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Confusion Assessment Method for the ICU - Screen for delirium in critically ill patients
Patient must have RASS score of -3 or higher to assess for delirium. Deeply sedated patients (RASS -4 or -5) cannot be assessed.
Is there an acute change from mental status baseline? OR has behavior fluctuated in the past 24 hours?
Difficulty focusing attention (e.g., easily distracted, difficulty following conversation). Use Attention Screening Examination (ASE).
ASE Instructions: Say "Squeeze my hand when I say the letter A." Read letters: SAVEAHAART or CASABLANCA. Count errors (wrong squeeze, no squeeze, squeeze on wrong letter).
Current RASS score anything other than zero?
Evidence of disorganized or incoherent thinking. Ask 4 questions and give 1 command:
Questions: 1) Will a stone float on water? 2) Are there fish in the sea? 3) Does 1 pound weigh more than 2 pounds? 4) Can you use a hammer to pound a nail?
Command: "Hold up this many fingers" (hold 2 fingers), then "Now do the same with the other hand" (don't repeat number).
| Feature | Assessment | Positive if: | Required for Delirium? |
|---|---|---|---|
| 1. Acute Onset/Fluctuation | Mental status change or fluctuation in 24h | Yes to either question | Required |
| 2. Inattention | Attention Screening Exam (ASE) | ≥3 errors on ASE | Required |
| 3. Altered Consciousness | Current RASS score | RASS ≠ 0 | Feature 3 OR 4 |
| 4. Disorganized Thinking | 4 questions + 1 command | <4 correct responses | Feature 3 OR 4 |
Delirium Present (CAM-ICU Positive): Feature 1 AND Feature 2 AND (Feature 3 OR Feature 4)
CAM-ICU is a validated tool to detect delirium in ICU patients, including those who cannot speak (intubated). Delirium affects 50-80% of ICU patients and is associated with increased mortality, longer ICU stays, and long-term cognitive impairment. Early detection allows intervention.
CAM-ICU should be performed at least once per nursing shift (every 8-12 hours) in all ICU patients with RASS ≥-3. More frequent assessment may be needed if mental status is fluctuating or after medication changes.
Delirium has acute onset (hours to days), fluctuates, and is reversible. Dementia has gradual onset (months to years), is progressive, and generally irreversible. However, patients with dementia are at much higher risk for delirium. Delirium can occur in patients with underlying dementia.
Hypoactive delirium is often missed because patients appear calm or "sedated." It's associated with higher mortality than hyperactive delirium. Patients may not receive treatment because the delirium isn't recognized. Requires active screening with CAM-ICU to detect.
Benzodiazepines are major risk factors for delirium. Other culprits include anticholinergics, antihistamines, corticosteroids, and opioids. Minimize sedation, avoid benzodiazepines when possible, and use antipsychotics cautiously. Review all medications daily.
Antipsychotics should be reserved for severe agitation posing safety risk, after non-pharmacologic interventions have been tried. Haloperidol or quetiapine are options. They don't reduce delirium duration but can manage dangerous behaviors. Use lowest dose for shortest time. Don't use for hypoactive delirium.
CAM-ICU is a validated clinical assessment tool that requires proper training for accurate use. This calculator is for educational purposes and should not replace clinical judgment or formal CAM-ICU training. Delirium assessment should be performed by qualified healthcare professionals. Always assess RASS score first before attempting CAM-ICU. Implement the ABCDEF bundle for comprehensive delirium prevention and management.