Delirium diagnostic criteria: Difference between revisions

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*Occipital lobe disorders can demonstrate various symptoms such as confabulation, cortical blindness, etc.  Imaging studies and focal neurological symptoms may be helpful to distinguish it from delirium.
*Occipital lobe disorders can demonstrate various symptoms such as confabulation, cortical blindness, etc.  Imaging studies and focal neurological symptoms may be helpful to distinguish it from delirium.
*Parital lobe disorders like Wernicke's aphasia can hinder patient's ability to follow examiner's instructions which is often misinterpreted as a state of confusion.
*Parital lobe disorders like Wernicke's aphasia can hinder patient's ability to follow examiner's instructions which is often misinterpreted as a state of confusion.
*Nonconvulsive epileptic episodes should also be considered when the diagnosis of the delirium is considered.  
*Nonconvulsive epileptic episodes should also be considered as a differential diagnosis of delirium.  





Revision as of 02:12, 14 February 2014

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vishal Khurana, M.B.B.S., M.D. [2] ; Pratik Bahekar, MBBS [3] ; Ahmed Zaghw, M.D. [4]


Diagnostic Criteria

Diagnostic and Statistical Manual (DSM-5) Diagnostic Criteria

  1. Diminished focus or concentration and lack of knowledge or perception of the surroundings .
  1. Developing in a brief period of time accounting to hours to days, a shift from a baseline which change in severity in it’s course.
  1. Also, interference in faculties of cognition like, memory, orientation, visuospatial ability, or language).
  1. 1st and 3rd criteria are not a result of any previous, current, or developing neurocognitive disorder and also not related to change in arousal status e.g. coma
  1. The manifestation of the disturbances resulting as a physiological sequel of a medical condition, intoxication or withdrawal of substance(s) or medicine(s), or a toxin(s); or is due to multiple etiologies, is explained by the history, physical examination, or laboratory findings.[1] [2]


ICD-10 Diagnostic Criteria

To make a definite diagnosis, symptoms (mild, moderate or severe) must be present in the following criteria,

  1. Curtailment in the consciousness and consciousness (as a result of clouding to coma; ( inability to direct, keep , transfer focus)
  1. Universal disruption in faculties of cognition (clouding of perception , illusions, and hallucinations— mostly visual; clouding of abstract thinking and comprehension, may or may not be accompanied by delusions, some degree of incoherence is likely to be present; reduced ability of immediate recall and of disturbance in the recent memory and relatively intact remote memory; lack of orientation to time and in more severe cases, to place and person)
  1. Impairment in psychomotor activity (increased or decreased, which may shift from increased to decreased activity; raised reaction time; change in the flow of speech; and an enhanced startle reaction);
  1. Disruption of the sleep - wake cycle (which may range from complete loss of sleep , insomnia or reversal of the sleep - wake cycle; drowsiness during the day; nocturnal worsening of symptoms; nightmares, sometimes continuing as hallucinations after waking up);
  1. Disruption in emotional state , e.g. depressed mood ,, apathy to euphoria, anxiety or fear, irritability, or wondering perplexity[2]

Scoring Systems for the Diagnosis of Delirium in Critically Ill Patients

  • Confusion Assessment Method for the ICU (CAM-ICU)

The test should be done on a sufficiently awake patient (RASS score, -3 or more)

The criteria of scoring scale:

  • An acute change from mental status at base line or fluctuating mental status during the past 24 hr(must be true to be positive)
  • More than 2 errors on a 10­point test of atten tion to voice or pictures (must be true to be positive)

The interpretation of scoring system:

  • If the RASS is not 0 and the above two criteria are positive, the patient is delirious
  • If the RASS is 0 and the above two criteria are positive, test for disorganized thinking using 4 yes/no questions and a 2­step command; >1 error means the patient is delirious; ≤1 error excludes delirium
  • Intensive Care Delirium Screening Checklist (ICDSC)


Scoring Systems for the Diagnosis of Delirium in Critically Ill Patients

  • Confusion Assessment Method for the ICU (CAM-ICU)

The test should be done on a sufficiently awake patient (RASS score, -3 or more)

The criteria of scoring scale:

  • An acute change from mental status at base line or fluctuating mental status during the past 24 hr(must be true to be positive)
  • More than 2 errors on a 10­point test of atten tion to voice or pictures (must be true to be positive)

The interpretation of scoring system:

  • If the RASS is not 0 and the above two criteria are positive, the patient is delirious
  • If the RASS is 0 and the above two criteria are positive, test for disorganized thinking using 4 yes/no questions and a 2­step command; >1 error means the patient is delirious; ≤1 error excludes delirium
  • Intensive Care Delirium Screening Checklist (ICDSC)

Diagnosis in ICU

In the ICU, international guidelines recommend that every patient gets checked for delirium every day (usually twice or more a day) using a validated clinical tool.[3] The two most widely used are the Confusion Assessment Method for the ICU (CAM-ICU)[4] and the Intensive Care Delirium Screening Checklist (ICDSC).[5] There are translations of these tools in over 20 languages and they are used globally in many thousands of ICUs, and instructional videos and a myriad of implementation tips are available.[6] It is not as important which tool is used as that the patient gets monitored. Without using one of these tools, 75% of ICU delirium is missed by the practicing team, which leaves the patient without any likely active interventions to help reduce the duration of his/her delirium.[7]

