THE MENTAL STATUS VITAL SIGN

Abstract

To the Editor: Wei et al.,1 in their article “The Confusion Assessment Method: A Systematic Review of Current Usage,” review the published literature on the performance characteristics, adaptations, translations, and applications of the Confusion Assessment Method (CAM). The CAM is a widely used instrument for identification of delirium developed by Sharon Inouye, one of the article's coauthors. Recognition of delirium is important because of its association with adverse outcomes,2 its implications for urgent evaluation and treatment, and its potential for prevention.3 The CAM is a sensitive, specific, and reliable instrument for detecting delirium, as this article shows. Nevertheless, healthcare providers lack a mental status tool with which to quickly assess and document usual mental status and recent changes and to help them decide whether to perform the CAM. As an outward indicator of the state of key physiological systems (especially neurological, cardiovascular, metabolic, and immunological), mental status is a “vital sign” akin to heart rate, temperature, and blood pressure. Finding a patient who is suddenly “unresponsive” and a patient whose blood pressure is “too low to be measured” trigger equally urgent reactions by healthcare workers, but less-dramatic changes in mental status often go unrecognized,4 because an objective marker of mental status is not routinely recorded or tracked. The Veterans Affairs Delirium Working Group believes that establishment of mental status as a vital sign—as a clinical dimension to be assessed, documented, and communicated at regular, frequent intervals and with high reliability—would fundamentally improve the quality of care and outcomes for older adults.5 A mental status vital sign would have a particularly major effect for ill older adults and those with dementia, because changes in mental status may precede or supplant changes in traditional vital signs such as temperature or heart rate.6 Although many current healthcare encounters include mental status assessment and documentation as part of routine protocols, its inclusion is far from universal. Even when employed, there is no standardized approach, and unreliable descriptive phrases such as “alert and oriented” may be used. Mental status documentation also falls short in high-risk circumstances for older adults, such as in the postoperative period and during transfer between facilities.7 Adoption of a mental status vital sign will require adaptation of old or development of new assessment techniques and better approaches to documentation and communication. There are several important factors that need to be addressed. First, unlike the other vital signs, mental status has multiple components (e.g., consciousness, memory, executive function). Which of these should be measured? For each, what represents a clinically significant change? Second, routinely used mental status assessment tools require active patient performance (e.g., digit span), and frequent repeated measurement (e.g., every day or every shift) may affect performance or cooperation. How will these effects be taken into account? Third, in most healthcare encounters, front-line nursing staff ascertain and document vital signs. Development of a mental status vital sign must be constructed with this use foremost in mind. The potential benefits of a mental status vital sign mandate that these issues be addressed. One solution may be a mental status vital sign that includes documentation of change (e.g., the CAM item “acute onset or fluctuation”8 or the Clinical Global Impression of Change9). With an eye toward developing a vital sign for use by front-line nursing staff, wording for nursing assistants' impressions of nonspecific changes has been developed and validated in the nursing home setting.10 In sum, we propose that efforts be undertaken to support the adoption of mental status as a vital sign, with reliable measurement, documentation, and widespread utilization. A mental status vital sign is essential to the wider recognition of delirium in healthcare settings and must become a standard of practice to achieve safe and equitable care for older adults.