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Ely EW, Inouye SK, Bernard GR, et al. Delirium in Mechanically Ventilated Patients: Validity and Reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). JAMA. 2001;286(21):2703–2710. doi:10.1001/jama.286.21.2703
Author Affiliations: Department of Internal Medicine, Divisions of General Internal Medicine and Center for Health Services Research and the Veterans Affairs Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (Drs Ely, Gordon, Speroff, Gautam, and Dittus and Mss May and Truman), and Division of Allergy/Pulmonary/Critical Care Medicine (Drs Ely and Bernard), Department of Geriatric Psychiatry and Neuroscience (Drs Gordon and Margolin), Vanderbilt University School of Medicine, Nashville, Tenn; Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn (Dr Inouye); Division of Quality and Data Management, St Vincent Hospital Health System, Indianapolis, Ind (Dr Francis); and the Department of Psychiatry, Virginia Commonwealth University Health Systems, Richmond (Dr Hart).
Caring for the Critically Ill Patient Section Editor: Deborah J. Cook, MD, Consulting Editor, JAMA.
Context Delirium is a common problem in the intensive care unit (ICU). Accurate
diagnosis is limited by the difficulty of communicating with mechanically
ventilated patients and by lack of a validated delirium instrument for use
in the ICU.
Objectives To validate a delirium assessment instrument that uses standardized
nonverbal assessments for mechanically ventilated patients and to determine
the occurrence rate of delirium in such patients.
Design and Setting Prospective cohort study testing the Confusion Assessment Method for
ICU Patients (CAM-ICU) in the adult medical and coronary ICUs of a US university-based
Participants A total of 111 consecutive patients who were mechanically ventilated
were enrolled from February 1, 2000, to July 15, 2000, of whom 96 (86.5%)
were evaluable for the development of delirium and 15 (13.5%) were excluded
because they remained comatose throughout the investigation.
Main Outcome Measures Occurrence rate of delirium and sensitivity, specificity, and interrater
reliability of delirium assessments using the CAM-ICU, made daily by 2 critical
care study nurses, compared with assessments by delirium experts using Diagnostic and Statistical Manual of Mental Disorders, Fourth
Results A total of 471 daily paired evaluations were completed. Compared with
the reference standard for diagnosing delirium, 2 study nurses using the CAM-ICU
had sensitivities of 100% and 93%, specificities of 98% and 100%, and high
interrater reliability (κ = 0.96; 95% confidence interval, 0.92-0.99).
Interrater reliability measures across subgroup comparisons showed κ
values of 0.92 for those aged 65 years or older, 0.99 for those with suspected
dementia, or 0.94 for those with Acute Physiology and Chronic Health Evaluation
II scores at or above the median value of 23 (all P<.001).
Comparing sensitivity and specificity between patient subgroups according
to age, suspected dementia, or severity of illness showed no significant differences.
The mean (SD) CAM-ICU administration time was 2 (1) minutes. Reference standard
diagnoses of delirium, stupor, and coma occurred in 25.2%, 21.3%, and 28.5%
of all observations, respectively. Delirium occurred in 80 (83.3%) patients
during their ICU stay for a mean (SD) of 2.4 (1.6) days. Delirium was even
present in 39.5% of alert or easily aroused patient observations by the reference
standard and persisted in 10.4% of patients at hospital discharge.
Conclusions Delirium, a complication not currently monitored in the ICU setting,
is extremely common in mechanically ventilated patients. The CAM-ICU appears
to be rapid, valid, and reliable for diagnosing delirium in the ICU setting
and may be a useful instrument for both clinical and research purposes.
Delirium is a disturbance of consciousness characterized by an acute
onset and fluctuating course of impaired cognitive functioning so that a patient's
ability to receive, process, store, and recall information is strikingly impaired.
It is associated with poor outcomes in hospitalized patients, including increased
length of stay, the need for subsequent institutionalization, and higher mortality
Although the frequency of delirium varies from 15% to 50% among general medical
or surgical patients,1,10,11
these rates apply to patients who are not in the intensive care unit (ICU),
and few data exist concerning delirium in the ICU.12-16
Mechanically ventilated ICU patients are at high risk for the development
of delirium due to multisystem acute illnesses, comorbidities, medications,
and numerous other risk factors.1,7,16-20
In this population, cognitive impairment has been reported to negatively effect
key outcome indicators such as liberation from the ventilator, the development
of nosocomial pneumonia, and length of stay.21-25
However, the incidence and implications of cognitive impairment manifesting
as delirium in critically ill ICU patients have been poorly studied, in part
because of the lack of a validated instrument to reliably diagnose delirium
in mechanically ventilated patients.
