Confusion Assessment Method for the ICU (CAM-ICU)

Confusion Assessment Method for the ICU (CAM-ICU)

1. Acute onset of mental status changes or a fluctuating course

and

2. Inattention

And

or 4. Disorganized Thinking

= Delirium

Ely et al, Crit Care Med 2001;29:1370-79 Ely, E.W., et al. JAMA 2001; 286, 2703-2710

3. Altered level of consciousness

Reliability and Validity of CAM-ICU• Compared CAM-ICU nurses’ and physicians’ rating

to reference standard evaluation using DSM-IV expert psychiatric ratings

• Validity ~95%

• In 2 studies encompassing 150 patients and over 750 patient encounters

• Inter-rater reliability ~ 0.92-0.96

Ely, Francis, Margolin et al, Crit Care Med 2001;29:1370-79Ely, Inouye, Bernard et al, JAMA 2001;286:2703-2710

Adaption and Implementation• 15 languages and coming soon: Korean,

Greek, Finnish, Thai

• Harvard CAM-ICU flow sheet

• pCAM-ICU (pediatrics)

• CAM-ED (emergency department)

Ely EW, JAMA 2001;286:2703-10

Patient Comfort

Pain Sedation Delirium• 0-10 Scale

VAS Scale• Subjective/

Physiologic indicators

Sedation Assessment

Scale

(e.g. RASS, SAS, MAAS)

CAM-ICU

A joint Task Force of the Society of Critical Care Medicine (SCCM), American College Critical Care Medicine (ACCM), and the American Society of Health-System Pharmacists (ASHP) in alliance with the

American College of Chest Physicians (ACCP).

* Jacobi J, Fraser GL, Coursin DB, Riker R, Fontaine D, Wittbrodt ET, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002; 30:119-141.

2002 Clinical Practice Guidelines*

What the CAM-ICU measures...CAAM

C – Change in Mental Status or Fluctuation

A – Attention is Impaired

A – Altered LOC or Arousal

M – Muddled Thinking

Both Required

Only one Required

Screening/Presenting on Rounds 4 items in 10 seconds

1. Target RASS (team’s goal)

2. Actual RASS (arousal)

3. CAM-ICU (content)

4. Drugs (iatrogenesis imperfecta)

RASS & CAM-ICUImplementing sedation Scale (RASS)

without delirium tool (CAM-ICU) …

• leaves only half of consciousness assessed (arousal not content)

• is clinically unsatisfying• hurts compliance

Teaching Point

Step 1: Arousal Assessment (RASS)+4 Combative

+3 Very agitated

+2 Agitated

+1 Restless

0 Alert /calm

-1 Drowsy eye contact >10 sec

-2 Light sedation eye contact <10 sec

-3 Moderate no eye contact

-4 Deep physical stimulation required

-5 Unarousable no response even with physical

Verbal Stimulus

PhysicalStimulus

Sessler CN, et al. AJRCCM 2002; 166:1338-1344. Ely et al, AJRCCM 2001;163:A954

Feature 1: Alteration/Fluctuation in Mental Status

Is the pt different than his/her baseline mental status?

OR

Has the patient had any fluctuation in mental status in the past 24 hours (eg fluctuating RASS, GCS, previous delirium assessments, etc)

Present: If either question is YES.

Feature 1: Alteration/Fluctuation in Mental Status

Common Questions:

• What if you do not know the patient’s baseline?– Assume normal unless you have red flags that make

you suspicious– Red Flag: patient came from institution

• What about dementia? – Ask family “What could she/he do prior to this

illness?”

Feature 2: Inattention

Screening for Attention– two options

Letter “A” test Letters: S A V E A H A A R T (or numbers)Say 10 letters (or numbers) and instruct the patient to

squeeze on the letter “A” (or on a certain number) PicturesSimilar test with pictures (instructions are in picture packets)

Feature 2: Inattention

1. Attempt Letters first.

2. If pt is able to perform the Letter test you are sure of the results, you are done with Inattention test.

3. If pt is unable to perform the Letter test or you are unsure of the results, use the Pictures.

If you perform both tests, use the Pictures result to determine if inattention is present.

