Identifying Delirium - Onehealth.ca

Identifying Delirium 

Resource Package

Case Study 

Margaret is a moderate-to-severely impaired 84-year old widowed woman admitted to 

your long-term care facility. Prior to admission, Margaret had been living with her only 

child, a daughter along with the daughter’s husband and teenage son for the past four 

years. The decision for placement was difficult. 

Margaret has a number of medical problems, all of which have been historically well 

controlled, including diabetes mellitus, hypertension and osteoarthritis in her hips and 

lower back. Margaret has no previous psychiatric history. Margaret has fallen twice 

since her recent admission and the slight bruise on her head distresses her family. Over 

a short period, the staff has noted changes in the client, which at first were quite subtle 

but now are becoming problematic. 

Staff observes Margaret picking at things on her clothes and in the air 

Margaret’s speech at times is “jumbled”, she can talk incessantly and be up 

throughout the night 

Margaret has become increasingly agitated and on one occasion has struck another 

mobile client 

Margaret has become increasingly sensitive to noise and all changes in her 

environment, she startles easily 

Margaret is easily distracted and has difficulty focusing attention at meal time for 

example 

Margaret becomes lost easily, unable to find her room 

Family have been called in on several occasions to help deal with Margaret’s 

emerging behaviours 

Although there is a new staff rotation on the unit, the staff has “heard of” Margaret. It is 

Margaret’s day for a shower and the assigned personal care attendant is not eager to 

do it. It is documented over the last few days that Margaret is becoming increasingly 

“uncooperative”, “resistive” or “bad” during personal care. Already, the unit staff is 

behind in the day’s schedule and it isn’t even 1000h!

Seniors’ Mental Health Programs Standardized Assessment Scales 

ADMINISTRATION AND SCORING GUIDELINES 

Scale/Screen: 

Use(s): 

Time Taken: 

The Modified Confusion Assessment Method (CAM) 

To facilitate the detection of delirium in patients with dementing 

illnesses. 

The actual completion of the CAM form takes less than 5 minutes. 

The time taken to assess each feature of the CAM depends upon 

how familiar the assessor is with the patient being assessed. An 

external assessor unfamiliar with the patient would need at least 30 

minutes to observe, interview the patient, and check collateral 

sources of information before completing the CAM. 

It has been noted that assessments completed with multiple 

observation points over time showed increased sensitivity and 

specificity for the diagnosis of delirium using the CAM format. 

Rationale(s): 

Commentary: 

Many studies have commented on the problems health 

professionals have in diagnosing delirium in older adults and the 

serious health consequences inherent in delayed treatment. 

Patients with a prior dementia are at increased risk for developing 

a delirium. 

The diagnosis of the delirium in those with dementia is particularly 

challenging because of the overlap in symptoms in the two 

disorders. 

The Modified CAM may help clinicians identify possible deliria in 

those with prior dementias and facilitate appropriate and early 

assessment and treatment interventions. 

The original CAM was developed to help detect delirium in acutely ill 

elderly hospitalized patients. It was designed for use by nonpsychiatrically 

trained clinicians to identify delirium quickly and 

accurately. The CAM was adopted from DSM III R criteria. 

Permission was obtained from Dr. Inouye to modify the format for 

patients with dementia. The Modified CAM is more likely to be of 

use in the detecting of delirium in those with mild to moderate 

dementia, as it has been noted that end-stage dementia may be 

indistinguishable from delirium (except by history). The widespread 

destruction of brain cells in end-stage dementia may, it is thought, 

cause a chronic delirious state. 

Enquiries: S.A.S. Committee Chair, c/o AHE Community Geriatric Psychiatry,(780) 424-4660


Administration: 

The assessor first notes whether or not the patient has a 

diagnosed Dementia and of what type and stage. 

Acute Onset: Acuity of onset for delirium has been variously 

defined from hours to a period usually not exceeding more than 

thirty days. Bear in mind that a temporal onset of delirium may 

not have been clearly recognized if the onset has been of the 

quieter, hypokinetic variety. 

