Recommended Methods for Assessing and Managing Delirium 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 delirium assessment tools for clinical settings, with the CAM-ICU specifically recommended for ICU patients. 1
Delirium Assessment Tools
Primary Assessment Tools
- The Confusion Assessment Method (CAM) demonstrates excellent psychometric properties with sensitivity of 82% and specificity of 99%, making it highly reliable for general clinical settings 2
- The CAM-ICU is specifically designed for ICU patients (both ventilated and non-ventilated) with very good psychometric properties (weighted score 19.6/20) 1
- The Intensive Care Delirium Screening Checklist (ICDSC) is an alternative tool with very good psychometric properties (weighted score 16.8/20) for ICU settings 1
Key Features of CAM Assessment
- CAM can be completed in less than 5 minutes and focuses on four key diagnostic criteria 3:
- Acute onset and fluctuating course
- Inattention
- Disorganized thinking
- Altered level of consciousness
- CAM diagnosis requires the presence of both criteria 1 and 2, plus either criterion 3 or 4 3
Assessment Frequency
- Delirium should be assessed and documented every 8-12 hours (at least once per shift) 1
- More frequent assessments may be needed for patients with fluctuating symptoms 4
Risk Factors and Identification
Baseline Risk Factors
- Four key baseline risk factors significantly associated with delirium development 1:
- Preexisting dementia
- History of hypertension
- History of alcoholism (defined as ingestion of 2-3 or more drinks daily)
- High severity of illness at admission
High-Risk Populations
- Patients with cancer, particularly those with advanced disease, are at high risk with up to 88% developing delirium in the last weeks to hours of life 1
- Older populations have increased risk, with delirium rates increasing with age 1
- ICU patients with history of alcoholism, cognitive impairment, hypertension, severe sepsis/shock, mechanical ventilation, or receiving parenteral sedatives/opioids require routine monitoring 1
Management Approach
Initial Workup
- Conduct thorough clinical assessment to identify underlying causes using CAM or CAM-ICU 4
- Laboratory testing should be guided by clinical evaluation rather than performed as routine battery, including CBC, comprehensive metabolic panel, urinalysis, blood glucose, and thyroid function tests 4
- Neuroimaging should be selective rather than routine, guided by specific clinical features (focal neurological deficits, recent head trauma, new seizures, signs of increased intracranial pressure) 4
Treatment Priorities
- Identify and treat underlying causes such as infections, metabolic disturbances, or medication effects 5
- Rapidly reversible delirium has outcomes similar to patients who never experience delirium, highlighting the importance of prompt identification and management 5
Important Clinical Considerations
Delirium Subtypes
- Hypoactive delirium is the most frequent clinical subtype in cancer patients and is commonly missed by clinical teams 1
- Combining assessments from multiple healthcare providers (physicians and nurses) improves delirium detection in terminal patients 1
Common Pitfalls to Avoid
- Failing to recognize hypoactive delirium due to its less obvious presentation 4
- Attributing symptoms to dementia without investigating for acute causes 4
- Inadequate screening leading to missed diagnosis, especially in emergency settings 4
- Underdiagnosis in clinical settings remains common despite available assessment tools 1