The Polish language version of the Confusion Assessment Method – a questionnaire for the screening of consciousness disorders

Introduction

Delirium caused by somatic factors is a widespread and dangerous problem associated with the aging of the population. It has been reported that consciousness disorders are experienced by 10-15% of patients on general wards and up to 50% of patients admitted emergently to geriatric wards [1]. The frequent occurrence of delirium stems from the commonness and number of risk factors for this complication, which include, among others: old age, organic injury of the central nervous system, alcoholism, malnutrition, chronic somatic diseases, chronic pain and analgesic treatment, long-term insomnia, electrolyte disorders, blood loss, dehydration, cognitive impairments, depression, metabolic disorders, use of psychoactive agents, immobility, urinary catheterization, and numerous factors associated (directly or indirectly) with surgical procedures [1-4]. One-year mortality of delirium in the population of intensive care unit patients is estimated to be around 40% [5, 6]. One should keep in mind that, although qualitative disorders of consciousness are reversible and transient, they directly precede the patient’s death in 88% of cases [7]. Persisting symptoms of delirium result in growing motor agitation, disorganization, and anxiety, which increases the risk of injury or self-harm, necessitates parenteral nutrition and the maintenance of water balance, and impedes cooperation, thus worsening the course and prognosis of the underlying disease [2]. Consciousness disorders are believed to be among the most challenging diagnostic problems and the most difficult therapeutic problem among psychotic disorders [2]. Differential diagnosis typically considers dementia as well as maniacal, paranoid, and delusional syndromes [1]. A particular diagnostic challenge is presented by hypoactive delirium, which is often confused with depression, depressive stupor, catatonia, or apathetic-abulic syndromes [2]. Retrospective studies state that this form of delirium with poor motor activity is observed in the decided majority of cases of delirium in old patients; its frequency correlates with the deterioration of the patient’s general condition [7]. These data indicate an obvious need for improving the diagnostics of consciousness disorders on somatic wards, especially those employing surgical procedures. In 1990, a new diagnostic tool for mid-level medical personnel was developed; the purpose of the Confusion Assessment Method (CAM) is the early detection of somatically induced delirium [8]. Numerous studies conducted over the period of 16 years established CAM’s position as an effective standardized diagnostic tool; its sensitivity was estimated at 94-100%, specificity: 90-95%, positive predictive value: 91-94%, and negative predictive value: 90-100% [8]. Therefore, the CAM questionnaire had been translated into 10 languages by 2008; it is widely used in Japan, Germany, Finland, Denmark, France, Italy, Spain, Portugal, Turkey, China, and other countries [8].
The aim of this article is to present the Polish version of this screening diagnostic tool.

Material and methods

The CAM questionnaire consists of 9 points with questions verifying the presence of: acute changes in mental status, attention disorders, disorganized thinking, altered level of consciousness, disorientation, memory impairment, perceptual disturbance, psychomotor agitation or retardation, and sleep-wake cycle disturbances. The questions require the respondent to evaluate the severity and dynamics of the symptoms; space is also provided for descriptive comments. Most questions pertain to information that can be acquired during a single patient examination; answers to the first and last question require information concerning the patient’s stay, which can be gathered from the patient’s records or the attending medical personnel. The preliminary diagnosis of delirium only requires answers to the first five questions, constituting the so-called short form of CAM. In order to interpret the questionnaire’s results, it is necessary to be acquainted with the scoring manual, which has also been translated in this article.
The aim of the authors was to provide a translation that would correspond to the intentions of the questionnaire’s original creators to the largest degree possible. Therefore, the original authors were invited to actively cooperate on the project. After receiving approval from Professor Sharon K. Inouye, the director of the Aging Brain Center, the first stage of work on the translation began: two independent translation groups were formed, each consisting of three physicians, including one psychiatrist. The first group translated the original text into Polish, while the second group translated the new Polish text back into English without knowing the original version. The full CAM scale was translated along with the scoring manual. Subsequently, the return translation was sent to the authors of the original questionnaire. Based on their concerns and suggestions, the final version was modified twice before receiving full approval of the original questionnaire’s authors. The new Polish version of CAM was accepted for publication among the other official translations on the HELP webpage: (http://www.hospitalelderlifeprogram.org/uploads/disclaimers/ CAM_Polish.pdf).

Results

The Polish version of the questionnaire is presented in Appendage.

Discussion

This paper introduces the first Polish translation of the American CAM questionnaire. Apart from CAM, other tools for consciousness disorder screening are used around the world, including the Delirium Symptom Interview (DSI) [9], the NEECHAM Confusion Scale [10], the Delirium Observation Screening (DOS) scale [11], the Cognitive Test for Delirium (CTD) [12], and the Descard Tool used in Poland [13]. Among these tools, the Confusion Assessment Method is characterized by the highest sensitivity and specificity [14]. Evaluation using the CAM questionnaire can be performed by any member of the medical staff based on the instructions contained within the CAM Training Manual. The tool has already been translated into 10 languages and is being used in 10 non-English speaking countries [8]. It can be suspected that introducing the CAM scale into everyday practice in Poland will also facilitate the diagnostics of consciousness disorders; however, one should keep in mind that evaluation using a questionnaire is only a screening tool, and one should always strive to confirm its preliminary diagnosis with a clinical examination, preferably conducted by a consulting psychiatrist. The questionnaire has been translated by physicians with active support provided by staff members of the Aging Brain Center, the creators of the original version. The Polish translation still requires validation on somatic wards as well as further studies to determine its effectiveness and sensitivity in clinical conditions.

Conclusions

The first obtained data indicate that the Polish version of CAM is characterized by good diagnostic accuracy, but its usefulness in everyday practice requires further studies with more precise validation of the questionnaire in clinical conditions.

Disclosure

Authors report no conflict of interest.

References

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