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]

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 also not related to change 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) or medicine(s), or a toxin(s); or is due to multiple etiologies, is explained by the history, physical examination, or laboratory findings.

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

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. The two most widely used are the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC). 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. 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.

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). 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.

Scoring Systems for the Diagnosis of Delirium in Critically Ill Patients

Confusion Assessment Method for the ICU (CAM-ICU)

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

The criteria of scoring scale:

1. An acute change from mental status at base line or fluctuating mental status during the past 24 hr(must be true to be positive)
2. 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:

• If the RASS is not 0 and the above two criteria are positive, the patient is delirious
• 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)

The criteria of the scoring system:

• Then score 1 point for each of the following features, as assessed in the manner

thought appropriate by the clinician:

1. Anything other than “normal wakefulness”
2. Inattention
3. Disorientation
4. Hallucination
5. Psychomotor agitation
6. Inappropriate speech or mood
7. Disturbance in sleep or wake cycle
8. Fluctuation in symptoms

The interpretation of the scoring system:

• A score of ≥ 4 is positive for delirium (with scores of 1 to 3 termed “subsyndromal delirium”)
• Patient must show at least a response to mild or moderate stimulation.