Delirium is frequent in older Emergency Department (ED) patients, but detection rates for delirium in the ED are low. To aid in identifying delirium, we developed and implemented a two-step systematic delirium screening and assessment tool in our ED: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Components of the mCAM-ED include: (1) screening for inattention, the main feature of delirium, which was performed with the Months Backwards Test (MBT); (2) delirium assessment based on a structured interview with questions from the Mental Status Questionnaire by Kahn et al. and the Comprehension Test by Hart et al. The aims of our study are (1) to investigate the performance criteria of the mCAM-ED tool in a consecutive sample of older ED patients, (2) to evaluate the performance of the mCAM-ED in patients with and without dementia and (3) to test whether this tool is efficient in keeping evaluation time to a minimum and reducing screening and assessment burden on the patient. For this prospective validation study, we recruited a consecutive sample of ED patients aged 65 and older during an 11-day period in November 2015. Trained nurses assessed patients with the mCAM-ED. Results were compared to the reference standard [i.e. the geriatricians’ delirium diagnosis based on the criteria of the Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)]. Performance criteria were computed. We included 286 consecutive ED patients aged 65 and older. The median age was 80.02 (Q1 = 72.15; Q3 = 86.76), 58.7% of included patients were female, 14.3% had dementia. We found a delirium prevalence of 7.0%. In patients with dementia, specificity and positive likelihood ratio were lower. When compared to the reference standard, delirium assessment with the mCAM-ED has a 0.98 specificity and a 39.9 positive likelihood ratio. In 80.0% of all cases, the first step of the mCAM-ED, i.e. screening for inattention with the MBT, took less than 30 s. On average, the complete mCAM-ED assessment required 3.2 (SD 2.0), 5.6 (SD 3.2), and 6.2 (SD 2.3) minutes in cognitively unimpaired patients, patients with dementia and patients with dementia or delirium, respectively. The mCAM-ED is able to efficiently rule out delirium as well as confirm the diagnosis of delirium in elderly patients with and without dementia and applies minimal screening and assessment burden on the patient.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Florian F. Grossmann
Modified Confusion Assessment method for the Emergency Department
Mental Status Questionnaire
Modified Richmond Agitation Sedation Scale
Association American Psychiatric, Task force on DSM-IV (2000) Diagnostic and statistical manual of mental disorders: DSM-IV-TR, 4th edn. American Psychiatric Association, Wachington, DC
Elie M, Rousseau F, Cole M, Primeau F, McCusker J, Bellavance F (2000) Prevalence and detection of delirium in elderly emergency department patients. CMAJ 163(8):977–981. http://www.cmaj.ca/cgi/content/abstract/2163/2008/2977. Retrieved July 2004
Hustey FM, Meldon SW, Smith MD, Lex CK (2003) The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med 41(5):678–684. https://doi.org/10.1067/mem.2003.152
Grossmann FF, Hasemann W, Graber A, Bingisser R, Kressig RW, Nickel CH (2014) Screening, detection and management of delirium in the emergency department—a pilot study on the feasibility of a new algorithm for use in older emergency department patients: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Scand J Trauma Resusc Emerg Med 22(1):19. https://doi.org/10.1186/1757-7241-22-19
Han JH, Shintani A, Eden S, Morandi A, Solberg LM, Schnelle J, Dittus RS, Storrow AB, Ely EW (2010) Delirium in the emergency department: an independent predictor of death within 6 months. Ann Emerg Med 56(3):244–252 e241
Han JH, Eden S, Shintani A, Morandi A, Schnelle J, Dittus RS, Storrow AB, Ely EW (2011) Delirium in older emergency department patients is an independent predictor of hospital length of stay. Acad Emerg Med 18(5):451–457. https://doi.org/10.1111/j.1553-2712.2011.01065.x
Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC (1995) Unrecognized delirium in ED geriatric patients. Am J Emerg Med 13(2):142–145
Hustey FM, Meldon SW (2002) The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med 39(3):248–253
Naughton BJ, Moran MB, Kadah H, Heman-Ackah Y, Longano J (1995) Delirium and other cognitive impairment in older adults in an emergency department. Ann Emerg Med 25(6):751–755
Han JH, Morandi A, Ely EW, Callison C, Zhou C, Storrow AB, Dittus RS, Habermann R, Schnelle J (2009) Delirium in the nursing home patients seen in the emergency department. J Am Geriatr Soc 57(5):889–894. https://doi.org/10.1111/j.1532-5415.2009.02219.x
