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1992 5: 14J Geriatr Psychiatry NeurolJohn W. Rowe

Marilyn S. Albert, Sue E. Levkoff, Catherine Reilly, Benjamin Liptzin, David Pilgrim, Paul D. Cleary, Denis Evans andPatients

The Delirium Symptom Interview: An Interview for the Detection of Delirium Symptoms in Hospitalized  

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The Delirium Symptom Interview: An Interview for the Detection of Delirium Symptoms in Hospitalized Patients Marilyn S. Albert, PhD; Sue E. Levkoff, ScD; Catherine Reilly, RN, MSN; Benjamin Liptzin, MD; David Pilgrim, MD; Paul D. Cleary, PhD; Denis Evans, MD; John W. Rowe, MD

Abstract

To study delirium in hospitalized elderly, a delirium symptom interview (DSI) was developed by an interdisciplinary group of investigators. This interview was administered in an acute care hospital to 50 patients who were over the age of 65 years. Results from the interview were compared to assessments of major symptoms of delirium made independently by a neurologist and a psychiatrist. This interview had good validity and reliability. The sensitivity of the DSI was .90 and the specificity was .80, when compared with the clinical judgment of a psychiatrist and neurologist. Interrater reliability, using lay interviewers, was .90 for the detection of major symptoms of delirium. These results indicate that the DSI could be used by lay interviewers to assess reliably the symptoms of delirium. (I Geriotr Psychintry Netirol 1992;5:14-21).

elirium is a prevalent and morbid clinical D problem, especially among hospitalized pa- tients. Estimates of its prevalence in general medical settings range from 25% to 3570.'-5 Several studies indicate that the prevalence of delirium is positively associated with age.3,5,6 Furthermore, patients with delirium tend to have longer stays in general hospi- t a l ~ ~ and higher mortality rates' than patients with- out delirium.

Delirium is a well-known clinical phenomenon,' but research has been limited by a lack of consensus about how to assess it. The primary guidelines for

Received January 4, 1991. Received revised and accepted for publication July 3, 1991.

From the Departments of Psychiatry and Neurology, Massa- chusetts General Hospital (Dr Albert); the Department of Psychi- atry, McLean Hospital (Dr Liptzin); the Department of Neurology (Dr Pilgrim), Department of Gerontology (Ms Reilly), and Depart- ment of Medicine (Dr Rowe), Beth Israel Hospital; the Depart- ment of Medicine, Brigham and Women's Hospital (Dr Evans); the Department of Social Medicine (Dr Levkoff), the Department of Health Care Policy (Dr Cleary) and the Division on Aging, Har- vard Medical School, Boston, MA.

Address correspondence to Dr Marilyn S. Albcrt, Depart- ment of Psychiatry and Neurology, Massachusetts General Hospi- tal, Boston, bIA.

diagnosis of delirium when the study began were the DSM-111 diagnostic criteria." These criteria, de- veloped by clinical consenshs without systematic data, state that delirium consists of: (1) disorienta- tion and/or memory impairment; (2) reduced clarity of awareness of the environment and/or disturbance of attention; (3) at least two of the following-per- ceptual disturbance, incoherence of speech, distur- bance of the sleep-wake cycle, or change in psychomotor activity; (4) clinical features that de- velop over a short period of time and that tend to fluctuate, and (5) evidence of a specific organic fac- tor judged to be etiologically related to the cognitive disturbance. These criteria were subsequently re- vised,*' but the symptoms considered part of delir- ium were substantially the same.

Unfortunately, there are no commonly agreed on operational definitions of these concepts. The Short Portable Mental Status Questionnaire" and an "accessibility test" developed by Anthony and col- l e a g u e ~ ~ ~ have been shown to have reasonable sensi- tivity and specificity for delirium, but the authors did not collect information on the symptoms speci- fied by DSM-Ill. Trzepacz and colleague^'^ have de-

14 Journal of Geriatric Psychiatry and Neurology / Vol. 5 I January-March 1992

Delirium Symptom Interview

veloped a 10-item clinician symptom rating scale for delirium that has been validated among delirious pa- tients on a psychiatric consultation liaison service. Application of that scale, however, requires inter- pretation of data from multiple sources by a skilled clinician.

The absence of easily administered instruments for delirium has hampered the execution of studies that might provide information on the risk factors and clinical course of acute confusion. The goal of the present study was to develop a structured inter- view with clear operational definitions of the symp- toms of delirium that could be used in combination with other data to define cases of delirium. Since de- lirium has a rapid onset (of hours or days), and the symptoms tend to fluctuate over time, it was impor- tant to develop an instrument that could be adminis- tered on a daily basis. In that way, prevalence and incidence of specific symptoms over time could be assessed. It was also desirable that the interview could be administered by nonclinicians, because daily interviews by experienced physicians are im- practical for most large-scale epidemiologic studies. The content of the instrument was guided by the DSM-ZZZ criteria for delirium, a systematic review of the literature, and the clinical experience of the in- vestigators. By scoring symptoms, the instrument was designed to be useful with alternative criteria for the diagnosis of delirium (eg, DSM-ZIZ or DSM- ZZZ-R) .

