Delirium
Delirium is an acute, fluctuating disturbance in attention, awareness, and cognition. It develops over a short period (hours to days) and is usually a direct consequence of an underlying medical condition, substance effect, or withdrawal.
Assessment
Confirm a diagnosis of delirium by carrying out a cognitive assessment based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, the short Confusion Assessment Method (short-CAM), or the 4A's test.
The CAM criteria for delirium:
Confusion that has developed suddenly and fluctuates, and
Inattention — ask if the person is easily distracted or has difficulty in focusing attention, and either
Disorganised thinking — ask if the person's thinking is disorganised, incoherent, illogical, or unpredictable (for example they have an unclear flow of ideas, change subject unpredictably, or have rambling or irrelevant conversation), or
Altered level of consciousness — ask about changes in level of consciousness from alertness to: lethargy (drowsy, easily aroused); stupor (difficult to arouse); comatose (unable to be aroused); or hypervigilant (hyper-alert).
The DSM-5 Criteria for Delirium:
A. Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
B. The disturbance develops over a short period of time (usually hours to a few days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during a day.
C. An additional disturbance in cognition (such as memory deficit, disorientation, language, visuospatial ability, or perception).
D. The disturbances in Criteria A and C are not better explained by a pre-existing, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma.
E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition,
substance intoxication, or withdrawal (due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple aetiologies.
The 4A’s Test (4AT)
This is a short, four-item tool designed for use in clinical practice (click here for a link to the test).
The four items are alertness, cognition (a short test of orientation), attention (recitation of the months in backwards order), and the presence of acute change or fluctuating course.
Identify Underlying Cause(s) Think “DELIRIUM”:
· Drugs
· Electrolyte imbalance
· Lack of drugs (withdrawal)
· Infection
· Reduced sensory input
· Intracranial causes
· Urinary/faecal retention
· Myocardial/pulmonary issues