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Performance of the Delirium Rating Scale-Revised-98 Against Different Delirium Diagnostic Criteria in a Population With a High Prevalence of Dementia
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Performance of the Delirium Rating Scale Revised–98 Against Different Delirium Diagnostic Criteria in a Population with a High Prevalence of Dementia Esteban Sepulveda M.D, José G. Franco M.D., M.S., Ph.D, Paula T. Trzepacz M.D, Ana M. Gaviria Ph.D, Eva Viñuelas M.D, José Palma M. D, Gisela Ferré B.S, Imma Grau M.D, Elisabet Vilella Ph.D
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S0033-3182(15)00058-4 http://dx.doi.org/10.1016/j.psym.2015.03.005 PSYM538
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Psychosomatics
Cite this article as: Esteban Sepulveda M.D, José G. Franco M.D., M.S., Ph.D, Paula T. Trzepacz M.D, Ana M. Gaviria Ph.D, Eva Viñuelas M.D, José Palma M. D, Gisela Ferré B.S, Imma Grau M.D, Elisabet Vilella Ph.D, Performance of the Delirium Rating Scale Revised–98 Against Different Delirium Diagnostic Criteria in a Population with a High Prevalence of Dementia, Psychosomatics, http://dx.doi. org/10.1016/j.psym.2015.03.005 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
PerformanceoftheDeliriumRatingScaleRevised–98AgainstDifferentDelirium DiagnosticCriteriainaPopulationwithaHighPrevalenceofDementia EstebanSepulveda,M.Da,JoséG.Franco,M.D.,M.S.,Ph.Da,b,PaulaT.Trzepacz,M.Dc,d,Ana M.Gaviria,Ph.Da,EvaViñuelas,M.Da,JoséPalma,M.Da,GiselaFerré,B.Sa,ImmaGrau,M.Da, ElisabetVilella,Ph.Da a
HospitalPsiquiatricUniversitariInstitutPereMata,IISPV,UniversitatRoviraiVirgili,Centrode InvestigaciónBiomédicaenReddeSaludMental(CIBERSAM),Reus,Tarragona,Spain. b UniversidadPontificiaBolivariana,FacultyofMedicine,Medellín,Colombia. c TuftsUniversitySchoolofMedicine,Boston,MA,USA. d IndianaUniversitySchoolofMedicine,Indianapolis,IN,USA. Correspondingauthor:JoséG.Franco,POB26,PC43850,Cambrils(Tarragona),Spain. [email protected]
ABSTRACT Background:Deliriumdiagnosisinelderlyisoftencomplicatedbyunderlyingdementia. Objective:WeevaluatedperformanceoftheDeliriumRatingScaleRevised98(DRSR98)in patientswithhighdementiaprevalenceandalsoassessedconcordanceamongpastand currentdiagnosticcriteriafordelirium. Methods:Crosssectionalanalysisofnewlyadmittedpatientstoaskillednursingfacilityover6 months,whowereratedwithin2448hoursafteradmission.InterviewforDSMIIIR,DSMIV, DSM5,andICD10deliriumratings,administrationoftheDRSR98,andassessmentof dementiausingtheInformantQuestionnaireonCognitiveDeclineintheElderlywere independentlyperformedby3researchers.Discriminantanalyses(receiveroperating characteristicscurves)wereusedtostudyDRSR98accuracyagainstdifferentdiagnostic criteria.Hanley&McNeiltestcomparedtheareaunderthecurve(AUC)forDRSR98’s discriminantperformanceforalldiagnosticcriteria. Results:Dementiawaspresentin85/125(68.0%)subjectsand36/125(28.8%)metcriteriafor deliriumbyatleastoneclassificationsystemwhileonly19/36(52.8%)didbyall.DSMIIIR diagnosedthemostasdelirious(27.2%),followedbyDSM5(24.8%),DSMIVTR(22.4%)and ICD10(16%).DRSR98hadthehighestAUCwhendiscriminatingDSMIIIRdelirium(92.9%), followedbyDSMIV(92.4%),DSM5(91%)andICD10(90.5%),withoutstatisticaldifferences amongthem.ThebestDRSR98cutoffscorewas14.5foralldiagnosticsystemsexceptICD 10(15.5). Conclusions:Thereisalowconcordanceacrossdiagnosticsystemsforidentificationof delirium.TheDRSR98performswelldespitedifferencesacrossclassificationsystemsperhaps becauseitbroadlyassessesphenomenology,eveninthispopulationwithahighprevalenceof dementia. Keywords:Delirium;Dementia;DeliriumRatingScaleRevised98;SensitivityandSpecificity; DiagnosticandStatisticalManualofMentalDisorders;InternationalClassificationofDiseases.
INTRODUCTION Phenomenologicalresearchrevealsdeliriumhasthreecoredomains:attentionandother cognitivedeficits(orientation,memory,visuospatialability),higherlevelthinkingdisturbances (thoughtprocess,language,executivefunction),andcircadiandisturbances(sleepwakecycle, motoractivity)thatmaybevariablyaccompaniedbylessprevalentpsychoticandaffective symptoms.15 Deliriumappearedasadiagnosticentitywithspecificinclusionandexclusioncriteriain1980in theDiagnosticandStatisticalManualofMentalDisorders,3rdedition(DSMIII)6andhas evolvedsincethenincludingitsrevision,DSMIIIR.7However,DSMIV(andDSMIVTR) eliminatedsymptomsofcircadiandomain,andthoughtprocess,whilepreserving attention/cognitivedomainandlanguagesymptoms.8,9TheInternationalClassificationof Diseases10thedition(ICD10)hasmoredetailedresearchdiagnosticcriteria,10withamore restrictivedefinitionofcognitivedysfunctionandtheinclusionofdisturbancesincircadian,but notofhigherlevelthinkingdomain.Researchcomparingcriteriashowsthatdeliriumpatient identificationdiffersamongthem:DSMIV’ssimplestcriteriahavethegreatestsensitivity, followedbyDSMIIIRandICD10.11,12Thesedifferencesmakeitdifficultforcliniciansand researcherstorelyonanyonesystemasthereferencestandard. DSM5criteria13increasedfocusonattentionandawarenessinthecardinalcriterionand slightlyreorganizedsomeDSMIVcontent,butdidnotaddcircadiandomainandthought processsymptomsdespitetheirbeingcoreindelirium,ostensiblytomakeiteasierforprimary carephysicianstodiagnosepossibledelirium.Forspecialists,however,theDSMIVandDSM5 arelessspecifictodeliriumduetotheirgreaterinclusiveness.11,12 TheDeliriumRatingScaleRevised98(DRSR98)14isawidelyemployedinstrumenttoevaluate delirium.Itwasdesignedtodiagnoseandevaluatethebreadthandseverityofdelirium symptoms.DSRR98wasdevelopedbasedondeliriumcharacteristicsratherthanany particular(apriori)diagnosticsystem.IthasshownverygoodaccuracyagainstDSMIVcriteria, withveryhighinterraterreliability(intraclasscorrelationcoefficient>0.9). Deliriumiscommonintheelderly,reaching33%prevalenceinlongtermcaresettingsand 53.3%inacutegeriatricwards.15,16Dementiaisapredisposingfactorfordeliriumandisoften comorbidwithitintheelderlythoughdeliriumsymptomsovershadowdementiawhenthey coexist,1723sodementiaposesdifferentialdiagnosticchallengesforcliniciansassessing delirium. AllpreviousDRSR98validationstudieshaveusedDSMIVasthegoldstandard,anddelirium anddementiagroupsevaluatedseparately.Theobjectivesofthisstudywere1)toassess discriminantperformanceoftheSpanishDRSR98againstDSMIIIR,DSMIV,DSM5,andICD 10criteriafordeliriumdiagnosisinpatientsadmittedinaskillednursingfacility,withahigh prevalenceofdementia,and2)toevaluateconcordanceamongthesepastandcurrent diagnosticcriteria.
METHODS DesignandSubjects Thisisaprospective,crosssectionalstudyofdeliriumdiagnosticaccuracy,designedand reportedaccordingtoStandardsforReportingofDiagnosticAccuracyguidelines(STARD).24 Consecutivelyadmittedpatientstoaskillednursingfacility(CentroSociosanitarioMonterols, InstitutPereMata,Tarragona,Spain),wereeligible.Patientswereadmittedfromhome, generalhospitalorassistedliving/seniorcommunityduringthe6monthstudyperiod. Exclusioncriteriawererefusaltoparticipate,coma,severelanguagedisorder,orinabilityto speakSpanish. ThisstudywasapprovedbyourcorrespondingInstitutionalEthicsCommittee(atHospitalSant Joan,Reus,Tarragona,Spain).Allpatientsortheirproxy,whenMinimentalStateExamination (MMSE)scorewas<24(routinepartoftheadmissionevaluation),gavewritteninformed consent. Measures Demographicandclinicaldatawerecollected.Wealsoreviewedmedicalrecordsforarecent diagnosisofdelirium. CharlsonComorbidityIndex(Shortform;CCISF) DevelopedfromtheCCIwithsimilarprognosticvalue,25thisversionisbasedonhistoryof8 medicalconditions:cerebrovascularaccident,diabetesmellitus,chronicobstructive pulmonarydisease,congestiveheartfailure,dementia,peripheralarterialdisease,chronic renalfailureandcancer.Eachofthefirstsixconditionsscores1pointwhenpresent,while eachofthe7thand8thscore2pointsifpresent(foramaximumpossibleof10).ACCISFscore of0or1indicatesnocomorbidity,2lowcomorbidity,and3highcomorbidity. SpanishInformantQuestionnaireonCognitiveDeclineintheElderly(SIQCODE) Thisstructuredinterviewiscomposedby26questionstoaninformantaboutthepatient’s cognitionandfunctionduringtheprecedingfiveyears.Directscoresrangefrom26to130.The validatedSpanishversionusescutoff>85forpossibledementia.26 TheDeliriumRatingScaleRevised98(DRSR98) TheDRSR9814includesphenomenologicaldescriptiveanchorstorateseveritylevelsforeach item(rangingfrom0to3),withamaximumDRSR98Totalscalescoreof46andDRSR98 Severityscaleof39points.Its16itemsincludethreediagnosticitems(includingacuteonset andtemporalfluctuation)and13itemswhichratetheseverityofsymptoms,including individualitemstoevaluatecoredeliriumcharacteristics:attention,shortandlongterm memory,visuospatialability,orientation,sleepwakecycledisturbances,abnormalitiesof languageandthoughtprocess,motoragitation,motorretardation,besidesotheritems evaluatingperceptualdisturbances,abnormalitiesinthoughtcontent,andaffectivelability. WeusedtheSpanishversionwhichhasverygoodinterraterreliability.27
