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A decrease of ⩾2 points on the Mini-Mental State Examination was the best determinant of delirium in elderly patients admitted to hospital
  1. Suzanne D Fields, MD
  1. SUNY Stony Brook School of Medicine
 Stony Brook, New York, USA

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 Q In elderly patients admitted to hospital, are serial Mini-Mental State Examinations (MMSEs) accurate for diagnosing delirium?

    Clinical impact ratings Internal medicine ★★★★★★☆ Geriatrics ★★★★★☆☆

    METHODS

    Embedded ImageDesign:

    blinded comparison of MMSE with geriatrician diagnosis of delirium.

    Embedded ImageSetting:

    a hospital in Galway, Republic of Ireland.

    Embedded ImagePatients:

    165 patients who were ⩾65 years of age (mean age 79 y, 46% women) and were admitted to hospital from the accident and emergency department. 36 patients had dementia. The most common diagnoses were respiratory (n = 68), cardiovascular (n = 35), gastrointestinal (n = 20), and cerebrovascular (n = 19). Exclusion criteria: severe aphasia or deafness, poor prognosis, or hospital stay <6 days.

    Embedded ImageDescription of test:

    MMSE was given on day 1 and day 6. The MMSE used was adapted and validated for use in Irish patients.

    Embedded ImageDiagnostic standard:

    an experienced consultant geriatrician interviewed patients on days 1 and 6 and determined the presence or absence of delirium, dementia, or both. Delirium was diagnosed using the Confusion Assessment Method diagnostic algorithm. The geriatrician did not know the MMSE results.

    Embedded ImageOutcomes:

    diagnosis of delirium on day 6.

    MAIN RESULTS

    138 patients were not delirious at admission. On day 6, 14 of these patients had delirium. A decrease of ⩾2 points on the MMSE was the best determinant for detecting delirium (area under the receiver operating characteristic curve 0.97, 95% CI 0.95 to 1.00). The table shows the diagnostic characteristics.

    Test characteristics for detecting delirium using a decrease of ⩾2 points on the Mini-Mental State Examination*

    CONCLUSION

    In elderly patients admitted to hospital, a decrease of ⩾2 points on the Mini-Mental State Examination was the best determinant of delirium.

    Commentary

    Delirium frequently accompanies acute medical illness among hospitalised patients. Characteristic features include acute onset and fluctuations in severity over time. Average duration is about 6 days,1 although for some patients the impairment may persist longer. Typically, delirious patients are older, frailer, and more likely to have baseline cognitive and physical impairments.2 Delirium is related to several adverse outcomes, including longer mean length of hospital stay, poorer functional status, greater likelihood of institutionalisation, and higher mortality, which may be sustained over 12 months.1,3 Prognostic indicators for poor outcome include baseline frailty, absence of agitation, and under-recognition of delirium.1 Busy clinicians require simple instruments to quickly recognise the syndrome.

    The study by O’Keeffe et al shows the utility of repeated MMSE measurements in vulnerable, hospitalised, elderly patients. A decrease of ⩾2 points was predictive of the development of delirium; an increase of ⩾3 points was associated with resolution. Mean change of MMSE scores in those who worsened or improved was −4.5 and 4.8, respectively. In patients with baseline dementia, frequent MMSEs can help determine who has concomitant dementia on admission and who develops delirium based on a rise or fall in MMSE of 4–5 points. However, a 6 day interval between tests may be too long. A low index of clinical suspicion with more frequent MMSEs may improve the utility of this method for diagnosing delirium. Another tool that has been used to monitor fluctuations over time is the Delirium Index, which may be more useful than the MMSE alone in patients with delirium.4

    References

    View Abstract

    Footnotes

    • For correspondence: Dr S O’Keeffe, Galway Regional Hospitals, Galway, Ireland. S.okeeffewhb.ie

    • Source of funding: no external funding.

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