Trigger-tools performance for screening potential hyperactive delirium in older people hospitalized in a Brazilian emergency department




Objective: Assess the performance of trigger-tools in detecting hospitalizations of older patients with potential hyperactive delirium in na emergency department. Methods: A cross-sectional study was performed with all patients aged ≥60 years old hospitalized in the emergency department of a Brazilian teaching hospital in 2018. The screening of potential hyperactive delirium was performed with the following trigger tools: prescription of intra-hospital antipsychotic medicines, codes of the 10th International Classification of Diseases (ICD-10) proposal by the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, and trigger-words related to hyperactive delirium registered in medical records by health professionals. The positive predictive value (PPV) was calculated to assess the performance of each trigger tool. Results: Most hospitalizations (193/286) were screened by at least one trigger tool, of which 49.2% showed potential hyperactive delirium. ICD-10 trigger tool showed better performance (PPV= 0.71), although the strategy had underestimated the detection of potential cases [2.6% (5/193)]. Despite the performance of intra-hospital prescriptions of antipsychotic and trigger-words had been lower (PPV= 0.69, and PPV=0.48, respectively), the prevalence of potential hyperactive delirium identified were greater with these methods [30.0% (58/193); and 47.1% (91/193); respectively]. Conclusion: The use of trigger tools detected one out three hospitalizations of older people with potential hyperactive delirium. The combination of the strategies may contribut to the recognition of the syndrome in emergency department. Data suggests the screening may be performed by pharmacists in association with multicomponent and interprofessional approaches to improve patient safety.


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APS. Diagnostic and Statistical Manual of Mental Disorders (DSM-5®) 5th Edition;2013.

Hshieh TT, Inouye SK, Oh ES. Delirium in the Elderly. Clin Geriatr Med. 2020; 36(2):183-199.

Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, et al. Delirium. Nature Sciences 2020; 6:90.

Pérez-Ros P. Martínez-Arnau FM. Delirium assessment in older people in emergency departments. A Literature Review. Diseases. 2019; 7(1):14.

Ahmed S, Leurent B, Sampson EL. Risk factors for incident delirium among older people in acute hospital medical units: A systematic review and meta-analysis.ffects Age Ageing. 2014;43(3):326-33.

Carpinter CR, Hammouda N, Linton EA, Doering M, Ohuabunwa UK, Ko KJ, et al. Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A geriatric emergency care applied research (GEAR) network scoping review and consensus statement. Acad Emerg Med 2021; 28(1):19-35

Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet 2014; 383(9920):911-22.

Monette J, Galbaud du Fort G, Fung SH, et al. Evaluation of the Confusion Assessment Method (CAM) as a screening tool for delirium in the emergency room. Gen Hosp Psychiatry. 2001; 23:20–5.]

Han JH, Eden S, Shintani A, Morandi A, Schnelle J, Dittus RS, et al. Delirium in older emergency department patients is na independent predictor of hospital length of stay. Acad Emerg Med. 2011;18(5):451-7.

Shenkin SD, Fox C, Godfrey M, Siddiqi N, Goodacre S, Young J, et al. Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method. BMC Med 2019;17(1):138.

Zalon ML, Sandhaus S, Kovaleski M, Roe-Prior P. Hospitalized older adults with established delirium: recognition, documentation, and reporting. J Gerontol Nurs. 2017;43(3):32-40.

Puelle MR, Kosar CM, Xu G, Schmitt E, Jones RN, Marcantonio ER, et al.The language of delirium: key words for identifying delirium from medical records. J Gerontol Nurs 2015;41(8):34-42.

Zimmerman KM, Paquin AM, Rudolph JL. Antipsychotic prescription to identify delirium: results from two cohorts. Clin Pharmacol. 2017; 9:113-117.

De Wet C, Bowie P. Screening electronic patient records to detect preventable harm: a trigger tool for primary care. Qual Prim Care 2011; 19(2):115–125.

