title: A prospective observational study to investigate the association between abnormal hand movements and delirium in hospitalised older people.
abstract: OBJECTIVE
  to examine the relationship between carphology (aimlessly picking at bedclothes), floccillation (plucking at the air) and delirium in older patients admitted to specialist elderly care wards.
  
  
  METHODS
  daily observation for behaviours of carphology and floccillation embedded within a 'before' and 'after' study.
  
  
  METHODS
  three specialist elderly care wards in a general hospital.
  
  
  METHODS
  older people admitted to hospital as emergencies.
  
  
  METHODS
  patients recruited into a delirium prevention study were observed daily for delirium using the confusion assessment method (CAM). Occurrences of carphology and/or floccillation were also recorded. Sensitivity, specificity and positive and negative predictive values for carphology/floccillation for the diagnosis of delirium were calculated. Inpatient mortality rates were compared for patients who did, and did not exhibit features of carphology and/or floccillation.
  
  
  RESULTS
  four hundred and thirty-seven patients were recruited into the study. One hundred and ten participants experienced an episode of delirium, 21 exhibited behaviours of carphology and/or floccillation. The sensitivity and specificity of carphology and/or floccillation for the diagnosis of delirium were 14 and 98%, respectively; positive likelihood ratio 6.8. Carphology and floccillation were associated with both hyper- and hypo-active delirium subtypes, and occurred early during incident delirium (67% within 2 days of delirium onset). The inpatient mortality rate in patients with carphology/floccillation was double the rate in patients without the behaviours (23.8 versus 11.2%, Fisher's exact test P = 0.16).
  
  
  CONCLUSIONS
  carphology and floccillation are uncommon physical signs, but their presence is highly suggestive of delirium. The behaviours are unrelated to delirium subtype making their presence particularly useful in the diagnosis of hypo-active delirium.
authors.affiliation: Elderly Care, York Teaching Hospital, NHS Foundation Trust, York, UK.
authors.forename: Rachel
authors.initials: R
authors.lastname: Holt
authors.affiliation: Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford, West Yorkshire, UK.
authors.forename: Elizabeth Ann
authors.initials: EA
authors.lastname: Teale
authors.affiliation: University of Leeds, Leeds, UK.
authors.forename: Graham Peter
authors.initials: GP
authors.lastname: Mulley
authors.affiliation: Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford, West Yorkshire, UK.
authors.forename: John
authors.initials: J
authors.lastname: Young
mesh_terms: D000369:Aged, 80 and over; D003693:Delirium / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology* / Q000523:psychology; D004739:England; D005260:Female; D015577:Geriatric Assessment; D006225:Hand / Q000294:innervation*; D017052:Hospital Mortality; D006760:Hospitalization; D006769:Hospitals, General; D006801:Humans; D007297:Inpatients; D008297:Male; D009043:Motor Activity; D011237:Predictive Value of Tests; D011446:Prospective Studies; D013997:Time Factors
keywords: delirium; diagnosis; older people; physical examination