ClinicalDiagnosticCriteria Todefinedeliriumstatusweusedfourdiagnosticcriteria:theDiagnosticandStatistical ManualofMentalDisorders5,IVandIIIRevisededitions(DSM5,DSMIVandDSMIIIR),7,8,13 andtheInternationalClassificationofDiseases10theditionforresearch(ICD10).10We designedadiagnosticcriteriachecklisttosystematicallyrateeachitemforalldiagnostic criteriadichotomously(aspresentornot)inordertoensuretheircompleteevaluation. Procedures Twotrainedresearchersindependentlyevaluatedallsubjects24to48hoursafteradmission toratetheSpanishDRSR98andthedeliriumdiagnosticcriteriachecklist,eachcoveringthe preceding24hoursusingallsourcesofinformation.Athirdresearchercontactedthefamilyor caregivertoadministertheSIQCODE. Statisticalanalysis Continuousvariablesareexpressedasmeans±standarddeviation(SD).Chisquaretest comparedcategoricalvariables(withcontinuitycorrectionasappropriate)andttest comparedcontinuousvariables.Statisticalsignificancewassetatp<0.05,exceptformultiple comparisonsofDRSR98itemswherepwassetat<0.01. DRSR98accuracy,sensitivity,specificityandoptimalcutoffscoreswereobtainedwith receiveroperatingcharacteristiccurve(ROC)analysisoftheareaunderthecurve(AUC)forthe wholesampleandforthosewithdementia,reportedwiththeircorrespondingstandarderror (SE).Hanley&McNeiltestcomparedtheAUCsforDRSR98’sdiscriminantperformancefor diagnosticcriteria. DatawereanalysedusingSPSS21.0,andEpidat3.01(ROCanalysis,comparisonofAUC,and correspondinggraphics).TheoverlapofthediagnosticcriteriaisreportedwithaVenndiagram createdonVENNYonlineprogram.28 RESULTS SampleCharacteristics Of141patientsadmittedduringthestudyperiod,16wereexcluded,leavingasampleof125 participants(seeFigure1forSTARDflowdiagram).Meanagewas78.73r9yearsand50.4% werewomen.Table1showsdemographicandclinicalcharacteristicsbydeliriumand nondeliriumgroupsaccordingtoDSM5criteriaforthewholesampleandthesubsamplewith dementia.Thedeliriumgroupwassignificantlyolderandhadhigherdementiaprevalence. DeliriumDiagnosisbyClassificationSystems TheVenndiagram(Figure2)showsthat36/125patients(28.8%)metcriteriafordeliriumbyat leastoneclassificationsystem,butonly19/36(52.8%)metallfourcriteriawhichisalow concordanceacrosstheclassificationsystems.Themostsubjectswerediagnosedasdelirious (27.2%)byDSMIIIR,followedbyDSM5(24.8%),DSMIV(22.4%)andICD10(16%).DSMIIIR hadthemostcases(14.7%)thatdidnotoverlapwithanyotherdiagnosticclassification,yet almostall(34/36)ofthedeliriumcasesdiagnosedusinganysystemmetDSMIIIRcriteria
showingitsinclusiveness.Almostallofthe20/36ICD10deliriumcasesoverlappedwithall othersystems(19/20). Dementia Possiblepreexistingdementia(SIQCODEscore>85)occurredin85(68%).Therewasno differenceinage(79.89r7.90vs.76.25r10.90,t=1.894,p=0.063)betweenthosewithand withoutdementia.Thosewithdementiahadmoremedicalcomorbidity(CCISFscore2.07r1.4 vs.1.48r1.3;t=2.245,p=0.027)andmorefrequentuseofatypicalantipsychotics(45.9%vs. 17.5%,F2=9.421,p=0.002)thanthosewithoutdementia. Dementiapatientshadasignificantlyhigheroccurrenceofdeliriumaccordingtoallfour diagnosticcriteriawhencomparedtothosewithoutdementia.UsingDSM5,itwas30.6%vs. 12.5%(F2=4.772,p=0.029),ICD1021.2%vs.5%(F2=5,296,p=0.021),DSMIIIR35.3%vs. 10%(F2=8.788,p=0.003),andDSMIV28.2%vs.10%(F2=5.203,p=0.023)whencomparing dementiavs.nondementiagroups. DRSR98scores MeanDRSR98TotalscoreforDSM5was22.48r7.71(range538)inthedeliriumvs. 7.91r7.02(range030)innondeliriumgroup.Similarly,forICD10,meanDRSR98Totalwas 23.75r6.60(range1538)vs.9.20r8.18(range032);forDSMIIIR,22.62r7.52(range538)vs. 7.38r6.44(range030);andforDSMIV,23.50r7.39(range538)vs.8.07r6.99(range030). Thereweresignificantdifferences(pζ0.01)inmeanvaluesofalmostallDRSR98items (exceptforitems#2and3representingpsychosis),forDRSR98Totalscores,andinSeverity scalescoresbetweensubjectswithandwithoutdeliriumaccordingtoalldiagnosticsystemsin thewholesample(datanotshown).Table2showsmeanvaluesforDRSR98itemsandTotal scalescoresforgroupswithandwithoutdeliriuminthedementiasubsample.Itemsevaluating thethreecoredomainsofdeliriumhadhighermeanscoresindementiapatientswithdelirium thannondelirium,butnodifferencesfornoncorepsychoticandaffectiveitems.Meanscores foritemsrepresentingthecircadiandomain(sleepwakecycle,motordisturbances),higher levelthinking(language,thoughtprocess),andthecognitivedomain(attention,visuospatial ability,orientation,memory)aswellasdiagnosticcharacteristics(temporalonset,fluctuation, presenceofamedicalcause)generallyhadhighsignificance(p<0.01)irrespectiveofthe deliriumdiagnosticcriteriaused. ROCAnalysesUsingDRSR98 ROCcurveanalysis(Figure3)showedverygooddiscriminantcapacityusingAUCfortheDRS R98Totalscalefordeliriumdiagnosedusingallfoursystems.AUCwashighestforDSMIIIR (92.92%)followedbyDSMIV,DSM5andICD10,buttherewasnostatisticaldifferencefor AUCamongthem,whethertestedforthewholesampleorthedementiasubsample. SensitivityandspecificityvaluesforvariouscutoffscoresoftheDRSR98Totalscaleare shownforthewholesampleinTable3andfordementiasubsampleinTable4.Selected highestvaluesthatbalancedsensitivityandspecificityforeachcriteriasystemareshownin
shadedrows.BestcutoffscorefortheDRSR98Totalwas14.5forallsystemsexceptICD10 (15.5),forbothallsubjectsandthesubsample. UsingthesebestDRSR98cutoffsfromROCanalysisinthewholesample,sensitivityvalues fromhighesttolowestwere:DSMIV,DSMIIIR,DSM5andICD10.Similarly,specificityvalues wererankedfromhighesttolowestasDSMIIIR,DSM5,DSMIV,andthenICD10.Inthe subsampleofpatientswithdementiatheorderfromhighertolowersensitivityatthebestcut offsfromROCanalysiswasDSMIV,DSMIIIR,DSM5andICD10,andtheorderfromhigherto lowerspecificitywasDSMIIIR,ICD10andDSM5withthesamescore,andDSMIV.Ifweuse 14.5asthecutoffscoreforICD10,asfortheothercriteria,sensitivityincreasedupto100% butspecificityworsens. Figure4comparesDRSR98TotalAUCbetweengroupswithandwithoutdementia.The discriminantcapacityofthetoolwaslowerinthedementiasubsamplethaninthewhole sample,irrespectiveofthediagnosticcriteriaused(p<0.03forallHanley&McNeiltestsF2). SimilarfindingswerefoundfortheDRSR98Severityscale(notshowninthefigure,p>0.02for allHanley&McNeiltestsF2). DISCUSSION WepresentnewdataonperformanceoftheDRSR98whenevaluatedagainstfourmajor deliriumdiagnosticsystemsinsubjectsadmittedtoaskillednursingfacilitythathadahigh prevalenceofpreexistingdementia.Therewaspoorconcordancefordeliriumdiagnosis amongthecriteriasystems.Despitethis,theDRSR98scalehadhighdiscriminantcapacityfor deliriumdiagnosisirrespectiveoftheclassificationsystem.UsingROCanalyses,AUCsfor deliriumdiagnosisrangedfrom90.5%(ICD10)to92.9%(DSMIIIR)forthewholesampleand weresomewhatlowerforthedementiasubsamplewhereAUCsrangedfrom86.7%(ICD10)to 88.5%(DSMIIIR).Balancingsensitivityandspecificityvaluesforeachdiagnosticsystemto determinethebestDRSR98cutoffvalue,allDSMcriteriaversionshadthesamevalue(14.5), whilethecutoffforICD10wasslightlyhigher(15.5).DRSR98showedhighersensitivityfor DSMcriteriathanforICD10attherecommendedcutoffs,withDSMIVhavingthehighest, followedbyDSMIIIR,andthenewDSM5.SpecificitywashigherusingDSMIIIRfollowedby DSM5,DSMIV,andICD10withalmostthesamevalueforthosethree. AccordingtoKendler(2009),inclusionofbothcurrentandhistoricaldeliriumcriteriainour analysisisimportantbecauseadefiningfeatureofamaturescienceisitscumulativenature andcapacitytobuildonwhathasgonebefore.Inthissense,evolutionofpsychiatriccriteria couldbeunderstoodasaniterativeprocessthatshouldincreasequalityofclinicaldiagnosis.29 So,lessonscanbelearnedfromquantifyingconcordanceamongtheevolvingdeliriumcriteria andanalyzingagainstthemtheperformanceofatoollikeDRSR98thatassessesthewide rangeofcoreandnoncorephenomenologicalcharacteristicsofthesyndrome. Therewasastrikinglylowconcordanceforidentificationofdeliriumsubjectsbyallfour approaches(around50%).Thephenomenologicalbreadthanddepthofcriteriavaries considerably,withDSMIIIRinvolvingmoresymptomsthaneitherDSMIVorDSM5thatwere
designedtobelessrestrictive.Thenumberofdeliriumcasesidentifiedindividuallybyeach systemalsovariedconsiderably(20forICD10,28forDSMIV,31forDSM5,and34forDSM IIIR)withtheICD10beingmostrestrictive(seeVenndiagraminFigure2).Therefore,one majorchallengeinevaluatingtheperformanceoftheDRSR98–oranytoolforthatmatter– againstagoldstandardiswhenthediagnosticcriteriavarysomuchacrosstheDSMandICD systemswhenappliedtoagivenpersonthatonemustquestionwhich,ifany,aretrulyagold standard.CertainlywehavelearnedinthefieldofAlzheimer’sdementiathatusingclinicalor researchdiagnosticcriteriaisnotwellvalidatedtoneuropathologicaldiagnosisonautopsy,30 therebymakinganyclinicaldiagnosisbasedstandardlessthan“golden.”Thisisprobablythe caseindeliriumwhereweneedbiomarkervalidationinconjunctionwiththeclinicalcriteriato ascertaintruecases.Biomarkerresearchindeliriumislaggingthoughanelectrophysiological approachmayhavethebestchanceofsuccesswereitavailableinaportablemethod. Inlinewithpreviousstudies,11,12,31wefoundICD10hadtheleastinclusivecriteriaduetoits requirementsformoredetailedsymptomsthoughitstilldoesnotevaluateall3coredomains ofdelirium.2,5,32Infact,thehighDRSR98meanscoresofalmost24indeliriumandaround9in nondeliriumaccordingtoICD10suggestsitcapturesmorefullsyndromaldeliriumandfewer subsyndromalcasesthandotheDSMsystems.DSMIIIRdiagnosedmorepatientsinour study,eventhoughitincorporatesmoresymptomsthantheDSMIV,similartothereportof Laurilaetal.(2003)whofoundDSMIIIRmoreinclusiveinnursinghomepatients.11Onthe otherhand,DRSR98hadthehighestspecificitywhencomparedtoDSMIIIRcriteria,soit couldalsobepossiblethatthegreaterinclusivenessofDSMIIIRbetterapproximatesthetrue prevalenceofdeliriumandcouldbeattributabletoitsinclusion(thoughnotallrequired)of symptomsfromallthreedeliriumcoredomains,inparticularcircadiandisturbancesofsleep wakecycleandmotoractivityanddisorganizedthinking.Otherclassificationsrelyonattention deficitsandomitordonotrequiremanysymptomsthatareconsideredcoreforthe syndrome.2,4,5,31,32Becauseofthebreadthoftypesofsymptomsthatcanoccurindelirium,it mightbethatevenamorecomprehensivelistingofsymptomsinDSM5couldenhancethe possibilityofdiagnosis. ThebestcutoffvaluesfortheDRSR98whenassessingDSMcriteria(14.5)arethesameas thosereportedinthevalidationagainstDSMIVoftheJapaneseversion33andrelativelysimilar tothoseoftheChineseversionvs.DSMIV(15.5)34thoughtheColombianversionvs.DSMIV wasalittlelower(12.0).35OurvaluesarelowerthanthoseintheoriginalEnglishversion againstDSMIV(17.75),14Portugueseversionvs.DSMIV(20.1),36andKoreanversionvs.DSM IV(18.5–19.5)37validationstudies.Differencesamongstudiesincutoffscorescouldbea consequenceofdifferencesinsociodemographicalandclinicalcharacteristicsofthesample. Wechosethestudysamplefromaskillednursingfacility,andtohaveahighcomorbidityof dementiabecausethisisachallengetocliniciansindiagnosingdelirium.SpecificDRSR98 itemsrepresentingthethreecoredeliriumdomains,aswellasdiagnosticcharacteristics, particularlydistinguisheddeliriuminthesubgroupofdementiapatients.Moreresearchis neededastowhetherclinicianscanrelyonthosefeaturestodetectdeliriumindementia patients.
