1. ICU Delirium and Cognitive Impairment Study Group
CAM-ICU Basics
ICU Delirium and Cognitive Impairment Study Group

2. Delirium is a common clinical syndrome characterized by:
What is Delirium?
Delirium is a common clinical syndrome characterized by:
Inattention
Acute cognitive
dysfunction
Pathophysiology: Disruption of neurotransmission (drug action, inflammation, acute stress response)
Delirium: Think rapid onset, inattention, clouding of consciousness (bewildered), fluctuation
Dementia: Think gradual onset, intellectual impairment, memory disturbance, personality/mood change, no conscious clouding

3. Combination of both types
Subtypes of Delirium
Hypoactive
Patient may be quiet and even peaceful, despite cognitive impairment. More difficult to assess.
Hyperactive
Patient may be combative with agitation that may require sedation (is diagnosed more frequently).
Mixed
Combination of both types

4. Why monitor for Delirium?
50-80% of ventilated patients develop delirium
20-50% of lower severity ICU patients develop delirium
Over 40,000 ventilated patients are delirious every day
Delirium leads to increased mortality, longer hospital stay, poorer recovery, higher costs of healthcare, long-term neurocognitive problems.
Ely EW JAMA 2001;286,
Ely EW CCM 2001;29,

5. ICU Delirium: The Canary in the Coal Mine
Under recognized form of organ dysfunction
3-fold increase in mortality at 6 months
Each DAY a patients is delirious = 10% INCREASE in risk of death

6. Delirium in the ICU Clinical Value of RASS/CAM-ICU Measurement
Stimulates thinking of Rx:
Delirium recognition is a Burglar Alarm for us (early sign of danger)
Forces us to consider treatable causes earlier
Utilize nonpharmacologic interventions
Do NOT automatically link delirium monitoring with a specific drug treatment

7. The ABCDEs of Critical Care
Awakening
Breathing
Coordination, Choice
Delirium monitoring/management
Early mobility and Exercise

8. Educational Delirium Website

9. Level of Consciousness (arousal): RASS
A Two Step Approach to Assessing Consciousness
Step 1
Level of Consciousness (arousal): RASS
Step 2
Content of Consciousness (delirium): CAM-ICU

10. Step 1: LOC Assessment
Assess for arousal

12. Step 1: Arousal Assessment (RASS)+3 +2 +1
- 1
- 2
- 3
- 4
- 5
Richmond Agitation-Sedation Scale (RASS)
Assessment is FAST
90% of RASS/CAM-ICU assessments take <1 minute. The other 10% take only a few minutes. Speed and ease of use make this feasible on a large scale multiple times daily (often done q8h).
For instance, one patient may be just below the level of consciousness (right below the water line) while another may be much, much deeper sedated. Once a patient is unresponsive we can’t really tell just how deep they are. 12

13. Step 2: Content Assessment
Assess for Delirium

14. Confusion Assessment Method for the ICU (CAM-ICU)
Feature 1: Acute change or fluctuating course of mental status
And
Feature 2: Inattention
Feature 3: Altered level of consciousness
Feature 4: Disorganized Thinking Or
Inouye, et. al. Ann Intern Med 1990; 113:
Ely, et. al. CCM 2001; 29:
Ely, et. al. JAMA 2001; 286:

16. Feature 1: Alteration/Fluctuation in Mental Status
Is the pt different than his/her baseline mental status? OR
Has the patient had any fluctuation in mental status in the past 24 hours (eg fluctuating RASS, GCS, previous delirium assessments, etc)
Present: If either question is YES.
You have a CAM-ICU worksheet. This is a great tool to use at the bedside as you get familiar with the CAM-ICU assessment.

17. Feature 1: Alteration/Fluctuation in Mental Status
Common Questions:
What if you do not know the patient’s baseline?
Assume normal unless you have red flags that make you suspicious
Red Flag: patient came from institution
What about dementia?
Ask family “What could she/he do prior to this illness?”

18. Feature 2: Inattention Screening for Attention– two options
Letter “A” test
Letters: S A V E A H A A R T (or numbers)
Say 10 letters (or numbers) and instruct the patient to squeeze on the letter “A” (or on a certain number)
Pictures
Similar test with pictures
(instructions are in picture packets)
Inattention (Feature 2)
THE cardinal feature and must be present
F2 is quick and simple
Picture method in <5%

19. Feature 2: Inattention 1. Attempt Letters first.
2. If pt is able to perform the Letter test you are sure of the results, you are done with Inattention test.
3. If pt is unable to perform the Letter test or you are unsure of the results, use the Pictures.
If you perform both tests, use the Pictures result to determine if inattention is present.
Inattention Present : If >2 errors

20. Feature 2: Inattention
What if the patient only squeezes once and then falls back to “sleep”? or What if the patient is too hyperactive/combative to participate in squeezing?
Remember what you are assessing—Attention
This patient is inattentive
If you have to explain the directions more than twice, start to be suspicious for inattention
In the absence of neurologic dysfunction, a patient who squeezes on all letters, squeezes on NO letters, or misses >2 letters is inattentive.
UTA: The term ‘Unable to Assess’ is only recorded when patients are in stupor/coma (RASS -4/-5).

