Delirium in the Hospital: Emphasis on the Management of Geriatric Patients: Prevention, Early Diagnosis, Comprehensive Treatment Are the Cornerstone of Care

By Bourgeois, James A.; Hategan, Ana et al. | Current Psychiatry, August 2014 | Go to article overview

Delirium in the Hospital: Emphasis on the Management of Geriatric Patients: Prevention, Early Diagnosis, Comprehensive Treatment Are the Cornerstone of Care


Bourgeois, James A., Hategan, Ana, Losier, Bruno, Current Psychiatry


Although delirium has many descriptive terms (Table 1, page 36), a common unifying term is "acute global cognitive dysfunction," now recognized as delirium; a consensus supported by DSM-5 (1) and ICD-10 (2) (Table 2, page 37). According to DSM-5, the essential feature is a disturbance of attention or awareness that is accompanied by a change in baseline cognition that cannot be explained by another preexisting, established, or evolving neurocognitive disorder (the newly named DSM-5 entity for dementia syndromes). (1) Because delirium affects the cortex diffusely, psychiatric symptoms can indude cognitive, mood, anxiety, or psychotic symptoms. Because many systemic illnesses can induce delirium, the differential diagnosis spans all organ systems.

Table 1

Terms for delirium

Acute confusional state

Acute brain failure

Agitation

Altered mental status

Confusion

Encephalopathy

ICU psychosis

status changes

Table 2

DSM-5 and lCD-i 0 criteria for delirium

DSM-5 criteria                        ICD-1O criteria

A. Disturbance in attention (ie,      A. Impairment of consciousness
reduced abihty to direct, focus,      and attention (reduced ability
sustain, and shift attention) and     to focus, sustain, and shift
awareness (reduced orientation to     attention)
the environment)

B. Disturbance develops over a short  B. Global disturbance of
period of time (usually hours to a    cognition (perceptual
few days), represents a change from   disturbance, impaired abstract
baseline attention and awareness,     thinking and comprehension,
and tends to fluctuate in severity    impaired immediate recall and
during the course of a day            recent memory, disorientation)

C. An additional change disturbance   C. Psychomotor disturbances
in cognition (eg, memory deficit,     (hypoactivity or hyperactivity,
disorientation, language,             increased reaction time,
visuospatial ability, or              increased or decreased flow of
perception)                           speech, enhanced startle
                                      reaction)

D. Disturbances in Criteria A and C   D. Disturbance of the sleep-wake
are not better explained by another   cycle (insomnia, reversal of the
preexisting, established, or          sleep-wake cycle, nocturnal
evolving neurocognitive disorder and  worsening of symptoms,
do not occur in the context of a      disturbing dreams or
severely reduced level of arousal,    nightmares)
such as coma

E. Disturbance is a direct            E. Emotional disturbances, (eg
physiological consequence of another  depression, anxiety or fear,
medical condition, substance          irritability, euphoria, apathy,
intoxication or withdrawal, or        or wondering perplexity)
exposure to a toxin, or is due to
multiple etiologies

[ILLUSTRATION OMITTED]

Three subtypes

Delirium can be classified, based on symptoms (3) , (4) into 3 subtypes: hyperactive-hyperalert, hypoactive-hypoalert, and mixed delirium. Hyperactive patients present with restlessness and agitation. Hyperactive patients are lethargic, confused, slow to respond to questions, and often appear depressed. The differential prognostic significance of these subtypes has been examined in the literature, with conflicting results. Rabinowitz' reported that hyperactive delirium has the worst prognosis, while Marcantonio et al (6) indicated that the hyperactive subtype is associated with the highest mortality rate. Mixed delirium, with periods of both hyperactivity and hypoactivity, is the most common type of delirium. (7)

A prodromal phase, characterized by anxiety, frequent requests for nursing and medical assistance, decreased attention, restlessness, vivid dreams, disorientation immediately after awakening, and hallucinations, can occur before an episode of full-spectrum delirium; this prodromal state often is identified retrospectively--after the patient is in an episode of delirium. …

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