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Wesley Gomez
Wesley Gomez

Delirium V2.5 Serial [HOT]


  • processing.... Drugs & Diseases > Psychiatry Delirium Clinical Presentation Updated: Apr 25, 2019 Author: Kannayiram Alagiakrishnan, MD, MBBS, MPH, MHA; Chief Editor: Glen L Xiong, MD more...

  • Share Email Print Feedback Close Facebook Twitter LinkedIn WhatsApp webmd.ads2.defineAd(id: 'ads-pos-421-sfp',pos: 421); Sections Delirium Sections Delirium Overview Practice Essentials

  • Background Pathophysiology Mortality/Morbidity Epidemiology Show All Presentation History

  • Physical Causes Show All DDx Workup Laboratory Studies

  • Imaging Studies Other Tests Show All Treatment Medical Care

  • Consultations Show All Guidelines Medication Medication Summary

  • Antipsychotics Benzodiazepines Vitamins Hypnotic, Miscellaneous Show All Follow-up Further Outpatient Care

Further Inpatient Care Deterrence/Prevention Complications Prognosis Patient Education Show All Questions & Answers Tables References Presentation History The diagnosis of delirium is clinical. No laboratory test can diagnose delirium. Obtaining a thorough history is essential.




Delirium v2.5 serial


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Delirium is mistaken for dementia or depression, especially when patients are quiet or withdrawn. However, by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) criteria, dementia cannot be diagnosed with certainty when delirium is present. Health professionals can do Mini-Mental Status Exam (MMSE), [20] depression assessment screening using DSM-5 criteria, [1] or the Geriatric Depression Scale (GDS). [21] They can also assess for suicidal and homicidal risk if necessary. Health professionals can directly ask patients about suicidal or homicidal ideation (thoughts), intent, and plan.


Depression symptoms are commonly seen with delirium. In a recent study, patients having symptoms of dysphoric mood and hopelessness are at risk for incident delirium while in the hospital. [22] On the other hand, hypoactive delirium may be mistaken for depression. Up to 42% of patients referred to psychiatry services for suspected depressive illness in the hospital may have delirium. [23] Screening for depression in the presence of delirium is quite challenging.


Patients with delirium who are hyperactive have an increased state of arousal, psychomotor abnormalities, and hypervigilance. In contrast, patients with delirium who are hypoactive are withdrawn, less active, and sleepy.


Subsyndromal delirium has been defined as the presence of some core diagnostic symptoms that do not meet the criteria for diagnostic threshold. Prevalence rates of 30-50% have been reported in intensive care units. [24, 25]


A prodromal phase lasting for hours to days can occur before full syndromal delirium becomes evident. This includes sleep disturbances, vivid dreams, frequent calls for assistance, and anxiety. [24, 25]


Impaired attention can be assessed with bedside tests that require sustained attention to a task that has not been memorized, such as reciting the days of the week or months of the year backwards, counting backwards from 20, or doing serial subtraction.


Gaps in the medical record such as once daily cognitive assessment or no formal assessments on the hallmarks of delirium (attention span and fluctuation) may make diagnosing the condition more difficult. The physicians depend on health records (nursing notes) to identify a fluctuating course. The type of information might also be less than adequate for developing a timely diagnosis. So the recognition of delirium can be delayed by infrequent observation or documentation. [27]


A simple cognitive test like the Mini-Cog can be a predictor of inhospital delirium. At the time of admission to the hospital, if the elderly patient does not have a history of dementia or cognitive impairment, the Mini-Cog can be used to identify patients at high risk for inhospital delirium.


The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) offers the clinician the opportunity to identify delirium in critical care patients, especially patients on mechanical ventilation. The CAM-ICU makes use of nonverbal assessments to evaluate the important features of delirium.


Another instrument that can be used in ICU settings is the Intensive Care Delirium Screening Checklist (ICDSC). The severity of delirium in the ICU can be estimated by the Delirium Detection Scale (DDS).


A 2012 meta-analysis showed a sensitivity of 75.5% and specificity of 95.8% for CAM-ICU, whereas sensitivity and specificity for the ICDSC were 80.1% and 74.6%, respectively. These results suggest the CAM-ICU is one of the most specific bedside tests that can be used to diagnose delirium in ICU patients. [28]


Almost any medical illness, intoxication, or medication can cause delirium. Often, delirium is multifactorial in etiology, and the physician treating the delirium should investigate each cause contributing to it. Medications are the most common reversible cause of delirium.


