Nursing Delirium Screening Scale, a Tool for Early Detection of Delirium: Integrative Review

Ángela María Henao-Castaño; Laura Elizabeth Pachón Cetina; Juan David Monroy Rodríguez

doi:10.5294/aqui.2020.20.4.5

Authors

Ángela María Henao-Castaño Author Universidad Nacional de Colombia http://orcid.org/0000-0003-4203-0016
Laura Elizabeth Pachón Cetina Author Universidad Nacional de Colombia http://orcid.org/0000-0003-2708-8391
Juan David Monroy Rodríguez Author Universidad Nacional de Colombia http://orcid.org/0000-0002-6534-9102

DOI:

https://doi.org/10.5294/aqui.2020.20.4.5

Keywords:

Delirium, Nu-DESC, screening, nursing, assessment, critical care, hospitalization, perioperative period.

Abstract

Nursing Delirium Screening Scale, una herramienta para la detección temprana del delírium: revisión integrativa

Nursing Delirium Screening Scale, uma ferramenta para detectar precocemente o delírio: revisão integrativa

Objective: To analyze the context and use of the Nursing Delirium Screening Scale (Nu-DESC) for early detection of delirium in adult patients, compiling the available evidence.

Method: Searching for relevant articles on databases such as Cinahl, Medline, Ovid, Scopus, and Web of Science. Inclusion criteria: Articles written in English, Spanish, and Portuguese, published between January 2013 and October 2019. Search terms: “nursing delirium screen,” “inpatient delirium screening,” and “nursing assessment.” We identified 23 articles in which the Nu-DESC was used. Two reviewers independently assessed the articles using the CASPe (Critical Appraisal Skills Program in Spanish) tool.

Results: The Nu-DESC is employed in different contexts such as the adult intensive care unit (ICU), post-anesthetic care unit (PACU), palliative care unit, and hospitalization unit. It is more frequently used in the PACU with a more sensitive threshold (≥ 1); the test showed greater sensitivity of 54.5 % (95 % CI: 32.2–75.6) and specificity of 97.1 % (95 % CI: 95.3–98.4).

Conclusion: The Nu-DESC facilitates the recognition of delirium episodes by the nursing team, makes care quicker and individualized for each patient, avoiding immediate pharmacological interventions, and coordinate interdisciplinary actions for diagnosis, especially in post-anesthetic care units.

Para citar este artículo / To reference this article / Para citar este artigo

Henao-Castaño AM, Pachón LE, Monroy JD. Nursing Delirium Screening Scale, a Tool for Early Detection of Delirium: Integrative Review. Aquichan. 2020;20(4):e2045. DOI: https://doi.org/10.5294/aqui.2020.20.4.5

Recibido: 09/03/2020

Aceptado: 14/08/2020

Publicado: 04/12/2020

Downloads

Download data is not yet available.

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed., Text Revision (DSM-IV-TR); 2000.

Slooter AJC, Van De Leur RR, Zaal IJ. Delirium in critically ill patients. In Handbook of Clinical Neurology. 1st ed. Vol. 141. Elsevier B.V.; 2017. p. 449–466. DOI: http://dx.doi.org/10.1016/B978-0-444-63599-0.00025-9

Gaudreau JD, Gagnon P, Harel F, Tremblay A, Roy MA. Fast, systematic, and continuous delirium assessment in hospitalized patients: The nursing delirium screening scale. J Pain Symptom Manage. 2005;29(4):368–75. DOI: http://dx.doi.org/10.1016/j.genhosppsych.2005.01.002

Hägi-Pedersen D, Thybo KH, Holgersen TH, Jensen JJ, Gaudreau JD, Radtke FM. Nu-DESC DK: The Danish version of the nursing delirium screening scale (nu-DESC). BMC Nurs. 2017;16(1):1–6. DOI: http://dx.doi.org/10.4040/jkan.2012.42.3.414

Çlnar F, Eti Aslan F. Evaluation of Post-operative Delirium: Validity and Reliability of the Nursing Delirium Screening Scale in the Turkish Language. Dement Geriatr Cogn Dis Extra. 2019;9(3)362–73. DOI: http://dx.doi.org/10.1159/000501903

