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CAM-ICU — ICU Delirium Screening and Management

Confusion Assessment Method for the ICU for early identification, prevention, and management of delirium.

Written by: Saygı Hospital Health Guide Editorial Board
Published: · Last updated:

This content is for general information; please consult your physician for diagnosis and treatment.

References (3)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Göğüs Hastalıkları department. Book Appointment →

What is CAM-ICU — ICU Delirium Screening and Management?

ICU delirium is an acute, fluctuating disturbance of attention, consciousness, and cognition in ICU patients. Prevalence is 60-80% in mechanically ventilated patients and 30-50% across all ICU patients. DSM-5 criteria: acute onset + fluctuation, attention deficit, change in consciousness or cognition, attributable to a general medical condition.

Subtypes — hyperactive (agitation, hallucinations — easy to recognize but only ~5%), hypoactive (quiet, apathetic, lethargic — most common at ~45% and often missed), and mixed (~40%). Hypoactive delirium has the worst prognosis; missed diagnosis raises mortality.

CAM-ICU (Confusion Assessment Method for the ICU) — a four-step bedside evaluation: 1) Acute onset / fluctuation, 2) Attention deficit (Letter Attention Test: counting the letter A in a 10-letter sequence), 3) Altered level of consciousness (RASS ≠0), 4) Disorganized thinking (four questions). Positive: 1 and 2 + (3 or 4).

Consequences — patients with delirium have longer mechanical ventilation, prolonged ICU and hospital stays, elevated long-term cognitive-impairment and dementia risk, and 1.4-3× higher mortality. Prevention and early management are therefore essential.

Symptoms

Acute onset and fluctuation — symptoms begin within hours to days and fluctuate across the day
Attention deficit — inability to focus on stimuli, scattered conversation, failure to follow simple commands
Altered level of consciousness — RASS +1 to +4 (hyperactive) or RASS -2 to -4 (hypoactive)
Cognitive impairment — disorganized thinking, disorientation (time, place, person), memory impairment, language problems
Perceptual disturbances — visual hallucinations (animals, people), auditory hallucinations, paranoid ideation

Risk Factors

Non-modifiable — age >65, pre-existing dementia/cognitive impairment, prior delirium, genetics (APOE4)
Acute illness — sepsis, hypoxia, electrolyte disturbances (hyponatremia), metabolic (renal/hepatic failure), infection
Treatment-related — benzodiazepines (especially midazolam, lorazepam — the strongest risk factor), anticholinergic drugs, high-dose opioids, mechanical ventilation
Environmental — sleep deprivation, immobilization, isolation, noise, excessive or insufficient light, absence of family, loss of day-night cycle
Alcohol or sedative withdrawal, nicotine withdrawal

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • CAM-ICU assessment at the beginning of every shift (every 8 hours) — should be standard practice
  • Positive CAM-ICU — clinical evaluation (review anticholinergic drugs, search for sepsis/hypoxia/metabolic causes)
  • Refractory delirium (>48 h despite intervention) — consultation (neurology, psychiatry, geriatrics)

Treatment Methods

01
ABCDEF Bundle — Assess and manage pain (A), Both SAT and SBT (B), Choice of sedation (C — dexmedetomidine > propofol > benzodiazepine), Delirium assess/manage (D), Early mobility (E), Family engagement (F). Bundle adherence reduces mortality by ~25%.
02
Non-pharmacological (foundation) — maintain day-night cycle (daytime light + activity, nighttime dark + quiet), ensure use of glasses/hearing aids, family visitation, orientation (calendar, clock), early mobilization from day 1, sleep hygiene
03
Medication optimization — taper/stop benzodiazepines (midazolam → dexmedetomidine transition), review anticholinergic drugs (diphenhydramine, atropine, scopolamine), minimize opioid doses, analgesia-first sedation
04
Dexmedetomidine — alpha-2 agonist, sedation with lower delirium risk (MIDEX/PRODEX). Infusion 0.2-1.4 mcg/kg/hour; an alternative to benzodiazepines in ventilated delirium patients
05
Haloperidol — reserved for hyperactive delirium with agitation and risk of self-harm (0.5-5 mg IV every 15-30 minutes). Risk of QTc prolongation — ECG monitoring required. Atypical antipsychotics (quetiapine, olanzapine) used locally. MIND-USA (2018) showed no routine benefit
06
Long-term follow-up — cognitive assessment after ICU discharge, rehabilitation, family education, post-ICU syndrome (PICS) monitoring

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.