Strengthsofthisstudyincludeindependentresearchratingsforclassificationsystems checklists,andDRSR98.Weusedmedicalrecords,historytaking,family/carerinterviewand IQCODEtodiagnosepreexistingdementiathoughthisislessrigorousthanacomplete dementiaevaluation.Wealsodidnotspecifythetypeofdementiaoritsseverity.Because differenttypesofdementia(e.g.Alzheimer’s,vascular,LewyBody,Frontotemporal)havetheir ownphenomenologicalpatterns,thedetectionusingadeliriumdesignedtool(DRSR98)may havebeenaffectedsomewhat,includingourfindingofhighermeanDRSR98Totalscoresin thenondeliriumcaseswithdementiathaninthewholesamplethatincludednondementia patients,suggestingdementiasymptomscontributetothescalescoresinafashionthatcould reducethescales’abilitytodiscriminate.Nonetheless,theROCanalysesweresimilar irrespectiveofpresenceofdementiaornot;moreover,DRSR98itemsevaluatingdiagnostic characteristicsandsymptomsfromdeliriumcoredomainsshoweddifferentiationofdelirium fromnondeliriumamongpatientswithdementia. Insummary,DRSR98provedtobeavalidandusefulinstrumentforassessing/discriminating deliriuminpostacuteelderlypatientsintheskillednursinghomesetting,regardlessofthe inclusivenessofdiagnosticsystemused.Furthermore,itprovedtobeavalidtooltodiagnose deliriuminpatientswithapreviousdementia,wheretheperformanceofdiagnosticcriteriais lower.Besidesconsiderationofbiomarkers,furtherevolutionofdeliriumdiagnosticcriteria shouldtakeintoaccountsymptomsrepresentingthethreecoredomainssothatdelirium couldbeassessedinamorespecificwayinordertobetterdistinguishfullsyndromalfrom subsyndromalandnondeliriumcaseseveninthosewithdementia.
Disclosures Therewasnoformalfundingforthisstudy. Dr.TrzepaczisaretiredemployeeandminorshareholderatEliLillyandCompany.Dr. TrzepaczholdsthecopyrightfortheDeliriumRatingScaleRevised98butdoesnotchargea feeforanotforprofituse.Allothercoauthorsreportnoproprietaryorcommercialinterestin anyproductmentionedorconceptdiscussedinthisarticle.
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Table1.Demographicandclinicalcharacteristicsaccordingtodiagnosisgroups.Deliriumcases arereportedasdiagnosedaccordingtoDSM5diagnosticcriteria.Datashownasmeans±SD unlessdenotedbyfrequencies(percents).Comparisonsarebetweendeliriumandnondelirium participants. Wholesample Subsamplewithdementia Nondelirium Delirium Nondelirium Delirium (n=94) (n=31) (n=59) (n=26) Variable ǤͳͳάͻǤͳ ͺ͵ǤͷάǤͻͳȗ ͺǤ͵ͶάǤʹ ͺ͵ǤͶʹάǤͷͲȗ ȋȌ ͶǤͻ͵ά͵Ǥͻͷ ͶǤ͵ͷάͶǤͶͶ ͶǤʹͲά͵Ǥ͵Ͷ ͶǤͳͻάͶǤͶͻ ͳǤͺͷάͳǤͶ͵ ͳǤͻάͳǤ͵͵ ʹǤͲͷάͳǤͶ͵ ʹǤͳʹάͳǤͶͲ ȋΨȌ ͶͶȋͶǤͺȌ ͳͺȋͷͺǤͳȌ ʹͷȋͶʹǤͶȌ ͳͷȋͷǤȌ ͷͲȋͷ͵ǤʹȌ ͳ͵ȋͶͳǤͻȌ ͵ͶȋͷǤȌ ͳͳȋͶʹǤ͵Ȍ ȋΨȌ ͳͲȋͳͲǤȌ ͶȋͳʹǤͻȌ ͵ȋͷǤͳȌ ͵ȋͳͳǤͷȌ ͵Ͷȋ͵ǤʹȌ ͳȋͷͳǤȌ ʹʹȋ͵Ǥ͵Ȍ ͳ͵ȋͷͲǤͲȌ Ȁ ͻȋͻǤȌ ͳȋ͵ǤʹȌ ȋͳͲǤʹȌ ͳȋ͵ǤͺȌ ͶͳȋͶ͵ǤȌ ͳͲȋ͵ʹǤ͵Ȍ ʹͺȋͶǤͷȌ ͻȋ͵ͶǤȌ ȋΨȌ ͳȋͳǤͳȌ Ǧ ͳȋͳǤȌ Ǧ ͵ȋ͵ǤʹȌ Ǧ ͳȋͳǤȌ Ǧ ͶʹȋͶͶǤȌ ʹͳȋǤȌ ʹȋͶͷǤͺȌ ͳȋͷǤͶȌ ȋȌ ͶȋͶͺǤͻȌ ͳͲȋ͵ʹǤ͵Ȍ ͵ͲȋͷͲǤͺȌ ͻȋ͵ͶǤȌ ʹȋʹǤͳȌ Ǧ Ǧ Ǧ Ș ȋΨȌ ͷͻȋʹǤͺȌ ʹȋͺ͵ǤͻȌȗ Ȁ Ȁ șȋΨȌ ͵ͻȋͶͳǤͷȌ ͳͷȋͶͺǤͶȌ ʹͶȋͶͲǤȌ ͳʹȋͶǤʹȌ ȋǤͶȌ ͵ȋͻǤȌ ͷȋͺǤͷȌ ʹȋǤȌ ʹͻȋ͵ͲǤͻȌ ͳȋͷͶǤͺȌȗ ʹͶȋͶͲǤȌ ͳͷȋͷǤȌ ͵ȋ͵ͻǤͶȌ ͳȋͷͳǤȌ ʹȋͶͶǤͳȌ ͳͶȋͷ͵ǤͺȌ ͺȋͺǤͷȌ ͳȋ͵ǤʹȌ ȋͳͳǤͻȌ ͳȋ͵ǤͺȌ ȋΨȌ ͳȋͳǤͲȌ ͻȋʹͻǤͲȌ ͳͷȋʹͷǤͶȌ ͻȋ͵ͶǤȌ ǣ Ȁ ͳ͵ȋͳ͵ǤͺȌ ͵ȋͻǤȌ ͺȋͳ͵ǤȌ ͵ȋͳͳǤͷȌ ͳͲȋͳͲǤȌ ʹȋǤͷȌ ͷȋͺǤͷȌ ͳȋ͵ǤͺȌ ͳʹȋͳʹǤͺȌ Ǧ ͳͳȋͳͺǤȌ Ǧȗ ȋǤͶȌ ȋͳͻǤͶȌ ͶȋǤͺȌ ͶȋͳͷǤͶȌ ȋǤͶȌ ͷȋͳǤͳȌ ͶȋǤͺȌ ͷȋͳͻǤʹȌ Ț ͳ͵ȋͳ͵ǤͺȌ ͳʹȋ͵ͺǤȌȗ ͳͲȋͳǤͻȌ ͳͲȋ͵ͺǤͷȌ Ǧͻͺ ǤͻͳάǤͲʹ ʹʹǤͶͺάǤͳȗ ͳͲǤͺάǤͲͻ ʹʹǤͻάǤʹȗ *p<0.05. † SIQCODE>85. ‡ During24hbeforeevaluation.
§
Asreportedinclinicalrecords. N/A:Notapplicable.