Ševčíková B, Kubešová HM, Šáteková L, Gurková E. Delirium screening instruments administered by nurses for hospitalized patients - Literature review. Cent Eur J Nurs Midwifery. 2019;10(4):1167–78. DOI: http://doi.org/10.15452/CEJNM.2019.10.0028

Kim K-N, Kim C-H, Kim K-I, Yoo H-J, Park S-Y, Park Y-H. Development and validation of the Korean Nursing Delirium Scale. J Korean Acad Nurs. 2012;42(3):414. DOI: http://dx.doi.org/10.4040/jkan.2012.42.3.414

Tarot A, Van Lander A, Pereira B, Guastella V. To study the relation between distress and delirium of patients in palliative care. Med Palliat [Internet]. 2019;18(6):271–8. DOI: https://doi.org/10.1016/j.medpal.2019.01.003

Watanabe H, Matsunuma R, Suzuki K, Matsuda Y, Mori M, Yamaguchi T. The Current Practice of Oxygen Therapy for Dyspnea in Terminally Ill Cancer Patients: A Nationwide Survey of Japanese Palliative Care Physicians. J Pain Symptom Manage. 2019;58(4):e2–4. DOI: https://doi.org/10.1016/j.jpainsymman.2019.06.028

Noh EY, Park YH. Prevalence of delirium and risk factors in heart surgery patients in intensive care unit: A retrospective study. Korean J Adult Nurs. 2019;31(2):146–55. DOI: https://doi.org/10.7475/kjan.2019.31.2.146

John M, Ely EW, Halfkann D, Schoen J, Sedemund-Adib B, Klotz S, et al. Acetylcholinesterase and butyrylcholinesterase in cardiosurgical patients with post-operative delirium. J Intensive Care. 2017;5(1):1–10. DOI: https://doi.org/10.1186/s40560-017-0224-1

Ri HS, Choi YJ, Park JY, Jin SJ, Lee YS, Son JM, et al. Elevation of Pre-operative Ammonia Level is not Associated with the Incidence of Post-operative Delirium in Patients with Liver Transplantation: A Propensity Score Matching Analysis. Transplant Proc [Internet]. 2020;52(1):219–26. DOI: https://doi.org/10.1016/j.transproceed.2019.11.012

Choi U, Kim SJ, Kang JS. Predictors for Incidence of Delirium after Musculoskeletal Operation in Elderly Patients. Korean J Stress Res. 2019;27(2):139–45. https://doi.org/10.17547/kjsr.2019.27.2.139

Becher KF. Das Delir bei geriatrischen Patienten in der Urologie. Urologe A. 2019;58(4):398–402. https://doi.org/10.1007/s00120-019-0887-4

Verdonk F. Le delirium postopératoire. Anesthésie & Réanimation [Internet]. 2019;5(6):502–9. DOI: https://doi.org/10.1016/j.anrea.2019.09.005

Hernandez BA, Lindroth H, Rowley P, Boncyk C, Raz A, Gaskell A, et al. Post-anaesthesia care unit delirium: Incidence, risk factors and associated adverse outcomes. Br J Anaesth. 2017;119(2):288–90. https://doi.org/10.1093/bja/aex197

Radtke FM, Franck M, Schneider M, Luetz A, Seeling M, Heinz A, et al. Comparison of three scores to screen for delirium in the recovery room. Br J Anaesth. 2008;101(3):338–43. https://doi.org/10.1093/bja/aen193

Menzenbach J, Guttenthaler V, Kirfel A, Ricchiuto A, Neumann C, Adler L, et al. Estimating patients’ risk for post-operative delirium from pre-operative routine data - Trial design of the PRe-Operative prediction of post-operative DElirium by appropriate SCreening (PROPDESC) study - A monocentre prospective observational trial. Contemp Clin Trials Commun. 2020;17. https://doi.org/10.1016/j.conctc.2019.100501

