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Tools to Help Hospitalists Spot Delirium

An excerpt of my article from the March ACP Hospitalist:

Delirium is common among older hospitalized patients and can lead to poor outcomes. HoweACPH delirium coverver, the condition is often missed during rushed morning rounds. Patients may seem simply sleepy or physicians might catch them in a good moment, despite fluctuating periods of delirium.
The 10-item Confusion Assessment Method (CAM) is often recommended for diagnosing delirium, but although a recently validated short version, the 3D-CAM, takes only 3 minutes to administer, even this may be too time-consuming for busy hospital practice.

“One of our challenges as hospitalists is that the methods of diagnosing and validating delirium in research trials don’t work very well in daily practice,” said Ethan Cumbler, MD, FACP, medical director of the Acute Care for the Elderly service at the University of Colorado Hospital in Aurora. “In general we don’t have 30 minutes to complete a dedicated cognitive assessment, so what practicing hospitalists really need is a rapid assessment tool.”

Recently developed screening tools that can be administered quickly at the bedside have the potential to provide that. A 2-item tool that asks patients to name the months of the year backwards and the day of the week, for example, accurately identified 93% of delirium cases in a study published in the October 2015 Journal of Hospital Medicine (JHM).

More user-friendly screening tools may encourage clinicians to routinely screen for delirium and raise awareness about the signs and symptoms, which include inattention, disorganized thinking, and altered level of consciousness. However, experts caution that every test has both advantages and limitations.

“When there is limited time, a brief assessment makes sense, but realize that you may sacrifice some diagnostic accuracy,” said Jin H. Han, MD, MSc, associate professor of emergency medicine at Vanderbilt University in Nashville, Tenn., who studies delirium. “These newer brief methods are appealing for hospitalists, but they have not been validated in large studies.”

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