CAM-ICU Worksheet (Confusion Assessment Method)

Feature 1: Acute Onset or Fluctuating Course

Positive if you answer ‘yes’ to either 1A or 1B.

Positive

Negative

1A: Is the pt different than his/her baseline mental status?

Or

1B: Has the patient had any fluctuation in mental status in the past 24 hours as evidenced by fluctuation on a sedation scale (e.g. RASS), GCS, or previous delirium assessment?

Yes

No

Feature 2: Inattention

Positive if either score for 2A or 2B is less than 8.

Attempt the ASE letters first. If pt is able to perform this test and the score is clear, record this score and move to Feature 3. If pt is unable to perform this test or the score is unclear, then perform the ASE Pictures. If you perform both tests, use the ASE Pictures’ results to score the Feature.

Positive

Negative

2A: ASE Letters: record score (enter NT for not tested)

Directions: Say to the patient, “I am going to read you a series of 10 letters. Whenever you hear the letter ‘A,’ indicate by squeezing my hand.” Read letters from the following letter list in a normal tone.

S A V E A H A A R T

Scoring: Errors are counted when patient fails to squeeze on the letter “A” and when the patient squeezes on any letter other than “A.”

Score (out of 10):

2B: ASE Pictures: record score (enter NT for not tested)

Directions are included on the picture packets.

Score (out of 10):

Feature 3: Disorganized Thinking

Positive if the combined score is less than 4

Positive

Negative

3A: Yes/No Questions

(Use either Set A or Set B, alternate on consecutive days necessary):

Set A Set B

1. Will a stone float on water? 1. Will a leaf float on water?

2. Are there fish in the sea? 2. Are there elephants in the sea?

3. Does one pound weigh more than 3. Do two pounds weigh two pounds? more than one pound?

4. Can you use a hammer to pound a nail? 4. Can you use a hammer to cut wood?

Score (Patient earns 1 point for each correct answer out of 4)

3B:Command

Say to patient: “Hold up this many fingers” (Examiner holds two fingers in front of patient) “Now do the same thing with the other hand” (Not repeating the number of fingers). *If pt is unable to move both arms, for the second part of the command ask patient “Add one more finger)

Score (Patient earns 1 point if able to successfully complete the entire command)

Combined Score (3A+3B):

(out of 5)

Feature 4: Altered Level of Consciousness

Positive if the Actual RASS score is anything other than “0” (zero)

Positive

Negative

Overall CAM-ICU (Features 1 and 2 and either Feature 3 or 4):

Positive

Negative