Major limitations exist in current methods to identify delirium in the
ICU. Standard delirium assessment instruments either require special psychiatric
training or have not been validated for use by health care professionals for
use in nonverbal patients who are mechanically ventilated.26-31
In fact, such patients have been excluded from most studies of delirium to
date because of the inability to carry out cognitive assessment, which usually
required verbal communication.1,10,11,17,18,29,31,32
The Confusion Assessment Method (CAM)31
is the most widely used instrument for diagnosing delirium by internists and
and has been found to have the best combination of ease, speed, reliability,
and validity.33 CAM provides a standardized
rating of delirium, which was validated against expert opinion and Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) definitions of the American Psychiatric
Association. The instrument was originally developed for use by nonpsychiatrically
trained clinicians to identify delirium in patients able to communicate verbally.31 After reviewing the literature and consulting with
numerous experts, we chose to adapt the CAM for use in nonverbal, mechanically
ventilated patients. The development phase of this investigation led to a
small pilot study of the CAM for ICU patients (CAM-ICU)34
that included 22 mechanically ventilated patients. Based on this work, the
CAM-ICU was further refined to standardize all elements.35
In keeping with the original intent of the CAM, the adapted CAM-ICU tested
in this investigation was designed for use by ICU personnel who have no formal
psychiatric training. The purposes of this investigation were to carry out
a validation study of the CAM-ICU, to incorporate the improvements from the
pilot study, and to determine the occurrence rate of delirium in mechanically
The study population, none of whom have been included in previous investigations,
included mechanically ventilated adult medical and coronary ICU patients admitted
to Vanderbilt University's 641-bed academic medical center with 96 adult ICU
beds. The institutional review board approved this study, and informed consent
was obtained from the patient or surrogate. The study interval was from February
1, 2000, to July 15, 2000. During this time, 158 mechanically ventilated patients
were admitted to the ICU, of whom 111 (70.3%) were enrolled and 47 (29.7%)
met exclusion criteria. A priori exclusion criteria included a history of
psychosis or neurologic disease (eg, cerebrovascular accident) that would
confound the diagnosis of delirium (n = 16), inability to communicate with
assessors (ie, did not speak or understand English or was deaf) (n = 5), admitted
to the ICU but extubated before study nurses' assessments (n = 10), previously
enrolled in the study (n = 5), patient or family refusal to participate (n
= 6), or died before study nurses' assessments (n = 5). In addition, 15 (13.5%)
of the 111 enrolled patients remained comatose throughout the investigation
and were excluded from further analysis. The final sample size was 96.
Two critical care study nurses enrolled patients and performed daily,
independent CAM-ICU ratings during the patients' ICU stay. The reference standard
evaluations were performed independently by the delirium experts (described
below), who applied DSM-IV criteria for delirium.
The delirium experts demonstrated excellent reliability (κ = 0.97) using
standardized methods to complete the DSM-IV ratings
during prestudy training period. All cognitive assessments by the nurses and
delirium experts were conducted independently in a blinded fashion in the
ICU between 1 and 5 PM. None of the raters had access to any of the other's
evaluations or ratings. From these ratings, reliability and validity measures
were calculated as described below.
Delirium, as defined by the CAM,31 has
4 features: (1) an acute onset of changes or fluctuations in the course of
mental status, (2) inattention, (3) disorganized thinking, and (4) an altered
level of consciousness (ie, other than alert). The patient is determined to
be delirious (ie, CAM positive) if he/she manifests both features 1 and 2,
plus either feature 3 or 4 (Figure 1).
