Objective To develop and validate a new standardized confusion assessment method (CAM) that enables nonpsychiatric clinicians to detect delirium quickly in high-risk settings. Design Prospective validation study. Setting Conducted in general medicine wards and in an outpatient geriatric assessment center at Yale University (site 1) and in general medicine wards at the University of Chicago (site 2). Patients The study included 56 subjects, ranging in age from 65 to 98 years. At site 1, 10 patients with and 20 without delirium participated; at site 2, 16 patients with and 10 without delirium participated. Measurements and main results An expert panel developed the CAM through a consensus building process. The CAM instrument, which can be completed in less than 5 minutes, consists of nine operationalized criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). An a priori hypothesis was established for the diagnostic value of four criteria: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. The CAM algorithm for diagnosis of delirium required the presence of both the first and the second criteria and of either the third or the fourth criterion. At both sites, the diagnoses made by the CAM were concurrently validated against the diagnoses made by psychiatrists. At sites 1 and 2 values for sensitivity were 100% and 94%, respectively; values for specificity were 95% and 90%; values for positive predictive accuracy were 91% and 94%; and values for negative predictive accuracy were 100% and 90%. The CAM algorithm had the highest predictive accuracy for all possible combinations of the nine features of delirium. The CAM was shown to have convergent agreement with four other mental status tests, including the Mini-Mental State Examination. The interobserver reliability of the CAM was high (kappa = 0.81 - 1.0). Conclusions The CAM is sensitive, specific, reliable, and easy to use for identification of delirium.

Clarifying Confusion: The Confusion Assessment Method: A New Method for Detection of Delirium

The factors that cause large individual differences in professional achievement are only partially understood. Nobody becomes an outstanding professional without experience, but extensive experience does not invariably lead people to become experts. When individuals are first introduced to a professional domain after completing their education, they are often overwhelmed and rely on help from others to accomplish their responsibilities. After months or years of experience, they attain an acceptable level of proficiency and are able to work independently. Although everyone in a given domain tends to improve with experience initially, some develop faster than others and continue to improve during ensuing years. These individuals are eventually recognized as experts and masters. In contrast, most professionals reach a stable, average level of performance within a relatively short time frame and maintain this mediocre status for the rest of their careers. The nature of the individual differences that cause the large variability in attained performance is still debated. The most common explanation is that achievement in a given domain is limited by innate factors that cannot be changed through experience and training; hence, limits of attainable performance are determined by one’s basic endowments, such as abilities, mental capacities, and innate talents. Educators with this widely held view of professional development have focused on identifying and selecting students who possess the necessary innate talents that would allow them to reach expert levels with adequate experience. Therefore, the best schools and professional organizations nearly always rely on extensive testing and interviews to find the most talented applicants. This general view also explains age-related declines in professional achievement in terms of the inevitable reductions in general abilities and capacities believed to result from aging. In this article, I propose an alternative framework to account for individual differences in attained professional development, as well as many aspects of age-related decline. This framework is based on the assumption that acquisition of expert performance requires engagement in deliberate practice and that continued deliberate practice is necessary for maintenance of many types of professional performance. In order to contrast this alternative framework with the traditional view, I first describe the account based on innate talent. I then provide a brief review of the evidence on deliberate practice in the acquisition of expert performance in several performance domains, including music, chess, and sports. Finally, I review evidence from the acquisition and maintenance of expert performance in medicine and examine the role of deliberate practice in this domain.

http://edianas.com/portfolio/proj_EricssonInterview/articles/2004_Academic_Medicine_Vol_10,_S70-S81.pdf

Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains.

In this innovative book, a well-known feminist and sociologist-who is also the founding editor of Gender & Society-challenges our most basic assumptions about gender. Judith Lorber argues that gender is wholly a product of socialization, subject to human agency, organization, and interpretation, and that it is a social institution comparable to the economy, the family, and religion in its significance and consequences. Calling into question the inevitability and necessity of gender, she envisions a society structured for equality, where no gender, racial ethnic, or social class group is allowed to monopolize positions of power.

