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Screening and detection of delirium in older ED patients: performance of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). A two-step tool

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Abstract

Delirium is frequent in older Emergency Department (ED) patients, but detection rates for delirium in the ED are low. To aid in identifying delirium, we developed and implemented a two-step systematic delirium screening and assessment tool in our ED: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Components of the mCAM-ED include: (1) screening for inattention, the main feature of delirium, which was performed with the Months Backwards Test (MBT); (2) delirium assessment based on a structured interview with questions from the Mental Status Questionnaire by Kahn et al. and the Comprehension Test by Hart et al. The aims of our study are (1) to investigate the performance criteria of the mCAM-ED tool in a consecutive sample of older ED patients, (2) to evaluate the performance of the mCAM-ED in patients with and without dementia and (3) to test whether this tool is efficient in keeping evaluation time to a minimum and reducing screening and assessment burden on the patient. For this prospective validation study, we recruited a consecutive sample of ED patients aged 65 and older during an 11-day period in November 2015. Trained nurses assessed patients with the mCAM-ED. Results were compared to the reference standard [i.e. the geriatricians’ delirium diagnosis based on the criteria of the Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)]. Performance criteria were computed. We included 286 consecutive ED patients aged 65 and older. The median age was 80.02 (Q1 = 72.15; Q3 = 86.76), 58.7% of included patients were female, 14.3% had dementia. We found a delirium prevalence of 7.0%. In patients with dementia, specificity and positive likelihood ratio were lower. When compared to the reference standard, delirium assessment with the mCAM-ED has a 0.98 specificity and a 39.9 positive likelihood ratio. In 80.0% of all cases, the first step of the mCAM-ED, i.e. screening for inattention with the MBT, took less than 30 s. On average, the complete mCAM-ED assessment required 3.2 (SD 2.0), 5.6 (SD 3.2), and 6.2 (SD 2.3) minutes in cognitively unimpaired patients, patients with dementia and patients with dementia or delirium, respectively. The mCAM-ED is able to efficiently rule out delirium as well as confirm the diagnosis of delirium in elderly patients with and without dementia and applies minimal screening and assessment burden on the patient.

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Abbreviations

WH:

Wolfgang Hasemann

FFG:

Florian F. Grossmann

ED:

Emergency Department

mCAM-ED:

Modified Confusion Assessment method for the Emergency Department

MSQ:

Mental Status Questionnaire

mRASS:

Modified Richmond Agitation Sedation Scale

References

  1. Association American Psychiatric, Task force on DSM-IV (2000) Diagnostic and statistical manual of mental disorders: DSM-IV-TR, 4th edn. American Psychiatric Association, Wachington, DC

    Google Scholar 

  2. Elie M, Rousseau F, Cole M, Primeau F, McCusker J, Bellavance F (2000) Prevalence and detection of delirium in elderly emergency department patients. CMAJ 163(8):977–981. http://www.cmaj.ca/cgi/content/abstract/2163/2008/2977. Retrieved July 2004

  3. Hustey FM, Meldon SW, Smith MD, Lex CK (2003) The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med 41(5):678–684. https://doi.org/10.1067/mem.2003.152

    Article  PubMed  Google Scholar 

  4. Grossmann FF, Hasemann W, Graber A, Bingisser R, Kressig RW, Nickel CH (2014) Screening, detection and management of delirium in the emergency department—a pilot study on the feasibility of a new algorithm for use in older emergency department patients: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Scand J Trauma Resusc Emerg Med 22(1):19. https://doi.org/10.1186/1757-7241-22-19

    Article  PubMed  PubMed Central  Google Scholar 

  5. Han JH, Shintani A, Eden S, Morandi A, Solberg LM, Schnelle J, Dittus RS, Storrow AB, Ely EW (2010) Delirium in the emergency department: an independent predictor of death within 6 months. Ann Emerg Med 56(3):244–252 e241

    Article  PubMed  PubMed Central  Google Scholar 

  6. Han JH, Eden S, Shintani A, Morandi A, Schnelle J, Dittus RS, Storrow AB, Ely EW (2011) Delirium in older emergency department patients is an independent predictor of hospital length of stay. Acad Emerg Med 18(5):451–457. https://doi.org/10.1111/j.1553-2712.2011.01065.x

    Article  PubMed  PubMed Central  Google Scholar 

  7. Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC (1995) Unrecognized delirium in ED geriatric patients. Am J Emerg Med 13(2):142–145

