I’ve been bad again, talking out of school and passing email messages that are too long and not paying any attention to the rules of the core group on communicating about the delirium prevention project.
One of the members suggested we use the mini-cog as a cognitive test to identify patients who might be at high risk for delirium. The mini-cog is a simple test I’ve mentioned in another blog. It is to be used alongside of the Confusion Assessment Method (CAM) since the CAM by itself doesn’t include a test for cognitive disorganization. It has a little memory test and a clock drawing task as well as orientation questions in it. A nurse could do it and it’s quick. I carry a laminated copy of the mini-cog and the CAM in my coat pocket[1, 2].
I’ve talked about the clock drawing task in a previous blog and described it as sort of a trick I use to persuade physicians who consult me that delirium is the problem with their patient, not depression, anxiety, or mania. The clock drawing task was not really designed for screening delirium; it’s actually a test for dementia. But many psychiatric consultants like me use it to yield a quick, graphic way of teaching doctors and nurses about delirium.
I liked the suggestion to use it, but I was also saddened because I had worked with a neuropsychologist and her research assistant on using another more sensitive cognitive test to check for subtle cognitive impairment. It was the Coding task, a quick subtest included in the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). You may have seen the exchange between me and Dr. Burgard in the comment section of a recent blog about it. That conversation was the beginning of the end for an ambitious plan to try an innovative way to assess subtle cognitive assessment in order to select patients for screening with the CAM or the CAM-ICU. The assumption is that those patients would be at higher risk for developing delirium and that may be a target population for delirium prevention interventions.
I was saddened because I felt like I had to give up on using the Coding task because it would probably add too much time to screening tasks for nurses, making it less likely to be a sustainable strategy in our delirium prevention efforts. I was sad because research by this same neuropsychology team has shown it to be a predictor for delirium in a sample of bone marrow transplant patients. The research assistant used good arguments in defense of keeping the Coding task in the game—but I got too many dissenting opinions about the risk of frustrating nurses with extra tasks.
These are the inner gears I’m seeing in the delirium prevention program machine. My colleague’s suggestion about using the mini-cog made me a little wistful because the CAM-ICU by itself probably underrepresents the construct of delirium. I suspect the mini-cog would be an inferior substitute for the Coding task.
But change is coming, especially if the kind of thinking that I see continues to flourish. Change is slow and I’m impatient, I know. But a “change is gonna come” Playing For Change | A Change Is Gonna Come. I’ve been here in this academic center as a medical student, resident, and staff psychiatrist for going on 23 years and I see change coming in the way we think about delirium—finally.
1. Inouye, S.K., et al., Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med, 1990. 113(12): p. 941-8.
2. Borson, S., et al., The mini-cog: a cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry, 2000. 15(11): p. 1021-7.