Original Study
The 4-DSD: A New Tool to Assess Delirium Superimposed on Moderate to Severe Dementia

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Abstract

Objectives

The purpose of this study was to create, standardize, and validate a new instrument, named 4-DSD, and determine its diagnostic accuracy in the diagnosis of delirium in subjects with moderate to severe dementia.

Design

Multicenter cross-sectional observational study.

Setting and Participants

Older patients consecutively admitted to acute and rehabilitation hospital wards.

Measures

The DSM-5 was used as the reference standard delirium assessment. The presence and severity of dementia was defined using the AD8 and the Global Deterioration Scale (GDS). The 4-DSD is a 4-item tool that ranges from 0 to 12. Item 1 measures alertness, item 2 altered function, item 3 attention, and item 4 acute change or fluctuation in mental status.

Results

A total of 134 patients were included in the study. Most of the patients were enrolled in acute hospital wards (60%), with 40% in rehabilitation settings. A minority of the patients were categorized with moderate dementia, with a GDS score of 5 (4%). Most of the patients were in the moderate-severe stage with a GDS score ≤6 (77%); 19% were classed as severe, with a GDS score of 7. A 4-DSD cutoff score ≥5 had a sensitivity of 80% and specificity of 80% with a positive predictive value (PPV) of 67% and a negative predictive value (NPV) of 89%. In the subgroup with moderate-severe dementia (n = 108), the sensitivity and the specificity were 79% and 82%, respectively, with a PPV and NPV of 62% and 92%. In the subgroup with severe dementia (n = 26) the sensitivity was 82% and the specificity 56% with a PPV of 78% and a NPV of 63%.

Conclusions and Implications

The availability of a specific tool to detect delirium in patients with moderate-severe dementia has important clinical and research implications, allowing all health care providers to improve their ability to identify it.

Section snippets

Methods

This study was a multicenter cross-sectional study carried out from January 2017 to September 2019 in Italy. The local ethical committee approved the study (Protocol N: 32595–16). Patients consecutively admitted between Monday and Thursday to one rehabilitation setting and to 3 acute hospital wards were included in the study. Patients eligible for inclusion were aged 65 years and older, with moderate to severe dementia or suspected dementia, according to a Dementia Screening Interview (AD8)23

Results

A total of 134 patients were included in the study (Supplementary Table 1). The mean age was 85.32 ± 5.79 years and 60.45% were women (Table 1). Most patients were enrolled in the acute hospital wards (60%) and 40% in rehabilitation settings. A minority of the patients were categorized with moderate dementia, with a GDS score of 5 (3%). Most of the patients were in the moderate-severe stage with a GDS score of 6 (76.87%), and 26% were in the severe stage of dementia with a GDS score of 7. Most

Discussion

This study reports the performance of the 4-DSD, a new tool specifically designed to diagnose delirium in patients with moderate-severe dementia. A 4-DSD cutoff ≥5 had an overall good sensitivity and specificity. The performances of the 4-DSD in the subgroup with severe dementia showed a similar sensitivity but a lower specificity. The 4-DSD takes approximately 3 minutes to be administered.

To our knowledge, there are no tools specifically designed for the diagnosis of delirium in patients with

Conclusion and Implications

The present findings provide initial support for the use the 4-DSD, a new tool that might be used to assess delirium in patients with moderate to severe dementia admitted to acute medical and rehabilitation wards. The tool is relatively rapid to administer (approximately 3 minutes) and has good sensitivity and specificity to detect delirium in this group of patients. The availability of a specific tool to detect delirium in patients with preexisting dementia has important clinical and research

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      Because of this fluctuating clinical picture of a delirium in future studies, more extensive clinical examinations on the day of the EEG session, weighed by a multidisciplinary team, may improve the diagnostic classification of DSD. For instance, a recent study on the validation of the 4-DSD instrument (Morandi et al., 2021) used a more comprehensive approach as a reference standard for delirium, see also Table 1 in Richardson et al. (2017). To investigate the exact relation between disturbances in EEG and delirium as a fluctuating syndrome, a future research design should include both the general clinical picture of a DSD patient as well as the fluctuations in the behavioral symptoms of the delirium.

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      However, the psychometric properties of the 4-DSD varied by the severity of the cognitive impairment. For example sensitivity and specificity were 79% and 82%, respectively, in persons with moderate-severe dementia (n = 108), and a sensitivity of 82% and a specificity of 56% were observed in a group of older adults with severe dementia (n = 26).22 The 4-DSD has a relatively brief administration time (3 minutes).

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    The authors declare no conflicts of interest.

    Author Contributions: Design (Morandi, Grossi, Lucchi, Cherubini, Mossello, Zambon); methods (all authors), subject recruitment (all), data collections (all authors), analysis and preparation of paper (all authors).

    Funding source: none.

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