    Article  PubMed  CAS  Google Scholar 

  8. Hustey FM, Meldon SW (2002) The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med 39(3):248–253

    Article  PubMed  Google Scholar 

  9. Naughton BJ, Moran MB, Kadah H, Heman-Ackah Y, Longano J (1995) Delirium and other cognitive impairment in older adults in an emergency department. Ann Emerg Med 25(6):751–755

    Article  PubMed  CAS  Google Scholar 

  10. Han JH, Morandi A, Ely EW, Callison C, Zhou C, Storrow AB, Dittus RS, Habermann R, Schnelle J (2009) Delirium in the nursing home patients seen in the emergency department. J Am Geriatr Soc 57(5):889–894. https://doi.org/10.1111/j.1532-5415.2009.02219.x

    Article  PubMed  PubMed Central  Google Scholar 

  11. Van de Meeberg EK, Festen S, Kwant M, Georg RR, Izaks GJ, Ter Maaten JC (2016) Improved detection of delirium, implementation and validation of the CAM-ICU in elderly Emergency Department patients. Eur J Emerg Med. https://doi.org/10.1097/mej.0000000000000380

    Article  Google Scholar 

  12. Morandi A, McCurley J, Vasilevskis EE, Fick DM, Bellelli G, Lee P, Jackson JC, Shenkin SD, Marcotrabucchi Schnelle J, Inouye SK, Ely EW, MacLullich A (2012) Tools to detect delirium superimposed on dementia: a systematic review. J Am Geriatr Soc 60(11):2005–2013. https://doi.org/10.1111/j.1532-5415.2012.04199.x

    Article  PubMed  PubMed Central  Google Scholar 

  13. Meagher J, Leonard M, Donoghue L, O’Regan N, Timmons S, Exton C, Cullen W, Dunne C, Adamis D, Maclullich AJ, Meagher D (2015) Months backward test: a review of its use in clinical studies. World J Psychiatry 5(3):305–314. https://doi.org/10.5498/wjp.v5.i3.305

    Article  PubMed  PubMed Central  Google Scholar 

  14. Stillman MJ, Rybicki LA (2000) The bedside confusion scale: development of a portable bedside test for confusion and its application to the palliative medicine population. J Palliat Med 3(4):449–456. https://doi.org/10.1089/jpm.2000.3.4.449

    Article  PubMed  CAS  Google Scholar 

  15. Kahn RL, Goldfarb AI, Pollack M, Peck A (1960) Brief objective measures for the determination of mental status in the aged. Am J Psychiatry 117:326–328

    Article  PubMed  CAS  Google Scholar 

  16. Hart RP, Levenson JL, Sessler CN, Best AM, Schwartz SM, Rutherford LE (1996) Validation of a cognitive test for delirium in medical ICU patients. Psychosomatics 37(6):533–546. https://doi.org/10.1016/S0033-3182(96)71517-7

    Article  PubMed  CAS  Google Scholar 

  17. Chester JG, Beth Harrington M, Rudolph JL (2012) Serial administration of a modified Richmond Agitation and Sedation Scale for delirium screening. J Hosp Med 7(5):450–453. https://doi.org/10.1002/jhm.1003

    Article  PubMed  Google Scholar 

  18. Grossmann FF, Hasemann W, Kressig RW, Bingisser R, Nickel CH (2017) Performance of the modified Richmond Agitation Sedation Scale in identifying delirium in older emergency department patients. Am J Emerg Med. https://doi.org/10.1016/j.ajem.2017.05.025

    Article  PubMed  Google Scholar 

  19. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 113(12):941–948

    Article  PubMed  CAS  Google Scholar 

  20. Inouye SK (2003) The Confusion Assessment Method (CAM). Training manual and coding guide. Yale University School of Medicine, New Haven

    Google Scholar 

  21. Bellelli G, Morandi A, Davis DH, Mazzola P, Turco R, Gentile S, Ryan T, Cash H, Guerini F, Torpilliesi T, Del Santo F, Trabucchi M, Annoni G, MacLullich AM (2014) Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing 43(4):496–502. https://doi.org/10.1093/ageing/afu021

    Article  PubMed  PubMed Central  Google Scholar 

  22. Adamis D, Meagher D, Murray O, O’Neill D, O’Mahony E, Mulligan O, McCarthy G (2016) Evaluating attention in delirium: a comparison of bedside tests of attention. Geriatr Gerontol Int 16(9):1028–1035. https://doi.org/10.1111/ggi.12592

