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## Complete Summary

#### TITLE

Delirium: proportion of patients meeting diagnostic criteria on the
Confusion Assessment Method (CAM).

#### SOURCE(S)

Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI.
Clarifying confusion: the confusion assessment method. A new method for
detection of delirium. Ann Intern Med1990 Dec 15;113(12):941-8.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2240918)

### Measure Domain

#### PRIMARY MEASURE DOMAIN

Outcome

The validity of measures depends on how they are built. By examining the
key building blocks of a measure, you can assess its validity for your
purpose. For more information, visit the [Measure
Validity](http://www.qualitymeasures.ahrq.gov/resources/measure_domains.aspx)
page.

#### SECONDARY MEASURE DOMAIN

Process

### Brief Abstract

#### DESCRIPTION

This measure assesses the proportion of patients meeting the diagnostic
criteria for delirium as measured by the Confusion Assessment Method
(CAM) instrument.

#### RATIONALE

Delirium is a common, serious, and potentially preventable source of
morbidity and mortality for older hospitalized patients. Delirium has
assumed particular importance because patients over 65 currently account
for more than 48% of all days of hospital care. Based on 1994 figures,
each year delirium complicates hospital stays for over 2.3 million older
persons, involving over 17.5 million inpatient days, and accounting for
over \$4 billion of Medicare expenditures. Substantial additional costs
accrue following hospital discharge because of the increased need for
institutionalization, rehabilitation, and home care. Importantly, the
incidence of delirium is likely to increase with the aging of the
population. These projections highlight the clinical and health policy
implications of delirium. Morevoer, delirium meets the criteria for a
health care quality indicator: it is common, frequently iatrogenic, and
integrally linked to processes of care. Thus, delirium fulfills
Williamson\'s principle of \"maximal achievable benefit: the diagnosis
is frequent, deficiencies in care are common and serious, and the
deficiencies are correctable.\" Because of its ease of use, the
Confusion Assessment Method is currently the most widely used instrument
for detection of delirium worldwide.

#### PRIMARY CLINICAL COMPONENT

Delirium; Confusion Assessment Method instrument; diagnosis

#### DENOMINATOR DESCRIPTION

All patients studied, typically a cohort of older persons, such as
hospital or nursing home admissions

#### NUMERATOR DESCRIPTION

The number of patients from the denominator meeting the diagnostic
criteria for delirium as assessed by the Confusion Assessment Method
(CAM) instrument.

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE CRITERION OF QUALITY

-   One or more research studies published in a National Library of
    Medicine (NLM) indexed, peer-reviewed journal

### Evidence Supporting Need for the Measure

#### NEED FOR THE MEASURE

Use of this measure to improve performance

#### EVIDENCE SUPPORTING NEED FOR THE MEASURE

Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D,
Holford TR, Cooney LM Jr. A multicomponent intervention to prevent
delirium in hospitalized older patients. N Engl J Med1999 Mar
4;340(9):669-76.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10053175)

Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium
after hip fracture: a randomized trial. J Am Geriatr Soc2001
May;49(5):516-22.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11380742)

Milisen K, Foreman MD, Abraham IL, De Geest S, Godderis J, Vandermeulen
E, Fischler B, Delooz HH, Spiessens B, Broos PL. A nurse-led
interdisciplinary intervention program for delirium in elderly
hip-fracture patients. J Am Geriatr Soc2001 May;49(5):523-32.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11380743)

### State of Use of the Measure

#### STATE OF USE

Current routine use

#### CURRENT USE

Internal quality improvement

### Application of Measure in its Current Use

#### CARE SETTING

Hospitals\
Long-term Care Facilities

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Nurses\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Single Health Care Delivery Organizations

#### TARGET POPULATION AGE

Age greater than or equal to 65 years

#### TARGET POPULATION GENDER

Either male or female

#### STRATIFICATION BY VULNERABLE POPULATIONS

Unspecified

### Characteristics of the Primary Clinical Component

#### INCIDENCE/PREVALENCE

Delirium, defined as an acute disruption of attention and cognition,
occurs in 14% to 56% of older hospitalized patients and is the most
frequent complication of hospitalization in these patients.

#### EVIDENCE FOR INCIDENCE/PREVALENCE

Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital
care is failing older persons and a window to improve quality of
hospital care. Am J Med1999 May;106(5):565-73. \[103 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10335730)

#### ASSOCIATION WITH VULNERABLE POPULATIONS

Delirium, also known as acute confusional state, is a common, serious,
and potentially preventable source of morbidity and mortality among
hospitalized older patients.

#### EVIDENCE FOR ASSOCIATION WITH VULNERABLE POPULATIONS

Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D,
Holford TR, Cooney LM Jr. A multicomponent intervention to prevent
delirium in hospitalized older patients. N Engl J Med1999 Mar
4;340(9):669-76.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10053175)

Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI.
Clarifying confusion: the confusion assessment method. A new method for
detection of delirium. Ann Intern Med1990 Dec 15;113(12):941-8.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2240918)

#### BURDEN OF ILLNESS

The development of delirium in the hospital is associated with mortality
rates of 25% to 33%, increased morbidity, functional decline, increased
need for nursing surveillance, greater hospital costs, increased length
of stay and greater rates of nursing home placement.