Methods

Subjects Study subjects were 50 patients, aged 65 years and over, who were hospitalized on the medical or surgi- cal units of an acute care hospital. Patients were se- lected first from a list of all patients 65 years of age and over who had been hospitalized for less than 1 week, who spoke English, and who did not reside in the geographic area targeted for a later study of de- lirium. We then asked the primary nurse of each po- tential study patient to evaluate the patient's ability to answer questions and to understand the informed consent procedure. If the primary nurse thought the patient was competent to consent to the study, an experienced geriatric nurse explained the study and sought verbal consent. Consecutive patients who agreed to participate were enrolled. The participa- tion rate was 91%. The age of, the subjects ranged from 65 years to 94 years with a mean of 80 k 8

years. Seventy-seven percent of the participants were female.

lnteruiezu Protocol The first task of the study was to develop an inter- view for detecting the symptoms of delirium in hos- pitalized patients. This was undertaken by a group (including a neurologist, a psychiatrist, a neuropsy- chologist, a nurse clinician, and a survey researcher) that met regularly over the course of 6 months. The group systematically reviewed the symptoms that are the basis of the DSM-ZZZ definition of delirium, discussed ways in which the symptoms of delirium are manifested in elderly hospitalized patients, and designed and piloted potential questions for their ability to detect symptoms reliably in randomly se- lected patients over the age of 65 years on medical- surgical units.

The resulting instrument was an interview pro- tocol for assessing the seven symptom domains de- lineated by the DSM-IIZ criteria for delirium: (1) disorientation, (2) disturbance of consciousness, (3) disruption of the sleephake cycle, (4) perceptual disturbance, (5) incoherence of speech, (6) change in psychomotor activity, and (7) fluctuating behavior. Each domain is assessed by a series of questions to determine the presence or absence of specific symp- toms. Some questions are addressed directly to the patient (eg, "Can you tell me what time of the day it is now?"). Others are designed to be answered solely on the basis of the interviewer's observations (eg, "During the interview, did the patient appear inappropriately distracted by environmental stimuli, for example, respond to questions asked of room- mate?"). In this way, a communicative patient can provide information concerning the nature of his or her symptoms, but a patient who is too sick or non- communicative can also be assessed through the be- havioral observations. Coding of the behavioral observations is done immediately after the interview is completed and after the interviewer has left the room.

The interview takes approximately 10 to 15 min- utes to complete, although interviews with inatten- tive, tangential, or distracted patients may take longer. A copy of the interview, which we refer to as the delirium symptom interview (DSI) and a manual of instructions that was developed to provide scor- ing guidelines is available from the authors.

Procedures The DSI was administered by a single lay inter- viewer, a college graduate with a master' degree in

Journal of Geriatric Psychiatry and Neurology I Vol. 5 I January-March 1992 15

Albert et a1

education and no previous clinical experience. A re- search nurse, who is a geriatric nurse specialist, trained the lay interviewer over a period of three weeks in the use of the DSI. In addition, a psychia- trist and a neurologist conducted clinical assess- ments of each study patient. The three evaluations were conducted on the same day, within hours of one another and usually in the early afternoon. The lay interviewer examined the patient first. The inter- views by the physicians followed that of the lay in- terviewer; the order of the physician assessments was varied randomly.

To evaluate the reliability of the DSI, two lay in- terviewers administered the instrument blinded to one another’s coding. One interviewer actually ad- ministered the DSI while a second observed. The in- terviewer who actually administered the DSI was varied randomly. A total of 21 patients were evalu- ated in this manner.

The physicians’ clinical interviews focused on the major symptoms of delirium: disorientation, dis- turbance of consciousness, and perceptual distur- bance. The physicians were asked to determine whether any of these symptoms of delirium was: ab- sent, borderline, possible, probable, or definite. These symptoms were selected because they are crit- ical clinical indicators of delirium and because we thought that the other symptoms (such as incoher- ent speech, disturbance of the sleep-wake cycle, and change in psychomotor activity) would be neither necessary nor sufficient for delirium in a hospital- ized sample. No physical examination was per- formed. Initially, the physicians completed their evaluations independently. They then reviewed each case together, relying on extensive notes taken during the interview, in an attempt to reach consen- sus. The consensus opinion was compared to the DS1,ratings because of the fluctuating and often sub- tle nature of the symptoms of delirium.

Analyses The reliability of the DSI was determined by calcu- lating a K coefficient for the agreement between the DSI filled out by two lay interviewers who observed the same patient.” The degree to which the symp- toms within each of the seven domains occurred to- gether was examined by calculating Cronbach‘s coefficient a, a measure of internal consistency.