21. If either Feature 1 or 2 are absent, Stop Overall CAM-ICU is Negative If Features 1 and 2 are present, Proceed to Feature 3

22. Feature 3: Alt Level of Consciousness
Any LOC other than Alert.
Present: If the Actual RASS score is anything other than “0” (zero).
You have already done this assessment.
It was the first thing you did when you walked in the room!

23. Feature 4: Disorganized Thinking
Yes/No Questions (Use either Set A or Set B) :
Set A Set B
1. Will a stone float on water? Will a leaf float on water?
2. Are there fish in the sea? Are there elephants in the sea?
3. Does one pound weigh more than Do two pounds weigh
two pounds? more than one pound?
4. Can you use a hammer to pound a nail? 4. Can you use a hammer to cut wood?
Note: Use whatever form of communication that works (nodding, hand squeezing, blinking, etc).
Rare Feature 4: It is only necessary to proceed to Disorganized Thinking (F4) when F1/F2 present and the patient is Awake and Alert (RASS 0) at the time of CAM-ICU evaluation.

24. Feature 4: Disorganized Thinking
Command
Say to patient: “Hold up this many fingers” (Examiner holds two fingers in front of patient) “Now do the same thing with the other hand” (Not repeating the number of fingers).
Patient gets credit only if able to successfully complete the entire command

25. Feature 4: Disorganized Thinking
Present: If there is >1 error for the combined questions + command.
Notes:
If pt is unable to move both arms, for the second part of the command ask patient “Add one more finger”.
If patient is unable to move arms at all (quadriplegic), then feature 4 is present if patient misses more than 1 question.

26. Confusion Assessment Method for the ICU (CAM-ICU)
Feature 1: Acute change or fluctuating course of mental status
And
Feature 2: Inattention
Feature 3: Altered level of consciousness
Feature 4: Disorganized Thinking Or
Inouye, et. al. Ann Intern Med 1990; 113:
Ely, et. al. CCM 2001; 29:
Ely, et. al. JAMA 2001; 286:

27. Case Studies

28. Case #1: Mr. Icy
45 y/o man, lawyer with no previous memory or attention problem
Dx: DKA, Intubated
In the past 24hrs the RASS scores have been -3 to +1.
Step 1: Arousal Assessment
Currently: Awake and moving around restless in bed, but not aggressive.
RASS = +1
What do we do next?

29. Case #1: Mr. Icy Step 2: CAM-ICU - Feature 1:
Pos
Neg
Feature 1
Feature 2
Feature 3
Feature 4
Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
- Feature 2:
Letters = 4 errors
- Feature 3:
RASS = +1
- Feature 4

31. Is this patient delirious??
Case #1: Mr. Icy
Pos
Neg
Feature 1 X
Feature 2
Feature 3
Feature 4
Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
Other RASS Scores: -3 +1
- Feature 2:
Letters = 4 errors
- Feature 3:
RASS = +1
- Feature 4
Is this patient delirious??
Yes, this patient is delirious

32. Case #2 Mrs. Dapple 75 y/o female
Dx: Severe pneumonia requiring prolonged mechanical ventilation and difficulty weaning
In past 24 hours: RASS scores -3 to -1
Step 1: Arousal Assessment
Eyes closed, but awakens to voice; maintains eye contact for >10 seconds
RASS = -1
What do we do next?

33. Case #2 Mrs. Dapple Step 2: CAM-ICU Pos Neg Feature 1 Feature 2
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 1 error
- Feature 3
- Feature 4

35. Is this patient delirious??
Case #2 Mrs. Dapple
Pos
Neg
Feature 1 X
Feature 2
Feature 3
Feature 4
Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
RASS Variance: 2
- Feature 2:
Letters = 1 error
- Feature 3
- Feature 4
Is this patient delirious??
No, this patient is not delirious

36. Case # 3 Miss Universe
Miss Universe was successfully extubated from the Vent at All sedation and analgesia had been stopped earlier in the AM. Yesterday evening and last night she had periods of agitation with a documented RASS range of -1 to +3.
Step 1: Arousal Assessment
Pt alert and calm.
RASS = 0
What do we do next?

