Dear Editor,
We have read with interest the paper of Brich et al. [1] published online in this journal on 27 November. We support the authors’ efforts to improve delirium detection in the ED setting. Their study showed moderate sensitivity and good specificity of the Nu-Desc delirium observation tool.
The authors’ conclusion, however, merits discussion. First, the Nu-Desc tool does not take inattention into account, which is—according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)—the main feature of delirium. Therefore, criterion validity might be questioned [2].
Further, we disagree with the conclusion that a sensitivity of 77.8%, as found in the modified Nu-Desc, is sufficient. Other validated screening tools, incorporating a formal test for inattention, showed better performance in ED patients [3,4,5]. The months of the year backwards test, for example, is frequently used in such tools. The screening step of the mCAM-ED [5], which is the months of the year backwards test, had a sensitivity of 95% and a negative likelihood ratio of 0.06 [5]. In the majority of patients (80%), the months of the year backwards test can be applied in less than 30 s. Of note, two-step tools such as DTS/bCAM [3] and mCAM-ED [5] will stop evaluation after a negative screening, which is ideal in the ED setting.
References
Brich J, Baten V, Wussmann J, Heupel-Reuter M, Perlov E, Kloppel S, Busch HJ (2018) Detecting delirium in elderly medical emergency patients: validation and subsequent modification of the German Nursing Delirium Screening Scale. Intern Emerg Med. https://doi.org/10.1007/s11739-018-1989-5
Savaskan E, Hasemann W (eds) (2017) Leitlinie Delir. Empfehlungen zur Prävention, Diagnostik und Therapie des Delirs im Alter, 1st edn. Hogrefe, Bern
Han JH, Wilson A, Vasilevskis EE, Shintani A, Schnelle JF, Dittus RS, Graves AJ, Storrow AB, Shuster J, Ely EW (2013) Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med 62(5):457–465. https://doi.org/10.1016/j.annemergmed.2013.05.003
O’Sullivan D, Brady N, Manning E, O’Shea E, O’Grady S, O‘Regan N, Timmons S (2018) Validation of the 6-Item Cognitive Impairment Test and the 4AT test for combined delirium and dementia screening in older emergency department attendees. Age Ageing 47(1):61–68. https://doi.org/10.1093/ageing/afx149
Hasemann W, Grossmann FF, Stadler R, Bingisser R, Breil D, Hafner M, Kressig RW, Nickel CH (2018) Screening and detection of delirium in older ED patients: performance of the modified confusion assessment method for the emergency department (mCAM-ED). A two-step tool. Intern Emerg Med 13(6):915–922. https://doi.org/10.1007/s11739-017-1781-y
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Grossmann, F.F., Hasemann, W. & Nickel, C.H. Detecting delirium in elderly medical emergency patients: validation and subsequent modification of the German nursing delirium screening scale—comment. Intern Emerg Med 14, 1009 (2019). https://doi.org/10.1007/s11739-018-02018-8
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DOI: https://doi.org/10.1007/s11739-018-02018-8