We defined a patient as “positive” on the DSI if he or she had any one of the critical symptoms of delirium: disorientation, disturbance of conscious- ness, or perceptual disturbance. It was the consen- sus of the study group that these symptom domains

were central to the diagnosis of delirium. Patients were not considered “positive” if they were rated as having only disturbance of the sleep-wake cycle, incoherent speech, or inappropriate level of psychomotor activity, because these symptoms were felt to be less central to a diagnosis of delirium. Al- though the use of broad criteria had the potential for identifying subjects who were not delirious (ie, false positives), they were selected in order to minimize the likelihood of failing to identify delirious subjects (ie, false negatives).

To determine the validity of the DSI, the ratings made by the lay interviewer using the DSI were compared with the assessments of the same patient by the psychiatrist and neurologist. To make this comparison, we calculated the sensitivity and speci- ficity, as well as positive and negative predictive value of the DSI. For these analyses, the physician assessments were used to define four categories of ”caseness.” We considered a patient to have a criti- cal symptom if both physicians rated the presence of any of the critical symptoms as “possible,” “proba- ble,” or “definite.” Remaining patients were classi- fied as noncases, borderline patients, or patients about whom the physicians disagreed.

Results The reliability (expressed ’ as coefficient e) for the symptoms in each domain assessed by the DSI were as follows: disorientation, .75; disturbance of con- sciousness, .80; perceptual disturbance, .53; incoher- ent speech, .61; psychomotor activity, .56; sleep disturbance, .45; fluctuating behavior, -50.

The K coefficient for the reliability between the two lay interviewers, with one administering the DSI and one observing, was .90. The agreement be- tween the DSI and the physicians’ consensus gave a K value of .93 for a positive rating on one of the three critical symptoms using the DSI. The K values for agreement between the DSI and the physicians’ consensus for the specific symptom domains were as follows: disorientation, 1.0; disturbance of con- sciousness, .81; perceptual disturbance, .&; sleep disturbance, 1.0; incoherent speech, .55; psychomo- tor activity, .31; fluctuating behavior, .46.

The physicians identified 30 patients as cases (60%), 15 as noncases (30%), and three as borderline (6%), and for two patients the physicians disagreed (4%). They agreed on their assessments for 96% of the patients, yielding a K value of .92.

The sensitivity of the DSI, when comparing the cases to all other categories, was -90. The specificity

16 Journal of Geriatric Psychiatry and Neurology I Vol. 5 I January-March 1992

Delirium Symptom Interview

of the DSI was 3 0 . The positive predictive value, that is, the proportion of persons who were positive on the DSI who were found to be cases by the phy- sicians, was 37. The negative predictive value, that is, the proportion of persons who were negative on the DSI who were found by the physicians to be noncases, was 34.

Since all seven domains were included in this analysis, persons identified as noncases by the DSI could have some positive domains. The mean num- ber of positive domains for the cases was 4.1, while the mean number of positive domains for the non- cases was 1.1 (t(43) = 7.7; P < .0001). The two bor- derline patients were almost identical to the noncases, with a mean of 1.0 positive domains. However, the two patients about whom the neurol- ' ogist and psychiatrist disagreed had a mean of 2.5 positive domains, suggesting that these patients were more symptomatic than either the noncases or borderline patients but that the physicians evaluated these symptoms differently.

The absolute number of specific symptoms among the cases and noncases also differed. The cases had more than five times as many symptoms as the noncases (12.8 2 6.6 versus 2.4 * 1.8). This difference was statistically significant at P < .001 (t(36) = 8.08). As before, the three borderline pa- tients had fewer symptoms than the two patients over which the psychiatrist and neurologist dis- agreed (3.0 versus 6.5).

Discussion The results indicate that the DSI is a reliable and valid method for assessing the critical symptoms of delirium among elderly hospitalized patients. It has good sensitivity and specificity when compared with the clinical assessment of a psychiatrist and neurolo- gist. The number of symptom domains with abnor- malities, as well as the absolute number of symptoms, relate in a systematic manner to the di- agnostic categorization of the patients, ie, cases had more symptoms and more symptom domains with abnormalities than noncases.

The DSI administered at a single point in time does not identify the duration of the delirium symp- toms. Thus, the few patients in the present study with preexisting dementia who met the criteria at the time of the study were identified both as positive by the DSI and as cases by the physicians. The inclu- sion of demented subjects is the most likely explana- tion for the high percentage of cases in the present study (60%). However, if the DSI is used on re-

peated occasions, it could be used to assess the course of symptoms in patients who are symptom- atic when first seen as well as in detecting the occur- rence of new symptoms.

The DSI is designed to provide a means of screening and assessing patients for the symptoms of delirium in an objective and straightforward man- ner. Patients with varying severity of underlying ill- ness and a variable ability to communicate can be screened. However, the diagnosis of delirium re- quires information about the rapidity of onset and etiology. This information is not assessed by the DSI because such information must be obtained from sources other than the patient. Rapidity of onset is generally determined through interviews with rela- tives and caretakers since patients with an altered mental status cannot reliably provide such informa- tion and it is uncommon for a patient to have pre- morbid cognitive testing. Etiology requires additional information, such as the results of physi- cal examinations and laboratory studies.