Table2.ComparisonofDRSR98individualitem(mean±SD)in85hospitalizeddementiapatientswithorwithoutdeliriumaccordingtodifferentDSMand ICDcriteria.Significantdifferencesatp<0.01forttestsarebolded. DSM5 ICD10 DSMIIIR DSMIV Nodelirium(n Delirium Nodelirium(n Delirium Nodelirium(n Delirium Nodelirium(n Delirium =59) (n=26) =67) (n=18) =55) (n=30) =61) (n=24) DRSR98Item 1. Sleepwakecycledisturbance 0.61±0.67 1.73±0.67 0.72±0.75 1.83±0.51 0.60±068 1.60±0.72 0.66±0.70 1.71±0.69 2. Perceptionsandhallucinations 0.56±1.10 0.62±1.02 0.55±1.06 0.67±1.03 0.53±1.07 0.67±1.03 0.59±1.10 0.54±0.93 3. Delusions 0.76±1.16 0.38±0.85 0.67±1.12 0.56±0.98 0.80±1.19 0.37±0.81 0.74±1.15 0.42±0.88 4. Labilityofaffect 0.36±0.55 0.69±0.79 0.37±0.57 0.78±0.81 0.36±0.56 0.63±0.76 0.36±0.55 0.71±0.81 5. Language 0.54±0.86 1.42±1.10 0.66±0.95 1.39±1.09 0.42±0.71 1.53±1.11 0.54±0.85 1.50±1.10 6. Thoughtprocessabnormalities 0.69±0.81 1.46±1.10 0.82±0.90 1.33±1.14 0.62±0.73 1.50±1.11 0.69±0.81 1.54±1.10 7. Motoragitation 0.36±0.66 1.12±0.86 0.37±0.67 1.39±0.78 0.27±0.59 1.17±0.83 0.36±0.66 1.17±0.87 8. Motorretardation 0.39±0.69 1.50±1.03 0.60±0.91 1.22±1.00 0.42±0.71 1.30±1.09 0.39±0.69 1.58±1.02 9. Orientation 1.20±0.89 2.15±0.73 1.30±0.92 2.22±0.65 1.11±0.83 2.20±0.71 1.21±0.88 2.21±0.72 10. Attention 0.63±0.74 2.04±0.87 0.79±0.90 2.06±0.80 0.62±0.73 1.87±0.97 0.64±0.73 2.13±0.85 11. Shorttermmemory 0.41±0.91 1.19±1.02 0.49±0.94 1.22±1.06 0.33±0.79 1.23±1.10 0.43±0.90 1.21±1.06 12. Longtermmemory 1.93±1.03 2.50±0.95 1.93±1.06 2.78±0.55 1.82±1.06 2.63±0.76 1.92±1.05 2.58±0.83 13. Visuospatialability 0.86±1.02 2.15±1.08 1.00±1.13 2.22±0.94 0.73±0.93 2.23±1.01 0.85±1.01 2.29±1.00 14. Temporalonsetofsymptoms 0.64±0.74 1.50±0.71 0.72±0.75 1.61±0.70 0.65±0.75 1.37±0.76 0.66±0.73 1.54±0.72 15. Fluctuationofsymptomseverity 0.22±0.46 1.00±0.49 0.28±0.49 1.11±0.47 0.20±0.45 0.93±0.52 0.25±0.47 1.00±0.51 16. Physicaldisorder 0.61±0.74 1.50±0.58 0.70±0.78 1.56±0.51 0.60±0.76 1.40±0.62 0.62±0.73 1.54±0.59 DRSR98Totalscore 22.96r7.72 11.97r8.03 23.94r6.81 10.07r6.55 22.63r7.67 10.90r7.03 23.67r7.55 10.78r7.09
Cut off ͶǤͷͲ ͷǤͷͲ ǤͷͲ ǤͷͲ ͺǤͷͲ ͻǤͷͲ ͳͲǤͷͲ ͳͳǤͷͲ ͳʹǤͷͲ ͳ͵ǤͷͲ ͳͶǤͷͲ ͳͷǤͷͲ ͳǤͷͲ ͳǤͷͲ ͳͺǤͷͲ ͳͻǤͷͲ ʹͲǤͷͲ ʹʹǤͷͲ ʹͶǤͷͲ ʹͷǤͷͲ ʹǤͷͲ ʹǤͷͲ ʹͻǤͲͲ ͵ͲǤͷͲ ͵ͳǤͷͲ ͵͵ǤͷͲ
Table3.SensitivityandspecificityfordeliriumdiagnosisoftheDRSR98Totalscale,according toeachdiagnosticclassificationcriteria,for125consecutivepatientsadmittedtoaskilled nursingfacility.Shadedareascorrespondtothebestcutoffscoressensibilityandspecificity values,foreachdiagnosticsystem. DSM5Criteria ICD10Criteria DSMIIIRCriteria DSMIVCriteria Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity (%) (%) (%) (%) (%) (%) (%) (%) ͳͲͲ ͵ͺǤ͵ ͳͲͲ ͵ͶǤ͵ ͳͲͲ ͵ͻǤ ͳͲͲ ͵Ǥͳ ͻǤͺ ͶǤͺ ͳͲͲ ͶʹǤͻ ͻͶǤͳ ͶǤ͵ ͻǤͶ ͶͷǤͶ ͻǤͺ ͷͺǤͷ ͳͲͲ ͷ͵Ǥ͵ ͻͶǤͳ ͷͻǤ͵ ͻǤͶ ͷǤ ͻǤͺ ͳǤ ͳͲͲ ͷǤʹ ͻͶǤͳ ʹǤ ͻǤͶ ͷͻǤͺ ͻǤͺ ͺǤͳ ͳͲͲ ͳǤͻ ͻͶǤͳ ͻǤʹ ͻǤͶ ǤͲ ͻǤͺ ͻǤͳ ͳͲͲ ʹǤͻ ͻͶǤͳ ͲǤ͵ ͻǤͶ ǤͲ ͻ͵Ǥͷ ͻǤͳ ͳͲͲ ͵Ǥͺ ͻͶǤͳ ͳǤͶ ͻǤͶ ͺǤͲ ͻͲǤ͵ ʹǤ͵ ͳͲͲ Ǥ ͻͶǤͳ ͷǤͺ ͻǤͶ ʹǤʹ ͻͲǤ͵ ͶǤͷ ͳͲͲ ͻǤͷ ͻͶǤͳ ͺǤͲ ͻǤͶ ͶǤʹ ͻͲǤ͵ ͻǤͺ ͳͲͲ ͶǤ͵ ͻͶǤͳ ͺ͵Ǥͷ ͻǤͶ ͻǤͶ ͻͲǤ͵ ͺͶǤͲ ͳͲͲ ͺǤͳ ͻͶǤͳ ͺǤͻ ͻǤͶ ͺ͵Ǥͷ ǤͶ ͺǤʹ ͻͲǤͲ ͺʹǤͻ ͺʹǤͶ ͻͳǤʹ ͺʹǤͳ ͺǤ ͶǤʹ ͺͻǤͶ ͺͷǤͲ ͺͶǤͺ ͻǤͶ ͻ͵ǤͶ ͺǤ ͺͺǤ ͳǤͲ ͺͻǤͶ ͺͲǤͲ ͺͶǤͺ Ǥͷ ͻ͵ǤͶ ͷǤͲ ͺͺǤ ͳǤ͵ ͻͲǤͶ ͷǤͲ ͺͷǡ Ǥ ͻͶǤͷ Ǥͻ ͻͲǤ ͳǤ͵ ͻͳǤͷ ͷǤͲ ͺǤ ͶǤ ͻͶǤͷ Ǥͻ ͻͳǤͺ ͷͺǤͳ ͻʹǤ ͲǤͲ ͺǤ ͳǤͺ ͻͷǤ ͶǤ͵ ͻʹǤͺ ͷͶǤͺ ͻͶǤ ͲǤͲ ͻͲǤͷ ͷʹǤͻ ͻͷǤ ͲǤ ͻͶǤͺ ͶͺǤͶ ͻͷǤ ͷͲǤͲ ͻͳǤͶ ͶǤͳ ͻǤ ͷ͵Ǥ ͻͷǤͻ ͶͳǤͻ ͻǤͺ ͶͲǤͲ ͻʹǤͶ ͶͳǤʹ ͻǤͺ ͶǤͶ ͻǤͻ ʹͻǤͲ ͻǤͺ ͵ͲǤͲ ͻͶǤ͵ ʹͻǤͶ ͻǤͺ ͵ʹǤͳ ͻǤͻ ʹʹǤ ͻǤͻ ʹͲǤͲ ͻͷǤʹ ʹͲǤ ͻǤͺ ʹͷǤͲ ͻǤͻ ʹʹǤ ͻͺǤͻ ʹͲǤͲ ͻǤʹ ʹͲǤ ͻͺǤͻ ʹͷǤͲ ͻͻǤͲ ͳǤͳ ͳͲͲ ͳͷǤͲ ͻͺǤͳ ͳͶǤ ͳͲͲ ͳǤͻ ͳͲͲ ͻǤ ͳͲͲ ͳͲǤͲ ͻͻǤͲ ͺǤͺ ͳͲͲ ͳͲǤ ͳͲͲ Ǥͷ ͳͲͲ ͳͲǤͲ ͳͲͲ ͷǤͻ ͳͲͲ Ǥͳ ͳͲͲ
Cut off ͶǤͷͲ ͷǤͷͲ ǤͷͲ ǤͷͲ ͻǤͷͲ ͳͳǤͷͲ ͳʹǤͷͲ ͳ͵ǤͷͲ ͳͶǤͷͲ ͳͷǤͷͲ ͳǤͷͲ ͳǤͷͲ ͳͺǤͷͲ ͳͻǤͷͲ ʹͲǤͷͲ ʹʹǤͷͲ ʹͶǤͷͲ ʹͷǤͷͲ ʹǤͷͲ ʹǤͷͲ ʹͻǤͲͲ ͵ͲǤͷͲ ͵ͳǤͷͲ ͵͵ǤͷͲ
Table4.SensitivityandspecificityfordeliriumdiagnosisoftheDRSR98Totalscale,according toeachdiagnosticclassificationcriteria,forthesubsampleof85patientswithdementia(S IQCODE>85),fromaskillednursingfacility.Shadedareascorrespondtothebestcutoffscores sensibilityandspecificityvalues,foreachdiagnosticsystem. DSM5 ICD10 DSMIIIR DSMIV Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity (%) (%) (%) (%) (%) (%) (%) (%) ͳͲͲ ͳ͵Ǥ ͳͲͲ ͳͳǤͻ ͳͲͲ ͳͶǤͷ ͳͲͲ ͳ͵Ǥͳ ͻǤʹ ʹʹǤͲ ͳͲͲ ʹͲǤͻ ͻ͵Ǥ͵ ʹͳǤͺ ͻͷǤͺ ʹͳǤ͵ ͻǤʹ ͶͲǤ ͳͲͲ ͵Ǥ͵ ͻ͵Ǥ͵ ͶͳǤͺ ͻͷǤͺ ͵ͻǤ͵ ͻǤʹ ͶͷǤͺ ͳͲͲ ͶͳǤͺ ͻ͵Ǥ͵ ͶǤ͵ ͻͷǤͺ ͶͶǤ͵ ͻǤʹ ͷͶǤʹ ͳͲͲ ͶͻǤ͵ ͻ͵Ǥ͵ ͷǤͶ ͻͷǤͺ ͷʹǤͷ ͻʹǤ͵ ͷͻǤ͵ ͳͲͲ ͷͷǤʹ ͻ͵Ǥ͵ ͵Ǥ ͻͷǤͺ ͷͻǤͲ ͻʹǤ͵ ͳǤͲ ͳͲͲ ͷǤ ͻ͵Ǥ͵ ͷǤͷ ͻͷǤͺ ͲǤ ͻʹǤ͵ ͻǤͷ ͳͲͲ ͶǤʹ ͻ͵Ǥ͵ ͶǤͷ ͻͷǤͺ ͺǤͻ ͻʹǤ͵ ͶǤ ͳͲͲ ͺǤ ͻ͵Ǥ͵ ͺͲǤͲ ͻͷǤͺ ͵Ǥͺ ͺͲǤͺ ͻǤ ͺͺǤͻ ͶǤ ͺ͵Ǥ͵ ͺͷǤͷ ͺ͵Ǥ͵ ͺǤ Ǥͻ ͺ͵Ǥͳ ͺ͵Ǥ͵ Ǥ ͺͲǤͲ ͺͻǤͳ ͻǤʹ ͺʹǤͲ ͵Ǥͳ ͺ͵Ǥͳ Ǥͺ Ǥ Ǥ ͺͻǤͳ ͷǤͲ ͺʹǤͲ ͷǤͶ ͺͶǤ Ǥ ͻǤͳ ͲǤͲ ͻͲǤͻ ͲǤͺ ͺͷǤʹ ͷǤͶ ͺǤͶ Ǥ ͺͲǤ Ǥ ͻͲǤͻ ͲǤͺ ͺǤͻ ͳǤͷ ͺͺǤͳ ͳǤͳ ͺʹǤͳ ͵Ǥ͵ ͻʹǤ Ǥ ͺͺǤͷ ͷǤ ͻͳǤͷ ͳǤͳ ͺǤ ͷ͵Ǥ͵ ͻʹǤ ʹǤͷ ͻͳǤͺ ͷͲǤͲ ͻ͵Ǥʹ ͷͲǤͲ ͺͺǤͳ ͶǤ ͻͷǤͷ ͷͶǤʹ ͻ͵ǤͶ ͶʹǤ͵ ͻͶǤͻ ͵ͺǤͻ ͺͻǤ ͶͲǤͲ ͻǤͶ ͶͷǤͺ ͻͷǤͳ ͵ͲǤͺ ͻͶǤͻ ͵͵Ǥ͵ ͻʹǤͷ ͵ͲǤͲ ͻǤͶ ͵͵Ǥ͵ ͻͷǤͳ ʹ͵Ǥͳ ͻǤ ʹʹǤʹ ͻͶǤͲ ʹͲǤͲ ͻǤͶ ʹͷǤͲ ͻǤ ʹ͵Ǥͳ ͻͺǤ͵ ʹʹǤʹ ͻͷǤͷ ʹͲǤͲ ͻͺǤʹ ʹͷǤͲ ͻͺǤͶ ͳͷǤͶ ͳͲͲ ͳǤ ͻͺǤͷ ͳ͵Ǥ͵ ͳͲͲ ͳǤ ͳͲͲ ͳͳǤͷ ͳͲͲ ͳͳǤͳ ͻͺǤͷ ͳͲǤͲ ͳͲͲ ͳʹǤͷ ͳͲͲ Ǥ ͳͲͲ ͳͳǤͳ ͳͲͲ Ǥ ͳͲͲ ͺǤ͵ ͳͲͲ
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Performance of the Delirium Rating Scale Revised–98 Against Different Delirium Diagnostic Criteria in a Population with a High Prevalence of Dementia Esteban Sepulveda M.D, José G. Franco M.D., M.S., Ph.D, Paula T. Trzepacz M.D, Ana M. Gaviria Ph.D, Eva Viñuelas M.D, José Palma M. D, Gisela Ferré B.S, Imma Grau M.D, Elisabet Vilella Ph.D
PII: DOI: Reference:
S0033-3182(15)00058-4 http://dx.doi.org/10.1016/j.psym.2015.03.005 PSYM538
To appear in:
Psychosomatics
Cite this article as: Esteban Sepulveda M.D, José G. Franco M.D., M.S., Ph.D, Paula T. Trzepacz M.D, Ana M. Gaviria Ph.D, Eva Viñuelas M.D, José Palma M. D, Gisela Ferré B.S, Imma Grau M.D, Elisabet Vilella Ph.D, Performance of the Delirium Rating Scale Revised–98 Against Different Delirium Diagnostic Criteria in a Population with a High Prevalence of Dementia, Psychosomatics, http://dx.doi. org/10.1016/j.psym.2015.03.005 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
PerformanceoftheDeliriumRatingScaleRevised–98AgainstDifferentDelirium DiagnosticCriteriainaPopulationwithaHighPrevalenceofDementia EstebanSepulveda,M.Da,JoséG.Franco,M.D.,M.S.,Ph.Da,b,PaulaT.Trzepacz,M.Dc,d,Ana M.Gaviria,Ph.Da,EvaViñuelas,M.Da,JoséPalma,M.Da,GiselaFerré,B.Sa,ImmaGrau,M.Da, ElisabetVilella,Ph.Da a
HospitalPsiquiatricUniversitariInstitutPereMata,IISPV,UniversitatRoviraiVirgili,Centrode InvestigaciónBiomédicaenReddeSaludMental(CIBERSAM),Reus,Tarragona,Spain. b UniversidadPontificiaBolivariana,FacultyofMedicine,Medellín,Colombia. c TuftsUniversitySchoolofMedicine,Boston,MA,USA. d IndianaUniversitySchoolofMedicine,Indianapolis,IN,USA. Correspondingauthor:JoséG.Franco,POB26,PC43850,Cambrils(Tarragona),Spain. [email protected]
ABSTRACT Background:Deliriumdiagnosisinelderlyisoftencomplicatedbyunderlyingdementia. Objective:WeevaluatedperformanceoftheDeliriumRatingScaleRevised98(DRSR98)in patientswithhighdementiaprevalenceandalsoassessedconcordanceamongpastand currentdiagnosticcriteriafordelirium. Methods:Crosssectionalanalysisofnewlyadmittedpatientstoaskillednursingfacilityover6 months,whowereratedwithin2448hoursafteradmission.InterviewforDSMIIIR,DSMIV, DSM5,andICD10deliriumratings,administrationoftheDRSR98,andassessmentof dementiausingtheInformantQuestionnaireonCognitiveDeclineintheElderlywere independentlyperformedby3researchers.Discriminantanalyses(receiveroperating characteristicscurves)wereusedtostudyDRSR98accuracyagainstdifferentdiagnostic criteria.Hanley&McNeiltestcomparedtheareaunderthecurve(AUC)forDRSR98’s discriminantperformanceforalldiagnosticcriteria. Results:Dementiawaspresentin85/125(68.0%)subjectsand36/125(28.8%)metcriteriafor deliriumbyatleastoneclassificationsystemwhileonly19/36(52.8%)didbyall.DSMIIIR diagnosedthemostasdelirious(27.2%),followedbyDSM5(24.8%),DSMIVTR(22.4%)and ICD10(16%).DRSR98hadthehighestAUCwhendiscriminatingDSMIIIRdelirium(92.9%), followedbyDSMIV(92.4%),DSM5(91%)andICD10(90.5%),withoutstatisticaldifferences amongthem.ThebestDRSR98cutoffscorewas14.5foralldiagnosticsystemsexceptICD 10(15.5). Conclusions:Thereisalowconcordanceacrossdiagnosticsystemsforidentificationof delirium.TheDRSR98performswelldespitedifferencesacrossclassificationsystemsperhaps becauseitbroadlyassessesphenomenology,eveninthispopulationwithahighprevalenceof dementia. Keywords:Delirium;Dementia;DeliriumRatingScaleRevised98;SensitivityandSpecificity; DiagnosticandStatisticalManualofMentalDisorders;InternationalClassificationofDiseases.
