Screening for Delirium
Confusion Assessment Method (CAM)
This method of assessment was developed in the 1990′s and is the standard tool for screening for delirium in all patients. It has been slow to be adopted in EDs and as a result we miss a lot of episodes of delirium. Though there is good evidence from multiple studies that up to 10% of all older patients in EDs have a delirium, only about one-third of them are recognized.
These features are based on the AIDA Mnemonic and the DSM-IV definition of delirium:
A– Acute and fluctuating
D– Disorganized thinking: incoherent, rambling
A– Altered level of consciousness: drowsy, lethargic, stuporous, hyper-alert, agitated
Summary of Features
Click on a feature below to learn more.
This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions:
- Is there evidence of an acute change in mental status from the patient’s baseline?
- Did the (abnormal) behaviour fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?
COLLATERAL HISTORY IS ESSENTIAL!
This feature is shown by a positive response to the following question:
Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?
Can test with 5 item forward digit span; 3 item backward digit span; months of the years backwards; WORLD; serial 7s
This feature is shown by a positive response to the following question: Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
This feature is shown by any answer other than “alert” for the following question:
Overall, how would you rate the patient’s level of consciousness? (alert [normal], vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable]).
- Watch the video below and answer the following question.
- What components of the Confusion Assessment Method are illustrated here?
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Discussion: Screening for Delirium
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acute delirium not recognized
Acute delirium was assessed and appropriately investigated further
Inattention and altered LOC
Made the correct questions fast and determined presence of deiirium early in the assesment
Physician recognized delirium while asking additional questions
Recognition of a problem.
with questioning delirium revealed
applying the confusion assessment method would be really helpful in ED assessments for delirium or altered level of cognition
Daughter advocated for the patient
The doctor realised patient is delirious clinically even though blood tests are normal
Patient shows classic signs of delirium – fluctuating ideas, disorganized train of thoughts and labile.
Patient was lethargic, daughter notes change in behavior. Patient could not spell world backwards before she started to speak of chickens.
MD realizes the acute problem
lethargy, inattentive and disorganized thoughts
very hlepful scenario
Physician listened to the daughter and confirmed acute onset and fluctuating course. Patient was demonstrating disorganized thinking during the assessment.
MD aware of problem
Physician listened to the daughter and asked more questions
Family’s observations are also crucial in assessment of delirium.
Inattention, Asses for delirium.
FAMILY INVOLVEMENT FOR HISTORY AND BASELINE IS SIGNIFICANT IN ASSESSING ACUTE CHANGES FOR DELIRIUM
good easy to understand
Acute delirium is observed
good engagement with daughter to get more information that revealed acute onset.
Good questioning and listening to the daughter which lead doctor to assess for acute delirium.
Excellent job of getting to root of problem.
By talking with the daughter, MD was able to get a more comprehensive look at what the pt was like before coming to the hospital. Also able to get an idea of timeline of how long she has not been at baseline.
Daughter had stated that this was her mothers normal state and thankfully the physician listened and was able to reevaluate the patients condition
yes reevaluating was very important because if missed the doctor would have most likely missed key parts that would accurately identify the patient’s mental status
Doctor realized concern for delerium
Pt’s daughter noted the acute changes,and the doctor changed the focus of his questions and agreed these changes needed further investigations.
caregiver’s assessment given credit
Good job noting a potential delirium
MD REALIZED, AN ACUTE DELIRIUM.
helpful easy to remember
good patient video shows multiple aspects
important aspect of assessment and exam was listening to pt daughter
The daughter was very quick to establish that this was not her mothers’s baseline
Collateral history from daughter key
Collateral information is so key. Without the daughter present, it would be hard to delineate whether this is acute or chronic.
Video provides good example of delerium.
Much more efficient questioning of the pt as well as the daughter to attempt to determine the pt’s status
Provider acknowledged the daughter’s concerns and used her thoughts and further questioning to determine that patient was altered.
AIDA was demonstrated well in such a short video
Listening to the family is important to get a good assessment.
Acknowledging the daughter’s concerns about her mother’s altered mental status improved his rapport and helped to develop a more trusting relationship. It also provided a rough baseline comparison, in the event it was not a regular patient.
He listed to her family and took the time to search for cognitive impartment
MD recognized the need to screen with Mini-cog
Pt could not follow simple commands. She had outbursts of confused speech and disorganized thoughts.
Better, more focused questioning on possibility of delirium.
inability to stay awake during active communication. disorganized thinking
Interviewer picking up on subtle and not so subtle cues of delerium
it was nice that the patient gave all of the key phrases in a few sentences. made the screening much quicker!
Inattention and altered LOC- patient cannot stay awake
including the daughter in the care of the patient opened more of a window to the actual patient issue
Good demonstration of the features of delirium. Sometimes patients seem even more normal in the ED, but the history from relatives indicates a different, more confused or aggressive person at home (fluctuation). Important to take a good history.
Always important to have collateral information- especially if delirium superimposed on dementia
amliar should interview to get more information
to interview the family again more information of acute onset of symptoms as well as the fluctuating thought is given
using the family as a resource the md identified the delirium
Proper and thorough screening of the delirium, listening to family members concerns as they know their family member best and can assess for acute changes in cognition.
I think with such patients , focus should be paid to the delirium status and start quickly screening for a reason so proper treatment can be started.
Inattention and altered LOC- cannot stay awake?
Key was the collateral information. When they are in the ED we have no basis of comparison regarding their baseline versus acute change.
Pt lethargic/inattentive. Daughter confirmed acute onset and fluctuating course. pt demonstrated disorganized thinking during assessment
MD realized there could be an acute delirium.