Running Head: REDUCING THE IMPACTS OF DELIRIUM

Reducing the Impacts of Delirium

Reducing the Impacts of Delirium in the Geriatric Population

In medicine, particularly for the inpatient hospital setting, patients can arrive at the

hospital with vague and common symptoms that don't offer a clear diagnosis. At times, the only

symptom offered is a change in mental status, increased agitation, lethargy, or new onset of

dementia. For nurses specializing in the elderly population, these vague symptoms can quickly

point to an infection or other underlying issue causing the change. Conversely, staff who don't

specifically work with elderly patients may dismiss the symptoms as a normal part of the aging

process or the new onset of dementia which in turn can cause infections to worsen and increase

risk to the patient for more severe conditions such as delirium. To address these issues, the

Confusion Assessment Method, a diagnostic algorithm, was developed in 1990 to empower

nursing staff to identify potential delirium in patients with a consistent format and standardized

series of questions.

According to the World Health Organization, delirium is a disturbance of cognition and

reduced clarity of awareness with rapid onset and fluctuating course (World Health

Organization, 2003). Delirium, which should be considered an acute medical emergency, can

require several months of recovery to return to baseline cognition even after the cause of the

initial delirium has resolved. This is in contrast to dementia, often confused with delirium, which

is a chronic neurological disease. Delirium has been linked to longer hospital stays, higher

treatment costs, increased rates of injury and falls, and worsening patient prognosis (Rosen, et

al., 2015). The primary tool for recognizing delirium is known as the Confusion Assessment

Method, or CAM diagnostic tool. The CAM diagnostic algorithm allows nursing staff to quickly

identify the markers of delirium to enable the cause of the delirium to be discovered and

addressed rapidly to reduce the potential for lasting effects on the patient.
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Catching Delirium Early is Key to Patient Outcomes

The proposed research question to evaluate the effectiveness of the Confusion

Assessment Method diagnostic algorithm in identifying and addressing the presence of delirium

in patients is vital to a timely response to minimize the effects of delirium on the patient. In an

inpatient setting, is the Confusion Assessment Method diagnostic algorithm a practical, accurate,

and comprehensive indicator of delirium in older adults? For a gerontological nurse, it is

expected that 20% to 50 % of their patients over the age of 65 are at risk for developing delirium

during their hospitalization (Singler, Singler, & Heppner, 2011). The presence of medical

devices, new medications, combinations of medications, and sleep deprivation or disturbances in

the sleep and wake cycles are the leading causes of delirium for adult patients, all of which are

concerns in the hospital setting (Grover & Avasthi, 2018). Longer stays in an inpatient setting

further increase the risk to the patient. To identify the onset of delirium, nurses can utilize the

CAM diagnostic algorithm to assess if a patient has a mental status altered from baseline with an

acute onset or fluctuating course, inattention, disorganized thinking, and an altered level of

consciousness. Depending on these four criteria the CAM will generate a positive or negative

result.

Literature Review

A literature review was conducted to identify research on the Confusion Assessment

Method diagnostic tool and its use in identifying delirium for inpatient populations. To identify

sources for research, a continuing education course was first identified for the correct application

of the CAM diagnostic tool in a clinical setting (McCabe, 2019). From there, additional research

and studies were identified with varying points of focus on the assessment of delirium in

patients. The inclusion of studies were narrowed based on the use of the CAM diagnostic
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algorithm to identify delirium, as well as the positive and negative outcomes following resolution

of the delirium episode, such as the study of delirium superimposed on dementia (Morandi, et al,

2015) and the Belgian study of patient perception of delirium (Rompaey, et al, 2016). Research

studies involving pediatric patients were excluded and additional source criteria was added to

include only studies that addressed a patient cohort which included adults over the age of 65.

Due to the limited number of sources available, studies were not excluded based on

cohort patients under the age of 65 being included in the study so long as participants were all

over the age of 18. Sources indicated that the CAM was sensitive and specific allowing nursing

staff to identify patients both with and without delirium (Grover & Avasthi, 2018). The validity

of the results were noted based on the training in use of the CAM algorithm for the nurse

administering the assessment (Rosen,et al, 2015). Additionally, reliability of results required

adherence to standardized questions that derived from other cognitive assessments including the

Mini-Mental State Exam and the Orientation-Memory-Concentration Test (McCabe, 2019).

