The CAM-S Score for Delirium Severity
Training Manual and Coding Guide
RECOMMENDED CITATION: Inouye SK. The CAM-S Training Manual and Coding Guide. 2014;
Boston: Hospital Elder Life Program.
REFERENCES: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying
confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern
Med. 1990; 113: 941-948.
Inouye SK, Kosar CM, Tommet D, Schmitt EM, Puelle MR, Saczynski JS, Marcantonio ER, Jones
RN. The CAM-S: Development and Validation of a New Scoring System for Delirium Severity in 2
Cohorts. Ann Intern Med. 2014; 160:526-533.
Date developed: 1988 (CAM); 2014 (Manual)
Last revised: January 2020
Reproduced by The American Geriatrics Society Inc. with permission. ©1999 Hospital Elder Life Program, LLC.
Not to be reproduced without permission.
1
Table of Contents
Background
3
CAM-S Short Form
4
CAM-S Short Form Scoring Instructions
5
CAM-S Long Form
6
CAM-S Long Form Scoring Instructions
7
CAM-S Training Instructions
8
Obtaining Copyright Clearance
9
Reproduced by The American Geriatrics Society Inc. with permission. ©1999 Hospital Elder Life Program, LLC.
Not to be reproduced without permission.
2
Background
Delirium (acute confusional state) is a common, serious, and potentially preventable source of
morbidity and mortality for older hospitalized patients. Currently, delirium affects as much as 50%
of elderly hospitalized patients, with associated hospital mortality rates of 22-76%. Each year
delirium complicates hospital stays for over 2.6 million older persons, involving over 17.5 million
inpatient days, and accounting for annual healthcare costs of >$164 billion dollars in the United
States alone (2011 USD). Substantial additional costs accrue following hospital discharge because
of the increased need for institutionalization, rehabilitation, and home care.
The Confusion Assessment Method (CAM) was originally developed in 1988-1990, to improve the
identification and recognition of delirium. The CAM was intended to provide a new standardized
method to enable non-psychiatrically trained clinicians to identify delirium quickly and accurately in
both clinical and research settings.
Since its development, the CAM has become the most widely used instrument for detection of
delirium world-wide, because of both its strong validation results as well as its ease of use. The
CAM instrument has been used in over 5,000 original articles to date, as either a process or
outcome measure, and has been translated into over 14 languages world-wide. When validated
against the reference standard ratings of geriatric psychiatrists based on comprehensive
psychiatric assessment, the CAM had a sensitivity of 94-100%, specificity of 90-95%, and high
inter-observer reliability in the original study of 50 patients (Inouye, 1990). More recently this work
has been extended (Wei, 2008), and in 7 high-quality validation studies on over 1,000 subjects, the
CAM had a sensitivity of 94% (95% CI 91-97%) and specificity of 89% (95% CI 85-94%).
This manual is intended to guide you in the use of the CAM-S. The CAM-S is a new scoring system
for assessing delirium severity. The CAM-S is intended to be used in addition to the original CAM
algorithm. It will not yield a delirium diagnosis but only a means to quantify the intensity of delirium
symptoms a patient experiences. The CAM-S is available in short and long forms. The 4-item
CAM-S short form is intended to be used with the short CAM. It takes less than 5-10 minutes to
complete and is recommended for clinical practice. The CAM-S long form should be used in any
research study.
In order to rate the CAM, it is important to perform formal cognitive testing. You can also use other
brief instruments, such as the Short Portable Mental Status Questionnaire or the Mini-Cog. Once
you have performed the cognitive testing with a patient you may move on to scoring the CAM.
Reproduced by The American Geriatrics Society Inc. with permission. ©1999 Hospital Elder Life Program, LLC.
Not to be reproduced without permission.
3
CAM-S DELIRIUM SEVERITY SCORING
The CAM can be used to determine both a CAM-S Long Form and CAM-S Short Form delirium
severity score.
Feature
Scoring the CAM-S: Rate each symptom of delirium listed in the CAM as absent (0), mild (1), marked (2).
Acute onset or fluctuation is rated as absent (0) or present (1). Add these scores into a composite. Higher
scores indicate more severe delirium.
Not Present
Present (mild)
Present (marked)
1. ACUTE ONSET &
FLUCTUATING COURSE
0
1
2. INATTENTION
0
1
2
3. DISORGANIZED
THINKING
0
1
2
4. ALTERED LEVEL
OFCONSCIOUSNESS
0
vigilant/lethargic:
1
stupor or coma:
2
5. DISORIENTATION
0
1
2
6. MEMORY
IMPAIRMENT
0
1
2
7. PERCEPTUAL
DISTURBANCES
0
1
2
8. PSYCHOMOTOR
AGITATION
0
1
2
9. PSYCHOMOTOR
RETARDATION
0
1
2
10. ALTERED
SLEEP-WAKE
CYCLE
0
1
2
Short Form
SEVERITY SCORE:
Long Form
SEVERITY SCORE:
Reproduced by The American Geriatrics Society Inc. with permission. ©1999 Hospital Elder Life Program, LLC.
