Development and validation of an aetiology in delirium diagnostic support tool.

BACKGROUND: recognition of the multifactorial causes of delirium represents a clinical challenge. OBJECTIVES: to develop and show proof of principle of a diagnostic support tool (DST) for identification of causes of delirium. METHODS: stage 1-development of the aetiology in delirium-diagnostic support tool (AiD-DST); stage 2-validation of the AiD-DST against reference standard diagnosis, based on clinical assessment from two independent consultant geriatricians. RESULTS: a series of eight steps AiD-DST were formulated by an expert group to identify possible causes of delirium. Forty inpatients admitted to a general medical unit with a consultant physician/geriatrician diagnosis of delirium were recruited, consented and reviewed against the AiD-DST. Mean age was 85.1 (standard deviation 7.9) years and 26 (65%) of participants were female. Participants had multiple chronic co-morbidities [median Charlson Comorbidity Index 7; interquartile range (IQR 6-9)] and median number of medications was 8 (IQR 6-11.75). Median number of causes of delirium detected on AiD-DST was 3 (IQR 3-4) versus 5 (IQR 3-6) using the reference standard diagnosis, with sensitivity of 88.8% (95% confidence interval, 81.6-93.9%) and specificity of 71.8% (63-79.5%). CONCLUSIONS: the aetiology in delirium DST shows promise in the identification of cause(s) in delirium.

Reliability of an Online Geriatric Assessment Procedure Using the interRAI Acute Care Assessment System.

OBJECTIVES: To determine whether geriatric triage decisions made using a comprehensive geriatric assessment (CGA) performed online are less reliable than face-to-face (FTF) decisions. DESIGN: Multisite noninferiority prospective cohort study. Two specialist geriatricians assessed individuals sequentially referred for an acute care geriatric consultation. Participants were allocated to one FTF assessment and an additional assessment (FTF or online (OL)), creating two groups-two FTF (FTF-FTF, n = 81) or online and FTF (OL-FTF, n = 85). SETTING: Three acute care public hospitals in two Australian states. PARTICIPANTS: Admitted individuals referred for CGA. INTERVENTION: Nurse-administered CGA, based on the interRAI Acute Care assessment system accessed online and other online clinical data such as pathology results and imaging enabling geriatricians to review participants' information and provide input into their care from a distance. MEASUREMENTS: The primary decision subjected to this analysis was referral for permanent residential care. Geriatricians also recorded recommendations for referrals and variations for medication management and judgment regarding prognosis at discharge and after 3 months. RESULTS: Overall percentage agreement was 88% (n = 71) for the FTF-FTF group and 91% (n = 77) for the OL-FTF group. The difference in agreement between the FTF-FTF and OL-FTF groups was -3%, indicating that there was no difference between the methods of assessment. Judgements made regarding diagnoses of geriatric syndromes, medication management, and prognosis (with regard to hospital outcome and location at 3 months) were found to be equally reliable in each mode of consultation. CONCLUSION: Geriatric assessment performed online using a nurse-administered structured CGA system was no less reliable than conventional assessment in making clinical triage decisions.

Web-based (online) comprehensive geriatric assessment is more time efficient, and as reliable, as reading patient medical records and conducting traditional in person consultations.

The aim of this study was to report the time taken by geriatricians to reach triage decisions using an online assessment format compared with face-to-face (FTF) assessment. Patients (N = 166) were randomly allocated to two groups: online and FTF assessments (OF group); and dual FTF assessments (FF group). Case preparation was conducted by trained nurse assessors using a web-enabled clinical decision support system. Geriatricians allocated to perform an 'online' assessment had access to this information only. Geriatricians allocated FTF assessments reviewed this data, as well as the paper-based medical file and then consulted directly with the patient and attending staff. Data were collected in relation to time taken to complete OL assessments, compared with FTF assessments. A complete OL consultation averages 10 minutes, and a FTF consultation almost 26 minutes. In FTF consultations, less time is spent using the OL material when the geriatrician is aware that they will have access to the patient chart and need time to speak with the patient. The less time taken using the OL approach did not significantly alter the triage decisions made by the geriatricians.

'Online' geriatric assessment procedure for older adults referred for geriatric assessment during an acute care episode for consideration of reliability of triage decisions.

BACKGROUND: Comprehensive geriatric assessment has been shown to improve patient outcomes, but the geriatricians who deliver it are in short-supply. A web-based method of comprehensive geriatric assessment has been developed with the potential to improve access to specialist geriatric expertise. The current study aims to test the reliability and safety of comprehensive geriatric assessment performed "online" in making geriatric triage decisions. It will also explore the accuracy of the procedure in identifying common geriatric syndromes, and its cost relative to conventional "live" consultations. METHODS/DESIGN: The study population will consist of 270 acutely hospitalized patients referred for geriatric consultation at three sites. Paired assessments (live and online) will be conducted by independent, blinded geriatricians and the level of agreement examined. This will be compared with the level of agreement between two independent, blinded geriatricians each consulting with the patient in person (i.e. "live"). Agreement between the triage decision from live-live assessments and between the triage decision from live-online assessments will be calculated using kappa statistics. Agreement between the online and live detection of common geriatric syndromes will also be assessed using kappa statistics. Resource use data will be collected for online and live-live assessments to allow comparison between the two procedures. DISCUSSION: If the online approach is found to be less precise than live assessment, further analysis will seek to identify patient subgroups where disagreement is more likely. This may enable a protocol to be developed that avoids unsafe clinical decisions at a distance. TRIAL REGISTRATION NUMBER: ACTRN12611000936921.

Probable trimethoprim/sulfamethoxazole-induced higher-level gait disorder and nocturnal delirium in an elderly man.

OBJECTIVE: To report a case of probable trimethoprim/sulfamethoxazole (TMP/SMX)-induced higher-level gait disorder (HLGD) and nocturnal delirium in an elderly patient on high-dose oral therapy. CASE SUMMARY: An 82-year-old man with a recent history of depression became comatose following an overdose of escitalopram and oxazepam. He was admitted, ventilated for 7 days in the intensive care unit, and treated with piperacillin/tazobactam and cefepime for aspiration pneumonia. Following discharge to a medical ward, respiratory symptoms persisted and imaging confirmed pulmonary abscesses. Stenotrophomonas maltophilia was isolated from sputum and, on day 15, TMP/SMX 800 mg/160 mg 1 tablet every 12 hours was initiated. On day 35, the dose was increased to 800 mg/160 mg 2 tablets every 12 hours. By day 37, the patient was unsteady when attempting to stand. From day 40, he was noted to have features of HLGD with gait ignition failure, poor balance, and frequent falls. His other medications at this time were thiamine 100 mg daily, multivitamin 1 tablet daily, omeprazole 20 mg every 12 hours, and modified-release venlafaxine 150 mg daily. Investigation did not reveal any cause for his acute gait disturbance. TMP/SMX was stopped on day 48 and, by day 51, the patient's gait had returned to normal. DISCUSSION: Neuropsychiatric adverse reactions with TMP/SMX have been infrequently reported. The Naranjo probability scale indicated that TMP/SMX was the probable cause of HLGD in this patient. CONCLUSIONS: At time of writing, this was the first reported case of HLGD associated with TMP/SMX. Clinicians should consider this adverse reaction as a potential cause of HLGD, especially in the elderly and those with malnutrition and hepatic or renal dysfunction.