INTRODUCTION Phenomenologicalresearchrevealsdeliriumhasthreecoredomains:attentionandother cognitivedeficits(orientation,memory,visuospatialability),higherlevelthinkingdisturbances (thoughtprocess,language,executivefunction),andcircadiandisturbances(sleepwakecycle, motoractivity)thatmaybevariablyaccompaniedbylessprevalentpsychoticandaffective symptoms.15 Deliriumappearedasadiagnosticentitywithspecificinclusionandexclusioncriteriain1980in theDiagnosticandStatisticalManualofMentalDisorders,3rdedition(DSMIII)6andhas evolvedsincethenincludingitsrevision,DSMIIIR.7However,DSMIV(andDSMIVTR) eliminatedsymptomsofcircadiandomain,andthoughtprocess,whilepreserving attention/cognitivedomainandlanguagesymptoms.8,9TheInternationalClassificationof Diseases10thedition(ICD10)hasmoredetailedresearchdiagnosticcriteria,10withamore restrictivedefinitionofcognitivedysfunctionandtheinclusionofdisturbancesincircadian,but notofhigherlevelthinkingdomain.Researchcomparingcriteriashowsthatdeliriumpatient identificationdiffersamongthem:DSMIV’ssimplestcriteriahavethegreatestsensitivity, followedbyDSMIIIRandICD10.11,12Thesedifferencesmakeitdifficultforcliniciansand researcherstorelyonanyonesystemasthereferencestandard. DSM5criteria13increasedfocusonattentionandawarenessinthecardinalcriterionand slightlyreorganizedsomeDSMIVcontent,butdidnotaddcircadiandomainandthought processsymptomsdespitetheirbeingcoreindelirium,ostensiblytomakeiteasierforprimary carephysicianstodiagnosepossibledelirium.Forspecialists,however,theDSMIVandDSM5 arelessspecifictodeliriumduetotheirgreaterinclusiveness.11,12 TheDeliriumRatingScaleRevised98(DRSR98)14isawidelyemployedinstrumenttoevaluate delirium.Itwasdesignedtodiagnoseandevaluatethebreadthandseverityofdelirium symptoms.DSRR98wasdevelopedbasedondeliriumcharacteristicsratherthanany particular(apriori)diagnosticsystem.IthasshownverygoodaccuracyagainstDSMIVcriteria, withveryhighinterraterreliability(intraclasscorrelationcoefficient>0.9). Deliriumiscommonintheelderly,reaching33%prevalenceinlongtermcaresettingsand 53.3%inacutegeriatricwards.15,16Dementiaisapredisposingfactorfordeliriumandisoften comorbidwithitintheelderlythoughdeliriumsymptomsovershadowdementiawhenthey coexist,1723sodementiaposesdifferentialdiagnosticchallengesforcliniciansassessing delirium. AllpreviousDRSR98validationstudieshaveusedDSMIVasthegoldstandard,anddelirium anddementiagroupsevaluatedseparately.Theobjectivesofthisstudywere1)toassess discriminantperformanceoftheSpanishDRSR98againstDSMIIIR,DSMIV,DSM5,andICD 10criteriafordeliriumdiagnosisinpatientsadmittedinaskillednursingfacility,withahigh prevalenceofdementia,and2)toevaluateconcordanceamongthesepastandcurrent diagnosticcriteria.
METHODS DesignandSubjects Thisisaprospective,crosssectionalstudyofdeliriumdiagnosticaccuracy,designedand reportedaccordingtoStandardsforReportingofDiagnosticAccuracyguidelines(STARD).24 Consecutivelyadmittedpatientstoaskillednursingfacility(CentroSociosanitarioMonterols, InstitutPereMata,Tarragona,Spain),wereeligible.Patientswereadmittedfromhome, generalhospitalorassistedliving/seniorcommunityduringthe6monthstudyperiod. Exclusioncriteriawererefusaltoparticipate,coma,severelanguagedisorder,orinabilityto speakSpanish. ThisstudywasapprovedbyourcorrespondingInstitutionalEthicsCommittee(atHospitalSant Joan,Reus,Tarragona,Spain).Allpatientsortheirproxy,whenMinimentalStateExamination (MMSE)scorewas<24(routinepartoftheadmissionevaluation),gavewritteninformed consent. Measures Demographicandclinicaldatawerecollected.Wealsoreviewedmedicalrecordsforarecent diagnosisofdelirium. CharlsonComorbidityIndex(Shortform;CCISF) DevelopedfromtheCCIwithsimilarprognosticvalue,25thisversionisbasedonhistoryof8 medicalconditions:cerebrovascularaccident,diabetesmellitus,chronicobstructive pulmonarydisease,congestiveheartfailure,dementia,peripheralarterialdisease,chronic renalfailureandcancer.Eachofthefirstsixconditionsscores1pointwhenpresent,while eachofthe7thand8thscore2pointsifpresent(foramaximumpossibleof10).ACCISFscore of0or1indicatesnocomorbidity,2lowcomorbidity,and3highcomorbidity. SpanishInformantQuestionnaireonCognitiveDeclineintheElderly(SIQCODE) Thisstructuredinterviewiscomposedby26questionstoaninformantaboutthepatient’s cognitionandfunctionduringtheprecedingfiveyears.Directscoresrangefrom26to130.The validatedSpanishversionusescutoff>85forpossibledementia.26 TheDeliriumRatingScaleRevised98(DRSR98) TheDRSR9814includesphenomenologicaldescriptiveanchorstorateseveritylevelsforeach item(rangingfrom0to3),withamaximumDRSR98Totalscalescoreof46andDRSR98 Severityscaleof39points.Its16itemsincludethreediagnosticitems(includingacuteonset andtemporalfluctuation)and13itemswhichratetheseverityofsymptoms,including individualitemstoevaluatecoredeliriumcharacteristics:attention,shortandlongterm memory,visuospatialability,orientation,sleepwakecycledisturbances,abnormalitiesof languageandthoughtprocess,motoragitation,motorretardation,besidesotheritems evaluatingperceptualdisturbances,abnormalitiesinthoughtcontent,andaffectivelability. WeusedtheSpanishversionwhichhasverygoodinterraterreliability.27
ClinicalDiagnosticCriteria Todefinedeliriumstatusweusedfourdiagnosticcriteria:theDiagnosticandStatistical ManualofMentalDisorders5,IVandIIIRevisededitions(DSM5,DSMIVandDSMIIIR),7,8,13 andtheInternationalClassificationofDiseases10theditionforresearch(ICD10).10We designedadiagnosticcriteriachecklisttosystematicallyrateeachitemforalldiagnostic criteriadichotomously(aspresentornot)inordertoensuretheircompleteevaluation. Procedures Twotrainedresearchersindependentlyevaluatedallsubjects24to48hoursafteradmission toratetheSpanishDRSR98andthedeliriumdiagnosticcriteriachecklist,eachcoveringthe preceding24hoursusingallsourcesofinformation.Athirdresearchercontactedthefamilyor caregivertoadministertheSIQCODE. Statisticalanalysis Continuousvariablesareexpressedasmeans±standarddeviation(SD).Chisquaretest comparedcategoricalvariables(withcontinuitycorrectionasappropriate)andttest comparedcontinuousvariables.Statisticalsignificancewassetatp<0.05,exceptformultiple comparisonsofDRSR98itemswherepwassetat<0.01. DRSR98accuracy,sensitivity,specificityandoptimalcutoffscoreswereobtainedwith receiveroperatingcharacteristiccurve(ROC)analysisoftheareaunderthecurve(AUC)forthe wholesampleandforthosewithdementia,reportedwiththeircorrespondingstandarderror (SE).Hanley&McNeiltestcomparedtheAUCsforDRSR98’sdiscriminantperformancefor diagnosticcriteria. DatawereanalysedusingSPSS21.0,andEpidat3.01(ROCanalysis,comparisonofAUC,and correspondinggraphics).TheoverlapofthediagnosticcriteriaisreportedwithaVenndiagram createdonVENNYonlineprogram.28 RESULTS SampleCharacteristics Of141patientsadmittedduringthestudyperiod,16wereexcluded,leavingasampleof125 participants(seeFigure1forSTARDflowdiagram).Meanagewas78.73r9yearsand50.4% werewomen.Table1showsdemographicandclinicalcharacteristicsbydeliriumand nondeliriumgroupsaccordingtoDSM5criteriaforthewholesampleandthesubsamplewith dementia.Thedeliriumgroupwassignificantlyolderandhadhigherdementiaprevalence. DeliriumDiagnosisbyClassificationSystems TheVenndiagram(Figure2)showsthat36/125patients(28.8%)metcriteriafordeliriumbyat leastoneclassificationsystem,butonly19/36(52.8%)metallfourcriteriawhichisalow concordanceacrosstheclassificationsystems.Themostsubjectswerediagnosedasdelirious (27.2%)byDSMIIIR,followedbyDSM5(24.8%),DSMIV(22.4%)andICD10(16%).DSMIIIR hadthemostcases(14.7%)thatdidnotoverlapwithanyotherdiagnosticclassification,yet almostall(34/36)ofthedeliriumcasesdiagnosedusinganysystemmetDSMIIIRcriteria