Inattention: In early to mid-stage dementia, attentional 

processes are usually unimpaired. (See attached table of 

differential features of delirium and dementia) 

Disorganized thinking: The assessor needs to identify whether 

or not there has been a change in the pattern or quality of the 

patient’s thinking. Generally, the thoughts of non-demented 

delirious patients may be illogical, bizarre, disjointed, or 

delusional. Their speech may be voluble, excited, or pressured. 

Impoverished thought, however, is more often seen in patients 

with a dementia and therefore, a delirious and demented patient 

may not present as floridly as the non-demented delirious patient. 

The sudden appearance of delusional thinking, particularly 

suspiciousness, in a previously non-delusional demented patient 

may be significant. 

Altered level of consciousness: The patient’s level of alertness 

in delirium may be abnormally high or low. The hyper-alert, easily 

startled, and fearful patient is more easily identified whereas the 

quieter, lethargic, hypo-alert patient may pose a more difficult 

problem for the assessor, where the patient’s reduced awareness 

may have resulted from other causes such as over-sedation with 

medication. It is important for the assessor to assess if there has 

been any fluctuation in the level of alertness over the assessment 

period. 

Disorientation and memory impairment: These are, of course, 

characteristic symptoms of dementia but it should be noted if 

there has been an abrupt decline in ability that may be attributed 

to a superimposed delirium. In the delirious non-demented 

patient, immediate and recent memory are impaired whereas in 

the demented, non-delirious patient, immediate memory is usually 

intact in the early to middle stages of the disease. 



Perceptual disturbances: It is important for the assessor to 

identify whether or not perceptual disturbances formed part of the 

patient’s previous dementia profile (example, Lewy Body 

Dementia), or if there has been an acute change in the type of 

perceptual disturbance experienced by the patient. Common 

perceptual disorders in delirium include micropsia, macropsia, 

distortion of shape and body image disturbance as well as 

feelings of depersonalization. Illusionary perceptions are 

common, for example, family and staff members may be 

misidentified; patterns on wallpaper or bed covers may be 

misperceived as insects or animals. Illusionary material may be 

incorporated into fragmentary delusions which accentuate the 

patient’s fear and anxiety. 

Psychomotor agitation or retardation: The classic portrayal of 

the delirious patient is usually one of hyperkinesis and excitement. 

In elderly persons, hypokinesis is more commonly seen. The 

hyperkinetic patient is unable to keep still, and repetitive 

purposeless behaviour is common. Autonomic signs of hyperarousal 

may be evident, for example, sweating, flushed skin, 

tachycardia and pupillary dilation. The hypokinetic patient, in 

contrast, is quieter and may be motionless, often drowsy, his/her 

speech may be slow and possibly slurred. A mixed presentation 

may be seen with the patient shifting between hyper and hypoactivity. 

Altered sleep-wake cycle: An altered sleep-wake cycle may be 

seen in dementia where its occurrence is attributed to reduced 

acetylcholine activity. It is therefore not a sensitive indicator of 

delirium, except if it occurs acutely in a patient with a previously 

stable circadian rhythm. 

Scoring: 

The assessor first notes, after each of the nine features, whether 

there is a change from the patient’s baseline cognitive/behavioural 

status. Then, at each of the features, the assessor notes whether the 

change is present in mild form or in marked form. Next, the assessor 

identifies whether or not features 1, 2 and either 3 or 4 are present in 

order for a diagnosis of delirium by CAM to be made, i.e., has the 

onset been acute with fluctuating symptoms; is there impaired 

“attention”, and are either “disorganized thinking” or an “altered level 

of consciousness” present. 



References: 

Inouye, SK, Van Dyck CH, Alessi, CA, , Balkin S, Siegal AP, Horwitz RI. 

Clarifying Confusion: The Confusion Assessment Method, Annals of Internal 

Medicine. 1990: 941-948. 

