Validation of the Brief Confusion Assessment Method for screening delirium in elderly medical patients in a German emergency department

Baten, Verena; Busch, Hans‐Jörg; Busche, Caroline; Schmid, Bonaventura; Heupel‐Reuter, Miriam; Perlov, Evgeniy; Brich, Jochen; Klöppel, Stefan (2018). Validation of the Brief Confusion Assessment Method for screening delirium in elderly medical patients in a German emergency department. Academic emergency medicine, 25(11), pp. 1251-1262. Wiley 10.1111/acem.13449

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Background
Delirium is frequent in elderly patients presenting in the emergency department (ED). Despite the severe prognosis, the majority of delirium cases remain undetected by emergency physicians (EPs). At the time of our study there was no valid delirium screening tool available for EDs in German‐speaking regions. We aimed to evaluate the brief Confusion Assessment Method (bCAM) for a German ED during the daily work routine.

Methods
We implemented the bCAM into practice in a German interdisciplinary high‐volume ED and evaluated the bCAM's validity in a convenience sample of medical patients aged ≥ 70 years. The bCAM, which assesses four core features of delirium, was performed by EPs during their daily work routine and compared to a criterion standard based on the criteria for delirium as described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Results
Compared to the criterion standard, delirium was found to be present in 46 (16.0%) of the 288 nonsurgical patients enrolled. The bCAM showed 93.8% specificity (95% confidence interval [CI] = 90.0%–96.5%) and 65.2% sensitivity (95% CI = 49.8%–78.7%). Positive and negative likelihood ratios were 10.5 and 0.37, respectively, while the odds ratio was 28.4. Delirium was missed in 10 of 16 cases, since the bCAM did not indicate altered levels of consciousness and disorganized thinking. The level of agreement with the criterion standard increased for patients with low cognitive performance.

Conclusion
This was the first study evaluating the bCAM for a German ED and when performed by EPs during routine work. The bCAM showed good specificity, but only moderate sensitivity. Nevertheless, application of the bCAM most likely improves the delirium detection rate in German EDs. However, it should only be applied by trained physicians to maximize diagnostic accuracy and hence improve the bCAM's sensitivity. Future studies should refine the bCAM

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