showingitsinclusiveness.Almostallofthe20/36ICD10deliriumcasesoverlappedwithall othersystems(19/20). Dementia Possiblepreexistingdementia(SIQCODEscore>85)occurredin85(68%).Therewasno differenceinage(79.89r7.90vs.76.25r10.90,t=1.894,p=0.063)betweenthosewithand withoutdementia.Thosewithdementiahadmoremedicalcomorbidity(CCISFscore2.07r1.4 vs.1.48r1.3;t=2.245,p=0.027)andmorefrequentuseofatypicalantipsychotics(45.9%vs. 17.5%,F2=9.421,p=0.002)thanthosewithoutdementia. Dementiapatientshadasignificantlyhigheroccurrenceofdeliriumaccordingtoallfour diagnosticcriteriawhencomparedtothosewithoutdementia.UsingDSM5,itwas30.6%vs. 12.5%(F2=4.772,p=0.029),ICD1021.2%vs.5%(F2=5,296,p=0.021),DSMIIIR35.3%vs. 10%(F2=8.788,p=0.003),andDSMIV28.2%vs.10%(F2=5.203,p=0.023)whencomparing dementiavs.nondementiagroups. DRSR98scores MeanDRSR98TotalscoreforDSM5was22.48r7.71(range538)inthedeliriumvs. 7.91r7.02(range030)innondeliriumgroup.Similarly,forICD10,meanDRSR98Totalwas 23.75r6.60(range1538)vs.9.20r8.18(range032);forDSMIIIR,22.62r7.52(range538)vs. 7.38r6.44(range030);andforDSMIV,23.50r7.39(range538)vs.8.07r6.99(range030). Thereweresignificantdifferences(pζ0.01)inmeanvaluesofalmostallDRSR98items (exceptforitems#2and3representingpsychosis),forDRSR98Totalscores,andinSeverity scalescoresbetweensubjectswithandwithoutdeliriumaccordingtoalldiagnosticsystemsin thewholesample(datanotshown).Table2showsmeanvaluesforDRSR98itemsandTotal scalescoresforgroupswithandwithoutdeliriuminthedementiasubsample.Itemsevaluating thethreecoredomainsofdeliriumhadhighermeanscoresindementiapatientswithdelirium thannondelirium,butnodifferencesfornoncorepsychoticandaffectiveitems.Meanscores foritemsrepresentingthecircadiandomain(sleepwakecycle,motordisturbances),higher levelthinking(language,thoughtprocess),andthecognitivedomain(attention,visuospatial ability,orientation,memory)aswellasdiagnosticcharacteristics(temporalonset,fluctuation, presenceofamedicalcause)generallyhadhighsignificance(p<0.01)irrespectiveofthe deliriumdiagnosticcriteriaused. ROCAnalysesUsingDRSR98 ROCcurveanalysis(Figure3)showedverygooddiscriminantcapacityusingAUCfortheDRS R98Totalscalefordeliriumdiagnosedusingallfoursystems.AUCwashighestforDSMIIIR (92.92%)followedbyDSMIV,DSM5andICD10,buttherewasnostatisticaldifferencefor AUCamongthem,whethertestedforthewholesampleorthedementiasubsample. SensitivityandspecificityvaluesforvariouscutoffscoresoftheDRSR98Totalscaleare shownforthewholesampleinTable3andfordementiasubsampleinTable4.Selected highestvaluesthatbalancedsensitivityandspecificityforeachcriteriasystemareshownin
shadedrows.BestcutoffscorefortheDRSR98Totalwas14.5forallsystemsexceptICD10 (15.5),forbothallsubjectsandthesubsample. UsingthesebestDRSR98cutoffsfromROCanalysisinthewholesample,sensitivityvalues fromhighesttolowestwere:DSMIV,DSMIIIR,DSM5andICD10.Similarly,specificityvalues wererankedfromhighesttolowestasDSMIIIR,DSM5,DSMIV,andthenICD10.Inthe subsampleofpatientswithdementiatheorderfromhighertolowersensitivityatthebestcut offsfromROCanalysiswasDSMIV,DSMIIIR,DSM5andICD10,andtheorderfromhigherto lowerspecificitywasDSMIIIR,ICD10andDSM5withthesamescore,andDSMIV.Ifweuse 14.5asthecutoffscoreforICD10,asfortheothercriteria,sensitivityincreasedupto100% butspecificityworsens. Figure4comparesDRSR98TotalAUCbetweengroupswithandwithoutdementia.The discriminantcapacityofthetoolwaslowerinthedementiasubsamplethaninthewhole sample,irrespectiveofthediagnosticcriteriaused(p<0.03forallHanley&McNeiltestsF2). SimilarfindingswerefoundfortheDRSR98Severityscale(notshowninthefigure,p>0.02for allHanley&McNeiltestsF2). DISCUSSION WepresentnewdataonperformanceoftheDRSR98whenevaluatedagainstfourmajor deliriumdiagnosticsystemsinsubjectsadmittedtoaskillednursingfacilitythathadahigh prevalenceofpreexistingdementia.Therewaspoorconcordancefordeliriumdiagnosis amongthecriteriasystems.Despitethis,theDRSR98scalehadhighdiscriminantcapacityfor deliriumdiagnosisirrespectiveoftheclassificationsystem.UsingROCanalyses,AUCsfor deliriumdiagnosisrangedfrom90.5%(ICD10)to92.9%(DSMIIIR)forthewholesampleand weresomewhatlowerforthedementiasubsamplewhereAUCsrangedfrom86.7%(ICD10)to 88.5%(DSMIIIR).Balancingsensitivityandspecificityvaluesforeachdiagnosticsystemto determinethebestDRSR98cutoffvalue,allDSMcriteriaversionshadthesamevalue(14.5), whilethecutoffforICD10wasslightlyhigher(15.5).DRSR98showedhighersensitivityfor DSMcriteriathanforICD10attherecommendedcutoffs,withDSMIVhavingthehighest, followedbyDSMIIIR,andthenewDSM5.SpecificitywashigherusingDSMIIIRfollowedby DSM5,DSMIV,andICD10withalmostthesamevalueforthosethree. AccordingtoKendler(2009),inclusionofbothcurrentandhistoricaldeliriumcriteriainour analysisisimportantbecauseadefiningfeatureofamaturescienceisitscumulativenature andcapacitytobuildonwhathasgonebefore.Inthissense,evolutionofpsychiatriccriteria couldbeunderstoodasaniterativeprocessthatshouldincreasequalityofclinicaldiagnosis.29 So,lessonscanbelearnedfromquantifyingconcordanceamongtheevolvingdeliriumcriteria andanalyzingagainstthemtheperformanceofatoollikeDRSR98thatassessesthewide rangeofcoreandnoncorephenomenologicalcharacteristicsofthesyndrome. Therewasastrikinglylowconcordanceforidentificationofdeliriumsubjectsbyallfour approaches(around50%).Thephenomenologicalbreadthanddepthofcriteriavaries considerably,withDSMIIIRinvolvingmoresymptomsthaneitherDSMIVorDSM5thatwere
designedtobelessrestrictive.Thenumberofdeliriumcasesidentifiedindividuallybyeach systemalsovariedconsiderably(20forICD10,28forDSMIV,31forDSM5,and34forDSM IIIR)withtheICD10beingmostrestrictive(seeVenndiagraminFigure2).Therefore,one majorchallengeinevaluatingtheperformanceoftheDRSR98–oranytoolforthatmatter– againstagoldstandardiswhenthediagnosticcriteriavarysomuchacrosstheDSMandICD systemswhenappliedtoagivenpersonthatonemustquestionwhich,ifany,aretrulyagold standard.CertainlywehavelearnedinthefieldofAlzheimer’sdementiathatusingclinicalor researchdiagnosticcriteriaisnotwellvalidatedtoneuropathologicaldiagnosisonautopsy,30 therebymakinganyclinicaldiagnosisbasedstandardlessthan“golden.”Thisisprobablythe caseindeliriumwhereweneedbiomarkervalidationinconjunctionwiththeclinicalcriteriato ascertaintruecases.Biomarkerresearchindeliriumislaggingthoughanelectrophysiological approachmayhavethebestchanceofsuccesswereitavailableinaportablemethod. Inlinewithpreviousstudies,11,12,31wefoundICD10hadtheleastinclusivecriteriaduetoits requirementsformoredetailedsymptomsthoughitstilldoesnotevaluateall3coredomains ofdelirium.2,5,32Infact,thehighDRSR98meanscoresofalmost24indeliriumandaround9in nondeliriumaccordingtoICD10suggestsitcapturesmorefullsyndromaldeliriumandfewer subsyndromalcasesthandotheDSMsystems.DSMIIIRdiagnosedmorepatientsinour study,eventhoughitincorporatesmoresymptomsthantheDSMIV,similartothereportof Laurilaetal.(2003)whofoundDSMIIIRmoreinclusiveinnursinghomepatients.11Onthe otherhand,DRSR98hadthehighestspecificitywhencomparedtoDSMIIIRcriteria,soit couldalsobepossiblethatthegreaterinclusivenessofDSMIIIRbetterapproximatesthetrue prevalenceofdeliriumandcouldbeattributabletoitsinclusion(thoughnotallrequired)of symptomsfromallthreedeliriumcoredomains,inparticularcircadiandisturbancesofsleep wakecycleandmotoractivityanddisorganizedthinking.Otherclassificationsrelyonattention deficitsandomitordonotrequiremanysymptomsthatareconsideredcoreforthe syndrome.2,4,5,31,32Becauseofthebreadthoftypesofsymptomsthatcanoccurindelirium,it mightbethatevenamorecomprehensivelistingofsymptomsinDSM5couldenhancethe possibilityofdiagnosis. ThebestcutoffvaluesfortheDRSR98whenassessingDSMcriteria(14.5)arethesameas thosereportedinthevalidationagainstDSMIVoftheJapaneseversion33andrelativelysimilar tothoseoftheChineseversionvs.DSMIV(15.5)34thoughtheColombianversionvs.DSMIV wasalittlelower(12.0).35OurvaluesarelowerthanthoseintheoriginalEnglishversion againstDSMIV(17.75),14Portugueseversionvs.DSMIV(20.1),36andKoreanversionvs.DSM IV(18.5–19.5)37validationstudies.Differencesamongstudiesincutoffscorescouldbea consequenceofdifferencesinsociodemographicalandclinicalcharacteristicsofthesample. Wechosethestudysamplefromaskillednursingfacility,andtohaveahighcomorbidityof dementiabecausethisisachallengetocliniciansindiagnosingdelirium.SpecificDRSR98 itemsrepresentingthethreecoredeliriumdomains,aswellasdiagnosticcharacteristics, particularlydistinguisheddeliriuminthesubgroupofdementiapatients.Moreresearchis neededastowhetherclinicianscanrelyonthosefeaturestodetectdeliriumindementia patients.
