READI: Researching Efficient Approaches to Delirium Identification

 描述(申请人提供)：精神错乱影响高达50%的住院老年人，并与功能和认知能力下降、疗养院安置、死亡率和1640亿美元的美国医疗费用独立相关。尽管有这些令人信服的数字，但对精神错乱的认识不足仍然是一个主要问题。在这种背景下，人们对在美国医院实施系统性精神错乱识别越来越感兴趣，然而，关于如何有效和高效地实施此类计划的证据很少。我们的目标是开发一种实用、有效和经济高效的方案来检测和监测高危住院老年人的精神错乱，并产生促进其广泛实施所需的证据基础。我们从R01AG030618获得的第一轮资助的产品“3D-CAM：派生和验证妄想症的3分钟诊断评估”，将作为我们方案的关键组件。这些设备包括：1)3D-CAM；可在3分钟内完成的高性能诊断面谈；2)超简短(30-40秒)两项筛查，可有效排除精神错乱。我们现在建议1)在两个独立的队列中验证筛选器；2)将筛选器和3D-CAM结合成一个两步精神错乱识别方案；3)测量让临床医生实施该方案的有效性和成本效益；4)使用定性方法来确定实施该方案的障碍和促进者。因此，我们的应用程序“READI：研究有效的妄想症识别方法”有以下具体目标：目标1)在两大、现有的严格进行精神错乱评估的老年患者队列中独立验证我们的2项超简短筛查：1)SAGES：选择性手术后的成功衰老，手术后没有基线痴呆的样本(N=566)，以及2)END-DSD：早期护士检测叠加痴呆症的妄想症(N=391)，这是一个急性医院样本，所有人都有痴呆症。目的2)在从一个大型城市学术医学中心和一家小型农村社区医院招募的400名全科医学患者的新队列中，评估由医生和护士执行的两步妄想鉴定方案和由注册护士助理(CNA)执行的超简短筛查的可行性、实施时间、有效性和成本，并将异常结果通知护士。目的3)对上述400名患者的精神障碍识别过程进行定性研究，包括直接观察和在每个协议结束时与参与者进行简短的开放式访谈，以确定执行协议的障碍和促进者。影响：当前的目标将利用我们以前的工作，并将为我们提供必要的工具和知识，以实施实用、有效和成本效益高的方案，检测和监测住院老年患者的精神错乱。因此，我们的工作将推动精神分裂症领域的研究向前发展，并具有提高护理质量、降低成本、促进弱势老年人独立的巨大潜力。

 DESCRIPTION (provided by applicant): Delirium affects up to 50% of hospitalized older adults, and is independently associated with functional and cognitive decline, nursing home placement, mortality, and $164 billion in U.S. healthcare costs. Despite these compelling figures, under-recognition of delirium remains a major problem. In this setting, there is increasing interest in implementing systematic delirium identification in U.S. hospitals, yet, ther is very little evidence on how to implement such programs in an effective and efficient manner. Our goals are to develop a practical, effective, and cost-efficient protocol for detection and monitoring of delirium in high risk hospitalized older adults, and to generate the evidence base needed to facilitate its widespread implementation. The products of our first cycle of funding from R01AG030618, "3D-CAM: Deriving and Validating a 3-minute Diagnostic Assessment for Delirium", will serve as key components of our protocol. These include: 1) the 3D-CAM; a highly performing diagnostic interview for delirium that can be completed in 3 minutes; 2) an ultra-brief (30-40 second) 2-item screener that can effectively rule out delirium. We now propose to 1) validate the screener in 2 independent cohorts; 2) combine the screener and 3D-CAM into a 2-step delirium identification protocol; 3) measure the effectiveness and cost-efficiency of having clinicians administer this protocol; 4) employ qualitative methods to determine barriers and facilitators to implementing the protocol. Thus, our application, "READI: Researching Efficient Approaches to Delirium Identification", has the following Specific Aims: Aim 1) To independently validate our 2-item ultra-brief screener in two large, existing cohorts of older patients with rigorously performed delirium assessments: 1) SAGES: Successful Aging after Elective Surgery, a post- surgical sample free of baseline dementia (N=566), and 2) END-DSD: Early Nurse Detection of Delirium Superimposed on Dementia (N=391), an acute hospital sample, all of whom have dementia. Aim 2) In a new cohort of 400 general medicine patients recruited from a large urban academic medical center and a small rural community hospital, to assess the feasibility, administration time, effectiveness, and costs of the 2-step delirium identification protocol performed by physicians and nurses, and the ultra-brief screener performed by certified nursing assistants (CNA's), who will notify the nurse of an abnormal result. Aim 3) To conduct a qualitative study of the delirium identification process in the 400 patients enrolled above, including both direct observation and brief open-ended interviews with participants at the end of each protocol to determine barriers and facilitators to implementation of the protocol. Impact: The current Aims will leverage our previous work, and will give us the necessary tools and knowledge to implement a practical, effective, and cost-efficient protocol for detection and monitoring of delirium in hospitalized older patients. Therefore, our work will move the field of delirium research forward, and has great potential to improve quality of care, reduce costs, and promote the independence of vulnerable older adults.