37. Case #3: Miss Universe Pos Neg Feature 1 Feature 2 Feature 3 Feature 4
Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you aren’t sure
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4

39. Do you need to do Feature 4??
Case #3: Miss Universe
Pos
Neg
Feature 1 X
Feature 2
Feature 3
Feature 4
Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
RASS Variance = 4
- Feature 2:
Letters = 3 errors, but you aren’t sure.
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4
Do you need to do Feature 4??
Yes, you need Feature 4

40. Case #3: Miss Universe Pos Neg Feature 1 Feature 2 Feature 3 Feature 4
Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you aren’t sure.
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4:
Answered half the questions wrong
Unable to perform 2-step command
3 errors

41. Is this patient delirious??
Case #3: Miss Universe
Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you aren’t sure.
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4:
Answered half the questions wrong
Unable to perform 2-step command
3 errors
Pos
Neg
Feature 1 X
Feature 2
Feature 3
Feature 4
Is this patient delirious??
Yes, this patient is delirious

42. What if Miss Universe had gotten all 4 of her
questions right?

43. Is this patient delirious??
Case #3: Miss Universe
Pos
Neg
Feature 1 X
Feature 2
Feature 3
Feature 4
Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you aren’t sure.
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4:
Answered all 4 questions correct
Unable to perform 2-step command
1 error
Is this patient delirious??
Subsyndromal Delirium: Patients may have some features without the full syndrome of delirium (e.g., F2 only or F1&4 only). This is a (subsyndromal) intermediate state of badness between normal and delirium. Reassess with CAM-ICU frequently to determine the clinical course of his/her emerging brain dysfunction.

44. Case # 4 Mr. Bubble
Mr. Bubble works as a traveling salesman, and has been fully independent until admission. He is admitted with acute pancreatitis. His sedatives were turned off 30 minutes ago for a Spontaneous Awakening Trial (SAT).
Step 1: Arousal Assessment
Eyes closed, moves head to verbal stimulation, no eye contact
RASS = -3
What do we do next?

45. Case #4: Mr. Bubble Pos Neg Feature 1 Feature 2 Feature 3 Feature 4
Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
- Feature 2:
Letters= no squeeze for any letters
- Feature 3:
RASS = -3
- Feature 4:

47. Is this patient delirious??
Case #4: Mr. Bubble
Pos
Neg
Feature 1 X
Feature 2
Feature 3
Feature 4
Step 2: CAM-ICU
- Feature 1:
Is he at his MS baseline?
Fluctuation?
- Feature 2:
Letters= no squeeze for any letters
- Feature 3:
RASS = -3
- Feature 4:
Is this patient delirious??
Yes

48. Confusion Assessment Method for the ICU (CAM-ICU)
Feature 1: Acute change or fluctuating course of mental status
And
Feature 2: Inattention
Feature 3: Altered level of consciousness
Feature 4: Disorganized Thinking Or
Inouye, et. al. Ann Intern Med 1990; 113:
Ely, et. al. CCM 2001; 29:
Ely, et. al. JAMA 2001; 286:

49. Consider antipsychotics after evaluating etiology & risk factors
Stop and THINK
Do any meds need to be stopped or lowered?
Especially consider sedatives
Is patient on minimal amount necessary?
Daily sedation cessation
Targeted sedation plan
Assess target daily
Do sedatives need to be changed?
Remember to assess for pain!
Toxic Situations
CHF, shock, dehydration
New organ failure (liver/kidney)
Hypoxemia
Infection/sepsis (nosocomial), Immobilization
Nonpharmacologic interventions
Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation
K+ or electrolyte problems
Consider antipsychotics after evaluating etiology & risk factors

50. Nonpharmacologic Interventions
Environmental changes (e.g. noise reduction)
Sensory aids (e.g. hearing aids, glasses)
Reorientation and stimulation
Sleep preservation & enhancement
Exercise and mobility

51. (N/D & reason if not done) CAM-ICU Feature 1
RASS
(N/D & reason if not done)
CAM-ICU Feature 1
(MS change or fluctuation)
Absent
Present
CAM-ICU Feature 2
(Inattention)
CAM-ICU Feature 3
(Altered LOC)
CAM-ICU Feature 4
(Disorganized thinking)
Overall CAM-ICU
[3 or 4] = CAM-ICU+
Negative
Positive
UTA (RASS -4/-5 only)
Not done:­­­­________
Documentation of RASS/CAM-ICU for MIND-USA study.

