Delirium differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Delirium}}
{{Delirium}}
{{CMG}}; {{AE}} [[User:Vishal Khurana|Vishal Khurana]], M.B.B.S., M.D. [mailto:vishdoc24@gmail.com]; {{PB}}
{{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: psychiatric Disorders, dementia, other neurological disorders etc.
[[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==
==Differential Diagnosis==
===Psychiatric Disorders===
*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>
*'''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]], and other psychotic disorders
:*[[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 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 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 undeling neuro cognitive disorders such as [[dementia]]. <ref>{{Cite web  | last = | first = | title = http://www.dsm5.org/Pages/Default.aspx | url = http://www.dsm5.org/Pages/Default.aspx | publisher = | date = | accessdate = }}</ref>
(see below)
===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'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.<ref>{{Cite web  | last = | first = | title = ABC of psychological medicine: Delirium | url =http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124165/ | publisher = | date = | accessdate =}}</ref>
{| border="3"
{| border="3"
|+ The difference between delirium and similar psychiatric illness
|+ '''The difference between [[delirium]] and similar [[psychiatric]] illness'''
! Attributes !! Delirium !! Alzhimers!!Depression!!Psychotic Diorders
! Attributes !! [[Delirium ]] !![[ Alzheimer]] disease!![[Depression]]!![[Psychotic]] Disorders
|-
|-
! Onset
! Onset
Line 34: Line 21:
! Progression
! Progression
| Shifts in severity, likely to resolve in days to weeks.
| Shifts in severity, likely to resolve in days to weeks.
| Worsens over period of time
| Worsens over a period of time
|Acute or chronic with acute exacerbation
|Acute or chronic with acute exacerbation
|Chronic with acute exacerbation
|Chronic with acute exacerbation
|-
|-
! Hallucinations
![[ Hallucinations]]
| May be present, mostly visual
| May be present, mostly [[visual]]
| Mostly absent (exceptions: Lewi body dementia, etc.)
| Mostly absent (exceptions: Lewi body [[dementia]])
| May be present if associated with psychotic features
| May be present if associated with [[ psychotic]] features
| Present
| Present
|-
|-
! Delusions
! [[Delusions]]
| Fleeting
| [[Fleeting]]
| Mostly not present
| Mostly not present
| May be present  
| May be present  
| Present
| Present
|-
|-
! Psychomotar activity
! [[Psychomotar]] activity
| Increased or decreased, may shift from increased to decreased states.
| Increased or decreased, may shift from increased to decreased states.
| May or may not change
| May or may not change
Line 56: Line 43:
| Change
| Change
|-
|-
! Attention
! [[Attention]]
| Poor attention span and impaired short term memory.
| Poor attention span and impaired short-term [[memory]]
| Progressive worsening short term memory.  Attention span is likely to be affected in severe cases
| Progressive worsening short-term [[memory]].  [[Attention]] span is likely to be affected in severe cases
| May be altered
| May be altered
| May be altered
| May be altered
|-
|-
! Consciousness
! [[Consciousness]]
| Altered, rapidly shifts
| Altered, rapidly shifts
| Mostly intact until severe stages
| Mostly intact until severe stages
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| Normal
| Normal
|-
|-
! Attention
! [[Attention]]
| Altered, rapidly shifts
| Altered, rapidly shifts
| Mostly intact until severe stages
| Mostly intact until severe stages
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| May be altered  
| May be altered  
|-
|-
! Orientation
! [[Orientation]]
| Altered, rapidly shifts
| Altered, rapidly shifts
| Mostly intact until severe stages
| Mostly intact until severe stages
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| Not altered  
| Not altered  
|-
|-
! Speech
! [[Speech]]
| Not coherent
| Not coherent
| Errors
| Errors
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| Normal or pressured
| Normal or pressured
|-
|-
! Thought  
! [[Thought]]
| Disorganized
| Disorganized
| Impoverished
| Impoverished
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| Disorganized  
| Disorganized  
|-
|-
! Perceptions
! [[Perceptions]]
| Altered, rapidly shifts
| Altered, rapidly shifts
| Mostly intact until severe stages
| Mostly intact until severe stages
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| May be altered  
| May be altered  
|-
|-
! EEG
! [[EEG]]
| Moderate to severe background slowing
| Moderate to severe background slowing
| Normal or mild diffuse slowing
| Normal or mild diffuse slowing
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| Normal
| Normal
|-
|-
! Reversibility
! [[Reversibility]]
| Mostly
| Mostly
| Very rarely
| Very rarely
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|-
|-
|}<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>
|}<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===
===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 differentiate from delirium.
*[[Frontal lobe disorders]] such as [[tumors]] can produce deficits in [[memory]], distorted [[emotional]] responses, impaired [[judgment]].
*Temporal lobe disorders may lead to memory deficits, cortical deafness, visual [[agnosia]], etc.  Imaging studies and focal neurological symptoms may be helpful to differentiate from delirium.  
* 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]], etc. 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]].   
*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.
* Imaging studies and focal [[neurological]] symptoms may be helpful to differentiate from [[delirium]].  
*Nonconvulsive epileptic episodes should also be considered as a differential diagnosis of delirium.  
* [[Occipital lobe]] disorders can demonstrate various symptoms such as [[confabulation]], [[cortical blindness]].  
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.
* Imaging studies and focal [[neurological]] symptoms may be helpful to differentiate from [[delirium]].
===Common usage of the term versus standard medical usage===
* [[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]].
In common usage, delirium is often used to refer to drowsiness and disorientation.  In broader [[medical terminology]], however, a number of other symptoms, including sudden inability of focus attention, and even (occasionally) sleeplessness and severe agitation and irritability, are also defined as "delirium."
* [[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===
===Complete List of Differential Diagnoses===
{{col-begin|width=80%}}
{{col-begin|width=80%}}
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* [[Typhoid Fever]]
* [[Typhoid Fever]]
* [[Viral encephalitis]]
* [[Viral encephalitis]]
|}  
|}
 
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

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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