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Review
December 17, 2018

Assessment of Instruments for Measurement of Delirium Severity: A Systematic Review

Author Affiliations
  • 1Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
  • 2Department of Neurology, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
  • 3Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
  • 4Hirsh Health Sciences Library, Tufts University, Boston, Massachusetts
  • 5Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
  • 6Center for Outcomes Research & Evaluation, Yale University School of Medicine, New Haven, Connecticut
  • 7Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago Medicine, Chicago, Illinois
  • 8University of Massachusetts Medical School, Worcester
  • 9Frontotemporal Degeneration Center, University of Pennsylvania School of Medicine, Philadelphia
  • 10Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 11Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
  • 12Department of Psychiatry, Massachusetts General Hospital, Boston
  • 13Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 14Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts
  • 15Department of Psychology, Brooklyn College and the Graduate Center of City University of New York, Brooklyn, New York
  • 16Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, China
  • 17Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 18Harvard Medical School, Boston, Massachusetts
  • 19Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 20Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts
JAMA Intern Med. Published online December 17, 2018. doi:10.1001/jamainternmed.2018.6975
Key Points

Question  Is there a method to identify high-quality delirium severity instruments for clinical care and research?

Findings  In this systematic review of 42 delirium severity instruments in 228 studies, 11 of 42 (26%) were multidomain, delirium-specific instruments providing a quantitative rating of severity. Applying prespecified criteria on frequency of use, methodologic quality, construct validity, and broad domain coverage, an expert panel selected 6 final high-quality instruments.

Meaning  The Confusion Assessment Method–Severity Score, Confusional State Examination, Delirium-O-Meter, Delirium Observation Scale, Delirium Rating Scale, and Memorial Delirium Assessment Scale may enable accurate measurement of delirium severity to improve clinical care for patients with this condition.

Abstract

Importance  Measurement of delirium severity has been recognized as highly important for tracking prognosis, monitoring response to treatment, and estimating burden of care for patients both during and after hospitalization. Rather than simply rating delirium as present or absent, the ability to quantify its severity would enable development and monitoring of more effective treatment approaches for the condition.

Objectives  To present a comprehensive review of delirium severity instruments, conduct a methodologic quality rating of the original validation study of the most commonly used instruments, and select a group of top-rated instruments.

Evidence Review  This systematic review was conducted using literature from Embase, PsycINFO, PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature, from January 1, 1974, through March 31, 2017, with the key words delirium, severity, tests, measures, and intensity. Inclusion criteria were original articles assessing delirium severity and using a delirium-specific severity instrument. Final listings of articles were supplemented with hand searches of reference listings to ensure completeness. At least 2 reviewers independently completed each step of the review process: article selection, data extraction, and methodologic quality assessment of relevant articles using a validated rating scale. All discrepancies between raters were resolved by consensus.

Findings  Of 9409 articles identified, 228 underwent full text review, and we identified 42 different instruments of delirium severity. Eleven of the 42 tools were multidomain, delirium-specific instruments providing a quantitative rating of delirium severity; these instruments underwent a methodologic quality review. Applying prespecified criteria related to frequency of use, methodologic quality, construct or predictive validity, and broad domain coverage, an expert panel used an iterative modified Delphi process to select 6 final high-quality instruments meeting these criteria: the Confusion Assessment Method–Severity Score, Confusional State Examination, Delirium-O-Meter, Delirium Observation Scale, Delirium Rating Scale, and Memorial Delirium Assessment Scale.

Conclusions and Relevance  The 6 instruments identified may enable accurate measurement of delirium severity to improve clinical care for patients with this condition. This work may stimulate increased usage and head-to-head comparison of these instruments.

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