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]

Overview

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

Diagnostic Criteria

Diagnostic and Statistical Manual (DSM-5) Diagnostic Criteria

1. Diminished focus or concentration and lack of knowledge or perception of the surroundings.
2. 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.
3. Also, interference in faculties of cognition like, memory, orientation, visuospatial ability, or language.
4. 1st and 3rd criteria are not a result of any previous, current, or developing neurocognitive disorder and is not related to a shift in arousal status e.g. coma.
5. The manifestation of the disturbances resulting as a

• Physiological sequel of a medical condition,
• Intoxication or Withdrawal of substance(s)/ medicine(s)/ toxin(s); or
• Is due to multiple etiologies,
• As explained by the history, physical examination, or laboratory findings.

Specify if,

Substance intoxication delirium: diagnosis of substance intoxication delirium is made rather than substance intoxication, when the symptoms in Criteria A and C predominate and are severe enough to require clinical attention.

Substance withdrawal delirium: diagnosis of substance withdrawal delirium is made rather than substance withdrawal, when the symptoms in Criteria A and C predominate and are severe enough to require clinical attention.

Delirium caused by another medical condition: When delirium is caused by another medical condition.

Delirium caused by multiple etiologies: Delirium is a consequence of multiple causes e.g. medical condition plus substance intoxication or side effect of medications.

Specify if delirium is:

Acute: Duration is restricted to a few hours to days.

Persistent: When delirium lasts for weeks or months.

Specify if delirium is:

Hyperactive: An increased psychomotor activity which may cooccue with incresed mood lability, agitation, and/or non cooperative attitude towards medical treatment.

Hypoactive: A hypoactive level of psychomotor activity which may exist along with increased sluggishness, lethargy or stupour.

Mixed level of activity: A normal level of psychomotor activity, individuals with rapidly fluctuating activity are also included in this category.

ICD-10 Diagnostic Criteria

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

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).