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Adult Non-ICU Care: Monitoring Delirium
Assessing for delirium throughout the entire hospital system is a an important part of patient care. The choice of which delirium assessment(s) to use is dependent on your needs, goals, and patient populations. An excellent systematic review on a number of delirium assessment tools can be found at Wong et al. JAMA. 2010.
Below are descriptions of tools available for use in non-ICU hospital settings:
The Delirium Triage Screen (DTS)
The Delirium Triage Screen (DTS) was designed to be the optional first step of a two-step delirium monitoring process for very busy clinical environments. The DTS is a 20 second assessment designed to rapidly rule-out delirium and reduce number of formal delirium assessments needed. It consists of a measure of level of consciousness and a brief measure of inattention. If negative, no additional testing is needed. If positive, confirmatory testing (Step 2) to rule-in delirium with more specific assessments such as the CAM or its offsprings (CAM-ICU, bCAM, 3D-CAM) or the 4AT are needed (described below). For additional details on how to perform the DTS, see the download link below.
In older Emergency Department (ED) patients, the DTS was found to be 98% sensitive and 55% specific for delirium as diagnosed by a psychiatrist assessment (see manuscript link below). Its diagnostic performance appears to be similar in older patients who are admitted to the hospital.
The DTS is now part of the Geriatric Emergency Medicine Guidelines released in October 2013.
Additional details about the DTS can be obtained by visiting the Emergency Department Delirium Study Group.
DTS Resources
Related Papers
Diagnosing Delirium in Older Emergency Department Patients: Validity and Reliability of the Delirium Triage Screen and the Brief Confusion Assessment Method
Han JH, Wilson A, Vasilevskis EE, Shintani A, Schnelle JF, Dittus RS, Graves AJ, Storrow AB, Shuster J, Ely EW. Ann Emerg Med. 2013;62:457-465.
The Brief Confusion Assessment Method (bCAM)
The Brief Confusion Assessment Method (bCAM) is a delirium assessment that takes less than 2 minutes to perform. The bCAM is a modified CAM-ICU designed to improve sensitivity in non-critically ill patients and uses objective testing to determine the presence of inattention and disorganized thinking. Like the CAM and CAM-ICU, a patient must be inattentive (cardinal feature of delirium) in order to be bCAM positive. Inattention is assessed for by asking the patient to recite the months backwards from December to July.
For additional details of how to perform he bCAM, see the download links below. In older ED patients, the bCAM was found to be 84% sensitive and 96% when performed by a physician and 78% sensitive and 97% specific when performed by a non-physician. The bCAM's diagnostic performance appears to be similar in older patients who are admitted to the hospital
The bCAM is now part of the Geriatric Emergency Medicine Guidelines released in October 2013.
Additional details about the bCAM can be obtained by visiting the Emergency Department Delirium Study Group.
bCAM Resources
Related Papers
Diagnosing Delirium in Older Emergency Department Patients: Validity and Reliability of the Delirium Triage Screen and the Brief Confusion Assessment Method
Han JH, Wilson A, Vasilevskis EE, Shintani A, Schnelle JF, Dittus RS, Graves AJ, Storrow AB, Shuster J, Ely EW. Ann Emerg Med. 2013;62:457-465.
Use of the brief Confusion Assessment Method in a veteran palliative care population: A pilot validation study.
Wilson JE, Boehm L, Samuels LR, Unger D, Leonard M, Roumie C, Ely EW, Dittus RS, Misra S, Han JH. Palliat Support Care. 2019 Mar 19:1-5.
Links
Geriatric Emergency Department Guidelines
American College of Emergency PhysiciansGeriatric Emergency Department Guidelines
Society for Academic Emergency Medicine
Delirium in the Elderly
Delirium is a common problem in settings outside of the ICU. Recently, Age-Friendly Health Systems, an initiative of the Institute for Healthcare Improvement, has recognized delirium care as a key component of best clinical care for older adults. In their Guide to Using 4Ms Care, the Age-Friendly Health Systems initiative helps health systems operationalize delirium prevention, identification, and appropriate management. While many delirium screening tools exist for non-ICU settings, the guide cites UB-2, CAM, 3D-CAM, CAM-ICU, bCAM, Nu-DESC as options.
The Confusion Assessment Method (CAM)
Though many other delirium assessments have been studied for non-ICU patients, the Confusion Assessment Method (CAM) is the most widely studied and used. The CAM is also the progenitor of the CAM-ICU, bCAM, and 3D-CAM. A patient must have altered mental status/fluctuating course and inattention, and either disorganized thinking or altered level of consciousness to be CAM positive; these features are determined by observing the patient during bedside cognitive testing. The original validation study observed that the CAM was 94% to 100% sensitive and 90% to 95% specific compared with a psychiatrist's assessment (Inouye et al. Ann Int Med.1990). Wong et al. performed a meta-analysis and observed a pooled sensitivity of 86% and pooled specificity of 93% (Wong et al. JAMA. 2010). It takes take approximately 5 minutes to complete.
Additional details of the CAM can be found at Hospital Elder Life Program (HELP).
The 3D-CAM
The 3D-CAM is a 3-minute delirium assessment that is also based upon the CAM algorithm. It utilizes both objective measures and clinical observation to determine the presence of some of the delirium features. Similar to the CAM, a patient must be inattentive (cardinal feature of delirium) in order to be 3D-CAM. In older patients, the 3D-CAM is 95% sensitive and 94% specific for delirium when performed by trained research assistants (Marcantonio et al. Ann Int Med. 2014).
Additional details of the 3D-CAM can be found at the Hospital Elder Life Program website.
The 4 ’A’s Test (4AT)
The 4AT is a brief delirium assessment that can be used outside of the ICU that takes less than 2 minutes to perform. The 4AT is not based upon the CAM algorithm and assigns a score to four delirium features. In older patients, the 4AT is 90% sensitive and 84% specific for delirium when performed by a geriatrician (Bellelli et al. Age Ageing. 2014).
Additional information about the 4AT can be found at The 4AT.