The most salient component of the definition of delirium that nurses and other healthcare professionals use at the bedside is whether or not the patient can pay attention and follow simple commands (see videos and literature[6]). The advent of daily monitoring for delirium had led to important changes in the culture of ICUs and rounds in that the entire team can now discuss the brain and how it is doing in terms of being “on” (not delirious) or “off” (delirious) and then focus on the several most likely causes of delirium in any specific patient. Thus, it is not the monitoring itself that changes the patient’s clinical course, but rather it is this combination of monitoring and then relaying the information on rounds in the ICU that makes such a huge difference in awareness of this form of organ dysfunction and then enables a difference to be made in clinical outcomes.

Differential Diagnosis

Differential points from other processes and syndromes that cause cognitive dysfunction:

Psychiatric Disorders

  • Delirium may be distinguished from psychosis, in which consciousness and cognition may not be impaired (however, there may be overlap, as some acute psychosis, especially with mania, is capable of producing delirium-like states).
  • Delirium is distinguished from depression.
  • Mania should be differentiated from hyperactive delirium. Previous history of bipolar disorder is useful in distinguishing delirium from mania.
  • Delirium is distinguished by time-course from the confusion and lack of attention which result from long term learning disorders and varieties of congenital brain dysfunction. Delirium has also been referred to as 'acute confusional state' or 'acute brain syndrome'. The key word in both of these descriptions is "acute" (meaning: of recent onset), since delirium may share many of the clinical (i.e., symptomatic) features of dementia, developmental disability, or attention-deficit hyperactivity disorder, with the important exception of symptom duration.
  • Delirium is not the same as confusion, although the two syndromes may overlap and be present at the same time. However, a confused patient may not be delirious (an example would be a stable, demented person who is disoriented to time and place), and a delirious person may not be confused (for example, a person in severe pain may not be able to focus attention because of the pain, and thus be by definition delirious, but may be completely oriented and not at all confused).

Dementia

  • Delirium is distinguished from dementia (chronic organic brain syndrome) which describes an "acquired" (non-congenital) and usually irreversible cognitive and psychosocial decline in function. Dementia usually results from an identifiable degenerative brain disease (for example Alzheimer disease orHuntington's disease). Dementia is usually not associated with a change in level of consciousness, and a diagnosis of dementia requires a chronic impairment.
  • Sundowning: Typically observed in patients suffering from dementia. It's an impairment in behavioral patterns in the evening hours. Similar symptomology can be observed in the patients suffering from other ailments such as impaired cincardial rhythm. New onset in change in behavioral patterns should always be assessed carefully and diagnosis of delirium should be considered.

Other Neurological Disorders

  • Frontal lobe disorders such as tumor can produce deficits in memory, distorted emotional responses, impaired judgment, etc. Imaging studies and focal neurological symptoms may be helpful to distinguish it from delirium.
  • Temporal lobe disorders may lead to memory deficits, cortical deafness, visual agnosia, etc. Imaging studies and focal neurological symptoms may be helpful to distinguish it from delirium.
  • Occipital lobe disorders can demonstrate various symptoms such as confabulation, cortical blindness, etc. Imaging studies and focal neurological symptoms may be helpful to distinguish it from delirium.
  • Parital lobe disorders like Wernicke's aphasia can hinder patient's ability to follow examiner's instructions which is often misinterpreted as a state of confusion.
  • Nonconvulsive epileptic episodes should also be considered as a differential diagnosis of delirium.


Delirium represents an organically caused decline from a previously attained level of cognitive functioning. It is a corollary of these differential criteria that a diagnosis of delirium cannot be made without a previous assessment, or knowledge, of the affected person's baseline level of cognitive function. In other words, a mentally disabled or demented person who is operating at their own baseline level of mental ability might appear to be delirious without a baseline functional status against which to compare.

References

  1. "http://www.dsm5.org/Pages/Default.aspx". External link in |title= (help)
  2. 2.0 2.1 "Delirium in elderly people. [Lancet. 2013] - PubMed - NCBI".
  3. Jacobi, J (January 2002). "Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult". Critical Care Medicine. 30 (1): 119–41. PMID 11902253. Unknown parameter |coauthors= ignored (help)
  4. Ely EW; Inouye SK; Bernard GR; et al. (December 2001). "Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU)". JAMA. 286 (21): 2703–10. doi:10.1001/jama.286.21.2703. PMID 11730446. Unknown parameter |author-separator= ignored (help)
  5. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y (May 2001). "Intensive Care Delirium Screening Checklist: evaluation of a new screening tool". Intensive Care Med. 27 (5): 859–64. doi:10.1007/s001340100909. PMID 11430542.
  6. 6.0 6.1 Ely, E.W.; et al. "ICU Delirium and Cognitive Impairment Study Group". Retrieved 6 December 2012.
  7. Jones, SF (April 2012). "ICU delirium: an update". Current opinion in critical care. 18 (2): 146–51. doi:10.1097/MCC.0b013e32835132b9. PMID 22322260. Unknown parameter |coauthors= ignored (help)

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