#### EVIDENCE FOR BURDEN OF ILLNESS

Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital
care is failing older persons and a window to improve quality of
hospital care. Am J Med1999 May;106(5):565-73. \[103 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10335730)

Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI.
Clarifying confusion: the confusion assessment method. A new method for
detection of delirium. Ann Intern Med1990 Dec 15;113(12):941-8.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2240918)

#### UTILIZATION

Based on 1994 figures, each year delirium complicates hospital stays for
over 2.3 million older persons, invovling over 17.5 million inpatient
days, and accounting for over \$4 billion of Medicare expenditures.
Substantial additional costs accrue following hospital discharge because
of the increased need for institutionalization, rehabilitation, and home
care.

#### EVIDENCE FOR UTILIZATION

Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D,
Holford TR, Cooney LM Jr. A multicomponent intervention to prevent
delirium in hospitalized older patients. N Engl J Med1999 Mar
4;340(9):669-76.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10053175)

Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital
care is failing older persons and a window to improve quality of
hospital care. Am J Med1999 May;106(5):565-73. \[103 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10335730)

#### COSTS

See \"Utilization\" field.

### Institute of Medicine National Healthcare Quality Report Categories

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### Data Collection for the Measure

#### CASE FINDING

Users of care only

#### DESCRIPTION OF CASE FINDING

A cohort of older persons, such as hospital or nursing home admissions

#### DENOMINATOR SAMPLING FRAME

Patients associated with provider

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
All patients studied, typically a cohort of older persons, such as
hospital or nursing home admissions

**Exclusions**\
Unspecified

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

All cases in the denominator are equally eligible to appear in the
numerator

#### DENOMINATOR (INDEX) EVENT 

Institutionalization

#### DENOMINATOR TIME WINDOW

Time window is a single point in time

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
The number of patients from the denominator meeting the diagnostic
criteria^\*^ for delirium as assessed by the Confusion Assessment Method
(CAM) instrument

^\*^The measure is scored based on ratings of four key features of
delirium:

1.  Acute onset and fluctuating course

2.  Inattention

3.  Disorganized thinking

4.  Altered level of consciousness

The diagnosis of delirium by CAM requires the presence of features (1),
(2), and either (3 or 4).

**Exclusions**\
Unspecified

#### MEASURE RESULTS UNDER CONTROL OF HEALTH CARE PROFESSIONALS, ORGANIZATIONS AND/OR POLICYMAKERS

The measure results are somewhat or substantially under the control of
the health care professionals, organizations and/or policymakers to whom
the measure applies.

#### NUMERATOR TIME WINDOW

Encounter or point in time

#### DATA SOURCE

Patient survey

#### LEVEL OF DETERMINATION OF QUALITY

Individual Case

#### OUTCOME TYPE

Proxy for Outcome

#### PRE-EXISTING INSTRUMENT USED

Unspecified

### Computation of the Measure

#### SCORING

Rate

#### INTERPRETATION OF SCORE

Better quality is associated with a lower score

#### ALLOWANCE FOR PATIENT FACTORS

Unspecified

#### STANDARD OF COMPARISON

Internal time comparison

### Evaluation of Measure Properties

#### EXTENT OF MEASURE TESTING

When validated against the reference standard ratings of geriatric
psychiatrists\' ratings based on comprehensive psychiatric assessment,
the Confusion Assessment Method (CAM) had a sensitivity of 94-100%,
specificity of 90-95%, positive predictive value of 91-94%, and a
negative predictive value of 90-100%. The interobserver reliability of
the CAM was high (Kappa = 0.81-1.0). Since delirium is a fluctuating
condition by nature, test-retest reliability cannot be validly assessed.

#### EVIDENCE FOR RELIABILITY/VALIDITY TESTING

Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI.
Clarifying confusion: the confusion assessment method. A new method for
detection of delirium. Ann Intern Med1990 Dec 15;113(12):941-8.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2240918)

### Identifying Information

#### ORIGINAL TITLE

The Confusion Assessment Method (CAM) for detection of delirium.

#### DEVELOPER

Inouye, Sharon K. M.D., M.P.H.

#### FUNDING SOURCE(S)

None

#### COMPOSITION OF THE GROUP THAT DEVELOPED THE MEASURE

Sharon K. Inouye, MD, MPH, Professor of Medicine, Harvard Medical School

#### FINANCIAL DISCLOSURES/OTHER POTENTIAL CONFLICTS OF INTEREST

None

#### ADAPTATION

This measure was not adapted from another source.

#### RELEASE DATE

1990 Dec

#### MEASURE STATUS

This is the current release of this measure.

#### SOURCE(S)

Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI.
Clarifying confusion: the confusion assessment method. A new method for
detection of delirium. Ann Intern Med1990 Dec 15;113(12):941-8.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2240918)

#### MEASURE AVAILABILITY

The individual measure, \"The Confusion Assessment Method (CAM) for
Detection of Delirium\" is published in the \"Annals of Internal
Medicine,\" 1990; 113:941-48.

For further information and to view the Training Manual, see
<http://hospitalelderlifeprogram.org/pdf/The_Confusion_Assessment_Method.pdf>.

#### NQMC STATUS

This NQMC summary was completed by ECRI on February 27, 2003. The
information was verified by the measure developer on March 3, 2003.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

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© 2008 National Quality Measures Clearinghouse

Date Modified: 11/3/2008