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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}} {{Sara.Zand}} {{PB}}; [[User:Vishal Khurana|Vishal Khurana]], M.B.B.S., M.D. [mailto:vishdoc24@gmail.com]; {{AZ}}; {{JH}}
{{PB}} ; {{AZ}}
==Overview==
 
The DSM V, and ICD-10 have provided diagnostic criteria for [[delirium]]. Definition based on [[DSM-5]] include disturbance in [[attention]] and [[awareness]] (reduced ability to direct, focus, shift [[attention]] and reduced [[orientation]] to [[envinment]]), initiation of disturbance over a short period of [[time]] during several hours or days  with fluctuation  in severity over a day, disturbance in [[cognition]] ([[memory deficit]], [[disorientation]], [[language]], [[visuospatial]] ability, [[perception, disturbance other than evolving [[neurocognitive]] disorder, disturbance due to [[medical]] [[condition]], [[substance intoxication]], or withdrawal. Other definitions of [[delirium]] include disturbance in [[cognition]],
impairment of [[immediate recall]] and [[recent memory]], [[disorientation]] to [[time]], [[place]], [[person]], disturbance in [[sleep wake]] cycle, [[Psychomotor disturbances]],[[emotional disturbances]] in a period of less than 6 months.


==Diagnostic Criteria==
==Diagnostic Criteria==
===DSM-V Diagnostic Criteria for [[Paranoid]] Personality Disorder<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>===


===Diagnostic and Statistical Manual (DSM-5) Diagnostic Criteria===


# Diminished  focus or concentration and lack of knowledge or perception of the surroundings  .
*A. A disturbance in [[attention]] ( reduced ability to direct, focus, sustain, and shift [[attention]]) and [[awareness]] (reduced [[orientation]] to the [[environment]])


# 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.
: '''''AND'''''


# Also, interference  in faculties of cognition like, memory,  orientation,  visuospatial ability, or language).
*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.


# 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
: '''''AND'''''


# 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.<ref name="www.dsm5.org">{{Cite web  | last =  | first =  | title = http://www.dsm5.org/Pages/Default.aspx | url = http://www.dsm5.org/Pages/Default.aspx | publisher =  | date =  | accessdate = }}</ref> <ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Delirium in elderly people. [Lancet. 2013] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/23992774 | publisher =  | date =  | accessdate =}}</ref>
*C. An additional disturbance in [[cognition]] ([[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]].


===ICD-10 Diagnostic Criteria===
: '''''AND'''''
To make a definite diagnosis, symptoms (mild, moderate or severe) must be present in the following criteria,


# Curtailment in the consciousness and consciousness  (as a result of clouding to coma; ( inability to direct, keep , transfer  focus)
*E. There is evidence from the [[history]], [[physical examination]], or [[laboratory]] findings that the [[disturbance ]] is a direct physiological consequence of another medical [[condition]], substance [[intoxication]] or [[withdrawal]] ( due to a drug of [[abuse]] or to a [[medication]]), or exposure to a [[toxin]], or is due to multiple [[etiologies]].


# 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)
Specify whether:


# 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);
: ''' Substance [[intoxication]] [[delirium]]:''' This diagnosis should be made instead of substance [[intoxication]] when the [[symptoms]] in Criteria A and C predominate in the [[clinical]] picture and when they are sufficiently severe to warrant [[clinical]] attention.


# 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);
: '''''OR'''''


#  Disruption in emotional state , e.g. depressed mood ,, apathy to euphoria, anxiety or fear, irritability,  or wondering perplexity<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Delirium in elderly people. [Lancet. 2013] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/23992774 | publisher =  | date =  | accessdate =}}</ref>
: ''' [[Substance]] withdrawal [[delirium]]:''' This diagnosis should be made instead of substance withdrawal when the symptoms in Criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant [[clinical]] attention.


====Scoring Systems for the Diagnosis of Delirium in Critically Ill Patients====
: '''''OR'''''
*:'''Confusion Assessment Method for the ICU (CAM-ICU)'''


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


The criteria of scoring scale:  
: '''''OR'''''


*An acute change from mental status at base  line or fluctuating mental status during the past 24 hr(must be true to be positive)
: '''[[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]].
*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:
: '''''OR'''''


*If the RASS is not 0 and the above two criteria are positive, the patient is delirious
: '''[[Delirium]] due to multiple etiologies:''' There is evidence from the [[history]], [[physical examination]], or [[laboratory findings]] that the [[delirium]] has more than one etiology (e.g. more than one etiological [[medical condition]]; another [[medical condition]] plus substance intoxication or [[medication]] side effect).
*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)'''
Specify if:
: '''Acute:''' Lasting a few hours or days.


