Wednesday, August 25, 2010

Confounded by Delirium

Ok so not everybody is interested in this, but there was an excellent review in JAMA recently which went over the evidence on the accuracy of several instruments in diagnosing delirium in adults.

As we all know, delirium is an indepenent marker for increased mortality, longer hospital stay, increased complications, persistent cognitive devicits and increased discharge rates to long term care.

So when you get a patient who is clearly "out of it".. what does the regular intern reflexively do. MMSE right? NO! According to the review, the MMSE was the LEAST useful for identifying patients with delirium (LR 1.5 for a score of less 24> better than guessing).

The study included 11 bedside delirium instruments. One instrument stood out: the Confusion Assessment Method (CAM) which has a +LR of 7.3 and -LR 0.08 and may be the most convenient because it can be performed in less than 5 minutes, and can be applied by nongeriatricians.

Some training is recommended and an instruction manual is available online. The algorithm is based on only 4 elements of the DSM-III-R criteria: acute onset and fluctuating course, inattention, disorganized thinking and altered level of consciousness(see inset).


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