Practice guideline for the treatment of patients with delirium. American Psychiatric Association. 1999 May. 41 pages.
American Psychiatric Press, Washington, DC. Single copies, $22.50. [For more info]
Treating delirium: A quick reference guide for psychiatrists. Washington, DC: American Psychiatric Association, 1999. 14 p.
Delirium: a patient and family guide. Washington, DC: American Psychiatric Association, 1999. 11 p.
Acute Confusion/Delirium with Quick Reference Guide.
University of Iowa Gerontological Nursing Interventions Research Center: Evidence-based Protocols.
Describes the assessment and management practice for elderly patients with acute confusion/delirium. This includes screening and ongoing surveillance for acute confusion/delirium based on identified risk factors with a focus on preventing or minimizing acute confusion/delirium. 42 pages. March 1998. $17.50
[For more info]

Also available from:
Rapp, C. G. (2001). Acute confusion/Delirium protocol. Journal of Gerontological Nursing, 27(4), 21-33.

Source: National Guideline Clearinghouse www.guideline.gov

 

Nurses Recognition

Inouye, S. K., Foreman, M. D., Mion, L. C., Katz, K. H., Cooney, L. M. Jr. (2001). Nurses' recognition of delirium and its symptoms: Comparison of nurse and researcher ratings. Archives of Internal Medicine, 161, 2467-2473.
"Nurses often missed delirium when present, but rarely identified delirium when absent."
"Four independent risk factors for underrecognition by nurses were : hypoactive delirium, age 80 years and older, vision impairment, and dementia. ... Patients with 3 or 4 risk factors had a 20-fold risk for underrecognition of delirium by nurses."

Risk Factors of Delirium Among Medical Patients:

• Inouye, S. K., Viscoli, C. M., & Horwitz, R. I. (1993). A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Annals of Internal Medicine, 119, 474-481
  --> Predisposing factors: Baseline vulnerability, admission characteristics
  
  
• Inouye, S. K. & Charpentier, P. A. (1996). Precipitating factors for delirium, in hospitalized elderly persons: Predictive model and interrelationship with baseline vulnerability. Journal of American Medical Association, 275, 852-857.
  --> Precipitating factors: Insults, events during hospitalizatin
  
  
• Inouye, S. K. (1999). Predisposing and precipitating factors for delirium in hospitalized elderly patients. Dementia and Geriatric Cognitive Disorders, 10, 393-400.
  --> Summary of the above two studies.

Assessment of Delirium/Acute Confusion:

Review of Assessment Methods/Instruments:

Smith, M.J., Breitbart, W.S., & Platt, M.M.(1995). A critique of instruments and methods to detect, diagnose, and rate delirium, Journal of Pain and Symptom Management, 10, 35-77.
Comprehensive review of assessment methods, inclouding diagnostic criteria, observational and interview scales, and pathophysiological measures.

Rapp, C. G., Wakefield, B., Fundrat, M., Mentes, J., Tripp-Reimer, T., Culp, K. et al. (2000). Acute confusion assessment instruments: Clinical versus research usability. Applied Nursing Research, 13, 37-45.
Review of Mini-Mental Status Exam, Delirium Rating Scale, Delirium Symptom Index, Confusion Assessment Method, Clinical Assessment of Confusion, and NEECHAM Confusion Scale regarding their clinical and research utility as well as psychometric properties. Recommendations: use Mini-Mental, NEECHAM, and Confusion Assessment Method.

Cacchione, P. Z. (2002). Four acute confusion assessment instruments: reliability and validity for use in long-term care facilities. Journal of Gerontological Nursing 28(1), 12-19.
A psychometric study of Visual Analogue Sacle of Confusion (VAS-C), Clinical Assessment of Confusion - type A and B (CAC-A/B), and NEECHAM Confusion Scale (NEECHAM) in long-term care setting. Recommendations: use VAS-C for brief screening, use NEECHAM for detailed assessment.

NEECHAM Confusion Scale:

"The NEECHAM Confusion Scale (Copyright 1985/1989, Virginia J. Neelon)" [Figure2-4]; and
"Instructions for Scoring the NEECHAM Confusion Scale" [Box 2-1]
Pages: 91-94 of "Gerontological Nursing: Concepts and Practice" (2nd ed.)
Editors: Matteson, E. S. McConnell & A. D. Linton
Publishers: W.B.Saunders, Philadelphia
Publication Year: 1997

Neelon, V. J., Champagne, M. T., Carlson, J. R., & Funk, S. G. (1996). The NEECHAM confusion scale: Construction, validation, and clinical testing. Nursing Research, 45, 324-330.
-->Psychometric paper.

Clinical Assessment of Confusion (CAC):

Vermeersch, P.E.H. (1992). Clinical assessment of confusion. In S. G. Funk, E. M. Tornquist, M. T. Champagne, R. A. Wiese (Eds.), Key aspects of elder care: Managing falls, incontinence, and cognitive impairment (pp. 251-262). New York: Springer.
Contains the original scales of the CAC type A (short version) and type B (full version) with psychometric information.

Vermerrsch, P. E. H., & Henly, S. J. (1997). Validation of the structure for the "Clinical Assessment of Confusion-A." Nursign Research, 46, 208-213.
Psychometric properties of the CAC-A with mailed samples of nurses' ratings of "confusion."

Confusion Assessment Method (CAM):

Inouye, S.K., van Dyck, C.H., Alessi, C.A., Balkin, S., Siegal, A.P., Horwitz, R.I. (1990). Clarifying confusion: The Confusion Assessment Method. Annals of Internal Medicine, 113, 941-948.
--> Widely used, easy four-step diagnostic algorithm: See also updated version of CAM below (CAM-ICU).

