Validation of the confusion assessment method in the palliative care setting

Abstract

The Confusion Assessment Method (CAM) is widely used in the palliative care setting despite the fact that its performance in this population has not been validated. The aim of the study was to determine the sensitivity and specificity of the CAM when used by Non-Consultant Hospital Doctors (NCHDs) working in a specialist palliative care unit. A pilot phase was performed in which NCHDs received a 1-hour training session based on the original CAM training manual. 32 patients underwent 33 assessments in the pilot phase but the sensitivity of the CAM was only 0.5 (0.22-0.78) and specificity was 1.0 (0.81-1.0). An 'enhanced' training programme was devised that took place over two 1-hour sessions and involved case-based learning focused on the areas where the NCHDs were experiencing difficulty. 52 patients underwent 54 assessments in the main phase of the study and the performance of the CAM improved significantly. Sensitivity was 0.88 (0.62-0.98) and specificity was 1.0 (0.88-1.0). The results suggest that the CAM is a valid screening tool for delirium in the palliative care setting but its performance is dependent on the skill of the operator. NCHDs require a certain standard of training before becoming proficient in its use.

Delirium prevalence, incidence, and implications for screening in specialist palliative care inpatient settings: A systematic review

“…62,64 Clinicians were involved in patient screening and assessment in half the studies, highlighting potential for routine delirium screening outside a research context, and feasibility of increasing delirium recognition capabilities by nonpsychiatric clinicians through training and access to validated delirium-screening and assessment tools. 38,50,54 Delirium screening by nurses in a hospice setting has been demonstrated to be feasible and effective. 14,25 However, the challenges of screening for delirium in palliative care populations was also demonstrated by the small proportion of included studies measuring delirium occurrence specifically in cohorts of patients who were dying, and proportion of patients and/or families who declined to participate in the delirium assessment process, indicating delirium assessment is not always acceptable to them.…”

“…4,38,41 The CAM 49 was validated in other clinical settings and languages, 43 and subsequently validated in the palliative care setting. 54 No studies reported perspectives of patients or families of the acceptability of delirium-screening and assessment processes.…”

Validation of the Confusion Assessment Method in Detecting Postoperative Delirium in Cardiac Surgery Patients

“…Similarly, Lemiengre et al 38 reported a low sensitivity when nurses in geriatric care used the CAM without concomitant cognitive testing, with difficulties identified in recognizing acute onset, fluctuation, and altered level of consciousness. In a palliative care setting, Ryan et al 41 reported that these problems were not limited to nurses; physicians also had problems recognizing these characteristics on the basis of CAM results. Because of the findings of low precision when CAM is used alone, combining the CAM with cognition testing might be a desirable practice to improve the detection of delirium, especially when CAM assessments are performed by caregivers who are not specialists in geriatric psychiatry.…”

Cancer-related pain management in clinical oncology

“…33,34 Te Confusion Assessment Method is a brief screening tool for delirium that has been validated in many patient populations, including patients with advanced illnesses. 35 More detailed diagnostic tools, such as the Delirium Rating Scale Revised-98 and the Memorial Delirium Assessment Scale, can be used to confrm the diagnosis of delirium and monitor changes over time. 36 It is important to be attentive to the various delirium subtypes (hypoactive, hyperactive or mixed) and identify any reversible causes, such as dehydration, electrolyte abnormalities, infection, pain, and medications (ie, opioids, benzodiazepines, anticholinergics, steroids).…”