: '''''OR'''''


====Scoring Systems for the Diagnosis of Delirium in Critically Ill Patients====
: '''Persistent:''' Lasting weeks or months.
*:'''Confusion Assessment Method for the ICU (CAM-ICU)'''


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


The criteria of scoring scale:
: '''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]].


*An acute change from mental status at base  line or fluctuating mental status during the past 24 hr(must be true to be positive)
: '''''OR'''''
*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:
: '''[[Hypoactive]]:''': The individual has a hypoactive level of psychomotor activity that may be accompanied by sluggishness and [[lethargy]] that approaches [[stupor]].


*If the RASS is not 0 and the above two criteria are positive, the patient is delirious
: '''''OR'''''
*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)'''
: '''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]].


===Diagnosis in ICU===
===ICD-10 Diagnostic Criteria===
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.<ref>{{cite journal|last=Jacobi|first=J|coauthors=Fraser, GL; Coursin, DB; Riker, RR; Fontaine, D; Wittbrodt, ET; Chalfin, DB; Masica, MF; Bjerke, HS; Coplin, WM; Crippen, DW; Fuchs, BD; Kelleher, RM; Marik, PE; Nasraway SA, Jr; Murray, MJ; Peruzzi, WT; Lumb, PD; Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists (ASHP), American College of Chest, Physicians|title=Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.|journal=Critical Care Medicine|date=January 2002|volume=30|issue=1|pages=119–41|pmid=11902253}}</ref>  The two most widely used are the Confusion Assessment Method for the ICU (CAM-ICU)<ref name=Ely2001>{{cite journal |author=Ely EW |title=Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU) |journal=JAMA |volume=286 |issue=21 |pages=2703–10 |date=December 2001 |pmid=11730446|doi=10.1001/jama.286.21.2703 |url=http://jama.ama-assn.org/content/286/21/2703.long |author-separator=, |author2=Inouye SK |author3=Bernard GR |display-authors=3 |last4=Gordon |first4=S |last5=Francis |first5=J |last6=May |first6=L |last7=Truman |first7=B |last8=Speroff |first8=T |last9=Gautam |first9=S}}</ref> and the Intensive Care Delirium Screening Checklist (ICDSC).<ref name=Bergeron2001>{{cite journal |author=Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y |title=Intensive Care Delirium Screening Checklist: evaluation of a new screening tool |journal=Intensive Care Med |volume=27 |issue=5 |pages=859–64|date=May 2001 |pmid=11430542 |doi=10.1007/s001340100909}}</ref> 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.<ref name="icudelirium" /> 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.<ref>{{cite journal|last=Jones|first=SF|coauthors=Pisani, MA|title=ICU delirium: an update.|journal=Current opinion in critical care|date=April 2012|volume=18|issue=2|pages=146–51|pmid=22322260|doi=10.1097/MCC.0b013e32835132b9}}</ref>
To make a definite diagnosis, symptoms (mild, moderate, or severe) must be present in the following criteria:
# Curtailment in the [[consciousness]] and [[consciousness]]  (as a result of clouding to coma; ( inability to direct, keep, transfer focus)
# 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; the 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]])
# 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)
# 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)
#  Disruption in [[emotional]] state , e.g. depressed [[mood]], [[apathy]] to [[euphoria]], [[anxiety]] or fear, [[irritability]], or wondering perplexity.<ref>{{Cite web | last = | first = | title = Delirium in elderly people. [Lancet. 2013] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/23992774 | publisher =  | date = | accessdate =}}</ref>


