovascular Diseases, 2012.