Strengthsofthisstudyincludeindependentresearchratingsforclassificationsystems checklists,andDRSR98.Weusedmedicalrecords,historytaking,family/carerinterviewand IQCODEtodiagnosepreexistingdementiathoughthisislessrigorousthanacomplete dementiaevaluation.Wealsodidnotspecifythetypeofdementiaoritsseverity.Because differenttypesofdementia(e.g.Alzheimer’s,vascular,LewyBody,Frontotemporal)havetheir ownphenomenologicalpatterns,thedetectionusingadeliriumdesignedtool(DRSR98)may havebeenaffectedsomewhat,includingourfindingofhighermeanDRSR98Totalscoresin thenondeliriumcaseswithdementiathaninthewholesamplethatincludednondementia patients,suggestingdementiasymptomscontributetothescalescoresinafashionthatcould reducethescales’abilitytodiscriminate.Nonetheless,theROCanalysesweresimilar irrespectiveofpresenceofdementiaornot;moreover,DRSR98itemsevaluatingdiagnostic characteristicsandsymptomsfromdeliriumcoredomainsshoweddifferentiationofdelirium fromnondeliriumamongpatientswithdementia. Insummary,DRSR98provedtobeavalidandusefulinstrumentforassessing/discriminating deliriuminpostacuteelderlypatientsintheskillednursinghomesetting,regardlessofthe inclusivenessofdiagnosticsystemused.Furthermore,itprovedtobeavalidtooltodiagnose deliriuminpatientswithapreviousdementia,wheretheperformanceofdiagnosticcriteriais lower.Besidesconsiderationofbiomarkers,furtherevolutionofdeliriumdiagnosticcriteria shouldtakeintoaccountsymptomsrepresentingthethreecoredomainssothatdelirium couldbeassessedinamorespecificwayinordertobetterdistinguishfullsyndromalfrom subsyndromalandnondeliriumcaseseveninthosewithdementia.
Disclosures Therewasnoformalfundingforthisstudy. Dr.TrzepaczisaretiredemployeeandminorshareholderatEliLillyandCompany.Dr. TrzepaczholdsthecopyrightfortheDeliriumRatingScaleRevised98butdoesnotchargea feeforanotforprofituse.Allothercoauthorsreportnoproprietaryorcommercialinterestin anyproductmentionedorconceptdiscussedinthisarticle.
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Table1.Demographicandclinicalcharacteristicsaccordingtodiagnosisgroups.Deliriumcases arereportedasdiagnosedaccordingtoDSM5diagnosticcriteria.Datashownasmeans±SD unlessdenotedbyfrequencies(percents).Comparisonsarebetweendeliriumandnondelirium participants. Wholesample Subsamplewithdementia Nondelirium Delirium Nondelirium Delirium (n=94) (n=31) (n=59) (n=26) Variable ǤͳͳάͻǤͳ ͺ͵ǤͷάǤͻͳȗ ͺǤ͵ͶάǤʹ ͺ͵ǤͶʹάǤͷͲȗ ȋȌ ͶǤͻ͵ά͵Ǥͻͷ ͶǤ͵ͷάͶǤͶͶ ͶǤʹͲά͵Ǥ͵Ͷ ͶǤͳͻάͶǤͶͻ ͳǤͺͷάͳǤͶ͵ ͳǤͻάͳǤ͵͵ ʹǤͲͷάͳǤͶ͵ ʹǤͳʹάͳǤͶͲ ȋΨȌ ͶͶȋͶǤͺȌ ͳͺȋͷͺǤͳȌ ʹͷȋͶʹǤͶȌ ͳͷȋͷǤȌ ͷͲȋͷ͵ǤʹȌ ͳ͵ȋͶͳǤͻȌ ͵ͶȋͷǤȌ ͳͳȋͶʹǤ͵Ȍ ȋΨȌ ͳͲȋͳͲǤȌ ͶȋͳʹǤͻȌ ͵ȋͷǤͳȌ ͵ȋͳͳǤͷȌ ͵Ͷȋ͵ǤʹȌ ͳȋͷͳǤȌ ʹʹȋ͵Ǥ͵Ȍ ͳ͵ȋͷͲǤͲȌ Ȁ ͻȋͻǤȌ ͳȋ͵ǤʹȌ ȋͳͲǤʹȌ ͳȋ͵ǤͺȌ ͶͳȋͶ͵ǤȌ ͳͲȋ͵ʹǤ͵Ȍ ʹͺȋͶǤͷȌ ͻȋ͵ͶǤȌ ȋΨȌ ͳȋͳǤͳȌ Ǧ ͳȋͳǤȌ Ǧ ͵ȋ͵ǤʹȌ Ǧ ͳȋͳǤȌ Ǧ ͶʹȋͶͶǤȌ ʹͳȋǤȌ ʹȋͶͷǤͺȌ ͳȋͷǤͶȌ ȋȌ ͶȋͶͺǤͻȌ ͳͲȋ͵ʹǤ͵Ȍ ͵ͲȋͷͲǤͺȌ ͻȋ͵ͶǤȌ ʹȋʹǤͳȌ Ǧ Ǧ Ǧ Ș ȋΨȌ ͷͻȋʹǤͺȌ ʹȋͺ͵ǤͻȌȗ Ȁ Ȁ șȋΨȌ ͵ͻȋͶͳǤͷȌ ͳͷȋͶͺǤͶȌ ʹͶȋͶͲǤȌ ͳʹȋͶǤʹȌ ȋǤͶȌ ͵ȋͻǤȌ ͷȋͺǤͷȌ ʹȋǤȌ ʹͻȋ͵ͲǤͻȌ ͳȋͷͶǤͺȌȗ ʹͶȋͶͲǤȌ ͳͷȋͷǤȌ ͵ȋ͵ͻǤͶȌ ͳȋͷͳǤȌ ʹȋͶͶǤͳȌ ͳͶȋͷ͵ǤͺȌ ͺȋͺǤͷȌ ͳȋ͵ǤʹȌ ȋͳͳǤͻȌ ͳȋ͵ǤͺȌ ȋΨȌ ͳȋͳǤͲȌ ͻȋʹͻǤͲȌ ͳͷȋʹͷǤͶȌ ͻȋ͵ͶǤȌ ǣ Ȁ ͳ͵ȋͳ͵ǤͺȌ ͵ȋͻǤȌ ͺȋͳ͵ǤȌ ͵ȋͳͳǤͷȌ ͳͲȋͳͲǤȌ ʹȋǤͷȌ ͷȋͺǤͷȌ ͳȋ͵ǤͺȌ ͳʹȋͳʹǤͺȌ Ǧ ͳͳȋͳͺǤȌ Ǧȗ ȋǤͶȌ ȋͳͻǤͶȌ ͶȋǤͺȌ ͶȋͳͷǤͶȌ ȋǤͶȌ ͷȋͳǤͳȌ ͶȋǤͺȌ ͷȋͳͻǤʹȌ Ț ͳ͵ȋͳ͵ǤͺȌ ͳʹȋ͵ͺǤȌȗ ͳͲȋͳǤͻȌ ͳͲȋ͵ͺǤͷȌ Ǧͻͺ ǤͻͳάǤͲʹ ʹʹǤͶͺάǤͳȗ ͳͲǤͺάǤͲͻ ʹʹǤͻάǤʹȗ *p<0.05. † SIQCODE>85. ‡ During24hbeforeevaluation.
§
Asreportedinclinicalrecords. N/A:Notapplicable.
