Delirium diagnostic criteria

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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]; Jesus Rosario Hernandez, M.D. [5]

Overview

DSM V, and ICD-10 have provided diagnostic criterias for delirium. Various screening scales also exists for detection of delirium.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Paranoid Personality Disorder

• A. A disturbance in attention (i.e.,reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).

AND

• B. The disturbance develops over a short period of time (usually hours to a few days),represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.

AND

• C. An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception).

AND

• D. The disturbances in Criteria A and C are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.

AND

• E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, sub stance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.

Specify whether:

Substance intoxication delirium: This diagnosis should be made instead of sub stance intoxication when the symptoms in Criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention.

OR

Substance withdrawal delirium: This diagnosis should be made instead of sub stance withdrawal when the symptoms in Criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention.

OR

Medication-induced delirium: This diagnosis applies when the symptoms in Criteria A and C arise as a side effect of a medication taken as prescribed.

OR

Delirium due to another medical condition: There is evidence from the history, physical examination, or laboratory findings that the disturbance is attributable to the physiological consequences of another medical condition.

OR

Delirium due to multiple etiologies: There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiol ogy (e.g., more than one etiological medical condition; another medical condition plus substance intoxication or medication side effect).

Specify if:

Acute: Lasting a few hours or days.

OR

Persistent: Lasting weeks or months.

Specify if:

Hyperactive:: The individual has a hyperactive level of psychomotor activity that may be accompanied by mood lability, agitation, and/or refusal to cooperate with medical care.

OR

Hypoactive:: The individual has a hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy that approaches stupor.

OR

Mixed level of activity: The individual has a normal level of psychomotor activity even though attention and awareness are disturbed. Also includes individuals whose activity level rapidly fluctuates.

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).
2. 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).
3. 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).
4. 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).
5. Disruption in emotional state , e.g. depressed mood, apathy to euphoria, anxiety or fear, irritability, or wondering perplexity.

Diagnosis in ICU

Patients admitted in the ICU should be screened for delirium twice a day. The two most widely used are the Confusion Assessment Method for the ICU (CAM-ICU). and the Intensive Care Delirium Screening Checklist (ICDSC). 75% of ICU delirium may be missed by caregivers without these tools, which in-turn may increase duration of delirium. These tools can be easily administered at bedside by caregivers, even if patient is not able to follow commands). This has resulted in focused care and better outcomes to patients suffering from delirium.

Confusion Assessment Method for the ICU (CAM-ICU)

Patient is accessed on following 4 features,

1. Onset of symptoms, is acute(change from baseline) or fluctuating as calibrated by Richmond Agitation Sedation Scale or Glasgow Coma Scale
2. Inability to focus as measured by Attention Screening Examination
3. Thinking is not organized
4. Altered level of consciousness if Vigilant, Lethargic, Stupor, Coma

If feature 1 and 2 are present along with 3 or 4 then patient is assessed to have delirium by CAM-ICU scale.

Intensive Care Delirium Screening Checklist (ICDSC)

The criteria of the scoring system:

1. Inability to focus
2. Altered level of consciousness
3. Not oriented to time, place and person
4. Hallucination/ delusions/ psychosis
5. Psychomotor agitation
6. Speech or mood is not appropriate
7. Disturbance in sleep-awake cycle
8. Fluctuation of symptoms.

The interpretation of the scoring system:

• A score of ≥ 4 is considered positive for the delirium
• Score more than 4 shows severity.
• Scores between 1 and 3 is termed as “Subsyndromal Delirium”.

Screening Instruments

Most screening tools are designed in way nursing staff can use it, as an availability of physician can be an issue.

• Clinical Assessment of Confusion–A (CAC-A)
• Confusion Rating Scale (CRS)
• MCV Nursing Delirium Rating Scale (MCV-NDRS)
• NEECHAM Confusion Scale.

Lay Interviewers and for Epidemiological Studies

• Delirium Symptom Interview(DSI).

Delirium Diagnostic Instruments

• Confusion Assessment Method (CAM)
• Delirium Scale (Dscale)
• Global Accessibility Rating Scale (GARS)
• Organic Brain Syndrome Scale (OBS)
• Saskatoon Delirium Checklist (SDC).

Delirium Symptom Severity Rating Scales

Often based both on behavioral symptoms and on confusion and cognitive impairment. They may be useful for monitoring the effect of an intervention or plotting the course of a delirium over time. These scales have also been used for the diagnosis of delirium.

• Delirium Rating Scale (DRS),
• Memorial Delirium Assessment Scale (MDAS).