Paradoxes of gender

With a psychiatrist's standardized clinical diagnosis as the criterion, the 'Mini-Mental State' Examination (MMSE) was 87% sensitive and 82% specific in detecting dementia and delirium among hospital patients on a general medical ward. The false positive ratio was 39% and the false negative ratio was 5%. All false positives had less than 9 years of education; many were 60 years of age or older. Performance on specific MMSE items was related to education or age. These findings confirm the MMSE's value as a screen instrument for dementia and delirium when later, more intensive diagnostic enquiry is possible; they reinforce earlier suggestions that the MMSE alone cannot yield a diagnosis for these conditions.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S0033291700046730

Limits of the 'Mini-Mental State' as a screening test for dementia and delirium among hospital patients

The neuropsychological tests developed for the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) are currently used to measure cognitive impairments of Alzheimer's disease (AD) in clinical investigations of this disorder. This report presents the normative information for the CERAD battery, obtained in a large sample (n = 413) of control subjects (ages 50 to 89) who were enrolled in 23 university medical centers in the United States participating in the CERAD study from 1987 to 1992. We compared separately the performance of subjects with high (> or = 12) and low (< 12) years of formal education. For many of the individual cognitive measures in the highly educated group, we observed significant age and gender effects. Only the praxis measure showed a significant age effect in the low-education group. Delayed recall, when adjusted for amount of material acquired (savings), was relatively unaffected by age, gender, and level of education. Our findings suggest that the savings scores, in particular, may be useful in distinguishing between AD and normal aging.

The Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Part V. A normative study of the neuropsychological battery

A brief mental status questionnaire adapted specifically to diagnose diffuse organic diffuse organic mental syndromes on busy medical words is developed and tested for reliability and validity. When the 30-item questionnaire was given to 17 medical patients diagnosed by consultation spychiatrists as having a diffuse organic mental syndrome, all score 20 or less. With hospitalized psychiatric patients the questionnaire was able to differentiate between the "functional psychoses" and diffuse organic brain syndromes. When administered to 69 consecutive medical admissions, fully one third showed marked cognitive limitations. A sample of normals suggested that results may be contaminated by severe cultural or educational variances. We discuss the role of cognitive dificiencies in medical patients, and suggestions are made regarding the broad usefulness of this questionniare to a medical service.

Screening for organic mental syndromes in the medically ill.

A meta-analysis of flight simulation research was conducted to identify important characteristics associated with the effectiveness of simulator training. Some 247 articles, research reports, and technical reports were located, from which 26 experiments were identified as having sufficient information for statistical meta-analysis. The major finding was that the use of simulators combined with aircraft training consistently produced improvements in training for jets compared to aircraft training only. Use of motion cuing added little to the training environments for jets. The average effectiveness of performance-paced training was greater than that for lock-step training. In general, training outcomes appear to be influenced considerably by the type of task and the amount and type of training given.

Flight Simulator Training Effectiveness: A Meta-Analysis

Associative and categorical processes in children's memory: The role of automaticity in the development of organization in free recall ☆

Detection of cognitive deficits by a brief mental status examination: the Cognitive Capacity Screening Examination, a reappraisal and a review.

Divorce is becoming a major mental health problem in the United States. With rare exception psychological attention has usually focused on the effect of divorce on children and mothers. The author suggests that as some fathers become more involved in family nurturing they will be more intensely affected by marital disruption, particularly as it involves changes in the relationship to their children. A review of the recent psychological literature on divorce and custody is presented as a framework for understanding the divorcing father who is requesting psychiatric help.

John W. Jacobs

Papers

Screening for organic mental syndromes in the medically ill.

Flight Simulator Training Effectiveness: A Meta-Analysis

Associative and categorical processes in children's memory: The role of automaticity in the development of organization in free recall ☆

Detection of cognitive deficits by a brief mental status examination: the Cognitive Capacity Screening Examination, a reappraisal and a review.

The effect of divorce on fathers: an overview of the literature