    Article  PubMed  Google Scholar 

  23. Morandi A, Han JH, Meagher D, Vasilevskis E, Cerejeira J, Hasemann W, MacLullich AM, Annoni G, Trabucchi M, Bellelli G (2016) Detecting Delirium Superimposed on Dementia: evaluation of the Diagnostic Performance of the Richmond Agitation and Sedation Scale. J Am Med Dir Assoc 17(9):828–833. https://doi.org/10.1016/j.jamda.2016.05.010

    Article  PubMed  PubMed Central  Google Scholar 

  24. Shi Q, Warren L, Saposnik G, MacDermid JC (2013) Confusion assessment method: a systematic review and meta-analysis of diagnostic accuracy. Neuropsychiatr Dis Treat 9:1359–1370. https://doi.org/10.2147/NDT.S49520

    Article  PubMed  PubMed Central  Google Scholar 

  25. Adamis D, Rooney S, Meagher D, Mulligan O, McCarthy G (2015) A comparison of delirium diagnosis in elderly medical inpatients using the CAM, DRS-R98, DSM-IV and DSM-5 criteria. Int Psychogeriatr 27(6):883–889. https://doi.org/10.1017/s1041610214002853

    Article  PubMed  Google Scholar 

  26. Grossmann FF, Nickel CH, Christ M, Schneider K, Spirig R, Bingisser R (2011) Transporting clinical tools to new settings: cultural adaptation and validation of the Emergency Severity Index in German. Ann Emerg Med 57(3):257–264. https://doi.org/10.1016/j.annemergmed.2010.07.021

    Article  PubMed  Google Scholar 

  27. Nemec M, Koller MT, Nickel CH, Maile S, Winterhalder C, Karrer C, Laifer G, Bingisser R (2010) Patients presenting to the emergency department with non-specific complaints: the Basel non-specific complaints (BANC) study. Acad Emerg Med 17(3):284–292. https://doi.org/10.1111/j.1553-2712.2009.00658.x

    Article  PubMed  Google Scholar 

  28. Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383

    Article  PubMed  CAS  Google Scholar 

  29. Agresti A, Coull BA (1998) Approximate is better than “exact” for interval estimation of binomial proportions. Am Stat 52(2):119–126

    Google Scholar 

  30. Zhou X-H, McClish DK, Obuchowski NA (2011) Statistical methods in diagnostic medicine, 2nd edn. Wiley-Blackwell, Oxford

    Book  Google Scholar 

  31. Flahault A, Cadilhac M, Thomas G (2005) Sample size calculation should be performed for design accuracy in diagnostic test studies. J Clin Epidemiol 58(8):859–862. https://doi.org/10.1016/j.jclinepi.2004.12.009

    Article  PubMed  Google Scholar 

  32. Hendry K, Quinn TJ, Evans J, Scortichini V, Miller H, Burns J, Cunnington A, Stott DJ (2016) Evaluation of delirium screening tools in geriatric medical inpatients: a diagnostic test accuracy study. Age Ageing 45(6):832–837. https://doi.org/10.1093/ageing/afw130

    Article  PubMed  Google Scholar 

  33. Voyer P, Champoux N, Desrosiers J, Landreville P, Monette J, Savoie M, Carmichael PH, Richard S, Bedard A (2016) Assessment of inattention in the context of delirium screening: one size does not fit all! Int Psychogeriatr. https://doi.org/10.1017/S1041610216000533

    Article  PubMed  Google Scholar 

  34. Mariz J, Costa Castanho T, Teixeira J, Sousa N, Correia Santos N (2016) Delirium diagnostic and screening instruments in the emergency department: an up-to-date systematic review. Geriatrics 1(3):22. https://doi.org/10.3390/geriatrics1030022

    Article  PubMed Central  Google Scholar 

  35. Fick DM, Inouye SK, Guess J, Ngo LH, Jones RN, Saczynski JS, Marcantonio ER (2015) Preliminary development of an ultrabrief two-item bedside test for delirium. J Hosp Med 10(10):645–650. https://doi.org/10.1002/jhm.2418

    Article  PubMed  Google Scholar 

  36. Hasemann W, Godwin J, Spirig R, Kressig RW, Frei IA, Tolson D (2013) Effects of the Interdisciplinary Basel Delirium and Dementia Prevention and Management Programme DEMDEL. Glasgow Caledonian University, Glasgow

    Google Scholar 

  37. Marcantonio ER, Ngo LH, O’Connor M, Jones RN, Crane PK, Metzger ED, Inouye SK (2014) 3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium: a cross-sectional diagnostic test study. Ann Intern Med 161(8):554–561. https://doi.org/10.7326/m14-0865