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<ref name=icudelirium>{{cite web|last=Ely, E.W., et al|title=ICU Delirium and Cognitive Impairment Study Group|url=http://www.icudelirium.org|accessdate=6 December 2012}}</ref>). 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.
==Diagnosis in ICU==
== Differential Diagnosis==
*[[Patients]] admitted in the [[ICU]] should be screened for delirium twice a day.
Differential points from other processes and syndromes that cause cognitive dysfunction:
* The two most widely used are the [[Confusion]] Assessment Method for the [[ICU]] (CAM-ICU) and the [[Intensive Care]] [[Delirium]] Screening Checklist (ICDSC)..<ref name=Ely2001>{{cite journal |author=Ely EW |title=Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU) |journal=JAMA |volume=286 |issue=21 |pages=2703–10 |date=December 2001 |pmid=11730446|doi=10.1001/jama.286.21.2703 |url=http://jama.ama-assn.org/content/286/21/2703.long |author-separator=, |author2=Inouye SK |author3=Bernard GR |display-authors=3 |last4=Gordon |first4=S |last5=Francis |first5=J |last6=May |first6=L |last7=Truman |first7=B |last8=Speroff |first8=T |last9=Gautam |first9=S}}</ref><ref name=Bergeron2001>{{cite journal |author=Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y |title=Intensive Care Delirium Screening Checklist: evaluation of a new screening tool |journal=Intensive Care Med |volume=27 |issue=5 |pages=859–64|date=May 2001 |pmid=11430542 |doi=10.1007/s001340100909}}</ref>  <ref name="icudelirium" /
===Psychiatric Disorders===
*>  75% of ICU [[delirium ]] may be missed by caregivers without these tools, which in-turn may increase duration of [[delirium]]<ref>{{cite journal|last=Jones|first=SF|coauthors=Pisani, MA|title=ICU delirium: an update.|journal=Current opinion in critical care|date=April 2012|volume=18|issue=2|pages=146–51|pmid=22322260|doi=10.1097/MCC.0b013e32835132b9}}</ref>
*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).
* These tools can be easily administered at bedside by [[caregivers]], even if patient is not able to follow commands<ref name=icudelirium>{{cite web|last=Ely, E.W., et al|title=ICU Delirium and Cognitive Impairment Study Group|url=http://www.icudelirium.org|accessdate= }}</ref>
*Delirium is distinguished from [[clinical depression|depression]].
* This has resulted in focused care and better outcomes to patients suffering from [[delirium]].
*Mania should be differentiated from hyperactive delirium. Previous history of bipolar disorder is useful in distinguishing delirium from mania.
====[[Confusion]] Assessment Method for the [[ICU ]] (CAM-ICU)====
*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.
[[Patient]] is accessed on following 4 features:
*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).
# Onset of symptoms, is acute(change from baseline) or fluctuating as calibrated by Richmond Agitation Sedation Scale or Glasgow Coma Scale
===Dementia===
# Inability to focus as measured by [[Attention ]] Screening Examination
*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.
# [[Thinking]] is not organized
*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.
# 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.<ref name="pmid28263192">{{cite journal |vauthors=Khan BA, Perkins AJ, Gao S, Hui SL, Campbell NL, Farber MO, Chlan LL, Boustani MA |title=The Confusion Assessment Method for the ICU-7 Delirium Severity Scale: A Novel Delirium Severity Instrument for Use in the ICU |journal=Crit Care Med |volume=45 |issue=5 |pages=851–857 |date=May 2017 |pmid=28263192 |pmc=5392153 |doi=10.1097/CCM.0000000000002368 |url=}}</ref>


===Other Neurological Disorders===
====Intensive Care [[Delirium ]] Screening Checklist (ICDSC)====
*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.
The criteria of the scoring system:
*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.  
# Inability to [[focus]]
*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.
# Altered level of [[consciousness]]
*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.
# Not oriented to time, place and person
*Nonconvulsive epileptic episodes should also be considered as a differential diagnosis of delirium.  
# [[Hallucination]]/ delusions/ psychosis
# [[Psychomotor agitation]]
# Speech or mood is not appropriate
# Disturbance in sleep-awake cycle
# [[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]].<ref name="pmid29537480">{{cite journal |vauthors=Boettger S, Garcia Nuñez D, Meyer R, Richter A, Rudiger A, Schubert M, Jenewein J |title=Screening for delirium with the Intensive Care Delirium Screening Checklist (ICDSC): a re-evaluation of the threshold for delirium |journal=Swiss Med Wkly |volume=148 |issue= |pages=w14597 |date=2018 |pmid=29537480 |doi=10.4414/smw.2018.14597 |url=}}</ref><ref name="Reade-2014">{{Cite journal  | last1 = Reade | first1 = MC. | last2 = Finfer | first2 = S. | title = Sedation and delirium in the intensive care unit. | journal = N Engl J Med | volume = 370 | issue = 5 | pages = 444-54 | month = Jan | year = 2014 | doi = 10.1056/NEJMra1208705 | PMID = 24476433 }}</ref>


==Screening Instruments==
Most screening tools are designed in a way [[ nursing]] staff can use them, as an availability of [[physician]] can be an issue.<ref name="pmid24175169">{{cite journal |vauthors=Grover S, Kate N |title=Assessment scales for delirium: A review |journal=World J Psychiatry |volume=2 |issue=4 |pages=58–70 |date=August 2012 |pmid=24175169 |pmc=3782167 |doi=10.5498/wjp.v2.i4.58 |url=}}</ref>
:* 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).<ref name="pmid33098368">{{cite journal |vauthors=Beishuizen SJ, Festen S, Loonstra YE, van der Werf HW, de Rooij SE, van Munster BC |title=Delirium, functional decline and quality of life after transcatheter aortic valve implantation: An explorative study |journal=Geriatr Gerontol Int |volume=20 |issue=12 |pages=1202–1207 |date=December 2020 |pmid=33098368 |pmc=7756254 |doi=10.1111/ggi.14064 |url=}}</ref>


