Comparison of diagnostic classification systems for delirium with new research criteria that incorporate the three core domains

Objective: Diagnostic classification systems do not incorporate phenomenological research findings about the three core symptom domains of delirium (Attentional/Cognitive, Circadian, Higher Level Thinking). We evaluated classification performances of novel Trzepacz, Meagher, and Franco research diagnostic criteria (TMF) that incorporate those domains and ICD-10, DSM-III-R, DSM-IV, and DSM-5. Methods: Primary data analysis of 641 patients with mixed neuropsychiatric profiles. Delirium (n = 429) and nondelirium (n = 212) reference standard groups were identified using cluster analysis of symptoms assessed using the Delirium Rating Scale-Revised-98. Accuracy, sensitivity, specificity, positive and negative predictive values (PPV, NPV), and likelihood ratios (LR +, LR -) are reported. Results: TMF criteria had high sensitivity and specificity (87.4% and 89.2%), more balanced than DSM-III-R (100% and 31.6%), DSM-IV (97.7% and 74.1%), DSM-5 (97.7% and 72.6%), and ICD-10 (66.2% and 100%). PPV of DSM-III-R, DSM-IV, and DSM-5 were < 90.0%, while PPV for ICD-10 and TMF were > 90%. ICD-10 had the lowest NPV (59.4%). TMF had the highest LR + (8.06) and DSM-III-R the lowest LR - (0.0). Overall, values for DSM-IV and DSM-5 were similar, whereas for ICD-10 and DSM-III-R were inverse of each other. In the pre-existing cognitive impairment/dementia subsample (n = 128), TMF retained its highest LR + though specificity (58.3%) became less well balanced with sensitivity (87.9%), which still exceeded that of DSM. Conclusions: TMF research diagnostic criteria performed well, with more balanced sensitivity and specificity and the highest likelihood ratio for delirium identification. Reflecting the three core domains of delirium, TMF criteria may have advantages in biological research where delineation of this syndrome is important.