Delirium differential diagnosis: Difference between revisions

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__NOTOC__
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{{Delirium}}
{{Delirium}}
{{CMG}}; {{AE}} [[User:Vishal Khurana|Vishal Khurana]], M.B.B.S., M.D. [mailto:vishdoc24@gmail.com]
{{CMG}}; {{AE}} {{PB}}; [[User:Vishal Khurana|Vishal Khurana]], M.B.B.S., M.D. [mailto:vishdoc24@gmail.com]


==Overview==
==Overview==
[[Delirium]] is differentiated from other causes [[cognitive]] dysfunction such as  [[psychiatric Disorders]], [[dementia]]. Unlike [[dementia]], the course of [[delirium]] is reversible with fluctuation in level of [[consciousness]].
==Differential Diagnosis==
*Shown below the table of differentiating [[delirium]] from other [[psychiatric]] disorders:<ref name="pmid30773695">{{cite journal |vauthors=Fong TG, Vasunilashorn SM, Libermann T, Marcantonio ER, Inouye SK |title=Delirium and Alzheimer disease: A proposed model for shared pathophysiology |journal=Int J Geriatr Psychiatry |volume=34 |issue=6 |pages=781–789 |date=June 2019 |pmid=30773695 |pmc=6830540 |doi=10.1002/gps.5088 |url=}}</ref><ref name="pmid26360863">{{cite journal |vauthors=O'Sullivan R, Inouye SK, Meagher D |title=Delirium and depression: inter-relationship and clinical overlap in elderly people |journal=Lancet Psychiatry |volume=1 |issue=4 |pages=303–11 |date=September 2014 |pmid=26360863 |pmc=5338740 |doi=10.1016/S2215-0366(14)70281-0 |url=}}</ref><ref name="CharltonKavanau2002">{{cite journal|last1=Charlton|first1=B.G|last2=Kavanau|first2=J.L|title=Delirium and psychotic symptoms – an integrative model|journal=Medical Hypotheses|volume=58|issue=1|year=2002|pages=24–27|issn=03069877|doi=10.1054/mehy.2001.1436}}</ref>
{| border="3"
|+ '''The difference between [[delirium]] and similar [[psychiatric]] illness'''
! Attributes !! [[Delirium ]] !![[ Alzheimer]] disease!![[Depression]]!![[Psychotic]] Disorders
|-
! Onset
| Sudden/acute/subacute
| Gradual
|Gradual
|Acute or gradual
|-
! Progression
| Shifts in severity, likely to resolve in days to weeks.
| Worsens over a period of time
|Acute or chronic with acute exacerbation
|Chronic with acute exacerbation
|-
![[ Hallucinations]]
| May be present, mostly [[visual]]
| Mostly absent (exceptions: Lewi body [[dementia]])
| May be present if associated with [[ psychotic]] features
| Present
|-
! [[Delusions]]
| [[Fleeting]]
| Mostly not present
| May be present
| Present
|-
! [[Psychomotar]] activity
| Increased or decreased, may shift from increased to decreased states.
| May or may not change
| Change
| Change
|-
! [[Attention]]
| Poor attention span and impaired short-term [[memory]]
| Progressive worsening short-term [[memory]].  [[Attention]] span is likely to be affected in severe cases
| May be altered
| May be altered
|-
! [[Consciousness]]
| Altered, rapidly shifts
| Mostly intact until severe stages
| Normal
| Normal
|-
! [[Attention]]
| Altered, rapidly shifts
| Mostly intact until severe stages
| May be altered
| May be altered
|-
! [[Orientation]]
| Altered, rapidly shifts
| Mostly intact until severe stages
| Not altered
| Not altered
|-
! [[Speech]]
| Not coherent
| Errors
| Slow
| Normal or pressured
|-
! [[Thought]]
| Disorganized
| Impoverished
| Normal
| Disorganized
|-
! [[Perceptions]]
| Altered, rapidly shifts
| Mostly intact until severe stages
| Normal
| May be altered
|-
! [[EEG]]
| Moderate to severe background slowing
| Normal or mild diffuse slowing
| Normal
| Normal
|-
! [[Reversibility]]
| Mostly
| Very rarely
| Yes
| Rarely
|-
|}<ref>{{Cite web  | last =  | first =  | title = Delirium in elderly adults: diagnosis, prevention and treatment | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065676/ | publisher =  | date =  | accessdate = }}</ref>
===[[Psychiatric]] Disorders===
*'''[[Psychotic]] disorders''': [[Delirium]] may be distinguished from [[psychosis]], in which [[consciousness]] and cognition may not be impaired (however, there may be overlap, in acute [[psychosis]], especially with [[mania]], is capable of producing [[delirium]]-like states).