Eertmans W, De Deyne C, Genbrugge C, Marcus B, Bouneb S, Beran M, et al. Association between post-operative delirium and post-operative cerebral oxygen desaturation in older patients after cardiac surgery. Br J Anaesth. 2020;124(2):146–53. https://doi.org/10.1016/j.bja.2019.09.042

Riegger H, Hollinger A, Seifert B, Toft K, Blum A, Zehnder T, et al. Baden Prevention and Reduction of Incidence of Postoperative Delirium Trial (PRIDe): A phase IV multicenter, randomized, placebo-controlled, double-blind clinical trial of ketamine versus haloperidol for prevention of postoperative delirium. Trials. 2018;19(1):1–12. https://doi.org/10.1186/s13063-018-2498-6

Guihard N, Stefani L, Villard M, Mousseau M. Dépistage du syndrome confusionnel en soins palliatifs : étude prospective à l’aide de l’échelle Nu-Desc (Nursing Delirium Screening Scale) au centre hospitalier universitaire de Grenoble. Médecine Palliat. 2008;7(3):121–9. DOI: https://doi.org/10.1016/j.medpal.2007.10.004

Leung J, Reino M, Leung VC, Leung C, Unido MR, C FHK, et al. Clinical utility and validation of two instruments (the Algorithm Confusion Evaluation Method and the Chinese version of nursing delirium screening scale) to detect delirium in geriatric patients. Hosp Gen Psychiatry. 2008;30:171–6. DOI: https://doi.org/10.1016/j.genhosppsych.2007.12.007

Gaudreau JD, Gagnon P, Roy MA, Harel F, Tremblay A. Opioid medications and longitudinal risk of delirium in hospitalized cancer patients. Cancer. 2007;109(11):2365–73. DOI: https://doi.org/10.1002/cncr.22665

Luetz A, Heymann A, Radtke FM, Chenitir C, Neuhaus U, Nachtigall I, et al. Different assessment tools for intensive care unit delirium: Which score to use? Crit Care Med. 2010;38(2):409–18. DOI: http://doi.org/10.1097/CCM.0b013e3181cabb42

Morandi A, Brummel NE, Ely EW. Sedation, delirium and mechanical ventilation: the ‘ABCDE’ approach. Curr Opin Crit Care 2. 2011;17(1):43–9. DOI: https://doi.org/10.1097/mcc.0b013e3283427243

Schiemann A, Hadzidiakos D, Spies C. Erratum: Managing ICU delirium. Curr Opin Crit Care. 2011;17:131–40. DOI: https://doi.org/10.1097/MCC.0b013e32834400b5

Ganong LH. Integrative reviews of nursing research. Res Nurs Health. 1987;10(1):1–11. DOI: https://doi.org/10.1002/nur.4770100103

Van Velthuijsen EL, Zwakhalen SMG, Warnier RMJ, Mulder WJ, Verhey FRJ, Kempen GIJM. Psychometric properties and feasibility of instruments for the detection of delirium in older hospitalized patients: a systematic review. Int J Geriatr Psychiatry. 2016;31(9):974–89.DOI: https://doi.org/10.1002/gps.4441

Heinrich TW, Kato H, Emanuel C, Denson S. Improving the Validity of Nurse-Based Delirium Screening: A Head-to-Head Comparison of Nursing Delirium-Screening Scale and Short Confusion Assessment Method. Psychosomatics [Internet]. 2019;60(2):172–8. DOI: https://doi.org/10.1016/j.psym.2018.09.002

Kim SY, Kim JM, Kim SW, Kim ES, Kang HJ, Lee JY, et al. Do the Phenotypes of Symptom Fluctuation Differ Among Motor Subtypes in Patients With Delirium? J Pain Symptom Manage [Internet]. 2018;56(5):667–77. DOI: https://doi.org/10.1016/j.jpainsymman.2018.07.022

Hargrave A, Bastiaens J, Bourgeois JA, Neuhaus J, Josephson SA, Chinn J, et al. Validation of a Nurse-Based Delirium-Screening Tool for Hospitalized Patients. Psychosomatics [Internet]. 2017;58(6):594–603. DOI: http://dx.doi.org/10.1016/j.psym.2017.05.005