Van de Meeberg EK, Festen S, Kwant M, Georg RR, Izaks GJ, Ter Maaten JC (2016) Improved detection of delirium, implementation and validation of the CAM-ICU in elderly Emergency Department patients. Eur J Emerg Med. https://doi.org/10.1097/mej.0000000000000380
Morandi A, McCurley J, Vasilevskis EE, Fick DM, Bellelli G, Lee P, Jackson JC, Shenkin SD, Marcotrabucchi Schnelle J, Inouye SK, Ely EW, MacLullich A (2012) Tools to detect delirium superimposed on dementia: a systematic review. J Am Geriatr Soc 60(11):2005–2013. https://doi.org/10.1111/j.1532-5415.2012.04199.x
Meagher J, Leonard M, Donoghue L, O’Regan N, Timmons S, Exton C, Cullen W, Dunne C, Adamis D, Maclullich AJ, Meagher D (2015) Months backward test: a review of its use in clinical studies. World J Psychiatry 5(3):305–314. https://doi.org/10.5498/wjp.v5.i3.305
Stillman MJ, Rybicki LA (2000) The bedside confusion scale: development of a portable bedside test for confusion and its application to the palliative medicine population. J Palliat Med 3(4):449–456. https://doi.org/10.1089/jpm.2000.3.4.449
Kahn RL, Goldfarb AI, Pollack M, Peck A (1960) Brief objective measures for the determination of mental status in the aged. Am J Psychiatry 117:326–328
Hart RP, Levenson JL, Sessler CN, Best AM, Schwartz SM, Rutherford LE (1996) Validation of a cognitive test for delirium in medical ICU patients. Psychosomatics 37(6):533–546. https://doi.org/10.1016/S0033-3182(96)71517-7
Chester JG, Beth Harrington M, Rudolph JL (2012) Serial administration of a modified Richmond Agitation and Sedation Scale for delirium screening. J Hosp Med 7(5):450–453. https://doi.org/10.1002/jhm.1003
Grossmann FF, Hasemann W, Kressig RW, Bingisser R, Nickel CH (2017) Performance of the modified Richmond Agitation Sedation Scale in identifying delirium in older emergency department patients. Am J Emerg Med. https://doi.org/10.1016/j.ajem.2017.05.025
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 113(12):941–948
Inouye SK (2003) The Confusion Assessment Method (CAM). Training manual and coding guide. Yale University School of Medicine, New Haven
Bellelli G, Morandi A, Davis DH, Mazzola P, Turco R, Gentile S, Ryan T, Cash H, Guerini F, Torpilliesi T, Del Santo F, Trabucchi M, Annoni G, MacLullich AM (2014) Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing 43(4):496–502. https://doi.org/10.1093/ageing/afu021
Adamis D, Meagher D, Murray O, O’Neill D, O’Mahony E, Mulligan O, McCarthy G (2016) Evaluating attention in delirium: a comparison of bedside tests of attention. Geriatr Gerontol Int 16(9):1028–1035. https://doi.org/10.1111/ggi.12592
Morandi A, Han JH, Meagher D, Vasilevskis E, Cerejeira J, Hasemann W, MacLullich AM, Annoni G, Trabucchi M, Bellelli G (2016) Detecting Delirium Superimposed on Dementia: evaluation of the Diagnostic Performance of the Richmond Agitation and Sedation Scale. J Am Med Dir Assoc 17(9):828–833. https://doi.org/10.1016/j.jamda.2016.05.010
Shi Q, Warren L, Saposnik G, MacDermid JC (2013) Confusion assessment method: a systematic review and meta-analysis of diagnostic accuracy. Neuropsychiatr Dis Treat 9:1359–1370. https://doi.org/10.2147/NDT.S49520
Adamis D, Rooney S, Meagher D, Mulligan O, McCarthy G (2015) A comparison of delirium diagnosis in elderly medical inpatients using the CAM, DRS-R98, DSM-IV and DSM-5 criteria. Int Psychogeriatr 27(6):883–889. https://doi.org/10.1017/s1041610214002853
Grossmann FF, Nickel CH, Christ M, Schneider K, Spirig R, Bingisser R (2011) Transporting clinical tools to new settings: cultural adaptation and validation of the Emergency Severity Index in German. Ann Emerg Med 57(3):257–264. https://doi.org/10.1016/j.annemergmed.2010.07.021
Nemec M, Koller MT, Nickel CH, Maile S, Winterhalder C, Karrer C, Laifer G, Bingisser R (2010) Patients presenting to the emergency department with non-specific complaints: the Basel non-specific complaints (BANC) study. Acad Emerg Med 17(3):284–292. https://doi.org/10.1111/j.1553-2712.2009.00658.x
Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383
Agresti A, Coull BA (1998) Approximate is better than “exact” for interval estimation of binomial proportions. Am Stat 52(2):119–126
Zhou X-H, McClish DK, Obuchowski NA (2011) Statistical methods in diagnostic medicine, 2nd edn. Wiley-Blackwell, Oxford
Flahault A, Cadilhac M, Thomas G (2005) Sample size calculation should be performed for design accuracy in diagnostic test studies. J Clin Epidemiol 58(8):859–862. https://doi.org/10.1016/j.jclinepi.2004.12.009