* [[Delirium]] must be differentiated from following [[psychiatric]] disorders which have [[psychotic]] features.
:*[[Brief psychotic disorder]]
:*[[Schizophrenia]]
:*[[Schizophreniform disorder]]
:*[[Bipolar Disorder|Bipolar]] and [[depression|depressive disorders with psychotic features]].
* [[Mania]] should be differentiated from hyperactive [[delirium]].
* Previous history of [[bipolar disorder]] is useful in distinguishing [[delirium]] from [[mania]].
*'''Acute [[stress disorder]]''': [[Delirium]] accompanied by [[fear]], [[anxiety]], and [[dissociative]] symptoms must be differentiated from [[acute stress disorder]]s.
*'''[[Malingering]] and [[factitious disorder]]'''.
*'''[[Confusional]] states''': [[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 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 because of the [[pain]], and thus be by definition delirious, but may be completely [[oriented]] and not at all [[confused]]).
*'''Other neurocognitive disorders''': Sometimes [[delirium]] is superimposed on underling [[neurocognitive]] disorders such as [[dementia]].<ref name="pmid26139023">{{cite journal |vauthors=Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK |title=The interface between delirium and dementia in elderly adults |journal=Lancet Neurol |volume=14 |issue=8 |pages=823–832 |date=August 2015 |pmid=26139023 |pmc=4535349 |doi=10.1016/S1474-4422(15)00101-5 |url=}}</ref>
===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]] or [[Huntington disease]]).
* [[Dementia]] is usually not associated with a change in the level of [[consciousness]], and a diagnosis of [[dementia]] requires a chronic impairment.
* Sundowning: In  [[patients] suffering from [[dementia]] or [[delirium]] which is an impairment in [[behavioral]] patterns in the evening hours.<ref name="pmid28083535">{{cite journal |vauthors=Canevelli M, Valletta M, Trebbastoni A, Sarli G, D'Antonio F, Tariciotti L, de Lena C, Bruno G |title=Sundowning in Dementia: Clinical Relevance, Pathophysiological Determinants, and Therapeutic Approaches |journal=Front Med (Lausanne) |volume=3 |issue= |pages=73 |date=2016 |pmid=28083535 |pmc=5187352 |doi=10.3389/fmed.2016.00073 |url=}}</ref>
===Other Neurological Disorders===
*[[Frontal lobe disorders]] such as [[tumors]] can produce deficits in [[memory]], distorted [[emotional]] responses, impaired [[judgment]].
* Imaging studies and focal [[neurological]] symptoms may be helpful to differentiate from [[delirium]].
*[[Temporal lobe]] disorders may lead to [[memory]] deficits, [[cortical]] deafness, [[visual]] [[agnosia]]. 
* Imaging studies and focal [[neurological]] symptoms may be helpful to differentiate from [[delirium]].
* [[Occipital lobe]] disorders can demonstrate various symptoms such as [[confabulation]], [[cortical blindness]].
* Imaging studies and focal [[neurological]] symptoms may be helpful to differentiate from [[delirium]].
* [[Parietal]] lobe disorders like [[Wernicke's aphasia]] can hinder a patient's ability to follow examiner's instructions which are 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.
===Complete List of Differential Diagnoses===
{{col-begin|width=80%}}
{{col-break|width=33%}}
* [[Acidosis]]
* After [[hypoxia]]
* [[Alcohol]]/[[drug withdrawal]]
* [[Meningitis|Bacterial Meningitis]]
* [[Cerebral]] [[contusion]]
* [[Cerebral]] [[ischemia]]
* [[Cerebral]] [[mass]]
* [[Congestive Heart Failure]] ([[CHF]])
* [[Ddx:Dementia|Dementia]]
* [[Ddx:Depression|Depression]]
* [[Drug intoxication]]
* [[Hepatic encephalopathy]]
* [[HIV]]
* [[Ddx:Hypoglycemia|Hypoglycemia]]
{{col-break|width=33%}}
* [[Pneumonia]]
* [[Trauma|Postoperative and postconcussive states]]
* [[Psychosis|Psychotic illness]],
* [[Rheumatic Fever]]
* [[Septicemia]]
* [[Stroke]]
* [[Ddx:Intracranial Bleeding|Subarachnoid hemorrhage]]
* [[Dementia|Sundowning]]
* [[Thiamine deficiency]]
* [[Thyrotoxicosis]]
* [[Toxin]]
* [[Tuberculosis]]
* [[Typhoid Fever]]
* [[Viral encephalitis]]
|}