Not to be reproduced without permission.
4
CAM-S Short Form Scoring Instructions
To score the CAM-S short form, rate the core features of the Confusion Assessment Method
(CAM) and apply a severity score to each rating. Summarize these scores into a composite that
ranges from 0-7.
A) Scoring instructions, acute change or fluctuation:
If the patient experiences either an acute change or fluctuation in mental status,
assign a score of 1. Otherwise, assign a score of 0.
B) Scoring instructions, all other features:
1. Assign scores of 0 when the feature is not present
2. Assign scores of 1 when the feature is present at a mild level. For the level of
consciousness item, this means the patient is either vigilant or lethargic
3. Assign scores of 2 when the feature is present at marked (moderate to severe)
level. For the level of consciousness item this means the patient is in stupor or coma
C) Note on Missing Data:
If a feature is not evaluated or the assessor is uncertain about its presence or
absence, do not assign 0. Instead, allow the rating to be missing and prorate the
summary score. It is recommended to this with two items scored at minimum.
Reproduced by The American Geriatrics Society Inc. with permission. ©1999 Hospital Elder Life Program, LLC.
Not to be reproduced without permission.
5
CAM-S LONG FORM DELIRIUM SEVERITY SCORING WORKSHEET
Feature
Question
Severity Score
1. ACUTE ONSET
& FLUCTUATING
COURSE
Is there evidence of an acute change in mental status from the
patient’s baseline? Did the patient’s behavior fluctuate at any
point during the interview for any of the 10 features?
No: 0
Yes: 1
2. INATTENTION
Did the patient have difficulty focusing attention, for example
being easily distractible, or having difficulty keeping track of
what was being said?
No: 0
Yes (mild): 1
Yes (marked): 2
3. DISORGANIZED
THINKING
Was the patient’s thinking disorganized or incoherent, such as
rambling or irrelevant conversation, unclear or illogical flow or of
ideas, unpredictable switching from subject to subject?
No: 0
Yes (mild): 1
Yes (marked): 2
4. ALTERED LEVEL
OF
CONSCIOUSNESS
Overall, how would you rate the patient’s level of
consciousness?
- Alert (normal)
- Vigilant
- Lethargic
- Stupor
- Coma
- Uncertain
Normal: 0
Mild: vigilant
or lethargic: 1
Marked:
stupor or coma: 2
5. DISORIENTATION
Was the patient disoriented at any time during the interview,
such as thinking he/she was somewhere other than the hospital,
using the wrong bed, or misjudging the time of day?
No: 0
Yes (mild): 1
Yes (marked): 2
6. MEMORY
IMPAIRMENT
Did the patient demonstrate any memory problems during the
interview, such as inability to remember events in the hospital or
difficulty remembering instructions?
No: 0
Yes (mild): 1
Yes (marked): 2
7. PERCEPTUAL
DISTURBANCES
Did the patient have any evidence of perceptual disturbances,
for example, hallucinations, illusions, or misinterpretations (such
as thinking something was moving when it was not)?
No: 0
Yes (mild): 1
Yes (marked): 2
8. PSYCHOMOTOR
AGITATION
At any time during the interview, did the patient have an
unusually increased level of motor activity, such as restlessness,
picking at bedclothes, tapping fingers, or making frequent
sudden changes of position?
No: 0
Yes (mild): 1
Yes (marked): 2
9. PSYCHOMOTOR
RETARDATION
At any time during the interview, did the patient have an
unusually decreased level of motor activity, such as
sluggishness, staring into space, staying in one position for a
long time, or moving very slowly?
No: 0
Yes (mild): 1
Yes (marked): 2
10. ALTERED
SLEEP-WAKE
CYCLE
Did the patient have evidence of disturbance of the sleep-wake
cycle, such as excessive daytime sleepiness with insomnia at
night?
No: 0
Yes (mild): 1
Yes (marked): 2
Long Form
SEVERITY SCORE:
Add the scores in rows 1-10. Range is 0-19.
LF Severity Score
Total (0-19)
Short Form
SEVERITY SCORE:
Add the scores in rows 1-4. Range is 0-7.
SF Severity Score
Total (0-7)
Scoring the CAM-S: Rate each symptom of delirium listed in the CAM instrument as absent (0), mild (1), marked (2).
Acute onset or fluctuation is rated as absent (0) or present (1). Summarize these scores into a composite.
Reproduced by The American Geriatrics Society Inc. with permission. ©1999 Hospital Elder Life Program, LLC.
Not to be reproduced without permission.
