Tressa Nese and Helen Diskevich
Center of Geriatric Nursing Excellence

Delirium is an acute, sudden, and usually reversible change in one’s mental state. Those affected often become disoriented, and experience reduced awareness, confusion, and behavioral or emotional changes. Approximately half of all hospitalized older adults may experience delirium. Delirium can lead to physical and mental decline, nursing home placement, and death. Delirium is costly, estimated to cost the United States $164 billion annually (Leslie et al., 2008; https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/413696). Despite these poor outcomes, delirium is greatly under-recognized and often poorly managed (Marcantonio et al., 2017; https://www.nejm.org/doi/full/10.1056/NEJMcp1605501). Supported by $2.4 million from the National Institute on Aging, this four-year interdisciplinary project, “Researching Efficient Approaches to Delirium Identification” (READI), aimed to improve the care of older adults by developing an identification protocol (UB-CAM) to detect delirium in hospitalized adults aged 70 and older (https://grantome.com/grant/NIH/R01-AG030618-06).

Delirium Screening Tools

READI MPIs Donna M. Fick, RN, PhD and Edward R. Marcantonio, MD, SM, developed and tested a two-step protocol (UB-CAM) for identifying delirium in hospitalized older adults. This multi-site study took place in Pennsylvania and Massachusetts (Medical Center in Central PA and Beth Israel Deaconess Medical Center in Boston). By the study’s conclusion, 527 older adults and 399 clinicians (53 hospitalists, 236 nurses, and 110 CNAs) were enrolled at the two study hospitals, and conducted 924 reference standard assessments of delirium, dementia, depression, and other variables, and 2693 clinician delirium screening protocols.  This study demonstrated that all 3 clinicians were able to complete the app-directed delirium detection protocol over 97% of the time. The protocol took an average of less than 1½ minutes to complete, with an overall accuracy rate of 89 percent (Marcantonio et al., 2021; https://www.acpjournals.org/doi/10.7326/M21-1687). In terms of feasibility and acceptance of the tool, all clinician types described the ability to integrate the UB-CAM into their role and routine, without adjustments in workflow, or assignments. The clinicians were very positive about the app and found it promoted efficiency and accuracy of documentation (Husser et al., 2021; https://pubmed.ncbi.nlm.nih.gov/33474729/).

UB-CAM

The READI study builds on their previous work deriving and validating the 3-Minute Diagnostic Assessment for the Confusion Assessment Method (3D-CAM) and the ultra-brief 2-item screen (UB-2), which consists of the 2 most sensitive items in the 3D-CAM. In READI, the UB-2 and 3D-CAM are combined into a 2-step protocol for delirium identification (see below for description of the two-step protocol). The UB-2 quickly rules out delirium in patients who answer both questions correctly. Otherwise, the protocol continues with the rest of the full 3D-CAM, or with a 3D-CAM skip pattern such that the first item with a response that triggers a Confusion Assessment Method (CAM) feature ends assessment of that feature. The UB-2 followed by 3D-CAM with the skip pattern is called the ultra-brief CAM (UB-CAM). This process is described in more detail below.

Step-One: The UB-2

The Ultra-Brief 2-Item Screener (UB-2) is administered by the clinician first and consists of just two items: “Please tell me the day of the week”, and “Please tell me the months of the year backward, say December as your first month”. If the patient gets both items correct, the screen is negative for delirium and the assessment is over (in less than 40 seconds). If possible, the clinician should document this in the health record so that they now have a baseline and can recognize a change in mental status if it occurs. If they are negative (meaning they do not have delirium) then the clinician should implement standard delirium prevention such as daily mobility goals, reorientation/validation, sensory enhancement, and avoidance of high-risk drugs such as anticholinergics. If one or both items are incorrect (or they give no response or a nonsensical response), the clinician continues to step-two in the screening protocol, which involves administering the 3-minute Diagnostic Confusion Assessment Method (3D-CAM). This combination of the UB-2 and 3D-CAM is called the UB-CAM.

Step Two: The 3D-CAM (the full and skip UB-CAM)

When a person fails to answer both questions on the UB-2 correctly, we follow-up with the 3-minute Diagnostic Confusion Assessment Method (3D-CAM). If they are positive for delirium, followed with evidence-based practices for delirium treatment including assessing for a reversible cause of delirium, preventing complications, avoiding central nervous system medications, and restoring function (https://www.nejm.org/doi/full/10.1056/nejmcp1605501).