Family Identification of Delirium in the Emergency Department in Patients With and Without Dementia: Validity of the Family Confusion Assessment Method (FAM‐CAM)

Abstract

See related editorial by Kennedy et al. in this issueOBJECTIVE: To examine the ability of the family-rated Family Confusion Assessment Method (FAM-CAM) to identify delirium in the emergency department (ED) among patients with and without dementia, as compared to the reference-standard Confusion Assessment Method (CAM). DESIGN: Validation study. SETTING: Urban academic ED. PARTICIPANTS: Dyads of ED patients, aged 70 years and older, and their family caregivers (N = 108 dyads). MEASUREMENTS: A trained reference standard interviewer performed a cognitive screen, delirium symptom assessment, and scored the CAM. The caregiver self-administered the FAM-CAM. Dementia was assessed using the Informant Questionnaire on Cognitive Decline in the Elderly and the medical record. For concurrent validity, performance of the FAM-CAM was compared to the CAM. For predictive validity, clinical outcomes (ED visits, hospitalization, and mortality) over 6 months were compared in FAM-CAM positive and negative patients, controlling for age, sex, comorbidity, and cognitive status. RESULTS: Among the 108 patients, 30 (28%) were CAM positive for delirium and 58 (54%) presented with dementia. The FAM-CAM had a specificity of 83% and a negative predictive value of 83%. Most false negatives (n = 9 of 13, 69%) were due to caregivers not identifying the inattention criteria for delirium on the FAM-CAM. In patients with dementia, sensitivity was higher than in patients without (61% vs 43%). In adjusted models, a hospitalization in the following 6 months was more than three times as likely in FAM-CAM positive compared to negative patients (odds ratio = 3.4; 95% confidence interval = 1.2-9.3). CONCLUSIONS: Among patients with and without dementia, the FAM-CAM shows qualities that are important in the ED setting for identification of delirium. Using the FAM-CAM as part of a systematic screening strategy for the ED, in which familiesʼ assessments could supplement healthcare professionalsʼ assessments, is promising. J Am Geriatr Soc 00:983-990, 2020. D elirium, an acute decline in cognitive function, is common among hospitalized older patients and is associated with poor clinical and functional outcomes. 1 The emergency department (ED) is the point of hospital entry for the vast majority of inpatients, and up to 20% of older patients in the ED have prevalent delirium. 2 Patients with delirium in the ED are at risk for poor outcomes, including longer and more complicated hospital stays, slower functional recovery, and readmission. 3 More important, patients discharged home with delirium have a high mortality rate. 4 Despite its high prevalence, delirium often goes undiagnosed in the ED, even though it is included in quality indicators, emergency medicine resident core competencies, and guidelines. 2,[5][6][7][8] In the context of the ED, identifying delirium is a primary concern; and since longer duration of delirium is associated with poorer outcomes, early identification is key. 3,4 Moreover, many older patients in the ED have dementia, which is a le...

COVID‐19 hospital and emergency department visitor policies in the United States: Impact on persons with cognitive or physical impairment or receiving end‐of‐life care

“…Our findings underscore the need to distinguish the different roles within the umbrella term of “visitors.” This term disregards or minimizes the critical roles of family and other caregivers of dependent older persons, who serve as surrogate decision‐makers, provide critical medical information, lend emotional support, and advocate for care quality on their behalf. 32 , 33 In the case of persons living with advanced dementia, caregivers serve the invaluable role of interpreting the non‐verbal clues of these persons, who otherwise may communicate pain, fear, overstimulation, or an unmet need only through agitation. 34 The roles of caregivers of older adults may practically parallel those of parents of young children, and the fact that parents were most likely to be granted an explicit exemption from visitor policies in our study demonstrates that hospitals recognize the benefit of such critical roles in the care of the patient.…”

Optimal Emergency Department Care Practices for Persons Living With Dementia: A Scoping Review

“…This review demonstrates that studies of components of ED care and emergency care needs for PLWDs are wide ranging with little depth on any topic. Studies on components of ED care for PLWDs included a comprehensive geriatric assessment and dedicated ED unit, 26 care partners in the ED and hospital care companions for PLWDs, 22,30 identifying delirium, 4,34,36 fall prevention, 41 admission to a home hospital program, 42 pain assessment and management, 21,28,31,32,43,44 palliative care, 23,37 and changes to the physical environment. 27,33 Four studies showed improvement in patient-centered outcomes or health services use: a comprehensive geriatric assessment and dedicated ED unit, 26 stimulation reduction and noncontact monitoring, 33 dementia companions, 22 and hospital at home program.…”

“…Three studies evaluated assessments to detect delirium superimposed on dementia. 24,34,36 The Family Confusion Assessment Method 24,34 demonstrated a sensitivity of 61%, specificity of 74%, and a positive likelihood ratio of 2.2. A positive Family Confusion Assessment Method score was associated with increased hospitalization, ED visit, and mortality.…”

Detection of delirium by family members in the intensive care unit: Translation, Cross‐Cultural adaptation and validation of the Family Confusion Assessment Method for the German‐Speaking area

“…In this study, in the emergency department setting, the authors tested the ability of the FAM-CAM to detect delirium in patients with or without dementia compared with the reference standard, the CAM. In addition, the authors had the objective to examine whether the FAM-CAM can perform similarly in patients with or without dementia (Mailhot et al, 2020). 52) 45 ( 90) -…”