4-Item Assessment Provides Good Bedside Diagnosis of Delirium

Norra MacReady

April 07, 2008

April 7, 2008 (San Diego) — A simple 4-item assessment reliably identifies delirium in hospitalized patients, investigators reported here at Hospital Medicine 2008, the Society of Hospital Medicine annual meeting.

Delirium is often underrecognized and undertreated in hospitalized patients, although it is associated with poor outcomes, including longer length of stay and higher risk of mortality, which may be avoided through prompt diagnosis and appropriate management, the investigators explained.

They used the Confusion Assessment Method (CAM), developed by Sharon K. Inouye, MD, from Harvard Medical School, Cambridge, Massachusetts, and colleagues, from criteria described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The CAM criteria are

  • acute change in mental status;

  • inattention;

  • and either disorganized thinking or an altered level of consciousness.

"The CAM has been validated and shown to have a sensitivity and specificity of 90% to 95%, so it truly is reflective of the gold standard definition of delirium," lead author Bryan Huang, MD, assistant clinical professor of medicine at the University of California, San Diego (UCSD), told Medscape Internal Medicine.

Dr. Huang and colleagues used the CAM to assess the incidence of delirium over a 3-day observation period in 5 general medical–surgical and intermediate care units at the UCSD Medical Center. All in all, they evaluated 84 patients. Of those patients, 10% screened positive for delirium.

That is actually about half of the average reported in other studies, said coauthor Tien Dam, MD, assistant clinical professor of medicine at UCSD; in some patient populations, the rate of delirium may be as high as 50%. Risk factors include advanced age, postoperative status, use of narcotics, and the presence of dementia or incontinence. For example, a prime candidate would be "an elderly person with a hip fracture, especially if she's on high doses of painkillers," Dr. Dam said.

The best treatment is prevention: avoiding high doses of narcotic painkillers and keeping the patient oriented through frequent reminders of place and time, visits from family members, and maintenance of normal sleep–wake patterns, Dr. Dam added. For patients who are already delirious, she recommended nonpharmacological interventions such as having someone around to reorient the patient and, if necessary, the use of physical restraints to prevent wandering.

A tool such as the CAM could be an important part of the hospitalist's arsenal, said Moira L. Ogden, MD, a hospitalist at Terrebonne Medical Center in Houma, Louisiana, who was not involved in the study. "We do need a standardized scale to assess acute delirium, because it is very common," Dr. Ogden told Medscape Internal Medicine.

The authors have disclosed no relevant financial relationships.

Hospital Medicine 2008: Abstract 103. Presented April 4, 2008.

J Hosp Med. 2008;3(suppl 1):60.

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