The development of the CAM-ICU began by adapting the patient assessment (without
modifying the actual CAM instrument) using nonverbal, objective tests derived
through a comprehensive literature review and consultation with numerous delirium
experts. This resulted in a pilot investigation that yielded promising results.34 Based on the pilot study, the CAM-ICU wasrefined
to improve face validity and further standardize the evaluation, as described
The CAM-ICU was completed by the study nurses as described in Table 1. To aid in the assessment of acute
onset or fluctuation of mental status changes, patients were followed up daily
with the Glasgow Coma Scale36 and an agitation/sedation
scale called the Richmond Agitation Sedation Scale (RASS) (See Table 1 footnotes).37,38
Any fluctuation during the prior 24-hour period in the patient's Glasgow Coma
Scale or RASS scores was used by the study nurse to indicate a positive mental
status, and as such these scales became a standardized part of the rating
of the CAM-ICU by the nurses.
To aid the assessment of inattention, we used an Attention Screening
Examination (ASE), which included a visual recognition component and an auditory
recognition component. The ASE visual was validated previously by Hart et
al39,40 in the Cognitive Test
for Delirium and the ASE auditory was validated as the Vigilance A random letter test.39,41
Both of these tools are presented in the pilot publication of the CAM-ICU,34 but during refinement it was decided to administer
both visual and auditory components of the ASE and limit the number of letters
in the sequence of auditory testing to only 10 letters. Data from the pilot
study34 were used to establish the cut point
for presence of inattention, which was rated as present if the patient scored
less than 8 correct answers on either the visual or auditory components of
Assessment of disorganized thinking was refined after the pilot study
by adding the standardized questions and commands included in Table 1. Disorganized thought was said to be present if the patient
was unable to answer at least 3 of the 4 questions correctly and could not
complete commands such as those described in Table 1. An altered level of consciousness, was rated as being vigilant
or lethargic or in a stupor or coma using the standardized definitions in Table 1.
Reference standard evaluations were performed by a geriatrician delirium
a board certified geriatric consult-liaison psychiatrist (R.M.), or a neuropsychologist
(S.G.). The delirium experts, basing evaluation on interviews with family
members, the patient's nurse, and chart review for lab data and nursing notes,
standardized their approach to DSM-IV delirium ratings
during the pilot study.34 Patients were rated
as either normal, delirious, stuporous, or comatose using the DSM-IV criteria for delirium or standardized definitions for stupor
and coma.34 These experts also rated the patient
for the presence or absence of dementia using standard DSM-IV criteria. To increase our sensitivity for detection of dementia,
the experts could rate a patient as demented if at any time during his/her
course it became clear (eg, through interviews with the patient, family members,
the patient's nurse, or chart review) that the patient's baseline cognitive
state met DSM-IV criteria. For cases in which the
experts rated their own confidence level of DSM-IV
ratings for either dementia or delirium as low or intermediate rather than
high, 2 raters would form a consensus opinion that day about the rating in
Criterion validity was determined by comparing the 2 CAM-ICU raters
to the delirium expert rating of delirium using the DSM-IV criterion as the reference standard. Interrater reliability was determined
by comparing the CAM-ICU ratings of nurse 1 with those of nurse 2 using the κ
coefficient. To determine validity and reliability, we used the first alert
or lethargic evaluation of each patient (as rated by the reference standard
delirium expert) for the comparison evaluation. This allowed us to avoid repeat
observer bias since patients had variable numbers of evaluations. For these
evaluations the patient had to be aroused with verbal stimulation, demonstrate
eye contact, and follow some commands.38 The
a priori decision to include this level of consciousness as the first comparison
for validation and reliability testing was made to include only interactive
patient evaluations, avoiding comatose and stuporous evaluations because they
lack characteristic delirium features and their relative ease of rating might
falsely elevate the test characteristics of the CAM-ICU.
Subgroup analyses were conducted for patients who would likely pose
the greatest challenge in delirium assessment: those 65 years or older, those
with possible dementia, and those with more severe illness (an Acute Physiology
and Chronic Health Evaluation II [APACHE II]45
score above the median). The first 2 subgroups (older age and possible dementia)
were prospectively determined while the subgroup based on higher level of
illness severity was not.
Some training is required for optimal use of the CAM-ICU. As an indicator
of ease of use, we measured time for completion of the CAM-ICU testing and
rating, and completion rates in patients with and without delirium.