Dementia is one of the strongest most consistent risk factors. Underlying dementia is observed in 25-50% of patients. The presence of dementia increases the risk of delirium 2-3 times. Low educational level, which may be an indicator of low cognitive reserve, is associated with increased vulnerability to delirium.


Drugs are a common risk factor for delirium, and drug-induced delirium is commonly seen in medical practice, especially in hospital settings. The risk of anticholinergic toxicity is greater in elderly persons, and the risk of inducing delirium by medications is high in frail, elderly persons and in those with dementia.


Delirium is common in older hospitalized patients, and is associated with negative consequences for the patients, next of kin, healthcare professionals and healthcare costs. It is important to understand its clinical features, as almost 40% of all cases in hospitals may be preventable. Yet, delirium in hospitalized patients is often unrecognized and untreated. Few studies describe thoroughly how delirium manifests itself in older hospitalized patients and what actions healthcare professionals take in relation to these signs. Therefore, the aim of this study was to describe signs of delirium in older hospitalized patients and action taken by healthcare professionals, as reported in patient records.


Improved knowledge about delirium in hospitals is needed in order to reduce human suffering, healthcare utilization and costs. It is important to enable older hospitalized patients with signs of delirium to participate in their own care and to protect them from harm. Delirium has to be seen as a preventable adverse event in all hospitals units. To improve the prevention and management of older hospitalized patients with signs of delirium, person-centered care and patient safety may be important issues.


Delirium is the most common complication in older hospitalized patients [1, 2] and is associated with negative hospital outcomes [3,4,5,6,7], including an increased risk of falling, prolonged hospital stays, cognitive and functional decline, mortality, increased healthcare utilization and increased costs [8, 9]. Still, delirium is often unrecognized [10] or poorly understood and managed in hospitals [11].


Delirium can be defined as acute brain failure occurring in persons with diminished reserve capacity [13], e.g., brain aging with greater sensitivity [9]. It is commonly due to underlying causes and is, in general, reversible when the underlying etiological factors are treated [2]. The etiology is complex and multifactorial [8, 12]. Predisposing and precipitating factors interact and patients with many predisposing factors may develop delirium easily [10]. The most important risk factor for delirium is cognitive impairment [2], and at least two third of all cases of delirium occur in patients with a preexisting neurocognitive disorder (NCD), e.g., Alzheimers disease [10].


It is important to understand the clinical features of delirium, as it is a clinical bedside diagnosis [9, 11]. Signs of delirium are disturbed attention, awareness and cognition that develop over a short period of time and fluctuate in severity. Hyperactive delirium is easiest to recognize with increased psychomotor activity and often mood fluctuations, agitation, refusal to co-operate, disruptive behavior, disturbance in the sleep-wake cycle and hallucinations. Hypoactive delirium, which is more common among the oldest [2] and in palliative care [14], is characterized by reduced psychomotor activity, sluggishness and lethargy. Rapid fluctuations between hyper- and hypoactive psychomotor activity, as well as a normal level of psychomotor activity with disturbed attention and awareness, indicate mixed delirium [2].


Although the signs of delirium are clearly described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [2], there is poor recognition and management by healthcare professionals of hospitalized patients with these signs [10, 11]. There are few studies that thoroughly describe which signs of delirium healthcare professionals report in the patient records and what action they take in relation to these signs. Therefore, this study aims to describe signs of delirium in older hospitalized patients and action taken by healthcare professionals, as reported in patient records.


Descriptions of signs of both hyperactive, hypoactive and mixed delirium in patient records were reviewed using a protocol based on the diagnostic features of delirium in the DSM-5 [2], e.g., a disturbance in attention and awareness. The timing of the signs was also reviewed.


Two qualitative content analyses according to Elo and Kyngäs [25] were performed, first an inductive analysis of patient signs of delirium, and then a deductive analysis of action taken by healthcare professionals in relation to these signs. In both analyses, the data were organized in a stepwise categorization process. First, text transferred from the review protocols was divided into two documents: signs and actions. In each analysis, the text was read through several times to get a sense of wholeness of the content. The co-authors also read the text independently. Throughout the analyses, each step was discussed with the co-authors until consensus was reached.


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