In Reply: We concur with Drs Bellelli and Trabucchi that delirium superimposed on dementia may present diagnostic challenges, particularly in the absence of caregivers to provide collateral information. Information about a fluctuating course of confusion should be easily obtained in hospitalized patients where there is 24-hour nursing care with careful documentation. We agree that inattention and disorganized thinking may be present due to preexisting conditions, particularly with severe dementia, but the CAM algorithm requires several cardinal features beyond inattention and disorganized thinking. In the original CAM study, Inouye et al1 deliberately challenged the CAM with a broad range of participants, including those with underlying dementia. The CAM has been shown to be valid in patients with and without dementia, in the original study and subsequent validation studies.2
Wong CL, Holroyd-Leduc JM, Straus SE. Diagnosing Delirium—Reply. JAMA. 2010;304(19):2124–2127. doi:10.1001/jama.2010.1618
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