In the pilot study of the CAM-ICU,34
the test sensitivity of mechanically ventilated patients was 95% averaging
across raters and test specificity was 88%. A group of 12 intensivists agreed
a priori that the instrument's sensitivity was the critical feature so as
not to miss the diagnosis, stating that it would be important to confirm the
lower limit of the 95% confidence interval (CI) to be 85% or higher while
an acceptable specificity would be 75% or higher. Sample size was calculated
to ensure the appropriate number of patients necessary to achieve the expected
lower limit of the 95% CI for the CAM-ICU test sensitivity and specificity
in alert or lethargic patients. Assuming an incidence of delirium of 50%,
it would require 50 mechanically ventilated patients to ensure that the lower
range of the CI for sensitivity in the entire study population was 85% and
another 45 patients to ensure that specificity was at least 75%. Thus, the
planned total sample size for the investigation was 95 patients. The study
was not powered for subgroup analyses.
Patient demographics and the severity of illness measurement using the
APACHE II45 were collected at time of enrollment.17,19 Baseline visual or auditory deficits
were recorded if patients wore corrective lenses (glasses, bifocals, or contacts)
or had a hearing aid, as well as if the family reported that the patient had
any documented impairment in vision or hearing. The modified Blessed Dementia
Rating scale (mBDRS),46 originally validated
against brain pathological specimens, was used to screen for dementia using
family interviews (an additional surrogate question asked them to rate on
a 5-point scale whether they believed the patient was demented). Because baseline
dementia could serve as a confounder in rating the CAM-ICU, we chose to increase
our sensitivity for detecting dementia by defining patients as having suspected
dementia if they met any of the following 3 criteria: (1) delirium expert
rated them as having dementia, (2) modified Blessed Dementia Rating scale
score of at least 3, or (3) rating by the surrogate of at least 3 out of 5
as possibly having dementia. At the time of hospital discharge, the patients
completed a Folstein Mini-Mental State Examination (MMSE)47
and CAM-ICU rating. The MMSE is a standard method of screening for dementia
or related cognitive impairment with a scale ranging from 0 to 30 points.
Scores below 24 indicate cognitive impairment.
To compare demographic variables and other baseline characteristics
between enrolled and excluded patients, the t test
was used. To compare proportions and rates, χ2 tests were used
when sample sizes were large and Fisher exact tests when appropriate.48 The performance test characteristics for the CAM-ICU
were calculated using standard definitions: sensitivity, specificity, predictive
values, overall accuracy (true positives + true negatives/true positives +
false positives + true negatives), and likelihood ratios (sensitivity/1 −
specificity) were estimated from simple 2 × 2 tables. Exact 95% CIs
for these test characteristics were calculated using SAS software version
8.02 (SAS Institute Inc, Cary, NC). The CIs for the likelihood ratios were
calculated using the bootstrapping technique using STATA 7.0 (STATA Corp,
College Station, Tex). All statistical tests were 2 sided, and a P value of <.05 was considered statistically significant.
The reference standard delirium experts and 2 critical care study nurses
completed evaluations in 111 patients. Comparison of the demographic variables
of the 111 enrolled patients with the 47 patients excluded based on criteria
designated a priori showed no significant differences in age, sex, race, severity
of illness, or other baseline characteristics (all P>.25).
After excluding 15 enrolled patients because they remained comatose throughout
the investigation, 96 (86.5%) of 111 enrolled patients remained and comprised
the final study population. Characteristics of these 96 patients at the time
of enrollment are presented in Table 2.
The mean (SD) age of the study population was 55.3 (17.4) years (range, 18-92
years). The study patients, all of whom were mechanically ventilated, had
high severity of illness with mean (SD) APACHE II scores of 22.9 (7.2) (median,
23; interquartile range [IQR], 18-29], and a wide spectrum of illnesses. The
presence of visual or auditory deficits were reported at baseline in 61.5%
of patients, supporting the need to have both visual and auditory means to
assess cognitive function as part of the CAM-ICU.
Patients were evaluated during their entire hospital stay and had a
total of 471 paired observations between the nurses and delirium experts.
Using the first alert (n = 91) or lethargic (n = 93) paired evaluation of
each patient, the test performance of the CAM-ICU was determined (Table 3). The 2 nurses' sensitivities using
the CAM-ICU compared with the reference standard were 100% for nurse 1 and
93.5% for nurse 2. Their specificities were 97.8% and 100%, respectively.