Mini-Mental Status Exam (MMSE):

Original Folstein's MMSE:
->A test of global cognitive function
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-Mental State: A practical method for grading the cognitive state of patients for clinicians. Journal of Psychiatric Research, 12, 189-198.

It is known that some of the MMSE items have age and educational bias (or effect). Here are several articles that address this issue and strategies to adjust the total score.

Anthony, J. C., LeResche, L., Niaz, U., von Korff, M. R. &, Folstein, M. F. (1982).
Limits of the 'Mini-Mental State' as a screening test for dementia and delirium among
hospital patients. Psychological Medicine, 12, 397-408.

Bleecker, M. L., Bolla-Wilson, K., Kawas, C., & Agnew, J. (1988). Age-specific norms for
the Mini-Mental State Exam. Neurology, 38, 1565-1568.

Crum, R. M., Anthony, J. C., Bassett, S. S., & Folstein, M. F. (1993). Population-based
norms for the Mini-Mental State Examination by age and educational level. Journal of
American Medical Association, 269, 2386-2391.
[This JAMA article has a table of mean, S.D., Median of the total MMSE scores weighted by age, sex, and race based on the 1980 US population census; population-based norms,
measured by trained interviewers at community settings; modified items -- adopted "serial
7's" or "spell 'world' backwards" - whichever scored higher].

Standardized MMSE
-> This version was developed to standardize administration methods, including verbal instructions/questions to be given to patients, time limits, and scoring methods. The SMMSE has a shorter administration time, an increased inter-rater reliability, etc. than does the MMSE.

Primary Sources:
Molloy, D. W. (1999). The Standardized Mini-Mental Status Exam (SMMSE). New Grange Press, Troy, Ontario, Canada.

Molloy, D. W., & Standish, T. I. (1997). A guide to the standardized Mini-Mental State
Examination. International Psychogeriatrics, 9 (Suppl.1), 87-94. [discussion, 143-150.]
[This is a conference minutes. I would recommend you to obtain the above original SMMSE from the author.]

Psychometrics:
Molly, D. W., Alemeyehu, E., & Roberts, R. (1991). Reliability of a Standardized Mini-Mental State Examination compared with the traditional Mini-Mental State Examination. American Journal of Psychiatry, 148, 102-105.

Secondary source:
Pangman, V. C., Sloan, J., & Guse, L. (2000). An examination of psychometric properties
of the Mini-Mental State Examination and the Standardized Mini-Mental State Examination:
Implications for clinical practice. Applied Nursing Research, 13, 209-213.
[The authors addressed the controversial issue of "time limits" in the SMMSE. Limited time allowed in each item may overestimate "cognitive disability" ... respondents may have physical disability that takes longer time than is allowed.]

Modified MMSE (3MS)
-> This version has additional four questions and extended/modified scoring methods, which may help identifying subtile cognitive decline such as early stage of dementia or dleirium.

Primary Source:
Teng, E. L., & Chui, H. C. (1987). The modified Mini-Mental State (3MS) Examination.
Journal of Clinical Psychiatry, 48, 314-318.

Secondary Source (a study used 3MS):
* McDowell, I., Kristjansson, B., Hill, G. B., & Hebert, R. (1997). Community screening
for dementia: the Mini Mental State Exam and Modified Mini-Mental State Exam compared.
Journal of Clinical Epidemiology, 50, 377-383.
[Authors say that the psychometric properties of the 3MS are superior to the MMSE,
probably due to the extended scoring system of the 3MS rather than to these additional
questions in the 3MS.]

Delirium in the ICU:

Justic, M. (2000). Does "ICU psychosis" really exist? Critical Care Nurse, 20(3), 28-37; quiz 38-39.

Ely et al. (2001) Delirium in the Intensive Care Unit: An Under-Recognized Syndrome of Organ Dysfunction

Confusion Assessment Method for the ICU (CAM-ICU):

ICU Derilium and Cognitive Impairment Study Group:
This site includes patient/family info, delirium assessment (CAM-ICU) in different languages, treatment, and other resources.

Psychometrics Preliminary Report:
Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001; 29:1370-1379.

Psychometrics Paper of Revised CAM-ICU:
Ely, E. W., Inouye, S. K., Bernard, G. R. Gordon, S., Francis, J., May, L., Truman, B. et al. (2001). Delirium in Mechanically Ventilated Patients: Validity and Reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)
Journal of American Medical Association, 286, 2703-2710. [Abstract]

Intervention Studies:

Inouye, S. K., Bogardus, S. T., Charpentier, P. A., Leo-Summers, L., Acampoora, D. et al. (1999) A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine, 340, 669-676.

Newspaper articles: Short reports: Sum Media-Canada site

Newspaper articles: Detailed reports: Yale U site

 

Review and Theoretical Basis:

• Dementia and Geriatric Cognitive Disorders, Vol. 10, 1999 (Special issue on delirium)
  
  
• Foreman, M. D. (1993). Acute Confusion in the Elderly. Annual Review of Nursing Research,11, 3-30.
  
  
• Lipowski, Z. (1990). Delirium: Acute Confusional States. New York: Oxford University Press.
  
  
• Wolanin, M. O. & Phillips, L. R. F. (1981). Confusion: Prevention and care. St. Louis: Mosby.
  
  
• Neelon, V. J. (1990). Postoperative confusion. Critical Care Nursing Clinics of North America, 2, 579-587.
  
  

Qualitative Studies:

Subjective experience of delirium:

Schofield, I. (1997). A small exploratory study of the reaction of older people to an episode of delirium. Journal of Advanced Nursing, 25, 942-52.