==References==
==References==

Latest revision as of 08:06, 22 April 2021

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

Overview

Delirium is differentiated from other causes cognitive dysfunction such as psychiatric Disorders, dementia. Unlike dementia, the course of delirium is reversible with fluctuation in level of consciousness.

Differential Diagnosis

The difference between delirium and similar psychiatric illness
Attributes Delirium Alzheimer disease Depression Psychotic Disorders
Onset Sudden/acute/subacute Gradual Gradual Acute or gradual
Progression Shifts in severity, likely to resolve in days to weeks. Worsens over a period of time Acute or chronic with acute exacerbation Chronic with acute exacerbation
Hallucinations May be present, mostly visual Mostly absent (exceptions: Lewi body dementia) May be present if associated with psychotic features Present
Delusions Fleeting Mostly not present May be present Present
Psychomotar activity Increased or decreased, may shift from increased to decreased states. May or may not change Change Change
Attention Poor attention span and impaired short-term memory Progressive worsening short-term memory. Attention span is likely to be affected in severe cases May be altered May be altered
Consciousness Altered, rapidly shifts Mostly intact until severe stages Normal Normal
Attention Altered, rapidly shifts Mostly intact until severe stages May be altered May be altered
Orientation Altered, rapidly shifts Mostly intact until severe stages Not altered Not altered
Speech Not coherent Errors Slow Normal or pressured
Thought Disorganized Impoverished Normal Disorganized
Perceptions Altered, rapidly shifts Mostly intact until severe stages Normal May be altered
EEG Moderate to severe background slowing Normal or mild diffuse slowing Normal Normal
Reversibility Mostly Very rarely Yes Rarely

[4]

Psychiatric Disorders

Dementia

Other Neurological Disorders

Complete List of Differential Diagnoses

References

  1. ↑ Fong TG, Vasunilashorn SM, Libermann T, Marcantonio ER, Inouye SK (June 2019). "Delirium and Alzheimer disease: A proposed model for shared pathophysiology". Int J Geriatr Psychiatry. 34 (6): 781–789. doi:10.1002/gps.5088. PMC 6830540 Check |pmc= value (help). PMID 30773695.
  2. ↑ O'Sullivan R, Inouye SK, Meagher D (September 2014). "Delirium and depression: inter-relationship and clinical overlap in elderly people". Lancet Psychiatry. 1 (4): 303–11. doi:10.1016/S2215-0366(14)70281-0. PMC 5338740. PMID 26360863.
  3. ↑ Charlton, B.G; Kavanau, J.L (2002). "Delirium and psychotic symptoms – an integrative model". Medical Hypotheses. 58 (1): 24–27. doi:10.1054/mehy.2001.1436. ISSN 0306-9877.
  4. ↑ "Delirium in elderly adults: diagnosis, prevention and treatment".
  5. ↑ Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK (August 2015). "The interface between delirium and dementia in elderly adults". Lancet Neurol. 14 (8): 823–832. doi:10.1016/S1474-4422(15)00101-5. PMC 4535349. PMID 26139023.
  6. ↑ Canevelli M, Valletta M, Trebbastoni A, Sarli G, D'Antonio F, Tariciotti L, de Lena C, Bruno G (2016). "Sundowning in Dementia: Clinical Relevance, Pathophysiological Determinants, and Therapeutic Approaches". Front Med (Lausanne). 3: 73. doi:10.3389/fmed.2016.00073. PMC 5187352. PMID 28083535.

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