Objective To develop and validate a new standardized confusion assessment method (CAM) that enables nonpsychiatric clinicians to detect delirium quickly in high-risk settings. Design Prospective validation study. Setting Conducted in general medicine wards and in an outpatient geriatric assessment center at Yale University (site 1) and in general medicine wards at the University of Chicago (site 2). Patients The study included 56 subjects, ranging in age from 65 to 98 years. At site 1, 10 patients with and 20 without delirium participated; at site 2, 16 patients with and 10 without delirium participated. Measurements and main results An expert panel developed the CAM through a consensus building process. The CAM instrument, which can be completed in less than 5 minutes, consists of nine operationalized criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). An a priori hypothesis was established for the diagnostic value of four criteria: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. The CAM algorithm for diagnosis of delirium required the presence of both the first and the second criteria and of either the third or the fourth criterion. At both sites, the diagnoses made by the CAM were concurrently validated against the diagnoses made by psychiatrists. At sites 1 and 2 values for sensitivity were 100% and 94%, respectively; values for specificity were 95% and 90%; values for positive predictive accuracy were 91% and 94%; and values for negative predictive accuracy were 100% and 90%. The CAM algorithm had the highest predictive accuracy for all possible combinations of the nine features of delirium. The CAM was shown to have convergent agreement with four other mental status tests, including the Mini-Mental State Examination. The interobserver reliability of the CAM was high (kappa = 0.81 - 1.0). Conclusions The CAM is sensitive, specific, reliable, and easy to use for identification of delirium.

Clarifying Confusion: The Confusion Assessment Method: A New Method for Detection of Delirium

ContextDelirium is a common problem in the intensive care unit (ICU). Accurate
diagnosis is limited by the difficulty of communicating with mechanically
ventilated patients and by lack of a validated delirium instrument for use
in the ICU.ObjectivesTo validate a delirium assessment instrument that uses standardized
nonverbal assessments for mechanically ventilated patients and to determine
the occurrence rate of delirium in such patients.Design and SettingProspective cohort study testing the Confusion Assessment Method for
ICU Patients (CAM-ICU) in the adult medical and coronary ICUs of a US university-based
medical center.ParticipantsA total of 111 consecutive patients who were mechanically ventilated
were enrolled from February 1, 2000, to July 15, 2000, of whom 96 (86.5%)
were evaluable for the development of delirium and 15 (13.5%) were excluded
because they remained comatose throughout the investigation.Main Outcome MeasuresOccurrence rate of delirium and sensitivity, specificity, and interrater
reliability of delirium assessments using the CAM-ICU, made daily by 2 critical
care study nurses, compared with assessments by delirium experts using Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, criteria.ResultsA total of 471 daily paired evaluations were completed. Compared with
the reference standard for diagnosing delirium, 2 study nurses using the CAM-ICU
had sensitivities of 100% and 93%, specificities of 98% and 100%, and high
interrater reliability (κ = 0.96; 95% confidence interval, 0.92-0.99).
Interrater reliability measures across subgroup comparisons showed κ
values of 0.92 for those aged 65 years or older, 0.99 for those with suspected
dementia, or 0.94 for those with Acute Physiology and Chronic Health Evaluation
II scores at or above the median value of 23 (all P<.001).
Comparing sensitivity and specificity between patient subgroups according
to age, suspected dementia, or severity of illness showed no significant differences.
The mean (SD) CAM-ICU administration time was 2 (1) minutes. Reference standard
diagnoses of delirium, stupor, and coma occurred in 25.2%, 21.3%, and 28.5%
of all observations, respectively. Delirium occurred in 80 (83.3%) patients
during their ICU stay for a mean (SD) of 2.4 (1.6) days. Delirium was even
present in 39.5% of alert or easily aroused patient observations by the reference
standard and persisted in 10.4% of patients at hospital discharge.ConclusionsDelirium, a complication not currently monitored in the ICU setting,
is extremely common in mechanically ventilated patients. The CAM-ICU appears
to be rapid, valid, and reliable for diagnosing delirium in the ICU setting
and may be a useful instrument for both clinical and research purposes.

