Long-Term Care Survey Alert

Consider adding the "Confusion Assessment Method" to your toolbox.

You need to identify a resident's delirium ASAP so you can identify the underlying cause. To aid you in that detection effort, the Confusion Assessment Method (CAM) is just what the nurse might order.

"The CAM is a very good measure for assessing delirium, which is an acute change that happens within 24 hours," says Barbara Resnick, PhD, RN, CRNP, FAAN, professor at the University of Maryland in Baltimore. Delirium "always warrants an immediate investigation and change to the care plan." (See the shortened version of the CAM in the next article.)

Beware the double-edged peril: Missing a case of delirium can result in a permanent loss of functioning for a resident -- or even death.

It can also put your survey record in a tailspin. Say after reading the chart or talking with residents and their families, surveyors found that the staff missed assessing delirium, which resulted in actual harm to a resident. In that case, the facility might be looking at a G-level deficiency, according to Sheila Capitosti, RNC, NHA, MHSA, a consultant with LTCQ Inc. in Lexington, MA. If surveyors determine that the shortfall in detecting delirium represented a "widespread" failure involving assessment, policies/procedures and quality assurance, the facility could face an immediate jeopardy citation, she says.

Solution: You can use the CAM to "tease out the hallmarks of delirium," which is "trickier to do" when the resident has pre-existing cognitive impairment, says Ann Marie Monahan, MSN, RN, RN, MSN, clinical nurse educator with the Vancouver Island Health Authority. 

The CAM is particularly sensitive to changes in mental status in people with dementia, but it "works well in all populations," adds Sharon Inouye, MD, PhD, the Harvard professor who developed it.

Use the Test Appropriately

Inouye advises healthcare staff to administer the CAM as part of a quick formal cognitive assessment. That's because the information required to score the CAM isn't easily collected as part of "routine conversation," she tells Eli. "The cognitive assessment can be quite brief, however," Inouye adds.

For example, staff can use "the Mini-Mental State Examination or the Short Portable Mental Status Questionnaire," both of which contain "brief questions to assess orientation, memory and attention."

Providers using the CAM instrument should refer to the training manual, advises Inouye. It's available at http://elderlife.med.yale.edu. (Click on the links "clinicians" and then "useful web sites.")

Tip: Facilities can also refer to the Delirium Resident Assessment Protocol triggers to see if the person appears to have delirium. The RAP also walks you through potential causes of delirium.

Resource: The Vancouver Island Health Authority has developed a DVD, "Delirium in the Older Adult: A Medical Emergency," available for $33.90 US. Access order forms at www.viha.ca/ppo/learning/delirium.