A prospective study of remote delirium screening using the modified K-4AT for COVID-19 inpatients

Hyun Jung Hur; Yu Na Jang; Hye Yoon Park; Young Seok Lee; Du Hyun Ro; Beodeul Kang; Kyoung-Ho Song; Hye Youn Park

doi:10.3389/fpsyt.2022.976228

A prospective study of remote delirium screening using the modified K-4AT for COVID-19 inpatients

Front Psychiatry. 2022 Aug 18:13:976228. doi: 10.3389/fpsyt.2022.976228. eCollection 2022.

Authors

Hyun Jung Hur¹, Yu Na Jang¹, Hye Yoon Park², Young Seok Lee³, Du Hyun Ro⁴, Beodeul Kang⁵, Kyoung-Ho Song⁶, Hye Youn Park¹

Affiliations

¹ Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seoul, South Korea.
² Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea.
³ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea.
⁴ Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, South Korea.
⁵ Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea.
⁶ Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea.

Abstract

Background: Delirium is a neuropsychiatric condition strongly associated with poor clinical outcomes such as high mortality and long hospitalization. In the patients with Coronavirus disease 2019 (COVID-19), delirium is common and it is considered as one of the risk factors for mortality. For those admitted to negative-pressure isolation units, a reliable, validated and contact-free delirium screening tool is required.

Materials and methods: We prospectively recruited eligible patients from multiple medical centers in South Korea. Delirium was evaluated using the Confusion Assessment Method (CAM) and 4'A's Test (4AT). The attentional component of the 4AT was modified such that respondents are required to count days, rather than months, backward in Korean. Blinded medical staff evaluated all patients and determined whether their symptoms met the delirium criteria of the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). An independent population of COVID-19 patients was used to validate the 4AT as a remote delirium screening tool. We calculated the area under the receiver operating characteristic curve (AUC).

Results: Out of 286 general inpatients, 28 (9.8%) inpatients had delirium. In this population, the patients with delirium were significantly older (p = 0.018) than the patients without delirium, and higher proportion of males were included in the delirium group (p < 0.001). The AUC of the 4AT was 0.992 [95% confidence interval (CI) 0.983-1.000] and the optimal cutoff was at 3. Of the independent COVID-19 patients, 13 of 108 (12.0%) had delirium. Demographically, the COVID-19 patients who had delirium only differed in employment status (p = 0.047) from the COVID-19 patients who did not have delirium. The AUC for remote screening using the 4AT was 0.996 (0.989-1.000). The optimal cutoff of this population was also at 3.

Conclusion: The modified K-4AT had acceptable reliability and validity when used to screen inpatients for delirium. More importantly, the 4AT efficiently screened for delirium during remote evaluations of COVID-19 patients, and the optimal cutoff was 3. The protocol presented herein can be used for remote screening of delirium using the 4AT.

Keywords: 4AT; COVID-19; delirium; delirium assessment tools; remote screening.