For a larger study of delirium in hospitalized elderly, we have developed an interview protocol and chart review instrument for collecting informa- tion from relatives, caregivers, and medical records. Data from those sources, in addition to information from the DSI, can be used to assess rapidity of onset and other etiologic factors. This type of information can be used to identify true cases of delirium, as op- posed to patients with symptoms of delirium that could be due to dementia or preexisting psychoses. The use of operationally defined symptoms also makes it possible to examine the specific symptom domains. The a coefficients indicated that two of the three symptom domains were internally consistent. The disorientation and disturbance of consciousness domains had high coefficient as (.75 and .80, respec- tively). This suggests that the specific symptoms within those domains often coexist. This was not necessarily expected since there was no reason to presuppose that the symptoms within each domain would occur together. For example, one would not have hypothesized that a patient with vivid night- mares would also experience reversal of the sleep- wake cycle. Thus, the low coefficient a of the items pertaining to sleep (ie, .45) confirms the fact that the symptoms within that domain do not generally oc- cur simultaneously. Further use of the DSI may shed additional light on the co-occurrence of specific symptoms, as well as on the general syndrome of delirium.

Although the sensitivity and specificity of the DSI is high, agreement between physicians and the

Journal of Geriatric Psychiatry and Neurology / Vol. 5 I January-March 1992 17

lay interviewer was imperfect. This is not surprising, given the fluctuating and evanescent nature of delir- ium. Although all three evaluations were conducted within hours of one another, there was anecdotal evidence that some of the disagreement between the physicians, and between the DSI and the physi- cians, was attributable to the changing condition of the patient. Furthermore, as Robins16 has suggested, a disagreement between a physician and a Iay inter- viewer does not necessarily mean that the results of the lay interviewer are wrong. Without some exter- nal criteria against which to assess the assessors, one cannot know which is more accurate.

The reliability of the DSI is also high: for the cri- terion domains, the K values ranged from 1.0 to .64, and for the diagnosis of "caseness" it was -90. Over- all, the noncritical domains had lower K values. In all instances, differences between the interviewers pertained to mild symptoms. Thus, one interviewer would code something as absent while the other coded the behavior as mild. Abnormalities in level of psychomotor activity appeared to be particularly dif- ficult to assess. There was, however, no evidence of a systematic error in this regard (ie, with one inter- viewer consistently identifying behavior as more ab- normal than the other), suggesting that operation- alizing ratings of mild changes of behavior in these domains 'is difficult.

The severity of the symptoms of the patients can affect the sensitivity of an assessment tool. The sen- sitivity of an instrument is affected by the propor- tion of severe cases in the test ample,'^ and there are likely to be more severe cases in a hospitalized population. Thus, the sensitivity of the DSI would be likely to decrease if it were used in a general pop- ulation sample or outpatient setting rather than in a hospital. The results of the present study suggest, however, that the DSI is a valid and reliable method for identifying hospitalized patients who have key symptoms of delirium. In conjunction with informa- tion concerning premorbid status, it can be used as an accurate and efficient assessment tool for clinical epidemiologic studies of delirium in the elderly.

APPENDIX A

Delirium Symptom Interview

HOSP. 1 LliITl - - - - - FLOOR Rn

QATE T I E 7

EVALUATION 1 _ _ 13

Hello nr/Hrs . Hov have you been feeling tDday? Xy naae is

we are interested in trying to find out vhy older people sometimes get confused vhen they come into the hospital. I as going to ask you some questions about hov you have been during the last day or SO. Some of the p e r t i o n s ray seem unusual, but Ye ask them of everyone. Also, I will be vriting things down aa we talk. ( I f patient is "on-communicative. i.e., produces no response to Questions 1-3. go to Page 8, Question la.) (Coda refusals or missing data vith 9.)

. I am involved in a study being conducted here at .

Albert et a1

18 Journal of Geriatric Psychiatry and Neurology / Vol. 5 / January-March 1992

DISORIENTATION

1) Have ve met before today?

2) Can you tell me vhat time of day it is now?

3 ) Can you tell re vhere Ye are nov?

- 1 correct 2 Incorrect 6 No Response 8 Don't Know

I Correct 2 Incorrect 6 No Response 8 Don't Knov

1 correct 2 Incorrect 6 No Response 8 Don't Knov

1 5

- 16

- .- 17

4 ) why are you in the hospital?

