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Validation of The Proxy Test for Delirium (PTD) Among
delirious patients in King Khalid University Hospital
(KKUH) in Riyadh, Saudi Arabia.
Principle Investigator: Dr. Fahad Alosaimi.
Co-Investigator(s): Dr. Bandar Althomali, Dr. Ayedh Alghamdi, Dr. Fadi Aljamaan,
Amjad Albatili, Ghadah Alhammad, Latifah Albatly, Raya Alsuhaibani.
Collage of Medicine - King Saud University.
Introduction
"Delirium is a serious neuropsychiatric syndrome
characterized by acute and fluctuating in attention,
other cognitive deficits and alternation in level of
consciousness”.
 Delirium is being misdiagnosed and undetected in the
Intensive Care Unit (ICU) sittings.
 To overcome this problem validated highly sensitive
tools are needed. The Proxy Test for Delirium (PTD) is a
new tool to detect delirium in patients admitted
to the ICU.
Research Question
Is the Proxy Test for Delirium (PTD) more
sensitive and specific than the Confusion
Assessment Method (CAM) in screening for
delirium?
Objective and Hypothesis
To validate PTD as a screening tool to detect delirium in patients admitted to
the ICU by comparing it with Confusion assessment method (CAM) and clinical
neuropsychiatric evaluation based on DSM-5 criteria performed by
psychosomatic medicine specialist.
Null hypothesis: PTD is as sensitive and specific in screening of delirium as CAM.
 Alternative hypothesis: PTD is superior to CAM in practicability and easy to use
by nurse.
Methodology (I)
 Study design: A cross-sectional approach.
 Study setting: Intensive care unit at King Khalid University
Hospital. (KKUH)
 Sampling (size, type): 288 patients – 50 were collected in
convenient sample.
Sample
Inclusion criteria:
ICU Patients who are
18 years and above.
Exclusion criteria:
Patients unwilling to participate.
Patient cannot communicate in
Arabic or English.
Patients “too sick” to participate.
Methodology (II)
Data collection tools: Three different delirium scales.
PTD
CAM
Doctor’s
assessment
Score (6-24)=
delirium
Delirium
Delirium
5 and less is not
delirium
Not
Delirium
Not
Delirium
All enrolled patients were separately and blindly screened for symptoms of
delirium within 24 hours time limit:
1. The patient's primary nurse performed the PTD at the end of their
shift (were trained in advance of the start of the study).
2. A trained research assistant (one of the medical students, the coinvestigators) performed CAM (were trained in advance of the start of the
study).
3. A clinical neuropsychiatric evaluation based on DSM-5 criteria
performed by Psychosomatic Medicine specialist.
Methodology (III)
Data management:
 The data was analyzed using SPSS and MedCalc programs.
 Descriptive statistic.
 Sensitivity, Specificity, PPV, NPV.
 ROC curve analysis.
Ethical considerations:
1. IRB committee approval.
2. Written informed consent.
Result (I)
Table 1
(The relation between The Confusion Assessment Method (CAM) and the doctor’s assessment)
CAM
Disease +
Disease -
Total
Sensitivity
53.33%
CAM+
8
0
8
Specificity
100.00%
CAM-
7
35
42
PPV
1
Total
15
35
50
NPV
0.833
ROC curve analysis
PTD
Cut-off Score
100
Criterion
80
60
Sensitivity: 60.0
Specificity: 94.3
Criterion : >5
40
20
0
0
20
40
60
100-Specificity
80
100
 Area under the ROC curve (AUC) = 0.776
 95% confident interval = 0.636 to 0.882
 Significance level P (area = 0.5) = 0.0010
Sensitivity
95% CI
Specificity
95% CI
+LR
-LR
>=0
100.00
78.2 - 100.0
0.00
0.0 - 10.0
1.00
>0
73.33
44.9 - 92.2
57.14
39.4 - 73.7
1.71
0.47
>0.5
73.33
44.9 - 92.2
60.00
42.1 - 76.1
1.83
0.44
>1
66.67
38.4 - 88.2
77.14
59.9 - 89.6
2.92
0.43
>2
66.67
38.4 - 88.2
82.86
66.4 - 93.4
3.89
0.40
>3
60.00
32.3 - 83.7
88.57
73.3 - 96.8
5.25
0.45
>5 *
60.00
32.3 - 83.7
94.29
80.8 - 99.3
10.50
0.42
>6
53.33
26.6 - 78.7
97.14
85.1 - 99.9
18.67
0.48
>7
53.33
26.6 - 78.7
100.00
90.0 - 100.0
0.47
>22
0.00
0.0 - 21.8
100.00
90.0 - 100.0
1.00
* Criterion corresponding with highest Youden index
Result (II)
Table 2
(The relation between The Proxy Test for Delirium (PTD) and the doctor’s assessment)
Cut off 5
Disease +
Disease -
Total
Sensitivity
60.00%
PTD +
9
2
11
Specificity
94.29%
PTD -
6
33
39
PPV
0.818
Total
15
35
50
NPV
0.846
Result (III)
 The result shows that the sensitivity of CAM was 53.33% and the
specificity was 100.00%. The positive predictive value and the
negative predictive value were 1 and 0.833, respectively. (table 1)
 Using a cutoff score more than 5, the PTD has sensitivity of 60.00%,
specificity of 94.29%, positive predictive value of 0.818 and negative
predictive value of 0.846. (table 2)
Result (IV)
 Thus using PTD in detecting delirium cases in ICU patients is more
sensitive and clinically significant in minimizing the misdiagnosed
and undetected cases.
 In the other hand, CAM shown to be more specific and reliable in
detecting delirium in ICU sittings which might help in confirming the
diagnosis.
 The basic socio-demographic and clinical data were collected
from patient’s chart, patient himself and/or family member if
available.
Gender
Age
Height and weight
Marital Status
Education level
Type of ICU
Place of Residence
Smoking and other substance
Reason of Admission
Medications
Vital signs and Lab results
Medical and psychiatric illnesses
Age
Gender
Mean
Std. deviation
56.32
17.325
Marital Status
Single
18%
Females
30%
Males
70%
Married
82%
Place of Residence
Tabuk
Almozahmya
Alkharj
2% Albahah 2%
2%
Najran
2%
Alhotah
2%
2% Abqaiq
Level of Education
2%
Alqassim
4%
Elementary
10%
University
12%
Secondary
30%
Intermediate
14%
Riyadh 82%
illiterate
18%
Other
16%
Conclusion
The PDT tool is a comprehensive, based on the Diagnostic and
Statistical Manual for Mental Disorders-5 (DSM-5), yet easy to use.
It eliminates the problem of a patient's lack or inability to cooperate
with the examination. Using an observation based tools, such as the
PTD, may help in early detection and diagnosis of delirium.
Limitations:
The shortage of ICU patients at King Khalid University Hospital (KKUH). This is
could be due to shortage of beds and long hospitalization stay.
We are planning to continue sampling until 2017, aiming to reach 288
participants.
Recommendations:
We recommend that future studies be carried out in multi-centers ICU settings
to get more generalizable data.
Acknowledgements
 Dr. Fahad Alosaimi, Associate professor, Psychiatry &
Psychosomatic medicine consultant, department of
Psychiatry.
 Dr. Fadi Aljamaan, Assistant Professor in Critical Care
Department, ICU consultant,
 Mr. Zakria Almasri, Nurse educator, nursing department.
 ICU Nurse staff.
References
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