Annals of Long Term Care

Best Practices in Nursing Care to Older Adults
from The Hartford Institute for Geriatric Nursing
New York University, College of Nursing

Issue Number 13, Revised 2007
Series Editor: Marie Boltz, MSN, APRN, BC, GNP
Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP
New York University College of Nursing

WHY: Delirium occurs in 25-60% of older hospitalized patients, and is associated with an increased risk of nursing home admission, increased costs, length of stay, mortality rates, functional decline, and increased use of chemical and physical restraints. Risk factors for delirium include older age, dementia, infection, severe illness, multiple co-morbidities, dehydration, psychotropic medication use, alcoholism, vision impairment, and fractures. Delirium is often unrecognized by clinicians. Therefore, patients should be assessed frequently using a standardized tool to facilitate prompt identification and management of delirium and underlying etiology.

BEST TOOL: The Confusion Assessment Method (CAM) was intended to provide a new standardized method to enable non-psychiatrically trained clinicians to identify delirium quickly and accurately in both clinical and research settings. Both a long and short version of the CAM are available. The long version is a comprehensive assessment instrument that screens for clinical features of delirium and correlates to DSM IV criteria. The short version includes only those four features that were found to have the greatest ability to distinguish delirium from other types of cognitive impairment. There is also a CAM-ICU version for use with non-verbal mechanically ventilated patients.

VALIDITY AND RELIABILITY: Both the CAM and the CAM–ICU have demonstrated sensitivity of 94-100%, specificity of 89-95% and high inter-rater reliability. Several studies have been done to validate clinical usefulness.

STRENGTHS AND LIMITATIONS: The CAM can be incorporated into routine assessment and has been translated into several languages. The CAM was designed and validated to be scored based on observations made during brief but formal cognitive testing, such as the Mini-Mental State Examination (or other brief mental status evaluations). There is a false positive rate of 10%. Training to administer and score the tool is necessary to obtain valid results. The tool identifies the presence or absence of delirium but does not assess the severity of the condition, making it less useful to detect clinical improvement or deterioration.

FOLLOW-UP: The presence of delirium warrants prompt intervention to identify and treat underlying causes and provide supportive care. Vigilant efforts need to continue across the healthcare continuum to preserve and restore baseline mental status.

MORE ON THE TOPIC:
Best practice information on care of older adults: www.GeroNurseOnline.org.

The Hospital Elder Life Program (HELP), Yale University School of Medicine. Home Page: http://elderlife.med.yale.edu.
Useful websites for clinicians including the CAM Training Manual: http://elderlife.med.yale.edu/public/doclinks.php?pageid=01.02.03.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington D.C.

Ely, E. Wesley, Margolin, R., Francis, J., May, L., Truman, B., Dittus, R, Speroff, T., Gautam, S., Bernard, G., & Inouye, S. (2001). Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Critical Care Medicine, 29(7), 1370-1379.

Inouye, S.K. (2006). Delirium in older persons. NEJM, 354, 1157-65.
Inouye, S.K., Foreman, M.D., Mion, L.C., Katz, K.H., & Cooney, L.M. (2001). Nurses’ recognition of delirium and its symptoms: Comparison of nurse and researcher ratings. Archives of Internal Medicine, 161, 2467-2473.