5)

1 correct 2 Incorrect 8 Don't Knov - During the past day did you think that you veren't really in the hospital? I NO 2 Yes 8 Don't m o v - Have you felt confused at any time during the past day? 1 No 2 Yes 8 Don't xnov

I8

19 6 ) - _ _

Z"

sa) (If Yes) At vhat time Of day did this confusion bother you the most? 1 Uorninq 2 Afternoon 3 Evening 4 Night 5 nany Different Times 7 Not Applicable 8 m n * t ~ n o v -

21 6b) (IK yes) Did this happen either just after you Yoke up

or just when you were falling asleep? 1 No 2 Yes 7 Not Applicable 8 Don't Knov

~~

sc) (If yes) Is this soaething nev that you have experienced since you caae to the hospital, o r is it sonethinq that you experienced at home? 1 Old 2 New 7 Not Applicabl. 8 Don't Knov -

23 66) During the interviev vas there evidence of disorientation,

for exarple, the patient first appeared to knov that he vas in the hospital but later indicated that he thought he was elsevhere?

DISORIENTATION SCORE - 25

1-Not Present 2-Present Present: 2-0 cn ite 1s 12-5. 66

NOV I'm going to ask you about your sleep

DISTURBANCE OF SLEEP

7) Did you have trouble falling asleep last night? I NO 2 yes 8 Don't m o v - - _ Did YOU have anv vroblems w i t h your sleep last niqht, l i k e trouble falling-aileep, vaking itp and habing trouble falling back t o sleep, vaking up too early in the nornlng, being sleepy during the day, or having nightmares that vere intense or bothersome?

2 Yes 8 Don't Knov 7 Not Applicable - >,

1 NO _.

Go to Q 12 Co to 7a

(If yes) HOV much difficulty did you have falling asleep last night? ' 1 None 2 some 3 A l o t 7 Not Applicable 8 Don't Knov -

7.a)

7b) (If yes) since you came to the hospital. or is it sonething that you experienced at home?

Is this something nev that you have experienced

1 Old 2 Nev 7 Not Applicable 8 Don't Know -

Delirium Symptom Interview

12e) Felt things 1 NO 2 Yes -

12f) (If yes) HOW often did you have this experience? 1 Rarely 2 sometimes 3 Frequently

4 9

7 Not Applicable -

8) After you fell asleep, did you wake up and have trouble falling back to sleep? 1 No 2 Yes 8 Wn't Know

(If yes) HOW much difficulty did you have falling back asleep last night? 1 None 2 Some 3 A lot 7 Not Applicable 8 Don't Know __

(If yes) Is this Something new that you have experienced since you came to the hospital. o r is it something that you experienced at home?

8b)

1 Old 2 New 7 Not Applicable 8 Don't Know - 32

9) old you wake up on your o m too early this morning? - 1 NO 2 Yes 8 mn't w o w

98) (If yes) this morning cause you? 1 None 2 Some 3 A lot 7 Not Applicable 8 Don't Know __

3 3 HOW much difficulty did waking up too early

9b) (If yes) Is this something new that you have experienced since you came to the hospital, or is this something that you experienced at boue? 1 Old 2 New 7 Sot Applicable 8 Don't Know - ..

35 10) were you sleepy during the day?

1 No 2 Yes 8 Wn't Know - 36

10a) (If yes) the day cause you? 1 None 2 Some 3 A lot 7 Not Applicable 8 Don't Know -

HOW much difficulty did being sleepy during the

37 lob) (If yes) since you came to the hospital, o r is it something that you experienced at hone?

Is this something new that you have experienced

1 Old 2 New 7 Not Applicable 8 Wn't Knov - 38

11) Did you have nightmares o r vivid dreams that were intense o r bothersome last night? 1 No 2 Yes 8 Wn't Know -

39 lla) (If yes) HOW much difficulty did having these dreaus cause you? 1 None 2 Some 3 A lot 7 Not Applicable 8 Don't Know -

4 0

llb) (If yes) Is this something new that you have experienced since you came to the hospital, or is it something that you experienced at hose? 1 Old 2 New 7 Not Applicable 8 Don't Know -

4 1 Notes On behavior:

DISTLTBIVICE OT SLEEP SCORE - 4 2

1-Not Present 2-Present Present: Items 7b. 8b. 9b. lob, llb

Sometimes when people are in the hospital. they have unusual thoughts or experiences which may or may not bother then. we're very interested in that.

PfRCEPNIL DISlVRWCE

12) Any time during the last day have you experienced o r imagined seeing, hearing, or feeling things that weren't really there? (Describe) 1 NO 2 Yes -

43

At any time during the last day have you: experienced or imagined seeing, hearing, or feeling things that weren't really there, min- interpreted objects o r sounds, or seen o r heard things that weren't reallv there?

2 Yes - 4 4

1 No

GO t o Q 16 GO to Q 12a

12s) saw things

1Zb) (If yes) HOW often did you have this experience? 1 Rarely 2 sometimes 3 Trequently

1 No 2 Yes - 4 5

7 Not Applicable - ~~

4 6 12c) Heard things

1 NO 2 Yes - ~~

47 12d) (If yes) HOW often did you have this experience?