Inattention Present : If >2 errors

Teaching Point

Inattention (Feature 2)

This is THE cardinal feature and must be present to diagnose delirium. F2 is quick and simple. 95%

of evaluations are done using only “hand squeezes” on correct letters or numbers. We need

the picture method of screening for inattention in <5%, who are often very interesting patients.

Pictures

Feature 2: Inattention

Common Questions:

• What if the patient only squeezes once and then falls back to “sleep”? or What if the patient is too hyperactive/combative to participate in squeezing?– Remember what you are assessing—Attention – This patient is inattentive

• If you have to explain the directions more than twice, start to be suspicious for inattention

Teaching Point

Hand Squeezing

In the absence of other specific neurological diagnoses, a patient who squeezes on all letters,

squeezes on NO letters, or misses >2 letters/numbers/pictures is inattentive and F2

positive. With a RASS other than “0,” he/she is delirious from many possible causes

(e.g.: sepsis, sedatives, CHF).

Confusion Assessment Method for the ICU (CAM-ICU)

1. Acute onset of mental status changes or a fluctuating course

and

2. Inattention

and

or 4. Disorganized Thinking

= Delirium

Ely et al, Crit Care Med 2001;29:1370-79 Ely, E.W., et al. JAMA 2001; 286, 2703-2710

3. Altered level of consciousness

If either Feature 1 or 2 are absent,

Stop

Overall CAM-ICU is Negative

If Features 1 and 2 are present,

Proceed

to Feature 3

Remember-Tailor your exam!

Feature 3: Alt Level of Consciousness

Any LOC other than Alert.

Present: If the Actual RASS score is anything other than “0” (zero).

You have already done this assessment. It was the first thing you did when you

walked in the room!

Teaching Point

UTA

The term ‘Unable to Assess’ is only recorded when patients are in stupor/coma

(RASS -4/-5).

Feature 4: Disorganized Thinking

Yes/No Questions (Use either Set A or Set B) :

Set A Set B

1. Will a stone float on water? 1. Will a leaf float on water?2. Are there fish in the sea? 2. Are there elephants in the sea?3. Does one pound weigh more than 3. Do two pounds weigh two pounds? more than one pound?

4. Can you use a hammer to pound a nail? 4. Can you use a hammer to cut wood?

Note: Use whatever form of communication that works (nodding, hand squeezing, blinking, etc).

Feature 4: Disorganized Thinking

Command

Say to patient: “Hold up this many fingers” (Examiner holds two fingers in front of patient) “Now do the same thing with the other hand” (Not repeating the number of fingers).

• Patient gets credit only if able to successfully complete the entire command

Feature 4: Disorganized Thinking

Present: If there is >1 error for the combined questions + command.

• Notes: – If pt is unable to move both arms, for the second

part of the command ask patient “Add one more finger”.

– If patient is unable to move arms at all (quadriplegic), then feature 4 is present if patient misses more than 1 question.

Confusion Assessment Method for the ICU (CAM-ICU)

1. Acute onset of mental status changes or a fluctuating course

and

2. Inattention

And

or 4. Disorganized Thinking

= Delirium

Ely et al, Crit Care Med 2001;29:1370-79 Ely, E.W., et al. JAMA 2001; 286, 2703-2710

3. Altered level of consciousness

What to THINK of when CAM+

• Toxic Situations

•CHF, shock, dehydration

•Deliriogenic meds

•New organ failure, e.g, liver, kidney

• Hypoxemia; also, consider giving Haloperidol or other antipsychotics?