Rapp CG, Wakefield B, Kundrat M, Mentes J, Tripp-Reimer T, Culp K, Mobily 

P, Akins J, Onega L. Acute Confusion Assessment Instruments: Clinical 

Versus Research Usability, Applied Nursing Research, Vol. 13, No. 1 

(February), 2000: pp 37-45. 

Trzepaca PT, Mulsant BH, Dew MA, Pasternak R, Sweet RA, Zubenko GS. Is 

Delirium Different When It Occurs in Dementia A Study Using the Delirium 

Rating Scale. The Journal of Neuropsychiatry and Clinical Neuroscience 

1998; 10:199-204. 

Zou Y, Cole MG, Primeau FJ, McCusker J, Bellavance F,Laplante J. Delirium: 

Detection and Diagnosis in the Elderly: Psychiatrist Diagnosis, Confusion 

Assessment Method, or Consensus Diagnosis International 

Psychogeriatrics, 10(3), September 1998. 

Monette J, Galbaud du Fort G, Fung SH, Massoud F, Moride Y, Arsenault L, 

Afilalo M. Evaluation of the confusion assessment method (CAM) as a 

screening tool for delirium in the emergency room. General Hospital 

Psychiatry23 (2001) 20-25. 

Culp K, Tripp-Reimer T, Wadle K, Wakefield B, Akins J, Mobily P, Kundradt M. 

Screening for Acute Confusion in Elderly Long Term Care Residents. Journal 

of Neuroscience Nursing April, 1997 Vol. 29, No.2, 86-94. 

January 3, 2003 

WP/SMHPCC/Guidelines – Modified CAM 



Modified Confusion Assessment Method (for detection of delirium) 

Date: _________________________________________ 

Assessed By: __________________________________ 

For patients with dementia, please indicate whether or 

not the observed feature represents a change from the 

patient’s baseline cognitive status (i.e. Change from 

patient’s baseline). 

Patient/Client Label 

Does the patient have a diagnosis of dementia Yes No 

1. Acute onset 

Is there evidence of an acute change in mental status from patient’s baseline Yes No 

2. Inattention * Change from patient’s baseline Yes No 

A. Did the patient have difficulty focusing attention, for example, being easily 

distractible, or having difficulty keeping track of what was being said 

B. (If present or abnormal) Did this behavior fluctuate during the interview, 

that is, tend to come and go or increase and decrease in severity 

Yes, in mild form 

Yes, in marked form 

No 

Yes 

No 

Uncertain 

C. (If present or abnormal) Please describe this behavior 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

3. Disorganized thinking * Change from patient’s baseline Yes No 

Was the patient thinking disorganized or incoherent, such as rambling 

conversation, unclear or illogical flow of ideas, or unpredictable switching from 

subject to subject 



No 

4. Altered level of consciousness 

Overall, how would you rate this patient’s level of consciousness 

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. 

Lemiengre, J., Nelis, T., Joosten, E., Braes, T., Foreman, M., Gastmans, C., & Milisen, K. (2006) . Detection of delirium by 

bedside nurses using the confusion assessment method. Journal of the American Geriatrics Society, 54 (4), 685-689. 

Revised: June 12, 2006 

Enquires: SAS Committee Chair/ Alberta Hospital Edmonton Community Geriatric Psychiatry, (780) 424-4660.


Alert (normal). 

Vigilant (hyperalert, overly sensitive to environmental stimuli, startled very easily). 

Lethargic (drowsy but easily aroused). 

Stupor (difficult to arouse). 

