Title: Investigation of the Delirium Observation Screening Scale for the routine detection of delirium in care homes by care home staff
Funder: Department of Health (England)

Abstract: Background Delirium is a common clinical syndrome comprising four key features: (i) acute onset and fluctuating course; (ii) inattention; (iii) disorganised thinking; and (iv) altered consciousness level. Despite these clear diagnostic criteria, delirium is often underdiagnosed. An episode of delirium has serious consequences for those in whom it develops, ultimately resulting in accelerated cognitive and functional decline, and increased risk of death (8). Delirium may develop as a consequence of several risk factors which are particularly prevalent in older people. Onset of delirium may be the first indicator of a change in health state, for example urinary tract infection. Early detection of delirium in care home residents may therefore allow more timely assessment for individuals at risk of deteriorating health to allow appropriate targeted interventions to prevent progression and the need for hospital admission. Delirium occurrence has been regarded as a sensitive indicator of care quality (3). Routine monitoring of delirium occurrence in care homes therefore has the potential to be developed into quality improvement programmes. Finally, care home research has been impeded by the lack of outcome measures with face validity for this population. Mortality is poorly related to quality of delivered care even after adjustment for case-mix (9). Quality of life in the frail elderly is difficult to measure; objective quality of life assessments (e.g. for those with dementia) are prohibitively time consuming for routine use (10). Delirium occurrence rate has the potential to fulfil this outcome gap and stimulate new and generalizable care home research. Aims We have identified a delirium screening tool that has clinical sensibility for daily administration by care home staff (the Delirium Observation Screening Scale (DOSS)) (5). We aim to embed the DOSS within routine practice in the care home setting. We will then test its sensitivity and specificity against the research standard instrument (the Confusion Assessment Method (short-CAM)), administered by trained research staff. Research Question How does the DOSS perform as a screening instrument for delirium when administered by care home staff as part of routine care in UK care homes in comparison to the research standard short-CAM? Plan of Investigation Participating care homes will be identified through the Care Homes Research Network in Leeds and Bradford. The DOSS delirium screening instrument will be incorporated into routine care within these homes. Eligible residents will be asked for consent to access their DOSS scores, and for administration of the short-CAM three times per week for the duration of the study (24 weeks). A consultee declaration will be sought for residents without capacity to consent to ensure that patients with cognitive impairment, at particularly high risk from delirium, are not excluded from the study. Each short-CAM measurement will be measured against the temporally closest DOSS measurement and sensitivities, specificities, positive and negative predictive values calculated. An average DOSS score of three or more across three readings obtained over a 24 hour period is indicative of delirium (5). We will explore the scaling properties of the DOSS, the optimal scoring method, and whether the frequency of measurement may be reduced. Summary of benefit Improved understanding of delirium, a condition closely linked to the quality of delivered care, will empower care home staff to identify precipitating factors, leading to improvements in the quality of care for all. Through timely attention to the precipitants of delirium, early and routine detection will benefit individual residents through attenuating the course of the delirium episode and reducing the likelihood of acute hospital admission. In addition, routine identification of residents with delirium in the care home setting will facilitate further research into specific delirium prevention or treatment interventions in this population.


Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: MENTAL HEALTH