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Symptoms Assessment Tools - Confusion

Nursing Delirium Screening Scale (Nu-DESC)

Summary

A brief delirium screening instrument that provides continuous cognitive status assessment as well as delirium symptom monitoring”

Tool

References

Gaudreau J-D, Gagnon P, Harel F, Tremblay A, Roy M-A (2005). Fast, systematic, and continuous delirium assessment in hospitalized patients: the nursing delirium screening scale. J Pain Symptom Mana​ge. 29(4):368-75

Radtke FM, Franck M, Schneider M, Luetz A, Seeling M, Heinz A, Wernecke KD, Spies CD (2008). Comparison of three scores to screen for delirium in the recovery room. Brit J Anaesth, 101(3):338-343

Confusion Assessment Method (CAM)

Summary

CAM was intended to provide a new standardized method to enable clinicians not trained in psychiatry to identify delirium quickly and accurately in both clinical and research settings. Both a long and short version of the CAM are available. The long version is a comprehensive assessment instrument that screens for clinical features of delirium and correlates to DSM IV criteria. The short version includes only those four features that were found to have the greatest ability to distinguish delirium from other types of cognitive impairment. There is also a CAM-ICU version for use with non-verbal mechanically ventilated patients.

Tool

Guidelines

References

Wei LA, Fearing MA, Sternberg E, Inouye SK. (2008). The Confusion Assessment Method (CAM): A systematic review of current usage. J Am Geriatr Soc.; 56:823-830.

Cole, M.G., Ciampi, A., Belzile, E., & Zhong, L. (2009). Persistent delirium in older hospital patients: A systematic review of frequency and prognosis. Age and Ageing, 38(1), 19-26.

Memorial Delirium Assessment Scale (MDAS)

Summary

A scale designed to quantify the severity of delirium symptoms and to allow for objective measurement of changes in delirium severity in response to medical changes or clinical interventions. Although not designed as a diagnostic tool, the MDAS may also be useful in establishing a delirium diagnosis in medically ill patients

Tool

References

Fadul, N., et al. (2007). "Evaluation of the Memorial Delirium Assessment Scale (Mdas) for the Screening of Delirium by Means of Simulated Cases by Palliative Care Health Professionals." Support Care Cancer 15.11: 1271-6​​​