5. Disorientation * Change from patient’s baseline Yes No 

Was the patient disorientated at any time during the interview, such as thinking 

that he or she was somewhere other than the hospital, using the wrong bed, or 

misjudging the time of day 



No 

6. Memory impairment * Change from patient’s baseline Yes No 

Did the patient demonstrate any memory problems during the interview, such 

as inability to remember events in the hospital or difficulty remembering 

instructions 



No 

7. Perceptual disturbances * Change from patient’s baseline Yes No 

Did the patient have any evidence of perceptual disturbances, for example, 

hallucinations, illusions, or misinterpretations (such as thinking something was 

moving when it was not) 



No 

8. Psychomotor agitation – Part 1 * Change from patient’s baseline Yes No 

At any time during the interview, did the patient have an unusually increased 

level of motor activity, such as restlessness, picking at bedclothes, tapping 

fingers, or making frequent sudden changes in position 



No 

8. Psychomotor Retardation – Part 2 * Change from patient’s baseline Yes No 

At any time during the interview, did the patient have an unusually decreased 

level of motor activity, such as sluggishness, staring into space, staying in one 

position for a long time, or moving very slowly 



No 








9. Altered sleep-wake cycle * Change from patient’s baseline Yes No 

Did the patient have evidence of disturbance of the sleep-wake cycle, such as 

excessive daytime sleepiness with insomnia at night 



No 

Diagnostic Algorithm 

- Diagnosis of delirium by C.A.M. requires the presence of features 1 and 2 and either 3 or 4. 

Feature 1 - Acute Onset or Fluctuating Course 

Is there evidence of an acute change in mental status from patient’s baseline 

Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase or 

decrease in severity 

Feature 2 - Inattention 

Did the patient have difficulty focusing attention, for example, being easily distractible, or having 

difficulty keeping track of what was being said 

Feature 3 - Disorganized Thinking 

Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, 

unclear or illogical flow of ideas, or unpredictable switching from subject to subject 

Feature 4 - Altered Level of Consciousness 

Feature is present if consciousness is assessed as other than alert. 








Modified Confusion Assessment Method (for detection of delirium) 

Date: _________________________________________ 

Assessed By: __________________________________ 

For patients with dementia, please indicate whether or 

not the observed feature represents a change from the 

patient’s baseline cognitive status (i.e. Change from 

patient’s baseline). 

Patient/Client Label 

Does the patient have a diagnosis of dementia Yes No 


Is there evidence of an acute change in mental status from patient’s baseline Yes No 

2. Inattention * Change from patient’s baseline Yes No 

A. Did the patient have difficulty focusing attention, for example, being easily 

distractible, or having difficulty keeping track of what was being said 

B. (If present or abnormal) Did this behavior fluctuate during the interview, 

that is, tend to come and go or increase and decrease in severity 



No 

Yes 

No 

Uncertain 

C. (If present or abnormal) Please describe this behavior 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

3. Disorganized thinking * Change from patient’s baseline Yes No 

Was the patient thinking disorganized or incoherent, such as rambling 

conversation, unclear or illogical flow of ideas, or unpredictable switching from 

subject to subject 



No 

4. Altered level of consciousness 

Overall, how would you rate this patient’s level of consciousness 








Alert (normal). 

Vigilant (hyperalert, overly sensitive to environmental stimuli, startled very easily). 

Lethargic (drowsy but easily aroused). 

Stupor (difficult to arouse). 

5. Disorientation * Change from patient’s baseline Yes No 

Was the patient disorientated at any time during the interview, such as thinking 

that he or she was somewhere other than the hospital, using the wrong bed, or 

misjudging the time of day 



No 

6. Memory impairment * Change from patient’s baseline Yes No 

Did the patient demonstrate any memory problems during the interview, such 

as inability to remember events in the hospital or difficulty remembering 

instructions 



No 

7. Perceptual disturbances * Change from patient’s baseline Yes No 

Did the patient have any evidence of perceptual disturbances, for example, 

hallucinations, illusions, or misinterpretations (such as thinking something was 

moving when it was not) 



No 

8. Psychomotor agitation – Part 1 * Change from patient’s baseline Yes No 

At any time during the interview, did the patient have an unusually increased 

level of motor activity, such as restlessness, picking at bedclothes, tapping 

fingers, or making frequent sudden changes in position 



No 

8. Psychomotor Retardation – Part 2 * Change from patient’s baseline Yes No 

At any time during the interview, did the patient have an unusually decreased 

level of motor activity, such as sluggishness, staring into space, staying in one 

position for a long time, or moving very slowly 



No 








9. Altered sleep-wake cycle * Change from patient’s baseline Yes No 

Did the patient have evidence of disturbance of the sleep-wake cycle, such as 

excessive daytime sleepiness with insomnia at night 



No 

Diagnostic Algorithm 

- Diagnosis of delirium by C.A.M. requires the presence of features 1 and 2 and either 3 or 4. 

