Confusion Assessment Method in the diagnostics of delirium among aged hospital patients: Would it serve better in screening than as a diagnostic instrument?

Department of Medicine, Helsinki University Central Hospital, Helsinki, Uusimaa, Finland
International Journal of Geriatric Psychiatry (Impact Factor: 2.87). 12/2002; 17(12):1112-9. DOI: 10.1002/gps.753
Source: PubMed


The Confusion Assessment Method (CAM) is an easy, four-step algorithmic diagnostic test developed to detect delirium.
To determine how sensitive and specific the CAM is in diagnosing delirium when compared with fully operationalized criteria of delirium according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) editions III, III revised, and IV, and the International Classification of Diseases (ICD) 10th edition.
A cross-sectional study with blinded assessments was performed on consecutive elderly patients (>70 years) (n=81) in two acute geriatric hospitals in Helsinki, Finland. The sensitivity, specificity, likelihood ratios, and positive and negative predictive values of CAM were assessed with the DSM-III, DSM-III-R, DSM-IV, and ICD-10 criteria of delirium used as reference standards.
Sensitivity rates of the CAM were proved to be only moderate (0.81-0.86) against all formal criteria of delirium. The specificity rates were lower (0.63-0.84), and far less than reported in previous studies using global assessment of the reference standard. Instead of the DSM-III-R, from which it is derived, the CAM seems more concordant with the DSM-IV criteria of delirium. The likelihood ratio for a positive CAM test was 5.06 and for a negative test 0.23, when compared with the DSM-IV.
The CAM seems to be an acceptable screening instrument for delirium, but the diagnosis should be ensured according to the formal criteria of delirium, preferably by the DSM-IV.

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Available from: Reijo S Tilvis
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    • "Primary caregivers are asked to complete the IQCODE-N in order to reflect on the participant’s cognitive function prior to hospitalisation [26]. The Confusion Assessment Method (CAM) will be used to diagnose delirium according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV) delirium criteria during the study intervention period, and to ensure delirium is not present on study inclusion [27]. Nurses register the Delirium Observation Screening (DOS) scale three times a day (once every day, evening and night shift) during the intervention period to evaluate delirium symptoms [28,29]. "
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    ABSTRACT: Background: Delirium is associated with substantial morbidity and mortality rates in elderly hospitalised patients, and a growing problem due to increase in life expectancy. Implementation of standardised non-pharmacological delirium prevention strategies is challenging and adherence remains low. Pharmacological delirium prevention with haloperidol, currently the drug of choice for delirium, seems promising. However, the generalisability of randomised controlled trial results is questionable since studies have only been performed in selected postoperative hip-surgery and intensive care unit patient populations. We therefore present the design of the multicenter, randomised, double-blind, placebo-controlled clinical trial on early pharmacological intervention to prevent delirium: haloperidol prophylaxis in older emergency department patients (The HARPOON study). Methods/design: In six Dutch hospitals, at-risk patients aged 70 years or older acutely admitted through the emergency department for general medicine and surgical specialties are randomised (n = 390) for treatment with prophylactic haloperidol 1 mg or placebo twice daily for a maximum of seven consecutive days. Primary outcome measure is the incidence of in-hospital delirium within seven days of start of the study intervention, diagnosed with the Confusion Assessment Method, and the Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria for delirium. Secondary outcome measures include delirium severity and duration assessed with the Delirium Rating Scale Revised 98; number of delirium-free days; adverse events; hospital length-of-stay; all-cause mortality; new institutionalisation; (Instrumental) Activities of Daily Living assessed with the Katz Index of ADL, and Lawton IADL scale; cognitive function assessed with the Six-item Cognitive Impairment Test, and the Dutch short form Informant Questionnaire on Cognitive Decline in the Elderly. Patients will be contacted by telephone three and six months post-discharge to collect data on cognitive- and physical function, home residency, all-cause hospital admissions, and all-cause mortality. Discussion: The HARPOON study will provide relevant information on the efficacy and safety of prophylactic haloperidol treatment for in-hospital delirium and its effects on relevant clinical outcomes in elderly at-risk medical and surgical patients. Trial registration: EudraCT Number: 201100476215; Identifier: NCT01530308; Dutch Clinical Trial Registry: NTR3207.
    Full-text · Article · Aug 2014 · BMC Geriatrics
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    • "The nurse needs to assess using the CAM assess - ment to rule out any pre - existing delirium before surgery . The CAM assessment is based on the sen - sitivity range of 91% to 94% and the specificity of 96% , in the detection of delirium ( Gonzalez et al . , 2004 ; Hestermann et al . , 2009 ; Laurila et al . , 2002 ) . The likelihood of patients having delirium when CAM had identified patients as being deliri - ous is high . The CAM assesses the following 3 cri - teria : acute onset and fluctuating course , inattention and disorganised thinking or altered level of consciousness . Cognitive impairment is thought to be highly associated with deliriu"
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    ABSTRACT: Background A high prevalence for the development of delirium after hip fracture was found in the group of geriatric patients. The National Institute for Health and Clinical Excellence has introduced a guideline for the management delirium (NICE, 2010). Protocols composed of detection, prevention and management of post-operative delirium required some adaptation to meet the needs of local nurses. Aim A protocol with a nursing care plan referenced from an international guideline and other literature was developed to predict, prevent and manage post-operative delirium for geriatric patients with hip fracture. Methods The literature suggests numerous risk factors are associated with post-operative delirium and its preventive interventions were adopted to develop the protocol and nursing care plan. Findings Six major risk categories included mental and behavioural influence, sensory impairment, physiological influence, immobility influence, electrolyte disturbance and infection influence. These were used for screening patients, accompanied by various preventive interventions. A protocol was developed to strive for the best management of geriatric patients receiving hip fracture surgery from admission to discharge. Conclusions The protocol incorporated with the Risk Assessment for Management of Postoperative delirium (RAMP) care plan was adapted for staff to implement in their local clinical area. Further study is required to determine its effectiveness on the prevention of the development of post operative delirium (POD) in the future.
    Full-text · Article · Jan 2013 · International Journal of Orthopaedic and Trauma Nursing
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    • "The CAM has become one of the most widely used screening tools for delirium and has been studied extensively. Reports of the CAM's sensitivity and specificities have varied widely, with sensitivities ranging from 13% to 100% and specificities ranging from 89% to 100% [20]. Although frequently used in research studies on older ED patients [4–6,15,16], only one study has evaluated the use of the CAM by lay-interviewers in the ED compared with a gold-standard CAM assessment. "
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    ABSTRACT: Altered mental status is a common chief compliant among older patients in the emergency department (ED). Acute changes in mental status are more concerning and are usually secondary to delirium, stupor, and coma. Although stupor and coma are easily identifiable, the clinical presentation of delirium can be subtle and is often missed without actively screening for it. For patients with acute changes in mental status the ED evaluation should focus on searching for the underlying etiology. Infection is one of the most common precipitants of delirium, but multiple causes may exist concurrently.
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