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Three clinically useful acronyms to take into account the most probable cause of delirium: the 7 I’s (left), DELIRIUMS(centre) and VINDICATE (right) ทมา Salvi, F., et al., 2007
Most probable cause of delirium
CAM Assessment• History - consistency from patient, family,
caregiver, medical record
• Observation over time
• Structured questions
• Orientation
• Three-item recall
• Days of week backward
• Months of year backward
CAM Criteria
• Acute onset or Fluctuating Course
• Inattention
• Disorganized thinking
• Altered level of consciousness
CAM WorksheetI. ACUTE ONSET OR FLUCTUATING COURSE
• Is there evidence of an acute change in mental status
from the patient’s baseline?
OR
• Did the (abnormal) behavior fluctuate during the day
(I.e., tend to come and go or increase and decrease in
severity)? NO YES
II.INATTENTION
• Did the patient have difficulty focusing attention (e.g.,
being easily distractible or having difficulty keeping track
of what was being said)? NO YES
CAM WorksheetIII. DISORGANIZED THINKING
• Was the patient’s thinking dis-
organized or incoherent (e.g.,
rambling or irrelevant conversa-
tion, unclear or illogical flow of
ideas, or unpredictable switching
from subject to subject)? No Yes
CAM WorksheetIV. ALTERED LEVEL OF CONSCIOUSNESS
Overall, how would you rate the patient’s level of consciousness?
____ Alert (normal)
____ Vigilant (hyperalert)
____ Lethargic (drowsy, easily aroused)
____ Stupor (difficult to arouse)
____ Coma (unarousable)
Do any checks appear in this box? No Yes
From Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment
method-a new method for detection of delirium. Ann Intern Med 1990;113:941-948
Mini-Mental State
Examination (MMSE)Add points for each correct response Score Points
Orientation
1. What is the : Year? ____ 1
Season? ____ 1
Date? ____ 1
Day? ____ 1
Month? ____ 1
2. Where are we? State? ____ 1
County? ____ 1
Town or city? ____ 1
Hospital? ____ 1
Floor? ____ 1
Mini-Mental State
Examination (MMSE)Registration Score Points
3. Name three objects, taking one second to
say each. Then ask the patient to repeat
all three after you have said them. ____ 3
Give one point for each correct answer.
Repeat the answers until patient learns all
three.
Attention and calculation
4. Serial sevens. Give one point for each correct
answer. Stop after five answers. Alternate: ____ 5
Spell WORLD backwards.
Mini-Mental State
Examination (MMSE)Recall Score Points
5. Ask for names of three objects learned in
question 3. Give one point for each correct ____ 3
answer.
Language
6. Point to a pencil and a watch. Have the patient
name them as you point. ____ 2
7. Have the patient repeat “No ifs, ands
or buts” ____ 1
Instructor’s Manual-Case Study 40
Mini-Mental State
Examination (MMSE)Score Points
8. Have the patient follow a three-stage command:
“Take a paper in your right hand. Fold the paper
in half. Put the paper on the floor. ____ 3
9. Have the patient read and obey the following
“CLOSE YOUR EYES.” (write it in large letters) ____ 1
10. Have the patient write a sentence of his or her
choice. (The sentence should contain a subject
and an object and should make sense. Ignore ____ 1
spelling errors when scoring.)
41
Mini-Mental State
Examination (MMSE)Score Points
11. Have the patient copy the design. (Give one
point if all sides and angles are preserved and ____ 1
if the intersecting sides form a quadrangle.)
___ = Total 30
In validation studies using a cutoff acore of 23 below, the MMSE has a sensitivity of 87% , a
specificity of 82%, a false-positive ratio of 39.4%, and a false-negative ratio of 4.7%. These
ratios refer to the MMSE’s capacity to accurately distinguish patients with clinically diagnosed
dementia or delirium from patients without these syndromes.
Cognitive Testing
Normal placement of hands.
Abnormal
“concrete” clock.
Thai MMSE 2002
DEPRESSION•Single Question: Do You Often Feel Sad Or