6
CAM-S Long Form Delirium Severity Scoring Instructions
The CAM-S Long form can be used to determine both a CAM-S Long and CAM-S Short score. To
score the CAM-S long form, rate the core features of the Confusion Assessment Method (CAM)
and apply a severity score to each rating. Summarize these scores into a composite that ranges
from 0-19. Higher scores indicate more severe delirium.
A) Scoring instructions, acute change or fluctuation:
If the patient experiences either an acute change or fluctuation in mental status,
assign a score of 1. Fluctuation in behavior can occur on any of the 10 features in
order for the patient to receive a 1. Otherwise, assign a score of 0.
B) Scoring instructions, all other features:
Assign scores of 0 when the feature is not present
Assign scores of 1 when the feature is present at a mild level. For the level of
consciousness item, this means the patient is either vigilant or lethargic
Assign scores of 2 when the feature is present at marked (moderate to severe)
level. For the level of consciousness item this means the patient is in stupor or coma
C) Note on Missing Data:
If a feature is not evaluated or the assessor is uncertain about its presence or
absence, do not assign 0. Instead, allow the rating to be missing and prorate the
summary score. It is recommended to this with two items scored at minimum.
Reproduced by The American Geriatrics Society Inc. with permission. ©1999 Hospital Elder Life Program, LLC.
Not to be reproduced without permission.
7
RECOMMENDED TRAINING PROCEDURE
We recommend the following procedure to initiate new interviewers to the cognitive assessment
and use of the CAM. The principal investigator or project director will provide a general overview
on the cognitive assessment instruments (e.g., Short Portable Mental Status Questionnaire, Mini-
Cog Test, digit span tests) and the CAM. Following this, we recommend the following approach:
One-on-one sessions where pairs of interviewers (ideally an experienced interviewer teamed
with a new interviewer to orient) who practice the interviews with each other
Pilot interviews on floors with delirious and non-delirious patients (usually 2 of each): These
are done with the project director teamed with a new interviewer, and feedback is given.
Inter-rater reliability assessments: These are done with pairs of interviewers observing the
same patient. One interviewer administers the cognitive assessment and CAM, and the other
observes. They both score the patient. On the next paired interview, the other interviewer
performs the interview. Ideally, this should be done on 5 delirious, and 5 non-delirious patients.
This process should be repeated until they achieve an agreement of 100% on presence or
absence of delirium. Early paired ratings should be observed by the PI or project director.
Special coding sessions are recommended once a month for all the interviewers with the
project director to answer questions about scoring the CAM. In addition, the inter-rater
reliability assessments are conducted every 6 months for the duration of the study.
Reproduced by The American Geriatrics Society Inc. with permission. ©1999 Hospital Elder Life Program, LLC.
Not to be reproduced without permission.
8
COPYRIGHT CLEARANCE
The CAM-S Delirium Severity is a copyrighted instrument. You are welcome to use the CAM
instrument and criteria for nonprofit clinical or research purposes only after permission is
granted by the American Geriatrics Society.
All delirium instruments on the help.agscocare.org website are copyrighted. You must create an
individual user account before gaining access to these instruments. These instruments are
available free of charge for nonprofit clinical and academic uses. All uses should include the
following acknowledgment and disclaimer:
Acknowledgment: “Confusion Assessment Method. Copyright 2003, Hospital Elder Life
Program, LLC. Not to be reproduced without permission.”
Disclaimer: “No responsibility is assumed by the AGS or the Hospital Elder Life Program, LLC
for any injury and/or damage to persons or property arising out of the application of any of the
content at help.agscocare.org.”
“Permission granted by the American Geriatrics Society, 2019.”
The CAM should be used in accordance with training and procedures outlined in the CAM
Training Manual. Brief cognitive testing is required for accurate scoring of the CAM. At a
minimum, testing of orientation and sustained attention is recommended, such as digit spans,
days of week, or months of year backwards. In order to use the CAM in any research you must
submit a request to our office by emailing Deena Sandos at [email protected]
and await approval.
Translations
If you would like to translate the CAM-S Delirium Severity Instrument, please email Deena
Sandos at [email protected] for guidance through this process. Include what
language you would like to translate the instrument to.
Prohibited Usage
The reproduction of the CAM-S Severity Delirium tool for any of the following uses is prohibited:
1.Publications: Please refrain from reproducing the CAM instrument in your publication. This
usage is strictly prohibited. Instead, provide a description of the CAM, include proper
acknowledgment (see above), and direct readers to the CAM tool on our website. If you have
questions about the usage of the CAM in your publication, please email us your publication to
review.
2.Website Posting/Smartphone Applications: The CAM tool may not be reproduced on any
website, online platform, or smartphone application. Please direct users to our website to
access the CAM.
3.Training Videos: The reproduction of the CAM tool in training videos is prohibited.
4.For-profit or industry use: The CAM tool must only be used for nonprofit clinical and academic
purposes.
Reproduced by The American Geriatrics Society Inc. with permission. ©1999 Hospital Elder Life Program, LLC.
Not to be reproduced without permission.
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