• Infection/sepsis (nosocomial), Immobilization

• Nonpharmacological interventions

•Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation

• K+ or Electrolyte problems

Delirium in the ICUClinical Value of RASS/CAM Measurement

• Stimulates thinking of Rx:

• Delirium Recognition is a Burglar Alarm for us

• Forces us to consider treatable causes earlier

• Avoid knee-jerk treatment with benzodiazepines

• Consider haloperidol or atypical antipsychotic

DDx and Contributing Factors to Delirium

DrugsEyes, EarsLow O2 States (MI,Stroke,PE)InfectionRetention (Urine or Feces)IctalUnderhydration, UndernutritionMetabolicSubdural

Drugs that can cause an ACUTE CHANGE IN MS

ANTIPARKINSON CV DRUGS INSOMNIA MUSCLE Relax.

CORTICOSTER. H2 BLOCKERS NSAIDS SEIZURE

URIN INCONT ANTIBIOTICS

THEOPHLLYINE NARCOTICS

EMPTYING DRUGS GERO-PSYCH

ENT

Flaherty JH. Clinics in Geriatric Medicine, 1998

?*

Blackburn & Dunn,Arch Int Med 1990

84 year old man,Admitted for CHF.Day 3 he feels better (less short breath)Day 4 he suddenly becomes agitated, uncooperative, confused. His urine output is less than before. Diagnosis?

Cystocerebral Syndrome*(Urinary Retention)

Symptoms: pain, agitated delirium, overflow incontinence, acute renal failure

Blackburn & Dunn,Arch Int Med 1990

The Treatment of Delirium

is the Identification and Treatment of the

Underlying Causes

Medication to control agitation Medication to control agitation may may exacerbateexacerbate and and

prolongprolong

the course of deliriumthe course of delirium

Case Studies

Confusion Assessment Method for the ICU (CAM-ICU)

1. Acute onset of mental status changes or a fluctuating course

and

2. Inattention

and

(NEW)

or 4. Disorganized Thinking

= Delirium

Ely et al, Crit Care Med 2001;29:1370-79 Ely, E.W., et al. JAMA 2001; 286, 2703-2710

3. Altered level of consciousness

Case #1: Mr. Icy

45 y/o man, lawyer with no previous memory or attention problem

Dx: DKA, IntubatedIn the past 24hrs the RASS scores have been -3 to +1. Step 1: Sedation AssessmentCurrently: Awake and moving around restless in bed, but

not aggressive. RASS = +1

What do we do next?

Step 2: CAM-ICU

- Feature 1:

Is he at his MS baseline?

Fluctuation?

- Feature 2:

Letters = 6/10

- Feature 3:

RASS = +1

- Feature 4

Pos Neg

Feature 1

Feature 2

Feature 3

Feature 4

Case #1: Mr. Icy

Step 2: CAM-ICU

- Feature 1:

Is he at his MS baseline?

Fluctuation?

Other RASS Scores: -3 +1

- Feature 2:

Letters = 6/10

- Feature 3:

RASS = +1

- Feature 4

Pos Neg

Feature 1

X

Feature 2

X

Feature 3

X

Feature 4

Is this patient

delirious??

Case #1: Mr. Icy

Case #2 Mrs. Dapple75 y/o femaleDx: Severe pneumonia requiring prolonged mechanical

ventilation and difficulty weaningIn past 24 hours: RASS scores -3 to -1

Step 1: Sedation AssessmentAsleep, but awakens to voice; maintains eye contact for >10

secondsRASS = -1

What do we do next?

Step 2: CAM-ICU- Feature 1:

Is she at her MS baseline?

Fluctuation?

- Feature 2:

Letters = 9/10

- Feature 3

- Feature 4

Pos Neg

Feature 1

Feature 2

Feature 3

Feature 4

Case #2 Mrs. Dapple

Step 2: CAM-ICU- Feature 1:

Is he at his MS baseline?

Fluctuation?

RASS Variance: 2

- Feature 2:

Letters = 9/10

- Feature 3

- Feature 4

Pos Neg

Feature 1

X

Feature 2

X

Feature 3

Feature 4

Is this patient

delirious??