52. Brain Road Map for Rounds (Script for Interdisciplinary Communication)
Skipping any of these steps could leave the clinical team wanting more information!
Investigate (Ask these questions)
Report (only takes 10 seconds)
Where is the patient going?
Target sedation score (RASS, SAS, etc)
Where is the patient now?
Actual sedation score (RASS, SAS, etc)
Delirium assessment (CAM-ICU, ICDSC, etc)
How did they get there?
Drug exposures
You can hide the roadmap slides if you would like.

53. Case Study - Day 1 What next? Female, age 61 Hx: hypertension
CC: altered mental status, pneumonia
Dx: Septic shock, ARDS, acute renal failure
Vent settings: A/C rate 16, TV 400, PEEP 14, FiO2 70%
Infusions: Levophed 8 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF
Assessment: Target RASS -3, actual RASS +1 to +2, displaying vent asynchrony, CAM-ICU positive, bilateral rhonchi, pulses present
Drugs: Receiving intermittent boluses of fentanyl and midazolam
What next?
Equip with the tools needed to think through delirium management, framework.

54. Review your Road Map Report: Action: What do you do now?
Where is the patient going?
Target sedation score: RASS -3
Where is the patient now?
Actual sedation score: RASS +1 to +2
Delirium: CAM-ICU positive
How did they get there?
Drug exposures: Intermittent fentanyl & midazolam
This is your script for discussion in rounds that leads to an action.
In this case, the patient is under-sedated in florid ARDS, increase drug delivery, continuous infusion is likely the best approach), mobilize

55. Case Study – Day 3 What next?
Vent settings: AC rate 16, TV 400, PEEP 6, FiO2 40%
Infusions: propofol 40 mcg/kg/hr, Levophed 4 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF
Drugs: Intermittent fentanyl for analgesia
Assessment: Target RASS -1, actual RASS -3, CAM-ICU positive, not breathing over vent set rate, bilateral rhonchi, pulses present, moving extremities spontaneously
What next?

56. Review your Road Map Report: Action: What do you do now?
Where is the patient going?
Target sedation score: RASS -1
Where is the patient now?
Actual sedation score: RASS -3
Delirium: CAM-ICU positive
How did they get there?
Drug exposures: Propofol infusion 40 mcg/kg/min & intermittent fentanyl for pain
Now the patient is over-sedated and delirious, stop sedation, daily wake-up, mobilize, cognitive stimulation, sleep preservation, sensory stimulation, tight titration
Reorientation and cognitive stimulation
Talk about family, friends, current events
Convey day, date, place
Reason for hospitalization
Hearing aids and/or eye glasses
Pain management
Sleep preservation
Maintain sleep hygiene
Minimize interruptions
Maintain vent synchrony
Promote comfort and relaxation

57. Case Study – Day 5 What next?
Vent settings: Pressure support 5, PEEP 5, 40% and tolerating spontaneous breathing trial
Infusions: Levophed/vasopressin off, insulin gtt, IVF, propofol off
Septic shock resolved, passed SAT/SBT
Assessment: Target RASS 0, actual RASS 0, CAM-ICU positive, lungs clear, moves all extremities
What next?

58. Review your Road Map Report: Action: What do you do now?
Where is the patient going?
Target sedation score: RASS 0
Where is the patient now?
Actual sedation score: RASS 0
Delirium: CAM-ICU positive
How did they get there?
Drug exposures: No sedatives/analgesics in the past 24h
Now we need to think about causes of delirium, possibly consider antipsychotics, mobilize,
Reorientation and cognitive stimulation
Talk about family, friends, current events
Convey day, date, place
Reason for hospitalization
Hearing aids and/or eye glasses
Pain management
Sleep preservation: Maintain sleep hygiene, Minimize interruptions, Maintain vent synchrony, Promote comfort and relaxation
THINK
Toxic Situations
CHF, shock, dehydration
Deliriogenic meds (Tight Titration)
New organ failure, e.g, liver, kidney
Hypoxemia; also, consider giving Haloperidol or other antipsychotics
Infection/sepsis (nosocomial), Immobilization
Nonpharmacological interventions
Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation
K+ or Electrolyte problems

59. Questions? www.ICUdelirium.org delirium@vanderbilt.edu
The website is a great resource.
Key to Success
MDs and RNs must be on the same page. The TEAM must understand the definition of delirium, its prognostic implications, modifiable causes, and treatment options. Enthusiasm is destroyed when physicians do not respond to nurses who report that a patient is CAM-ICU positive. Overcome this implementation barrier by engaging and educating all members of the ICU team and having experts.