    Article  PubMed  PubMed Central  Google Scholar 

  38. O’Sullivan D, Brady N, Manning E, O’Shea E, O’Grady S, O’Regan N, Timmons S (2017) Validation of the 6-Item Cognitive Impairment Test and the 4AT test for combined delirium and dementia screening in older Emergency Department attendees. Age Ageing. https://doi.org/10.1093/ageing/afx149

    Article  PubMed Central  PubMed  Google Scholar 

  39. Han JH, Wilson A, Vasilevskis EE, Shintani A, Schnelle JF, Dittus RS, Graves AJ, Storrow AB, Shuster J, Ely EW (2013) Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med 62(5):457–465. https://doi.org/10.1016/j.annemergmed.2013.05.003

    Article  PubMed  PubMed Central  Google Scholar 

  40. Han JH, Wilson A, Graves AJ, Shintani A, Schnelle JF, Dittus RS, Powers JS, Vernon J, Storrow AB, Ely EW (2014) Validation of the Confusion Assessment Method for the Intensive Care Unit in older emergency department patients. Acad Emerg Med 21(2):180–187. https://doi.org/10.1111/acem.12309

    Article  PubMed  PubMed Central  Google Scholar 

  41. Folstein M, Folstein S, McHugh P (1975) ‘Mini-mental state’: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189–198

    Article  PubMed  CAS  Google Scholar 

  42. Richardson SJ, Davis DHJ, Bellelli G, Hasemann W, Meagher D, Kreisel SH, MacLullich AMJ, Cerejeira J, Morandi A (2017) Detecting delirium superimposed on dementia: diagnostic accuracy of a simple combined arousal and attention testing procedure. Int Psychogeriatr 27(10):1585–1593. https://doi.org/10.1017/s1041610217000916

    Article  Google Scholar 

  43. LaMantia MA, Messina FC, Hobgood CD, Miller DK (2014) Screening for delirium in the emergency department: a systematic review. Ann Emerg Med 63(5):551–560 e552. https://doi.org/10.1016/j.annemergmed.2013.11.010

    Article  PubMed  Google Scholar 

  44. Junghans C, Jones M (2007) Consent bias in research: how to avoid it. Heart 93(9):1024–1025. https://doi.org/10.1136/hrt.2007.120113

    Article  PubMed  PubMed Central  Google Scholar 

  45. Gaspardo P, Peressoni L, Comisso I, Mistraletti G, Ely EW, Morandi A (2014) Delirium among critically ill adults: evaluation of the psychometric properties of the Italian ‘Confusion Assessment Method for the Intensive Care Unit’. Intensive Crit Care Nurs 30(5):283–291. https://doi.org/10.1016/j.iccn.2014.05.002

    Article  PubMed  Google Scholar 

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Acknowledgements

We are thankful to all the ED staff, the geriatricians who performed the gold standard assessments, and Dr. Duncan Shabb for helpful discussions and proofreading the manuscript.

Funding

This study was funded through Scientific Funds of the University Hospital Basel.

Author information

Authors and Affiliations

  1. Department of Nursing and Allied Health Professions, University Hospital Basel, Hebelstrasse 2, Basel, 4031, Switzerland

    Wolfgang Hasemann

  2. Emergency Department, University Hospital Basel, Basel, Switzerland

    Florian F. Grossmann, Rahel Stadler, Roland Bingisser & Christian H. Nickel

  3. University Center for Medicine of Aging, Felix Platter Hospital Basel, Basel, Switzerland

    Dieter Breil, Martina Hafner & Reto W. Kressig

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  1. Wolfgang Hasemann
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  2. Florian F. Grossmann
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Correspondence to Wolfgang Hasemann.

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All authors declare that they have no conflict of interest with this study.

Statement of human rights

The study was approved by the cantonal ethics committee (identifier EKNZ-2015-123) and registered with ClinicalTrials.gov (identifier NCT02782143). All procedures performed in this study involving human participants were in accordance with the ethical standards of the local/national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

If possible, oral informed consent was obtained directly from the patient or an authorized proxy. Due to the minimal risk, little burden and potential benefit to the patient, the ethics committee allowed patients to be assessed even if there was no chance to obtain informed patient consent due to the nature of delirium or availability of a proxy.

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Hasemann, W., Grossmann, F.F., Stadler, R. et al. Screening and detection of delirium in older ED patients: performance of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). A two-step tool. Intern Emerg Med 13, 915–922 (2018). https://doi.org/10.1007/s11739-017-1781-y

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