Raso J, Santos LMC, Reis DA, Frangiotti MAC, Zanetti ACB, Capucho HC, et al. Hospitalizations of older people in na emergency department related to potential medication-induced hyperactive delirium: a cross-sectional study. Int J Clin Pharm. 2022; 44(2):548-556.

World Alliance for Patient Safety. Summary of the evidence on patient safety: implications for research. The Research Priority Setting Working Group of the World Alliance for Patient Safety. Geneva:World Health Organization, 2008.

Miguel A, Azevedo LF, Lopes F, Freitas A, Pereira AC. Methodologies for the detection of adverse drug reactions: comparison

of hospital databases, chart review and spontaneous reporting. Pharmacoepidemiol Drug Saf. 2013: 22(1):98-102.

Du W, Pearson SA, Buckley NA, Day C, Banks E. Diagnosis-based and external cause-based criteria to identify adverse drug reactions in hospital ICD-coded data: Application to an Australian population- based study. Public Health Res Pract. 2017;27(2):2721716.

Casey P, Cross W, Mart WS, Baldwin C, Riddell K, P. Hospital discharge data under-reports delirium occurrence: results from a point prevalence survey of delirium in a major Australian health service. Intern Med J 2019;49(3):338-344.

Inouye SK, Leo-Summers L, Zhang Y, Bogardus ST, Leslie DL, Agostini JV. A char-based method for identification of delirium: validation compared with interviewer ratings using de Confusion Assessment Method. J Am Geriatr Soc 2005;53(2):312-8.

Clegg A, Westby M, Young JB. Underreporting of delirium in the NHS. Age Ageing 2011; 40: 283–6.

Kim DH, Lee J, Kim CA, Huybrechts KF, Bateman BT, Patorno E, et al. Evaluation of algorithms to identify delirium in administrative claims and drug utilization database. Pharmacoepidemiol Drug Saf 2017;26(8):945-953.

Hope C, Estrada N, Weir CW, Teng CC, Damal K, Sauer B. Documentation of delirium in the VA electronic health record. BMC Res Notes. 2014; 7:208.

Collins N, Blanchard MR, Tookman A, Sampson EL. Detection of delirium in the acute hospital. Age Ageing 2010; 39:131–5.

Slooter AJC, Otte WM, Devlin JWm Arora RC, Bleck TP, Claassen J, et al. Updated nomenclature of delirium and acute encephalopathy: statement of ten societies. Intensive Care Med.2020; 46(5):1020-1022.

Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. 2019. Accessed 25 Mar 2020.

National Institute for Health and Care Excellence (NICE). Delirium: Diagnosis, prevention and management. Clinical Guideline 103. 2010, update March 2019. Accessed 25 Mar 2020.

Burry L, Mehta S, Perreault MM, Luxenberg JS, Siddiqi N, Hutton B, et al. Antipsychotics for treatment of delirium in hospitalised non-ICU patients. Cochrane Database Syst Ver 2018;6(6):CD005594.

Yu F, Rafizadeh R, Mabsa VH, Kang N. Risk Evaluation for Antipsychotic Agents Used in Elderly Inpatients (REPAIR). Can J Hosp Pharm2018;71(6):370-375.

Kassie GM, Ellett LMK, Nguyen TA, Roughead EE. Current practice and opinions of hospital pharmacists regarding their role in the screening, prevention and treatment of delirium. Int J Clin Pharm 2017;39(6):1194-1200.

McMaster C, Liew D, Keith C, Aminian P, Frauman A. A machine-learning algorithm to optimise automated adverse drug reaction detection from clinical coding. Drug Saf. 2019;42(6):721-725.



How to Cite

RASO J, SANTOS LM, REIS DA, FRANGIOTTI MA, ZANETTI AC, CAPUCHO HC, HERDEIRO MT, ROQUE F, LEIRA-PEREIRA LR, VARALLO FR. Trigger-tools performance for screening potential hyperactive delirium in older people hospitalized in a Brazilian emergency department. Rev Bras Farm Hosp Serv Saude [Internet]. 2022Dec.23 [cited 2024Feb.25];13(4):874. Available from: