PRINCIPLE 3: Assessment of older people with confusion
Older people who are confused will be assessed. The cause of their confusion will be investigated to determine the appropriate management.
The Confusion Assessment Method (CAM) is a validated tool that is recommended to determine whether a patient’s confusion is due to delirium.1 It was created by Dr. Sharon Inouye and her colleagues at the Hospital Elder Life Program.
The CAM should be used for any older person who appears to be disorientated /confused or who has any change in behaviour or loss of consciousness. It should be used in conjunction with a cognitive screening tool, good clinical and medical assessment, together with baseline cognition information from carers and family or the community or residential aged care service.2
- If the CAM is positive for delirium, then the cause of delirium should be investigated and symptoms managed.
- If the CAM is negative for delirium, investigations should be undertaken to identify the cause of the older person’s confusion such as dementia (new or existing) or mental health conditions (depression, psychosis, anxiety).3,4 Person-centred care strategies should be used to manage their confusion. For mental health conditions, referral should be made to mental health services as per local arrangements.
The CAM instrument
The CAM instrument, scale and manual can be downloaded from the Delirium Instruments page of the American Geriatrics Society CoCare HELP
The CAM should be used in accordance with training and procedures outlined in the CAM Training Manual. Brief cognitive testing is required for accurate scoring of the CAM. At a minimum, testing of orientation and sustained attention is recommended, such as digit spans, days of week, or months of year backwards.
Who should do the assessment?
The CAM can be performed by any member of the multidisciplinary team. This will usually be completed by the doctor, nurse or occupational therapist. They should be trained on the use of the CAM tool.5
Identifying the cause
A comprehensive bio-psychosocial assessment should be performed to identify and address the cause of the confusion. This should include the following components.5
- Hospital Elder Life Program, LLC. Confusion Assessment Method. 2003.
- NSW Agency for Clinical Innovation. Cognitive Assessment of the Older Person. 2012.
- National Institute for Health and Clinical Excellence (NICE). Delirium: diagnosis, prevention and management. NICE, July 2010.
- Young J, Murthy L, Westby M, Akunne A, O’Mahony R, Guideline Development G. Diagnosis, prevention, and management of delirium: summary of NICE guidance. BMJ. 2010;341:c3704.
- Clinical Epidemiology and Health Service Evaluation Unit Melbourne Health in collaboration with the Delirium Clinical Guidelines Expert Working Group. Clinical Practice Guidelines for the Management of Delirium in Older People, 2006.