Feature 1 - Acute Onset or Fluctuating Course 

Is there evidence of an acute change in mental status from patient’s baseline 

Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase or 

decrease in severity 

Feature 2 - Inattention 

Did the patient have difficulty focusing attention, for example, being easily distractible, or having 

difficulty keeping track of what was being said 

Feature 3 - Disorganized Thinking 

Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, 

unclear or illogical flow of ideas, or unpredictable switching from subject to subject 

Feature 4 - Altered Level of Consciousness 

Feature is present if consciousness is assessed as other than alert. 








Handout Package

©P.I.E.C.E.S. 2004 


THE CONFUSION 

ASSESSMENT METHOD 

Delirium, or 

Acute 

Confusional 

State is 

a global 

disorder 

of cognition 

and attention. 

Recognition of Delirium 

Studies have documented that 32-66% 

of delirium cases were unrecognized by 

physicians caring for clients, often 

being mistaken for dementia, 

depression or normal changes of aging 

(Inouye, 1998) 

6.1

©P.I.E.C.E.S. 2004 

Signs & Symptoms 

of Delirium 

• Acute, sudden onset 

• Fluctuating symptoms 

• Disturbance in sleep/wake pattern 

• Fluctuation in activity 

• Decreased attention 

• Change in cognition 

Recognizing Delirium – 

Need for: 

• Education of health care 

personnel 

• Assessment practices 

• Documentation 

• Reporting 

• Intervention 

• Prevention strategies 

CAUSES OF DELIRIUM 

I 

W 

A 

T 

C 

H 

D 

E 

A 

T 

H 

Infections 

Withdrawal 

Acute Metabolic 

Toxins, drugs 

CNS Pathology 

Hypoxia 

Deficiencies 

Endocrine 

Acute Vascular 

Trauma 

Heavy Metals 

6.2

©P.I.E.C.E.S. 2004 

IMPLICATIONS OF DELIRIUM 

• Loss of function 

• Mortality 

• Risk for Dementia/Death 

• Quality of Life 

• Costs of Care 

• Hospitalization/Placement 

• Stress: Client, family, staff 

INTERVENTIONS 

• Assessment Tools 

• Diagnostic Tests 

• Treat Underlying Pathology 

• Supportive Care 

• Education 

• Referral to Specialists 

PREVENTION 

Six Risk Factors For Delirium: 

Cognitive Impairment 

Sleep Deprivation 

Immobility 

Visual Impairment 

Hearing Impairment 

Dehydration 

6.3

©P.I.E.C.E.S. 2004 

THE CONFUSION 

ASSESSMENT METHOD 

• Quick 

• Use in conjunction with : 

• Structured Interview 

• Mini Mental Status Exam 

• Collateral Information 

• A Screening Tool, not a Diagnostic Tool 

• Further evaluation required to confirm 

diagnosis 

Confusion Assessment Method 


2. Inattention 

3. Disorganized Thinking 

4. Altered Level of Consciousness 

5. Disorientation 

6. Memory Impairment 

7. Perceptual Disturbances 

8. Psychomotor Agitation and Retardation 

9. Sleep/Wake Cycle Disturbance 

Case Study 

Use the Confusion Assessment 

Method (CAM) to assess for 

delirium 

6.4

©P.I.E.C.E.S. 2004 

CONCLUSION 

• Know the person’s capabilities 

• Listen to the people who know the 

client the best: Families and Front 

Line Staff 

• Look to assessment tools such as 

the CAM to assist in your practice 

• Learn to recognize the Hallmarks of 

Delirium 

6.5

Identifying Delirium - Onehealth.ca

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