/pdf/delirium-in-mechanically-ventilated-patients-validity-and-3er9o5ci52.pdf

Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU).

Delirium is a common and serious acute neuropsychiatric syndrome with core features of inattention and global cognitive dysfunction. The etiologies of delirium are diverse and multifactorial and often reflect the pathophysiological consequences of an acute medical illness, medical complication or drug intoxication. Delirium can have a widely variable presentation, and is often missed and underdiagnosed as a result. At present, the diagnosis of delirium is clinically based and depends on the presence or absence of certain features. Management strategies for delirium are focused on prevention and symptom management. This article reviews current clinical practice in delirium in elderly individuals, including the diagnosis, treatment, outcomes and economic impact of this syndrome. Areas of future research are also discussed.

/pdf/delirium-in-elderly-adults-diagnosis-prevention-and-27g6hdarxu.pdf

Delirium in elderly adults: diagnosis, prevention and treatment.

OBJECTIVES: To describe the motoric subtypes of delirium in critically ill patients and compare patients aged 65 and older with a younger cohort.

DESIGN: Prospective cohort study.

SETTING: The medical intensive care unit (MICU) of a tertiary care academic medical center.

PARTICIPANTS: Six hundred fourteen MICU patients admitted during a process improvement initiative to monitor levels of sedation and delirium.

MEASUREMENTS: MICU nursing staff assessed delirium and level of consciousness in all MICU patients at least once per 12-hour shift using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale. Delirium episodes were categorized as hypoactive, hyperactive, and mixed type.

RESULTS: Delirium was detected in 112 of 156 (71.8%) subjects aged 65 and older and 263 of 458 (57.4%) subjects younger than 65. Mixed type was most common (54.9%), followed by hypoactive delirium (43.5%) and purely hyperactive delirium (1.6%). Patients aged 65 and older experienced hypoactive delirium at a greater rate than younger patients (41.0% vs 21.6%, P<.001) and never experienced hyperactive delirium. Older age was strongly and independently associated with hypoactive delirium (adjusted odds ratio=3.0, 95% confidence interval=1.7–5.3), compared with no delirium in a model that adjusted for other important determinants of delirium including severity of illness, sedative medication use, and ventilation status.

CONCLUSION: Older age is a strong predictor of hypoactive delirium in MICU patients, and this motoric subtype of delirium may be missed in the absence of active monitoring.

Delirium and its motoric subtypes: A study of 614 critically ill patients.

https://www.amjmed.com/article/0002-9343(94)90011-6/pdf

The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients

Cognitive disorders are on the rise. Their growing importance as a medical and psychiatric problem reflects the continued increase in the number of the elderly worldwide.1,2 In the United States, there are 25.5 million persons aged 65 years and older. Dementia and delirium, the main cognitive disorders, are most common among the elderly. Recent medical editorials speak of dementia as a “quiet epidemic” and “one of the greatest problems facing modern society.”3 4 The elderly, and especially the demented, are uniquely prone to transient cognitive disorders, usually referred to in the literature as delirium or acute confusional states.5 As the prevalence of dementia is expected to rise in the coming years because of the aging of the populaion, so the incidence of delirium is likely to follow suit. While dementia has attracted growing attention.6, 7 delirium in the elderly continues to be neglected.8, 9 A recent report of the Royal College of Physicians emphasizes that insufficient attention has been paid to this common and important mental disorder, one whose onset in an elderly patient usually heralds physical illness and hence calls for immediate medical evaluation.8 Furthermore, delirium is still often mistaken for an irreversible dementia. The present overview may help prevent such grave diagnostic errors in the future and stimulate sorely needed research on transient cognitive disorders.

Transient Cognitive Disorders (Delirium, Acute Confusional Sates) in the Elderly

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Transient Cognitive Disorders (Delirium, Acute Confusional Sates) in the Elderly