OASIS E item C1310 consists of the Confusion Assessment Method (CAM), an evidence-based, standardized assessment tool that helps clinicians without formal psychiatric training detect signs and symptoms of delirium quickly so they can take necessary action to improve patient outcomes.
Why is it important to recognize and report signs and symptoms of delirium?
Delirium is often the first or only indication of an underlying medical condition. For example, an elderly patient with an acute UTI (urinary tract infection), may manifest no other physical symptoms of an infectious process, but may suddenly have a change in mental status that prompts investigation and leads to diagnosis and treatment.
The underlying etiology of delirium should always be aggressively explored. Acute mental status (AMS) change can be the result of a medical emergency or related to an acute issue caused by a chronic medical condition. Delirium is closely related to increased mortality, long term cognitive and functional impairment, injury due to falls, and other potentially avoidable events that can require long-term care or hospitalization with associated healthcare costs.
Establishing a baseline mental status at the time of admission to home health, makes it easier to identify deterioration in cognitive function, which may be reversible if identified and treated in a timely fashion.
How does OASIS E Item C1310 help a clinician identify signs and symptoms of delirium?
Observe, Assess, and Interview
The CAM is completed after observing patient behavior during the BIMS (Brief Interview of Mental Status). Clinicians should review medical record documentation and can consult with other staff, family members/caregivers, and anyone else who can offer information about the patient’s baseline status compared to the status on the day of assessment. Then the clinician should consider all relevant information and use their clinical judgment during assessment to determine if an acute mental status change has occurred.
Know the four cardinal signs of delirium
Acute AMS with fluctuating behaviors
Fluctuation in behavior is when comes and goes and/or increases or decreases in severity during the interview or assessment period. A patient who is usually noisy may become quiet, lethargic, or inattentive. A patient who is quiet may become suddenly noisy or restless.
Inattention
Inattention is the reduced ability to maintain attention to external stimuli and to appropriately shift attention to new external stimuli. A patient may appear dazed or have darting attention that requires continual redirection throughout the assessment or interview.
Disorganized Thinking
Disorganized thinking often involves a patient who rambles or responds to a conversation with an irrelevant response. The patient often switches from subject to subject and has an unclear or illogical flow of ideas.
Altered LOC (Level of Consciousness)
Altered LOC is typically indicative when any of the following criteria are present during assessment:
- Vigilance-the patient startles easily to sound or touch
- Lethargy-repeatedly dozes off but responds to voice or touch
- Stupor-very difficult to arouse and keep aroused during assessment
- Comatose-unable to arouse and unresponsive to stimuli
How can you tell the difference between delirium and dementia?
Delirium can be misdiagnosed as dementia, which can delay treatment of the underlying etiology. Delirium starts suddenly and is characterized by new or acute worsening of symptoms, such as confusion and hallucinations, that often vary a lot over the course of the day. In contrast, the symptoms of dementia come on slowly, over months or even years. Behaviors associated with dementia are often continuously present and do not fluctuate, but progress over time.
What indicates a CAM positive for delirium?
A patient is considered to have signs and symptoms of delirium if after assessment and review of all documentation and collection of input from other involved in care, the clinician confirms the patient is experiencing:
- BOTH altered mental status with an acute onset and fluctuation course AND inattention
- ALONG WITH the presence of disorganized thinking OR an altered level of consciousness
These findings warrant investigation and should be brought to the attention of the patient’s physician immediately so that proper identification and treatment can be initiated to increase the patient’s odds of improved outcomes or recovery.