Submission for MD University of Limerick, Graduate Entry Medical School Student name: Henry O’Connell ID number: 12110213 Title: Detection and diagnosis of delirium: a study of the application of computer - assisted technologies. 1 | P a g e Table of Contents List of tables ............................................................................................................................................ 4 List of figures ........................................................................................................................................... 5 Abbreviations .......................................................................................................................................... 6 Acknowledgements ................................................................................................................................. 7 Assessments and scales used .................................................................................................................. 8 Rater A assessments ........................................................................................................................... 8 Rater B assessments ........................................................................................................................... 8 Abstract ................................................................................................................................................... 9 Background ..................................................................................................................................... 9 Aims............................................................................................................................................... 10 Methods ........................................................................................................................................ 10 Results ........................................................................................................................................... 11 Conclusions ................................................................................................................................... 12 Thesis outline ........................................................................................................................................ 14 Chapter 1: Background and hypotheses ............................................................................................... 15 Delirium: evolution of the concept definition .............................................................................. 15 Delirium: epidemiology, risk factors and costs ............................................................................. 21 Delirium: neuropathogenesis ....................................................................................................... 28 Delirium: assessment .................................................................................................................... 32 Android applications (apps) for cognitive assessment: background literature to the development of the Lighthouse app ............................................................................................. 37 Delirium: management and prevention ....................................................................................... 50 Study hypotheses .................................................................................................................................. 53 Chapter 2: Systematic review of bedside tests of attention ................................................................ 54 Methods ................................................................................................................................................ 56 Results ................................................................................................................................................... 57 Summaries of studies ........................................................................................................................ 64 Discussion.............................................................................................................................................. 72 Tests of attention .......................................................................................................................... 74 Differentiating delirium and dementia ......................................................................................... 75 Post-operative delirium ................................................................................................................ 76 Depression .................................................................................................................................... 76 2 | P a g e ‘Head-to-head’ studies .................................................................................................................. 77 Younger populations ..................................................................................................................... 78 Acceptability to patients and assessors ........................................................................................ 78 Computerised tests ....................................................................................................................... 80 Study limitations ................................................................................................................................... 80 Conclusion ............................................................................................................................................. 82 Chapter 3: Methods .............................................................................................................................. 95 Subjects and Design ...................................................................................................................... 95 Ethical approval ............................................................................................................................. 96 Definitions for delirium and dementia.......................................................................................... 96 Statistical analyses ........................................................................................................................ 97 Rater A clinical assessments ......................................................................................................... 98 Tests and rating scales .................................................................................................................. 99 Cognitive testing ......................................................................................................................... 103 Rater B assessments ................................................................................................................... 106 Lighthouse test ............................................................................................................................ 107 Letter and Shape Drawing (LSD) Test .......................................................................................... 108 Chapter 4: Results ............................................................................................................................... 109 Description of study subjects .......................................................................................................... 109 Performance on ‘gold standard’ tests ................................................................................................ 113 Performance on the Lighthouse app tests ...................................................................................... 121 Lighthouse identification (LH-ID) .................................................................................................... 121 Focussed Attention (FA) component of Lighthouse test ................................................................ 123 Sustained Attention (SA) component of Lighthouse test ............................................................... 125 Concordance measures ................................................................................................................... 131 Study hypotheses ................................................................................................................................ 133 Chapter 5: Discussion .......................................................................................................................... 135 ‘Gold standard’ tests ....................................................................................................................... 136 Lighthouse app tests ....................................................................................................................... 139 Study limitations ......................................................................................................................... 143 Implications ................................................................................................................................. 144 References .......................................................................................................................................... 145 3 | P a g e List of tables Table 1: DSM 5 criteria for delirium (APA, 2013) .................................................................................. 18 Table 2: DSM guidance notes: assessing attention..............................................................................