1 Rarely 2 sonetiues 3 Frequently 7 Not Applicable - ..

5 0 129) m r l n g the interview was there evidence of any of the above hallucinations, for exaople. patient thought he was at hole because the rOOn seemed like home? (Describe1 1 Never 2 Rarely 3 So=etimes 4 rrequently -

5 1

13) I just asked you about thinqs that weren't really there. NOW I want to ask you about objects that you have seen or sounds that vou have heard that YOU mav have misintemreted.

&anple,-sounds that you hea;d wer; not what theiappeared to be. (Probe, if necessary) If no, go to 139. 1 No 2 Yes

13a) People doing things that they were not really doing? 1 NO 2 Yen

l3b) (If yes) HOW often did you have this experience? 1 Rarely 2 Sometimes 3 Frequently 7 Not Applicable -

13c) sounds were not what they seemed to be? 1 No 2 Yes -

13d) (If yes) HOW Often did you have this experience? 1 Rarely 2 Sometimes 3 Frequently 7 Not Applicable -

lJe) An object was not what it seemed to be? i NO 1 Yes -

13f) (If yes) HOW often did you have this experience? 1 Rarely 2 Sometimes 3 irequently 7 Not Applicable -

- 52

- 53

5 4

55

56

57

58 139) Did you think that people were trying to harm you

when they weren't? 1 No 2 Yes -

59

13h) (If yes) How Often did you have this experience? 1 Rarely 2 sonetimes 3 Frequently -

6 0

131) m r i n g the interview, was there evidence of any of the above misperceptione or delusions, for example, patient answered intercom or thought spot on wall was a surveillance camera? 1 None 2 Rarely 3 Sometimes 4 Frequently -

61 14) NOW I'd like to ask you vhether thinqs that you recognized

cor;ectly looked distorted or strange, for example, things looked biaaer or smaller than they really were? _ _ [Probe, if necessary). If no, go-to 1s.- 1 No 2 Yes

Ira) Things looked smaller 1 No 2 Yes

l4b) (If yes) How often did you have this experience?

- 62

- 6 3

1 Rarely 2 Sometimes 3 Trequently - 64

14c) Things looked bigger 1 No 2 Yes -

65 lad) (If yes) HOW often did you have this experience?

1 Rarely 2 sometimes 3 Trequently - 66

14e) Things were moving that were not really roving 1 No 2 Yes - .-

67 14f) (If yes) HOW often did you have this experience?

149) Things seemed as if they were moving in slow motion 1 No 2 Yes

l4h) (If yes) How often did you have this experience?

l4i) The patients body sire. shape, o r weight looked different

1 Rarely 2 sometimes 3 Trequently - 6 8

- 69

1 Rarely 2 Solretimes 3 Trequently - 70

from what it is 1 NO 2 Yes - -.

14j) (If yes) How often did you have this experience? 1 Rarely 2 Sometimes 3 Frequently

14k) other:

141) (If yes) HOW often did you have this experience?

- 1 No 2 Yes 71

1 Rarely 2 Sometimes 3 Frequently - 74

Journal of Geriatric Psychiatry and Neurology I Vol. 5 / January-March 1992 19

Albert et a1

The folloving three questions are given whenever there is a YES to any PerceDtual disturbance

14m) (If yes for any perceptual disturbances) At vhat time of day did this/these disturbance(s) bother you the most? 1 Mornlng 2 Afternoon 3 Evening 4 Night 5 many Different Times 7 Not Applicable 8 Don't Know __

happen either just after you woke up or just when you were falling asleep?

75 14n) (If yes for any perceptual disturbances1 Did this/these

1 No 2 Yes 7 Not Applicable 8 Don't lvlov - 76

140) (IK yes for any perceptual disturbances) Is this/these something new that you have experienced since you came to the hospital, o r is it socethlng that you experienced at hone? 1 Old 2 New 7 Not Applicable -

77 15) During the interviev, was there evidence Of any OK the

above perceptual distortions, for exaxple. patlent thought , a light vas swirling that wasn't?

1 Never 2 Rarely 3 Sometimes 4 Frequently - 78

Notes on behavior:

PERCEPTUAL DISTKJRWCE SCORE - 79

1-not Present 2-Present Present: 2-5 on it e?5 fl2-15

This is the last group of questlons I need to ask you. Some of them may sound unusual, but we ask then of everyone.

DISTLXBWCE OF CONSCIOUSNESS

16) Can you tell me the days of the week backwards, starting with Saturday? (S,F.T.W.T,U,SI

Enter nunber representing longest correct consecutive series of days

9 refused -

8 0

17) Can you tell me the months of the year backwards, starting with Deceaber? ( D , N , O , S , A , J , J . U , A , M , F , J ~

Enter nuzber representing longest correct consecutive series of m n t h :

9 refused -- End of Patient Questions

Thank you. to ask me?

Is there anything else you Vant to tell Re, or anything you want

OBSERVArIOIiS

FOM - - STUDY ID - - - - HOSP LHIT I - - - - - -

EVALUATION I - -

3

7

13 18) Did the patient stare into space and appear unaware

OK his/her environment? 1 Never 2 Rarely 3 sometimes 4 Most of the time -

change the subject suddenly (e.9.. non-sequitur] o r tell a story unrelated to the interview? (Tangential)

If present, hov twch of the time?