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.
===[[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)<ref name="pmid11449030">{{cite journal |vauthors=Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N |title=Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium |journal=J Neuropsychiatry Clin Neurosci |volume=13 |issue=2 |pages=229–42 |date=2001 |pmid=11449030 |doi=10.1176/jnp.13.2.229 |url=}}</ref>
:* [[Memorial]] [[Delirium]] Assessment Scale (MDAS)


==References==
==References==

Latest revision as of 08:27, 22 April 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Pratik Bahekar, MBBS [3]; Vishal Khurana, M.B.B.S., M.D. [4]; Ahmed Zaghw, M.D. [5]; Jesus Rosario Hernandez, M.D. [6]

Overview

The DSM V, and ICD-10 have provided diagnostic criteria for delirium. Definition based on DSM-5 include disturbance in attention and awareness (reduced ability to direct, focus, shift attention and reduced orientation to envinment), initiation of disturbance over a short period of time during several hours or days with fluctuation in severity over a day, disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, [[perception, disturbance other than evolving neurocognitive disorder, disturbance due to medical condition, substance intoxication, or withdrawal. Other definitions of delirium include disturbance in cognition, impairment of immediate recall and recent memory, disorientation to time, place, person, disturbance in sleep wake cycle, Psychomotor disturbances,emotional disturbances in a period of less than 6 months.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Paranoid Personality Disorder[1]

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
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

Specify whether:

Substance intoxication delirium: This diagnosis should be made instead of substance 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 substance 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 etiology (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; the 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.[2]

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)..[3][4]
  • These tools can be easily administered at bedside by caregivers, even if patient is not able to follow commands[5]
  • 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.[6]

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.[7][8]

Screening Instruments

Most screening tools are designed in a way nursing staff can use them, as an availability of physician can be an issue.[9]

  • 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 Diagnostic Instruments

  • Confusion Assessment Method (CAM)
  • Delirium Scale (Dscale)
  • Global Accessibility Rating Scale (GARS)
  • Organic Brain Syndrome Scale (OBS)
  • Saskatoon Delirium Checklist (SDC).[10]

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.

References

  1. ↑ Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  2. ↑ "Delirium in elderly people. [Lancet. 2013] - PubMed - NCBI".
  3. ↑ 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)
  4. ↑ 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.
  5. ↑ Ely, E.W.; et al. "ICU Delirium and Cognitive Impairment Study Group".
  6. ↑ Khan BA, Perkins AJ, Gao S, Hui SL, Campbell NL, Farber MO, Chlan LL, Boustani MA (May 2017). "The Confusion Assessment Method for the ICU-7 Delirium Severity Scale: A Novel Delirium Severity Instrument for Use in the ICU". Crit Care Med. 45 (5): 851–857. doi:10.1097/CCM.0000000000002368. PMC 5392153. PMID 28263192.
  7. ↑ Boettger S, Garcia Nuñez D, Meyer R, Richter A, Rudiger A, Schubert M, Jenewein J (2018). "Screening for delirium with the Intensive Care Delirium Screening Checklist (ICDSC): a re-evaluation of the threshold for delirium". Swiss Med Wkly. 148: w14597. doi:10.4414/smw.2018.14597. PMID 29537480.
  8. ↑ Reade, MC.; Finfer, S. (2014). "Sedation and delirium in the intensive care unit". N Engl J Med. 370 (5): 444–54. doi:10.1056/NEJMra1208705. PMID 24476433. Unknown parameter |month= ignored (help)
  9. ↑ Grover S, Kate N (August 2012). "Assessment scales for delirium: A review". World J Psychiatry. 2 (4): 58–70. doi:10.5498/wjp.v2.i4.58. PMC 3782167. PMID 24175169.
  10. ↑ Beishuizen SJ, Festen S, Loonstra YE, van der Werf HW, de Rooij SE, van Munster BC (December 2020). "Delirium, functional decline and quality of life after transcatheter aortic valve implantation: An explorative study". Geriatr Gerontol Int. 20 (12): 1202–1207. doi:10.1111/ggi.14064. PMC 7756254 Check |pmc= value (help). PMID 33098368 Check |pmid= value (help).
  11. ↑ Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N (2001). "Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium". J Neuropsychiatry Clin Neurosci. 13 (2): 229–42. doi:10.1176/jnp.13.2.229. PMID 11449030.

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