What is the recommended method for assessing confusion in clinical settings?

Recommended Methods for Assessing Confusion in Clinical Settings

The Confusion Assessment Method (CAM) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) are the most valid and reliable tools for assessing confusion and delirium in clinical settings. 1

Primary Assessment Tools

Confusion Assessment Method (CAM)

The CAM is the gold standard tool for delirium assessment in most clinical settings and can be completed in less than 5 minutes. It evaluates four key diagnostic features:

1. Acute onset and fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness

For a positive delirium diagnosis, both criteria 1 and 2 must be present, along with either criterion 3 or 4 2. The CAM has demonstrated:

• Sensitivity: 82%
• Specificity: 99% 3

CAM-ICU

For mechanically ventilated or critically ill patients, the CAM-ICU is specifically designed to assess delirium in ICU settings, with:

• Sensitivity: 81%
• Specificity: 98% 3

Setting-Specific Recommendations

General Hospital Settings

• Use the standard CAM for non-intubated, verbal patients
• The CAM may detect more subtle cases of delirium compared to the CAM-ICU in alert, non-intubated patients 4

Intensive Care Units

• Use the CAM-ICU for both ventilated and non-ventilated patients
• The Society of Critical Care Medicine (SCCM) Pain, Agitation, and Delirium guidelines strongly recommend using either CAM-ICU or the Intensive Care Delirium Screening Checklist (ICDSC) 1
• First assess arousal level using a validated sedation scale (Richmond Agitation Sedation Scale or Sedation-Agitation Scale) before performing delirium assessment 1

Neurocritical Care

• Use either the CAM-ICU or ICDSC
• When assessing delirium in neurologically injured patients, search for new neurologic insults in addition to using standard delirium assessment tools 1
• Pay attention to level of wakefulness during screening to avoid confounding due to residual sedative effects 1

Cancer Patients

• The CAM is recommended for delirium assessment in cancer patients 1
• Be particularly vigilant for hypoactive delirium, which is the most common subtype in cancer patients and frequently missed by clinical teams 1

Implementation Best Practices

1. Regular screening: Implement routine delirium monitoring for all high-risk patients
2. Proper training: Ensure staff are trained in the correct use of the chosen assessment tool
3. Consistent application: Use the same tool consistently for a given patient to track changes over time
4. Documentation: Document all assessments and communicate findings to the healthcare team

Common Pitfalls to Avoid

• Underdiagnosis: Hypoactive delirium is frequently missed without formal screening tools 1, 5
• Inconsistent assessment: Using different tools or methods across shifts leads to inconsistent detection
• Inadequate training: Improper application of assessment tools reduces their sensitivity and specificity
• Failure to distinguish: Not differentiating between delirium and dementia (delirium has acute onset, fluctuating course, and disordered attention) 5

Clinical Implications

Early and accurate delirium detection is critical as:

• Delirium is associated with increased mortality (at least twofold increase) 1
• Delirium is linked to longer hospital stays and higher institutionalization rates 1, 5
• Early detection enables prompt investigation of underlying causes and implementation of appropriate management strategies 5

By implementing validated delirium assessment tools like the CAM and CAM-ICU, clinicians can significantly improve detection rates and ultimately patient outcomes through timely intervention.