15 19) Did the patient talk about something else, for example,

1 No 2 Kild 3 noderate 4 severe .. - 11

20) Did the patient appear inappropriately distracted by cnviromental stirnull, for example. respond to questions asked of roomate? IDistractlble) If Dresent. how much of -. ~~ ~. ~ . . the time? 1 Never 2 Rarely 3 sometimes 4 nost of the time - .-

21) Did t h e patient show excessive absorption with ordinary objects in the environment, for example, repetitively fold sheets or examine the I V tube over and over? (Hypervigilant) 1 No 1 Uild 3 noderate 4 severe -

22) Did the patlent have a recurring thought that prevented him/her from responding appropriately to the environment. for exanple, continuously look for Shoes that weren't there? (Persistent Thought) 1 NO 2 nild . 3 Moderate 4 severe -

I8

19 23) Did the patient have trouble keeping track of what was

being said during the interview, for example, rail to follow instructions or answer auestlons one at a time? [Inattentive) -. ~ .. If present, how much of -the time? 1 Never 2 Rarely 3 Sometimes 4 nost of the time -

24) Did the patient appear inappropriately startled by stimuli in the environment?

25) Did the patient's level O K consciousness fluctuate during the interview, for example, start to respond appropriately and then drift off? 1 No 2 Mild

1 Aware

20

1 NO 2 11116 _ . 3 noderate 4 Severe - 21

3 noderate 4 Severe - 22

26) was t h e patient - 2 sleepy 3 Stuporous 4 Comatose _ _

Notes on behavior:

DISTIIRBWCE OF CONSCIOUSNESS SCORE - 24

1-Not Present

-?em: 2-1 on I t e x . 818-15 I f the patient Is non-coerunlcatlve, answer all quesclons on this page &e of 7 (Not A c ~ l I c able1 and 90 on to Page 1 1 .

INCOHERENT SPEECH

27) Was the patient's speech:

27a) UnUSUAlly linited o r sparse (0.g.. Yes/No answers)

27b) unusually slow or halting

27s) unusually slurred

276) unusually fast o r pressured

27e) Unusually loud

27f) unusually repetltive (e.g., repeats phrase over and over)

279) have speech sounds In the vrong place 1 No 2 nild 3 noderate 4 Severe

27h) have words o r phrases that vere disjointed o r inappropriate 1 No 2 Mild 3 noderate 4 Severe

28) (If present) Did the patlent's speech fluctuate during the

1 NO 2 Mild 3 Moderate 4 Severe - 25

1 No 2 Mild 3 noderate 4 Severe - 1 No 2 Mild 3 Noderate 4 Severe - 1 No 2 nild 3 noderate 4 Severe -

26

27

28

1 No 2 nild 3 Moderate 4 Severe - 29

1 No 2 Mild 3 mderate 4 Severe - 30

- 31

- 32

interview, for exanple, patient spoke normally for a while, then aped up? 1 No 2 Yes 7 Not Applicable -

3 3

Botes on behavior:

XXCOHERTNT SPEECH SCORE - 34

20 Journal of Geriatric Psychiatry and Neurology I Vol. 5 I January-March 1992

Delirium Symptom Interview

I-Not Present 2-Prese"t

LEVEL OF PSYCHOXOTOR ACTIVITY

29) Was there evidence of:

29a) restlessness (e.q., Gets in and out or bed) 1 No 2 Mild 3 Moderate 4 Severe -

35 29b) tremors

2%) grasping/pickinq

296) increased speed of motor response (e.9.. Crabs

1 No 2 Mild 3 Moderate 4 Severe - 36

1 No 2 Mild 3 Xoderata 4 Severe -

f o r a glass suddenly)

37

1 No 2 Mild 3 noderate 4 Severe - 1 No 2 Mild 3 Woderate 4 Severe - 1 No 2 Mild 3 Moderate 4 Severe -

38 29e) wandering

29f) lethargy and sluggishness

299) slowmess of motor response

29h) staring into space

3 9

4 0

I No 2 Wild 3 Moderate 4 Severe - 4 1

1 No 2 Wild 3 Moderate 4 Severe - 4 2

3 0 ) (If any Of the above, i.e., 29a-29h, are present) Did the psychomotor activity fluctuate during the interview, for example, patient was first sluggish and then began moving very quickly? 1 No 2 Mild 3 noderate 4 Severe -

7 Not Applicable 4 3

30a) During the interview was the patient poseyed, mittened, o r othervise restrained? 1 NO 2 Yes 7 Not Applicable -

4 4 Notes on behavior:

LEVEL OF PSYOIOMUTUR AmIVITY SCORE - 4 s

1-Not Present 2-Present

29a-h

GENERAL BEHAVIORAL OBSERVATIONS

31) Did the patient show expressions of:

