Identification and management

Think: Mr. Williams has a confirmed hip fracture and he has surgery to repair this fracture. His surgery is uneventful however the following evening he is reported to be confused. To establish his confusion you must assess his cognitive status. How would you assess his current cognitive status and compare this to his baseline cognitive status? What questions would you ask?

"As a rule of thumb, any sudden change in an older person's cognition or behaviour should be considered to be delirium and possible causes investigated"(1).

Staff caring for older patients must be knowledgeable about delirium as it will increase their awareness and detection of delirium and consequent treatment of the underlying cause resulting in improved patient outcomes(1).

Cognitive testing is a necessity for all older people admitted to hospitals and serial measures may help detect the onset of delirium or resolution of an existing delirium. However, by themselves these tools cannot distinguish between delirium and other causes of cognitive impairment, for example, dementia but are certainly useful in the screening process.

Some aspects of cognition can be tested quickly using the following:

  • serial 7s (count backwards from 100 by 7s down to 72), or reciting days of the week backwards (attention) and;
  • a short term memory recall (ask patient to repeat 3 objects and then repeat them at 2 minutes).

However it is preferable to use a valid and reliable tool such as the Mini-Cog or MMSE(29,30).

Additionally a history from an informant (a relative, carer or someone who has known the person for an extended period of time) about the onset and course of their confusion is essential as they are the most knowledgeable about whether a person's current cognitive state differs from their usual state (i.e. is normal or abnormal for them)(1,31).

Informants may describe an acute change or decline in function including: confusion, reduced memory clarity, language or behaviour that is unusual for them, disturbed sleep/wake patterns, and /or fluctuating anxiety or change in personality over the day.

If there is a decline from baseline cognitive testing a screen for delirium must be performed. The Confusion Assessment Method (CAM)(26) is considered the gold standard and is relatively easy to learn and takes less than 5 minutes to perform. Additionally you may be able to assess for delirium using CAM whilst doing other non delirium specific tasks. Understanding the elements of the CAM and its application is an essential outcome for users of this web-site. Other delirium screening tools include: The Nursing Delirium Screening Scale (Nu-DESC), Delirium Rating Scale (DRS) and Global Assessment Rating (GAR).

Delirium in Intensive Care:

The CAM-ICU (PDF file) Linked to another web site has been developed to assess patients in ICU who cannot talk (e.g. ventilated but awake). For further information please visit the Vanderbilt University Medical Centre Linked to another web site website. This site provides information about delirium in the ICU and provides useful video clips including a video showing how to use the CAM-ICU.