Hendry K, Quinn TJ, Evans J, Scortichini V, Miller H, Burns J, Cunnington A, Stott DJ (2016) Evaluation of delirium screening tools in geriatric medical inpatients: a diagnostic test accuracy study. Age Ageing 45(6):832–837. https://doi.org/10.1093/ageing/afw130
Voyer P, Champoux N, Desrosiers J, Landreville P, Monette J, Savoie M, Carmichael PH, Richard S, Bedard A (2016) Assessment of inattention in the context of delirium screening: one size does not fit all! Int Psychogeriatr. https://doi.org/10.1017/S1041610216000533
Mariz J, Costa Castanho T, Teixeira J, Sousa N, Correia Santos N (2016) Delirium diagnostic and screening instruments in the emergency department: an up-to-date systematic review. Geriatrics 1(3):22. https://doi.org/10.3390/geriatrics1030022
Fick DM, Inouye SK, Guess J, Ngo LH, Jones RN, Saczynski JS, Marcantonio ER (2015) Preliminary development of an ultrabrief two-item bedside test for delirium. J Hosp Med 10(10):645–650. https://doi.org/10.1002/jhm.2418
Hasemann W, Godwin J, Spirig R, Kressig RW, Frei IA, Tolson D (2013) Effects of the Interdisciplinary Basel Delirium and Dementia Prevention and Management Programme DEMDEL. Glasgow Caledonian University, Glasgow
Marcantonio ER, Ngo LH, O’Connor M, Jones RN, Crane PK, Metzger ED, Inouye SK (2014) 3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium: a cross-sectional diagnostic test study. Ann Intern Med 161(8):554–561. https://doi.org/10.7326/m14-0865
O’Sullivan D, Brady N, Manning E, O’Shea E, O’Grady S, O’Regan N, Timmons S (2017) Validation of the 6-Item Cognitive Impairment Test and the 4AT test for combined delirium and dementia screening in older Emergency Department attendees. Age Ageing. https://doi.org/10.1093/ageing/afx149
Han JH, Wilson A, Vasilevskis EE, Shintani A, Schnelle JF, Dittus RS, Graves AJ, Storrow AB, Shuster J, Ely EW (2013) Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med 62(5):457–465. https://doi.org/10.1016/j.annemergmed.2013.05.003
Han JH, Wilson A, Graves AJ, Shintani A, Schnelle JF, Dittus RS, Powers JS, Vernon J, Storrow AB, Ely EW (2014) Validation of the Confusion Assessment Method for the Intensive Care Unit in older emergency department patients. Acad Emerg Med 21(2):180–187. https://doi.org/10.1111/acem.12309
Folstein M, Folstein S, McHugh P (1975) ‘Mini-mental state’: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189–198
Richardson SJ, Davis DHJ, Bellelli G, Hasemann W, Meagher D, Kreisel SH, MacLullich AMJ, Cerejeira J, Morandi A (2017) Detecting delirium superimposed on dementia: diagnostic accuracy of a simple combined arousal and attention testing procedure. Int Psychogeriatr 27(10):1585–1593. https://doi.org/10.1017/s1041610217000916
LaMantia MA, Messina FC, Hobgood CD, Miller DK (2014) Screening for delirium in the emergency department: a systematic review. Ann Emerg Med 63(5):551–560 e552. https://doi.org/10.1016/j.annemergmed.2013.11.010
Junghans C, Jones M (2007) Consent bias in research: how to avoid it. Heart 93(9):1024–1025. https://doi.org/10.1136/hrt.2007.120113
Gaspardo P, Peressoni L, Comisso I, Mistraletti G, Ely EW, Morandi A (2014) Delirium among critically ill adults: evaluation of the psychometric properties of the Italian ‘Confusion Assessment Method for the Intensive Care Unit’. Intensive Crit Care Nurs 30(5):283–291. https://doi.org/10.1016/j.iccn.2014.05.002
We are thankful to all the ED staff, the geriatricians who performed the gold standard assessments, and Dr. Duncan Shabb for helpful discussions and proofreading the manuscript.
This study was funded through Scientific Funds of the University Hospital Basel.
Conflict of interest
All authors declare that they have no conflict of interest with this study.
Statement of human rights
The study was approved by the cantonal ethics committee (identifier EKNZ-2015-123) and registered with ClinicalTrials.gov (identifier NCT02782143). All procedures performed in this study involving human participants were in accordance with the ethical standards of the local/national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
If possible, oral informed consent was obtained directly from the patient or an authorized proxy. Due to the minimal risk, little burden and potential benefit to the patient, the ethics committee allowed patients to be assessed even if there was no chance to obtain informed patient consent due to the nature of delirium or availability of a proxy.
About this article
Cite this article
Hasemann, W., Grossmann, F.F., Stadler, R. et al. Screening and detection of delirium in older ED patients: performance of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). A two-step tool. Intern Emerg Med 13, 915–922 (2018). https://doi.org/10.1007/s11739-017-1781-y
- Emergency medicine