The likelihood ratios for the CAM-ICU for the 2 nurses were 50 and greater
than 100, respectively, and the accuracy of the CAM-ICU was 98.4% (95% CI,
In reviewing the 2 misclassified CAM-ICU ratings by the nurses (of which
there was 1 false-positive and 1 false-negative), the 2 best explanations
for these discordant ratings were: (1) a dose of sedative or analgesic drug
had been given between the CAM-ICU rating and the reference standard rating,
and (2) a lapse of more than 3 hours between ratings.
In the 84-paired assessments of the first alert or lethargic evaluation
for each patient, the CAM-ICU was completed with excellent interrater reliability
between nurse 1 and nurse 2 (κ = 0.96, 95% CI, 0.92-0.99).
We conducted 3 subgroup analyses (Table 4) to evaluate the performance of the CAM-ICU in patient groups
that could pose particular challenges in delirium assessment: (1) those 65
years or older, (2) those with suspected dementia as defined in the "Methods"
section, and (3) those with higher severity of illness. Interrater reliability
measures across comparisons showed high agreement with κ values: 0.92
for those 65 or older, 0.99 for those with suspected dementia, and 0.94 for
those with APACHE II scores at or above the median value of 23 (all P<.001). Comparing sensitivity and specificity between
patient subgroups according to age, suspected dementia, and severity of illness
showed no significant differences (all P>.56).
The CAM-ICU instrument and rating were completed in a mean (SD) of 2
(1) minutes, demonstrating the relative ease with which it could be incorporated
into nurses' daily routine. When patients were either alert or lethargic,
they were able to complete the visual ASE in 167 (69.6%) of 240 cases and
able to complete the auditory ASE in 176 (73.3%) of 240 cases. Delirious patients
were unable to complete both ASE tests and were considered nonresponsive in
82% of cases while nondelirious patients could complete both ASE tests in
91% of testing attempts.
Delirium occurred in 80 patients (83.3%) during their ICU stay for a
mean (SD) duration of 2.4 (1.6) days (median, 2; IQR, 1-3 days). Of 471 daily
evaluations completed during this study, a diagnosis by the reference standard
of delirium was made in 25.2%, stupor in 21.3%, and coma in 28.5% of all observations
(with the remaining 25.0% rated as normal). The level of confidence of the
delirium experts was recorded for each evaluation. Overall, the level of confidence
was scored as high in 414 observations, moderate in 54, and low in 3. Each
of these 57 observations of moderate-to-low confidence was reviewed by 2 delirium
experts, who rendered a consensus opinion using DSM-IV
criteria. Although the exact duration of the reference standard evaluations
was not recorded, a review of notes taken by the delirium experts during the
study showed that their delirium evaluations frequently lasted 30 to 45 minutes.
When patients were alert or easily aroused, able to make eye contact,
and able to follow commands (as measured objectively using RASS37,38),
they were still found to be delirious in 39.5% of observations as rated by
the reference standard and in 42.5% of observations as rated using the CAM-ICU.
The mean (SD) length of stay for the patients in the ICU was 8.3 (6.9)
days (median, 6; IQR, 4-11 days) and in the hospital was 17.9 (15.6) days
(median, 8; IQR, 8-23 days). In-hospital mortality was 30.2% (29/96) and 6-month
mortality was 47.7% (43/90), with 6 of the patients lost to follow-up after
hospital discharge. Of the 67 patients (69.8%) surviving to hospital discharge,
disposition was as follows: 36 (53.7%) went home, 17 (25.4%) went to a subacute
facility, 9 (13.4%) were transferred to another hospital, and 5 (7.5%) went
to a nursing home.
At the time of hospital discharge, the mean (SD) MMSE score was 22.2
(7.8). The discharge MMSE was abnormal (a score of <24 out of possible
30 points) in 33 (49.3%) of 67 survivors. Even after excluding 3 patients
with suspected dementia at baseline, 44.8% were rated as cognitively impaired
by the MMSE at hospital discharge. In addition, the CAM-ICU performed by the
study nurses fulfilled full delirium criteria in 10.4% of patients and partial
delirium criteria in 20.5% at the time of hospital discharge. Among patients
fulfilling at least partial delirium criteria at discharge, 70.3% were judged
to require a level of care other than home.
