Accuracy of Dementia Screening Instruments in Emergency Medicine: A Diagnostic Meta-analysis
Accuracy of Dementia Screening Instruments in Emergency Medicine: A Diagnostic Meta-analysis
复制标题
DOI：
10.1111/acem.13573
复制
发表时间：
2019-02-01
影响因子：
4.4
通讯作者：
LaMantia, Michael A.
中科院分区：
文献类型：
--
作者：
Carpenter, Christopher R.;Banerjee, Jay;LaMantia, Michael A.
老年人急诊科（艾德）患者对痴呆的认识不足，这威胁到手术效率、诊断准确性和患者满意度。学术急诊医学协会老年艾德指南提倡使用经验证的仪器进行痴呆症筛查。目的本研究的目的是对老年艾德患者中痴呆的足够简短的筛查工具的诊断准确性进行系统回顾和荟萃分析。第二个目标是根据已发表的研究定义一个基于证据的痴呆症预测概率，然后估计痴呆症筛查最合适的疾病阈值。该系统性综述已在PROSPERO注册（CRD 42017074855）。方法计算机检索PubMed、EMBASE、CINAHL、CENTRAL、DARE和SCOPUS。如果报告了足够的详细信息以重建2 x 2表格，则纳入年龄≥ 65岁的痴呆艾德患者的研究。使用QUADAS-2评估研究质量，如果多项研究根据相同的参考标准评价相同的仪器，则报告荟萃分析。结果为敏感性、特异性、阳性和阴性似然比（LR+和LR-）。为了确定测试和治疗阈值，我们采用了Pauker-Kassirer方法。结果共识别出1，616篇出版物，其中16篇进行了全文审查;纳入了9项研究，加权平均痴呆患病率为31%（范围，12%-43%）。八项研究使用简易精神状态检查（MMSE）作为参考标准，另一项研究将MMSE与老年医学专家的神经认知评估结合使用。在4项研究中，对索引检测和/或参比标准品设盲不充分。在欧洲和北美四个国家的2，423名患者中评价了八种工具。简易智力测验（AMT-4）最准确地排除了痴呆（LR+ = 7.69 [95%置信区间{CI} = 3.45-17.10]），而简易阿尔茨海默病筛查最准确地排除了痴呆（LR- = 0.10 [95% CI = 0.02-0.28]）。使用本荟萃分析中AMT-4诊断准确性的估计值作为更全面的老年脆弱性评估的一个触发因素，当痴呆的预筛选概率在14%至36%之间时，艾德痴呆筛查对患者有益。结论ED为基础的诊断研究痴呆症筛查是有限的，少数研究使用不充分的标准与变量掩蔽的解释器的访问索引测试和标准的标准。标准化老年艾德认知评估方法，措施和命名是必要的，以减少不确定性的诊断准确性，可靠性和相关性，在这个急性护理设置。AMT-4是目前最准确的艾德筛查工具，可增加痴呆的概率，而简易阿尔茨海默氏症筛查是最准确的，可降低痴呆的概率。痴呆症筛查作为一个标志的脆弱性，启动全面的老年评估是必要的基础上测试治疗阈值计算。
Background Dementia is underrecognized in older adult emergency department (ED) patients, which threatens operational efficiency, diagnostic accuracy, and patient satisfaction. The Society for Academic Emergency Medicine geriatric ED guidelines advocate dementia screening using validated instruments. Objectives The objective was to perform a systematic review and meta-analysis of the diagnostic accuracy of sufficiently brief screening instruments for dementia in geriatric ED patients. A secondary objective was to define an evidence-based pretest probability of dementia based on published research and then estimate disease thresholds at which dementia screening is most appropriate. This systematic review was registered with PROSPERO (CRD42017074855). Methods PubMed, EMBASE, CINAHL, CENTRAL, DARE, and SCOPUS were searched. Studies in which ED patients ages 65 years or older for dementia were included if sufficient details to reconstruct 2 x 2 tables were reported. QUADAS-2 was used to assess study quality with meta-analysis reported if more than one study evaluated the same instrument against the same reference standard. Outcomes were sensitivity, specificity, and positive and negative likelihood ratios (LR+ and LR-). To identify test and treatment thresholds, we employed the Pauker-Kassirer method. Results A total of 1,616 publications were identified, of which 16 underwent full text-review; nine studies were included with a weighted average dementia prevalence of 31% (range, 12%-43%). Eight studies used the Mini Mental Status Examination (MMSE) as the reference standard and the other study used the MMSE in conjunction with a geriatrician's neurocognitive evaluation. Blinding to the index test and/or reference standard was inadequate in four studies. Eight instruments were evaluated in 2,423 patients across four countries in Europe and North America. The Abbreviated Mental Test (AMT-4) most accurately ruled in dementia (LR+ = 7.69 [95% confidence interval {CI} = 3.45-17.10]) while the Brief Alzheimer's Screen most accurately ruled out dementia (LR- = 0.10 [95% CI = 0.02-0.28]). Using estimates of diagnostic accuracy for AMT-4 from this meta-analysis as one trigger for more comprehensive geriatric vulnerability assessments, ED dementia screening benefits patients when the prescreening probability of dementia is between 14 and 36%. Conclusions ED-based diagnostic research for dementia screening is limited to a few studies using an inadequate criterion standard with variable masking of interpreter's access to the index test and the criterion standard. Standardizing the geriatric ED cognitive assessment methods, measures, and nomenclature is necessary to reduce uncertainties about diagnostic accuracy, reliability, and relevance in this acute care setting. The AMT-4 is currently the most accurate ED screening instrument to increase the probability of dementia and the Brief Alzheimer's Screen is the most accurate to decrease the probability of dementia. Dementia screening as one marker of vulnerability to initiate comprehensive geriatric assessment is warranted based on test-treatment threshold calculations.