Grossmann FF, Hasemann W, Nickel CH. Detecting delirium in elderly medical emergency patients: validation and subsequent modification of the German nursing delirium screening scale—comment. In: Internal and Emergency Medicine. Vol. 14; 2019. p. 1009. DOI: https://doi.org/10.1007/s11739-018-1989-5

Spedale V, Di Mauro S, Del Giorno G, Barilaro M, Villa CE, Gaudreau JD, et al. Delirium assessment in hospitalized elderly patients: Italian translation and validation of the nursing delirium screening scale. Aging Clin Exp Res. 2017;29(4):675–83.DOI: https://doi.org/10.1007/s40520-016-0621-7

Abelha F, Veiga D, Norton M, Santos C, Gaudreau JD. Delirium assessment in post-operative patients: Validation of the Portuguese version of the Nursing Delirium Screening Scale in critical care. Brazilian J Anesthesiol [Internet]. 2013;63(6):450–5. DOI: http://dx.doi.org/10.1016/j.bjane.2012.09.003

Lingehall HC, Smulter N, Engström KG, Gustafson Y, Olofsson B. Validation of the Swedish version of the Nursing Delirium Screening Scale used in patients 70 years and older undergoing cardiac surgery. J Clin Nurs. 2013 Oct;22(19–20):2858–66. DOI: https://doi.org/10.1111/j.1365-2702.2012.04102.x

Xará D, Silva A, Mendonça J, Abelha F. Inadequate emergence after anesthesia: Emergence delirium and hypoactive emergence in the Postanesthesia Care Unit. J Clin Anesth. 2013 Sep 1;25(6);439–46. DOI: https://doi.org/10.1016/j.jclinane.2013.02.011

Ramroop R, Hariharan S CD. Emergence delirium following sevoflurane anesthesia in adults: prospective observational study. Brazilian J Anesthesiol. 2019;69(3):233–41. DOI: https://doi.org/10.1016/j.bjane.2018.12.012

Saller T, MacLullich AMJ, Schäfer ST, Crispin A, Neitzert R, Schüle C, et al. Screening for delirium after surgery: validation of the 4 A’s test (4AT) in the post-anaesthesia care unit. Anaesthesia. 2019;74(10):1260–6. DOI: https://doi.org/10.1111/anae.14682

Cristelo D, Ferreira MN, Castro JSE, Teles AR, Campos MAF. Quality of recovery in elderly patients with postoperative delirium. Saudi J Anesth. 2019;13(4):285-289. DOI: https://doi.org/10.4103/sja.SJA_747_18

Neufeld KJ, Leoutsakos JS, Sieber FE, Joshi D, Wanamaker BL, Rios-Robles J, et al. Evaluation of two delirium screening tools for detecting post-operative delirium in the elderly. Br J Anaesth. 2013;111(4):612–8. DOI: https://doi.org/10.1093/bja/aet167

Alcoba Pérez T, Ciria Poza S, Carracedo Catalán C, García Fernández A, Marcos Vidal JM. Valoración de la concordancia entre la escala CAM-ICU y la nursing delirium screening scale en el postoperatorio de cirugía cardiaca en una unidad de críticos. Enferm Intensiva [Internet]. 2014;25(3):100–6. DOI: http://dx.doi.org/10.1016/j.enfi.2014.03.003

Stukenberg S, Franck M, Spies CD, Neuner B, Myers I, Radtke FM. How can post-operative delirium be predicted in advance? A secondary analysis comparing three methods of early assessment in elderly patients. Minerva Anestesiol. 2016;82(7):751–9. Available from: https://pubmed.ncbi.nlm.nih.gov/27453295/

Poikajärvi S, Salanterä S, Katajisto J, Junttila K. Validation of Finnish Neecham Confusion Scale and Nursing Delirium Screening Scale using Confusion Assessment Method algorithm as a comparison scale. BMC Nurs. 2017;16(1):1–11. DOI: https://doi.org/10.1186/s12912-016-0199-6