3la) apathy

31b) fear

3lc) anger

316) euphoria

3le) irritability

31f) anxiety

319) conbativeness

31h) impatience

311) sadness

1 No 2 Mild 3 Moderate 4 severe - 1 No 2 Mild 3 Moderate 4 Severe - 1 No 2 Mild 3 moderate 4 severe - 1 No 2 Mild 3 moderate 4 severe - 1 No 2 Mild 3 Moderate 4 Severe - 1 No 2 Mild 3 Moderate 6 Severe - 1 NO 2 Mild 3 Moderate 4 Severe - 1 No 2 Mild 3 Xoderate 4 Severe - 1 No 2 Mild 3 Moderate 4 Severe -

4 6

4 1

4 8

4 9

50

51

52

53

32) Did the patient do any of the following inappropriately?

32a) crying

32b) laughing

32c) singing

326) swearing I NO 2 Wild 3 Xodderate 4 Severe -

32e) Did the patient Show emotional lability?

1 No 2 Mild 3 Moderate 4 Severe - 5 5

1 No 2 Mild 3 Woderate 4 Severe - 1 No 2 Xild 3 Moderate 4 Severe -

56

57

58

1 No- 2 Mild 3 Woderate 4 Severe - 59

Notes on behavior:

TLUCNATIHG B M V I O R SCORE - 60

1-Not Present 2-Present Present: Items 2 W O . 3 2 e

33) Uncooperatlveness - midence of resistance, unfriendliness, resentment, and lack of readiness to cooperate with the interviewer. (Rate only on the basis or the patient's attitude and responses to the interviewer and the interview situation. Do not rate on basis of reported resentment o r uncooperative- ness outside the interview situation.)

34) Patient meets criteria for delirium 1 No 2 Yes

1 No 2 Wild 3 noderate 4 Severe - 61

-

References

1. Hodkinson HM: Merztnl Inipiririerzt i r z the Elderly. Colf Physi- cinrzs 1973;7:305-307.

2. Seymour DG, Herschke PJ, Cape RD: Acute confusional states and dementia in the elderly: The rate of dehydration, volume depletion, physical illness and age. Age Agirig

3. Gillick MR, Serrell NA, Gillick LS: Adverse consequences of hospitalization in the elderly. Soc Sci Med 1982;161033-1038.

4. Chisholm SE, Deniston OL, Igrisan RM, Barbus AJ: Preva- lence of confusion in elderly hospitalized patients. Gerorztol Nirrs 1982;8:87-96.

5. LVarshaw GA, Moore IT, Friedman SW: Functional disability in the hospitalized elderly. JAMA 1982;248:817-850.

6. Burrows J, Briggs RS, Elkington AR: Cataract extraction and confusion in elderly patients. Cliri Exp Gerozztol 1985;751-70.

7. Thomas RI, Cameron DJ, Fahs M C A prospective study of delirium and prolonged hospital stay. Arch Getz Psychinf y

8. Rabins PV, Folstein M F Delirium and dementia: Diagnostic criteria and fatality rates. Br Psychintry 1982;140:149-153.

9. Lipoivski ZJ: Delirium (acute confusional state), in Vinken PJ, Bruyn GW, Klaivans HL (eds): Hnrid6ook of Clirzicnl NeirrolosIJ. New York, Elsevier, 1985, pp 523-559.

10. American Psychiatric Association: Dingriostic nrzd Sfnfisfirnl Mnrizinl of Meizfnl Disorders, 3rd ed. Washington, DC, Ameri- can Psychiatric Association, 1980.

11. American Psychiatric Association: Dingriostic nrzd Sfntisticnl Mniiiinl of Merifnl Disorders. 3rd ed, revised. Washington, DC, American Psychiatric Association, 1987.

12. Erkinjuntti T, Sulkava R, Wikstrom J, Autio L Short portable mental status questionnaire as a screening test for dementia and delirium among the elderly. J Arrz Gerinfr Soc

13. Anthony JC, LeResche LA, Von Korff MR, Niaz U, Folstein M F Screening for delirium on a general medical ward: The Tachistoscope and a Global Accessibility Rating. Get1 Hosp Psyclzint y 1985;736-42.

14. Trzepacz PT, Baker RW, Greenhouse J: A symptom rating scale for delirium. Psychintry Res 1988;23:89-97.

15. Cohen J: A coefficient for nominal scales. Edirc Psyc/iosoc Mens 1960;20:37-45.

16. Robins L N Epidemiology: Reflections on testing the validity of psychiatric interviews. Arch Gel1 Psychintry 1985;42:918-924.

17. Sackett DL, Haynes RB, Tugwell P: Cliriirnl Epidezriiology: A Bn- sic Scierzce for Cliriicnl Mrdicirie. Boston, Little, Brown, 1985.

1980;9:137- 146.

1988;45:937-940.

1987;35:412-416.

Journal of Geriatric Psychiatry and Neurology / Vol. 5 / January-March 1992 21