Building A Better Tool

Though the CAM diagnostic algorithm is effective in up to 95% of delirium cases there are

several shortcomings with regard to the usefulness of the assessment method. First, nurses must

be trained in how to correctly identify and classify the symptoms of delirium based on the

categories of the assessment (McCabe, 2019). Some of the areas can be open to interpretation

which can cause a delay in recognition of symptoms, and even the way questions are asked can

impact the accuracy of the algorithm. Also, the CAM algorithm has only been translated into six

languages, and reliance on translation services can result in a less accurate assessment if the

translation is not relayed verbatim to the patient’s response (Rosen, et al, 2015). Furthermore,
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patients who speak limited English but do not utilize interpreter services can be at a higher risk

of delay in delirium identification due to impaired communication with the nurse.

Next, the CAM diagnostic algorithm helps to recognize delirium after it has occurred but

fails to address contributing factors to delirium to actively prevent the condition. Promoting

restful and consistent sleep patterns, encouraging social interaction, maintaining physical

activity, and stimulating the patients mentally have been shown to reduce the risk of delirium in

patients, but the presence or absence of these stimulus are not a part of the algorithm (McCabe,

2019). Inclusion of these assessments could allow for a more targeted response if delirium is

identified in a patient.

Finally, there are greater inconsistencies for patients being identified as being positive for

delirium with a pre-existing diagnosis of dementia. In many cases, the diagnosis of delirium

superimposed on dementia is delayed due to the nature of dementia and the progression of the

disease process (Morandi, et al, 2015). In some cases, delirium was already present in patients

when they were presented to the emergency department due to delays in identifying infections or

other issues in the presence of dementia (Rosen, et al, 2015).

Analysis

The standardized assessment for the presence of delirium using the Confusion

Assessment Method diagnostic algorithm is an effective tool in the rapid recognition of delirium

and is useful as an integral part of ongoing patient assessments in the inpatient setting. In

answering the questions of the practicality, accuracy, and comprehensiveness of identifying

delirium with the CAM algorithm, it can be determined that the tool is indeed practical and

accurate. It can only be considered comprehensive if both the nurse and patient speak the same

language and the assessment is completed correctly. These conclusions are based on addressing
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the qualitative and quantitative results of the studies reviewed in this research. The tool is noted

to have less reliability in consideration of patients with delirium superimposed on dementia

which can result in delay of care if practitioners are not specifically trained.

Recommendations

Additional guidelines should be added for the use of the CAM diagnostic algorithm for

patients with a pre-existing diagnosis of dementia to improve the efficiency of the tool in

differentiating a new onset of delirium as opposed to a progression of the disease process as

limited data is available. Furthermore, additional translations of the CAM algorithm should be

completed to increase the viability of the tool in more communities and for a wider range of

patients because the tool is noted to be more effective when the questions are standardized and

consistent. In hospitals that utilize the CAM algorithm, nurses should be required to complete the

course to ensure accurate and timely utilization of the tool.

References

Grover, S., & Avasthi, A. (2018, February). Clinical Practice Guidelines for Management of

Delirium in Elderly. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles

/PMC5840908/

Langford, R., & Young, A. (2013). Making a difference with nursing research. Boston: Pearson.

McCabe, Donna. “The Confusion Assessment Method (CAM): ConsultGeri Assessment Tool.”

ConsultGeri, 4 Oct. 2019, Retrieved from https://consultgeri.org/try-this/general-

assessment/issue-13.

Morandi, A., Lucchi, E., Turco, R., Morghen, S., Guerini, F., Santi, R., … Bellelli, G. (2015,

October). Delirium superimposed on dementia: A quantitative and qualitative evaluation

of patient experience. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles

/PMC4686231/

Rompaey, B. V., Hoof, A. V., Bogaert, P. V., Timmermans, O., & Dilles, T. (2016). The

patients perception of a delirium: A qualitative research in a Belgian intensive care unit.

Intensive and Critical Care Nursing, 32, 66 74. doi: 10.1016/j.iccn.2015.03.002

Rosen, T., Connors, S., Clark, S., Halpern, A., Stern, M. E., DeWald, J., … Flomenbaum, N.

(2015). Assessment and Management of Delirium in Older Adults in the Emergency

Department: Literature Review to Inform Development of a Novel Clinical Protocol.

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4633298/

Singler, K., Singler, B., & Heppner, H. (2011). Delirium in the elderly . Dtsch Med Wochenschr,

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Van Eijik M, Van Den Boogaard M, Van Marum R, Benner P, Eikelenboom P, et al. (2011)

Routine use of the confusion assessment method for the intensive care unit. Am J Resp
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World Health Organization. (2003). The Icd-10 classification of mental and behavioural

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