Herrero S, Carrero E, Valero R, Rios J, Fábregas N. Monitoramento de pacientes neurocirúrgicos no pós‐operatório – utilidade dos escores de avaliação neurológica e do índice bispectral. Brazilian J Anesthesiol. 2017 Mar 1;67(2):153–65. DOI: https://doi.org/10.1016/j.bjan.2016.12.001

Winter A, Steurer MP, Dullenkopf A. Post-operative delirium assessed by post anesthesia care unit staff utilizing the Nursing Delirium Screening Scale: A prospective observational study of 1000 patients in a single Swiss institution. BMC Anesthesiol [Internet]. 2015;15(1):1–6. DOI: http://dx.doi.org/10.1186/s12871-015-0168-8

Sousa G, Pinho C, Santos A, Abelha FJ. Delirio postoperatorio en pacientes con historial de abuso de alcohol. Rev Esp Anestesiol Reanim [Internet]. 2017;64(4):214–22. DOI: http://dx.doi.org/10.1016/j.redar.2016.07.009

Smulter N, Claesson Lingehall H, Gustafson Y, Olofsson B, Engström KG. The use of a screening scale improves the recognition of delirium in older patients after cardiac surgery—A retrospective observational study. J Clin Nurs. 2019;28(11–12):2309–18. DOI: https://doi.org/10.1111/jocn.14838

De La Cruz M, Noguera A, San Miguel-Arregui MT, Williams J, Chisholm G, Bruera E. Delirium, agitation, and symptom distress within the final seven days of life among cancer patients receiving hospice care. Palliat Support Care. 2015;13(2):211–6. DOI: https://doi.org/10.1016/j.psym.2018.09.002

Hosie A, Lobb E, Agar M, Davidson PM, Chye R, Phillips J. Nurse perceptions of the Nursing Delirium Screening Scale in two palliative care inpatient units: A focus group study. J Clin Nurs. 2015;24(21–22):3276–85. DOI: https://doi.org/10.1111/jocn.12925

Hosie A, Lobb E, Agar M, Davidson P, Chye R, Lam L, et al. Measuring delirium point-prevalence in two Australian palliative care inpatient units. Int J Palliat Nurs. 2016;22(1):13–21. DOI: https://doi.org/10.12968/ijpn.2016.22.1.13

Powell TL, Nolan M, Yang G, Tam M, Metter D, Gibran NS, et al. Nursing Understanding and Perceptions of Delirium: Assessing Current Knowledge, Attitudes, and Beliefs in a Burn ICU. J Burn Care Res. 2019;40(4):471–7. DOI: https://doi.org/10.1093/jbcr/irz040

Saller T, Hofmann-Kiefer KF, Saller I, Zwissler B, von Dossow V. Implementation of strategies to prevent and treat post-operative delirium in the post-anesthesia caring unit: A German survey of current practice. J Clin Monit Comput [Internet]. 2020;(0123456789). DOI: https://doi.org/10.1007/s10877-020-00516-9

Gomes de Oliveira Tostes IC, Pereira SRM, De Almeida LF, Dos Santos MM. Delirium em terapia intensiva: utilização do Confusion Assessment Method for the Intensive Care Unit pelo enfermeiro. Rev Pesqui Cuid é Fundam Online. 2018;10(1):2. DOI: https://doi.org/10.9789/2175-5361.2018.v10i1.2-8

Mansouri P, Javadpour S, Zand F, Ghodsbin F, Sabetian G, Masjedi M, et al. Implementation of a protocol for integrated management of pain, agitation, and delirium can improve clinical outcomes in the intensive care unit: A randomized clinical trial. J Crit Care [Internet]. 2013;28(6):918–22. Available from: http://dx.doi.org/10.1016/j.jcrc.2013.06.019

Velásquez Gaviria LM. Instruments for the diagnosis of delirium in Spanish speakers: a review article. Med UPB. 2016;35(2):100–10. DOI: https://doi.org/10.18566/medupb.v35n2.a04

Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009 Jul 21;6(7):e1000097. DOI: https://doi.org/10.1371/journal.pmed.1000097