In this investigation, we have validated the CAM-ICU, a 2-minute assessment
instrument, which demonstrated a sensitivity of 93% to 100%, a specificity
of 98% to 100%, and high interrater reliability (κ = 0.96) in the detection
of delirium. In 96 consecutive mechanically ventilated patients, delirium
occurred in 83.3% while they were in the ICU. In the 3 subgroups expected
to pose the greatest challenges for the CAM-ICU (ie, those 65 years or older,
those with suspected dementia, and those with the highest severity of illness),
the instrument retained excellent sensitivity, specificity, and interrater
We simultaneously assessed ICU patients for level of sedation and delirium,
finding that 40% of patients who were at a neutral level (neither agitated
nor overly sedated) were delirious by both the reference standards' (DSM-IV) and nurses' evaluations (CAM-ICU). Notably, 10%
of patients met full delirium criteria, 20% met partial delirium criteria,
and nearly 50% demonstrated substantial cognitive impairment (MMSE score,
<24) at the time of hospital discharge.
The strengths of this study include the challenging study population
of medically diverse but severely ill mechanically ventilated patients, the
large number of patient evaluations, and the use of recognized delirium experts
for the reference standard ratings. Another important strength of the study
design was the use of a standardized, easily performed nursing assessment,
which should allow the CAM-ICU to be readily implemented in both academic
and community hospitals.
Limitations of this investigation warrant comment. In developing the
CAM-ICU, we sought to develop a tool for detecting delirium, not dementia.49 However, it is commonplace for mildly demented patients
to be cared for in the ICU setting. Because such patients could pose a challenge
for the CAM-ICU, we used liberal inclusion of patients with suspected dementia
in our subgroup analysis to verify performance of the CAM-ICU in patients
with dementia. The findings of 100% sensitivity and specificity in this group
are based on a small number of patients but are consistent with our data in
another cohort.34 This investigation also represents
a selected population at a single site, and future studies will need to evaluate
the generalizability of performance across other patient populations including
those with a lower prevalence of delirium.
The validation of a delirium instrument for the ICU opens a new frontier
for investigation: to evaluate the impact of this important problem in the
ICU, especially as it relates to the outcomes of older, mechanically ventilated
Important areas for future investigation include determination of risk factors
for delirium in the ICU20 and the impact of
delirium in mechanically ventilated patients on clinical outcomes such as
reintubation, nosocomial pneumonia, as well as broader outcomes such as quality
Although the use of psychoactive medications such as sedatives and analgesics
in mechanically ventilated patients is intended to relieve anxiety and suffering,
recent studies have suggested that these medications may be prescribed overzealously.58-61 Interventional
trials designed to reduce overuse of these medications and their attendant
contributions to delirium and long-term cognitive deficits are greatly needed.
Cognitive impairment in the ICU may be independently related to prolonged
but studies specifically analyzing the interactions between delirium in the
ICU and long-term neurocognitive function are lacking. A significant percentage
of individuals developing delirium in the hospital continue to demonstrate
symptoms of delirium after discharge.11 Such
patients demonstrate decreased cerebral activity and increased cognitive deterioration67 and are more likely to develop dementia than patients
without delirium.68 Finally, patients who develop
delirium have a greater rate of decline on cognitive tests than nondelirious
patients.43 Importantly, future studies are
needed to determine the prognostic significance of delirium in the ICU on
long-term cognitive outcomes.
In conclusion, delirium occurred in more than 8 of 10 mechanically ventilated
adult medical ICU patients in this cohort, and it was present in 4 of 10 alert
or easily aroused patients who are usually assumed to be cognitively intact
by ICU personnel. Unfortunately, delirium is often not recognized by clinicians1,32,69; when it is noted
in the ICU, it is often considered an "expected" occurrence attributed to
The most common type of delirium, hypoactive or quiet delirium, may be associated
with a worse prognosis than hyperactive or agitated delirium.2,42,44,80-83
We documented that bedside nurses in the ICU with no formal psychiatric training
can reliably detect delirium in mechanically ventilated patients with a high
degree of sensitivity and specificity using the CAM-ICU. Requiring only a
modest degree of training, this instrument is rapid and easy to use. Incorporation
of the CAM-ICU into clinical practice and future investigations may lead to
a more precise understanding of the incidence, predictors, and consequences
of delirium among critically ill patients.
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