Case #2 Mrs. Dapple

Rest of CAM-ICU done anyway…

• Something is amiss with this patient’s thinking. Rest of CAM-ICU shows disorganized thinking (Feature 4 +)

• So…– Fluctuation of MS (Feature 1 +)– NOT inattentive (Feature 2 -)– LOC is “other than alert” (RASS -1, Feature 3 +)– Disorganized thinking (Feature 4 +)

What do you call this?

A. Delusions

B. Need to determine if having hallucinations

C. Subsyndromal delirium

D. Hyperactive Delirium

Teaching Point

Subsyndromal Delirium

Patients may have some features without the full syndrome of delirium (e.g., F2 only or F1&4 only).

This is a (subsyndromal) intermediate state between normal and delirium. Reassess with CAM-ICU frequently to determine the clinical course of his/her emerging brain dysfunction.

Case # 3 Miss Universe

Miss Universe was successfully extubated from the Vent at 0800. All sedation and analgesia had been stopped earlier in the AM. Yesterday evening and last night she had periods of agitation with a documented RASS range of -1 to +3.

Step 1: Sedation Assessment Pt alert and calm. RASS = 0

What do we do next?

Step 2: CAM-ICU

- Feature 1:

Is she at her MS baseline?

Fluctuation?

- Feature 2:

Letters = 7/10, but you aren’t sure

Pictures = 6/10

- Feature 3:

RASS = 0

- Feature 4

Pos Neg

Feature 1

Feature 2

Feature 3

Feature 4

Case #3: Miss Universe

Step 2: CAM-ICU

- Feature 1: Is she at her MS baseline? Fluctuation? RASS Variance = 4- Feature 2: Letters = 7/10, but you aren’t

sure. Pictures = 6/10- Feature 3: RASS = 0- Feature 4

Pos Neg

Feature 1

X

Feature 2

X

Feature 3

X

Feature 4

Case #3: Miss Universe

Do you need to

do Feature 4??

Step 2: CAM-ICU

- Feature 1: Is she at her MS baseline? Fluctuation?- Feature 2: Letters = 7/10, but you aren’t sure.

Pictures = 6/10- Feature 3: RASS = 0- Feature 4: Answered half the questions wrong Unable to perform 2-step command Total Score: 2/5

Pos Neg

Feature 1

Feature 2

Feature 3

Feature 4

Case #3: Miss Universe

Step 2: CAM-ICU

- Feature 1: Is she at her MS baseline? Fluctuation?- Feature 2: Letters = 7/10, but you aren’t sure.

Pictures = 6/10- Feature 3: RASS = 0- Feature 4: Answered half the questions wrong Unable to perform 2-step command Total Score: 2/5

Pos Neg

Feature 1

X

Feature 2

X

Feature 3

X

Feature 4

X

Case #3: Miss Universe

Is this patient

delirious??

What if Miss Universe had gotten all 4 of her

questions right?

Step 2: CAM-ICU

- Feature 1: Is she at her MS baseline? Fluctuation?- Feature 2: ASE Letters = 7/10, but you aren’t

sure. ASE Pictures = 6/10- Feature 3: RASS = 0- Feature 4: Answered all 4 questions correct Unable to perform 2-step command Total Score: 4/5

Pos Neg

Feature 1

X

Feature 2

X

Feature 3

X

Feature 4

X

Case #3: Miss Universe

Is this patient

delirious??

Teaching Point

Subsyndromal Delirium

Patients may have some features without the full syndrome of delirium (e.g., F2 only or F1&4 only).

This is a (subsyndromal) intermediate state between normal and delirium. Reassess with CAM-ICU frequently to determine the clinical course of his/her emerging brain dysfunction.

Future of Delirium • More “targeted” approach

– Neurophysiological types of delirium

• More “management” studies• More drug studies

– PMD, MIND-USA, Dexlirium

• American Delirium Society– “Bringing Delirium Specific

Medications to the Bedside: A Global Regulatory Approval Framework for Delirium Drugs” (Boustani MA, President of the ADS)

www.ICUdelirium.org

Educational Delirium Website

Mental Status is the

6th

Vital Sign

The VA Delirium Working Group, June 2007

www.americandeliriumsociety.org

Questions?