Table2.ComparisonofDRSR98individualitem(mean±SD)in85hospitalizeddementiapatientswithorwithoutdeliriumaccordingtodifferentDSMand ICDcriteria.Significantdifferencesatp<0.01forttestsarebolded. DSM5 ICD10 DSMIIIR DSMIV Nodelirium(n Delirium Nodelirium(n Delirium Nodelirium(n Delirium Nodelirium(n Delirium =59) (n=26) =67) (n=18) =55) (n=30) =61) (n=24) DRSR98Item 1. Sleepwakecycledisturbance 0.61±0.67 1.73±0.67 0.72±0.75 1.83±0.51 0.60±068 1.60±0.72 0.66±0.70 1.71±0.69 2. Perceptionsandhallucinations 0.56±1.10 0.62±1.02 0.55±1.06 0.67±1.03 0.53±1.07 0.67±1.03 0.59±1.10 0.54±0.93 3. Delusions 0.76±1.16 0.38±0.85 0.67±1.12 0.56±0.98 0.80±1.19 0.37±0.81 0.74±1.15 0.42±0.88 4. Labilityofaffect 0.36±0.55 0.69±0.79 0.37±0.57 0.78±0.81 0.36±0.56 0.63±0.76 0.36±0.55 0.71±0.81 5. Language 0.54±0.86 1.42±1.10 0.66±0.95 1.39±1.09 0.42±0.71 1.53±1.11 0.54±0.85 1.50±1.10 6. Thoughtprocessabnormalities 0.69±0.81 1.46±1.10 0.82±0.90 1.33±1.14 0.62±0.73 1.50±1.11 0.69±0.81 1.54±1.10 7. Motoragitation 0.36±0.66 1.12±0.86 0.37±0.67 1.39±0.78 0.27±0.59 1.17±0.83 0.36±0.66 1.17±0.87 8. Motorretardation 0.39±0.69 1.50±1.03 0.60±0.91 1.22±1.00 0.42±0.71 1.30±1.09 0.39±0.69 1.58±1.02 9. Orientation 1.20±0.89 2.15±0.73 1.30±0.92 2.22±0.65 1.11±0.83 2.20±0.71 1.21±0.88 2.21±0.72 10. Attention 0.63±0.74 2.04±0.87 0.79±0.90 2.06±0.80 0.62±0.73 1.87±0.97 0.64±0.73 2.13±0.85 11. Shorttermmemory 0.41±0.91 1.19±1.02 0.49±0.94 1.22±1.06 0.33±0.79 1.23±1.10 0.43±0.90 1.21±1.06 12. Longtermmemory 1.93±1.03 2.50±0.95 1.93±1.06 2.78±0.55 1.82±1.06 2.63±0.76 1.92±1.05 2.58±0.83 13. Visuospatialability 0.86±1.02 2.15±1.08 1.00±1.13 2.22±0.94 0.73±0.93 2.23±1.01 0.85±1.01 2.29±1.00 14. Temporalonsetofsymptoms 0.64±0.74 1.50±0.71 0.72±0.75 1.61±0.70 0.65±0.75 1.37±0.76 0.66±0.73 1.54±0.72 15. Fluctuationofsymptomseverity 0.22±0.46 1.00±0.49 0.28±0.49 1.11±0.47 0.20±0.45 0.93±0.52 0.25±0.47 1.00±0.51 16. Physicaldisorder 0.61±0.74 1.50±0.58 0.70±0.78 1.56±0.51 0.60±0.76 1.40±0.62 0.62±0.73 1.54±0.59 DRSR98Totalscore 22.96r7.72 11.97r8.03 23.94r6.81 10.07r6.55 22.63r7.67 10.90r7.03 23.67r7.55 10.78r7.09
Cut off ͶǤͷͲ ͷǤͷͲ ǤͷͲ ǤͷͲ ͺǤͷͲ ͻǤͷͲ ͳͲǤͷͲ ͳͳǤͷͲ ͳʹǤͷͲ ͳ͵ǤͷͲ ͳͶǤͷͲ ͳͷǤͷͲ ͳǤͷͲ ͳǤͷͲ ͳͺǤͷͲ ͳͻǤͷͲ ʹͲǤͷͲ ʹʹǤͷͲ ʹͶǤͷͲ ʹͷǤͷͲ ʹǤͷͲ ʹǤͷͲ ʹͻǤͲͲ ͵ͲǤͷͲ ͵ͳǤͷͲ ͵͵ǤͷͲ
Table3.SensitivityandspecificityfordeliriumdiagnosisoftheDRSR98Totalscale,according toeachdiagnosticclassificationcriteria,for125consecutivepatientsadmittedtoaskilled nursingfacility.Shadedareascorrespondtothebestcutoffscoressensibilityandspecificity values,foreachdiagnosticsystem. DSM5Criteria ICD10Criteria DSMIIIRCriteria DSMIVCriteria Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity (%) (%) (%) (%) (%) (%) (%) (%) ͳͲͲ ͵ͺǤ͵ ͳͲͲ ͵ͶǤ͵ ͳͲͲ ͵ͻǤ ͳͲͲ ͵Ǥͳ ͻǤͺ ͶǤͺ ͳͲͲ ͶʹǤͻ ͻͶǤͳ ͶǤ͵ ͻǤͶ ͶͷǤͶ ͻǤͺ ͷͺǤͷ ͳͲͲ ͷ͵Ǥ͵ ͻͶǤͳ ͷͻǤ͵ ͻǤͶ ͷǤ ͻǤͺ ͳǤ ͳͲͲ ͷǤʹ ͻͶǤͳ ʹǤ ͻǤͶ ͷͻǤͺ ͻǤͺ ͺǤͳ ͳͲͲ ͳǤͻ ͻͶǤͳ ͻǤʹ ͻǤͶ ǤͲ ͻǤͺ ͻǤͳ ͳͲͲ ʹǤͻ ͻͶǤͳ ͲǤ͵ ͻǤͶ ǤͲ ͻ͵Ǥͷ ͻǤͳ ͳͲͲ ͵Ǥͺ ͻͶǤͳ ͳǤͶ ͻǤͶ ͺǤͲ ͻͲǤ͵ ʹǤ͵ ͳͲͲ Ǥ ͻͶǤͳ ͷǤͺ ͻǤͶ ʹǤʹ ͻͲǤ͵ ͶǤͷ ͳͲͲ ͻǤͷ ͻͶǤͳ ͺǤͲ ͻǤͶ ͶǤʹ ͻͲǤ͵ ͻǤͺ ͳͲͲ ͶǤ͵ ͻͶǤͳ ͺ͵Ǥͷ ͻǤͶ ͻǤͶ ͻͲǤ͵ ͺͶǤͲ ͳͲͲ ͺǤͳ ͻͶǤͳ ͺǤͻ ͻǤͶ ͺ͵Ǥͷ ǤͶ ͺǤʹ ͻͲǤͲ ͺʹǤͻ ͺʹǤͶ ͻͳǤʹ ͺʹǤͳ ͺǤ ͶǤʹ ͺͻǤͶ ͺͷǤͲ ͺͶǤͺ ͻǤͶ ͻ͵ǤͶ ͺǤ ͺͺǤ ͳǤͲ ͺͻǤͶ ͺͲǤͲ ͺͶǤͺ Ǥͷ ͻ͵ǤͶ ͷǤͲ ͺͺǤ ͳǤ͵ ͻͲǤͶ ͷǤͲ ͺͷǡ Ǥ ͻͶǤͷ Ǥͻ ͻͲǤ ͳǤ͵ ͻͳǤͷ ͷǤͲ ͺǤ ͶǤ ͻͶǤͷ Ǥͻ ͻͳǤͺ ͷͺǤͳ ͻʹǤ ͲǤͲ ͺǤ ͳǤͺ ͻͷǤ ͶǤ͵ ͻʹǤͺ ͷͶǤͺ ͻͶǤ ͲǤͲ ͻͲǤͷ ͷʹǤͻ ͻͷǤ ͲǤ ͻͶǤͺ ͶͺǤͶ ͻͷǤ ͷͲǤͲ ͻͳǤͶ ͶǤͳ ͻǤ ͷ͵Ǥ ͻͷǤͻ ͶͳǤͻ ͻǤͺ ͶͲǤͲ ͻʹǤͶ ͶͳǤʹ ͻǤͺ ͶǤͶ ͻǤͻ ʹͻǤͲ ͻǤͺ ͵ͲǤͲ ͻͶǤ͵ ʹͻǤͶ ͻǤͺ ͵ʹǤͳ ͻǤͻ ʹʹǤ ͻǤͻ ʹͲǤͲ ͻͷǤʹ ʹͲǤ ͻǤͺ ʹͷǤͲ ͻǤͻ ʹʹǤ ͻͺǤͻ ʹͲǤͲ ͻǤʹ ʹͲǤ ͻͺǤͻ ʹͷǤͲ ͻͻǤͲ ͳǤͳ ͳͲͲ ͳͷǤͲ ͻͺǤͳ ͳͶǤ ͳͲͲ ͳǤͻ ͳͲͲ ͻǤ ͳͲͲ ͳͲǤͲ ͻͻǤͲ ͺǤͺ ͳͲͲ ͳͲǤ ͳͲͲ Ǥͷ ͳͲͲ ͳͲǤͲ ͳͲͲ ͷǤͻ ͳͲͲ Ǥͳ ͳͲͲ
Cut off ͶǤͷͲ ͷǤͷͲ ǤͷͲ ǤͷͲ ͻǤͷͲ ͳͳǤͷͲ ͳʹǤͷͲ ͳ͵ǤͷͲ ͳͶǤͷͲ ͳͷǤͷͲ ͳǤͷͲ ͳǤͷͲ ͳͺǤͷͲ ͳͻǤͷͲ ʹͲǤͷͲ ʹʹǤͷͲ ʹͶǤͷͲ ʹͷǤͷͲ ʹǤͷͲ ʹǤͷͲ ʹͻǤͲͲ ͵ͲǤͷͲ ͵ͳǤͷͲ ͵͵ǤͷͲ
Table4.SensitivityandspecificityfordeliriumdiagnosisoftheDRSR98Totalscale,according toeachdiagnosticclassificationcriteria,forthesubsampleof85patientswithdementia(S IQCODE>85),fromaskillednursingfacility.Shadedareascorrespondtothebestcutoffscores sensibilityandspecificityvalues,foreachdiagnosticsystem. DSM5 ICD10 DSMIIIR DSMIV Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity (%) (%) (%) (%) (%) (%) (%) (%) ͳͲͲ ͳ͵Ǥ ͳͲͲ ͳͳǤͻ ͳͲͲ ͳͶǤͷ ͳͲͲ ͳ͵Ǥͳ ͻǤʹ ʹʹǤͲ ͳͲͲ ʹͲǤͻ ͻ͵Ǥ͵ ʹͳǤͺ ͻͷǤͺ ʹͳǤ͵ ͻǤʹ ͶͲǤ ͳͲͲ ͵Ǥ͵ ͻ͵Ǥ͵ ͶͳǤͺ ͻͷǤͺ ͵ͻǤ͵ ͻǤʹ ͶͷǤͺ ͳͲͲ ͶͳǤͺ ͻ͵Ǥ͵ ͶǤ͵ ͻͷǤͺ ͶͶǤ͵ ͻǤʹ ͷͶǤʹ ͳͲͲ ͶͻǤ͵ ͻ͵Ǥ͵ ͷǤͶ ͻͷǤͺ ͷʹǤͷ ͻʹǤ͵ ͷͻǤ͵ ͳͲͲ ͷͷǤʹ ͻ͵Ǥ͵ ͵Ǥ ͻͷǤͺ ͷͻǤͲ ͻʹǤ͵ ͳǤͲ ͳͲͲ ͷǤ ͻ͵Ǥ͵ ͷǤͷ ͻͷǤͺ ͲǤ ͻʹǤ͵ ͻǤͷ ͳͲͲ ͶǤʹ ͻ͵Ǥ͵ ͶǤͷ ͻͷǤͺ ͺǤͻ ͻʹǤ͵ ͶǤ ͳͲͲ ͺǤ ͻ͵Ǥ͵ ͺͲǤͲ ͻͷǤͺ ͵Ǥͺ ͺͲǤͺ ͻǤ ͺͺǤͻ ͶǤ ͺ͵Ǥ͵ ͺͷǤͷ ͺ͵Ǥ͵ ͺǤ Ǥͻ ͺ͵Ǥͳ ͺ͵Ǥ͵ Ǥ ͺͲǤͲ ͺͻǤͳ ͻǤʹ ͺʹǤͲ ͵Ǥͳ ͺ͵Ǥͳ Ǥͺ Ǥ Ǥ ͺͻǤͳ ͷǤͲ ͺʹǤͲ ͷǤͶ ͺͶǤ Ǥ ͻǤͳ ͲǤͲ ͻͲǤͻ ͲǤͺ ͺͷǤʹ ͷǤͶ ͺǤͶ Ǥ ͺͲǤ Ǥ ͻͲǤͻ ͲǤͺ ͺǤͻ ͳǤͷ ͺͺǤͳ ͳǤͳ ͺʹǤͳ ͵Ǥ͵ ͻʹǤ Ǥ ͺͺǤͷ ͷǤ ͻͳǤͷ ͳǤͳ ͺǤ ͷ͵Ǥ͵ ͻʹǤ ʹǤͷ ͻͳǤͺ ͷͲǤͲ ͻ͵Ǥʹ ͷͲǤͲ ͺͺǤͳ ͶǤ ͻͷǤͷ ͷͶǤʹ ͻ͵ǤͶ ͶʹǤ͵ ͻͶǤͻ ͵ͺǤͻ ͺͻǤ ͶͲǤͲ ͻǤͶ ͶͷǤͺ ͻͷǤͳ ͵ͲǤͺ ͻͶǤͻ ͵͵Ǥ͵ ͻʹǤͷ ͵ͲǤͲ ͻǤͶ ͵͵Ǥ͵ ͻͷǤͳ ʹ͵Ǥͳ ͻǤ ʹʹǤʹ ͻͶǤͲ ʹͲǤͲ ͻǤͶ ʹͷǤͲ ͻǤ ʹ͵Ǥͳ ͻͺǤ͵ ʹʹǤʹ ͻͷǤͷ ʹͲǤͲ ͻͺǤʹ ʹͷǤͲ ͻͺǤͶ ͳͷǤͶ ͳͲͲ ͳǤ ͻͺǤͷ ͳ͵Ǥ͵ ͳͲͲ ͳǤ ͳͲͲ ͳͳǤͷ ͳͲͲ ͳͳǤͳ ͻͺǤͷ ͳͲǤͲ ͳͲͲ ͳʹǤͷ ͳͲͲ Ǥ ͳͲͲ ͳͳǤͳ ͳͲͲ Ǥ ͳͲͲ ͺǤ͵ ͳͲͲ
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