Evaluation of delirium

chronic impairment of memory with 1 or more of the following criteria: aphasia, apraxia, agnosia, and disturbances in executive function; usually not acute and not associated with changes in attention; chronic confusion not associated with changes in alertness and coherence except in the most severe cases; history of long-term cognitive decline from caregivers[89]Kalapatapu RK, Neugroschl JA. Update on neuropsychiatric symptoms of dementia: evaluation and management. Geriatrics. 2009 Apr;64(4):20-6. http://www.ncbi.nlm.nih.gov/pubmed/19400596?tool=bestpractice.com

previous cognitive status examination (e.g., Folstein Mini-Mental Examination, Montreal Cognitive Assessment) helpful to establish the chronicity of confusional states; chronic confusion more likely dementia; acute on chronic changes can occur in mixed delirium/dementia states[13]Roche V. Southwestern Internal Medicine Conference. Etiology and management of delirium. Am J Med Sci. 2003 Jan;325(1):20-30. http://www.ncbi.nlm.nih.gov/pubmed/12544081?tool=bestpractice.com [52]Oh ES, Li M, Fafowora TM, et al. Preoperative risk factors for postoperative delirium following hip fracture repair: a systematic review. Int J Geriatr Psychiatry. 2015 Sep;30(9):900-10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4465414 http://www.ncbi.nlm.nih.gov/pubmed/25503071?tool=bestpractice.com

pain; may be history of falls or trauma (e.g., causing hip fracture)

tachycardia, tachypnea, sweating, reluctance to move and distress on movement

acute changes in mental status likely; associated with neurologic symptoms; unilateral weakness or numbness; change in vision (unilateral or bilateral); difficulty with speech, comprehension; loss of coordination, difficulty walking; severe headache[90]van der Worp HB, van Gijn J. Clinical practice: acute ischemic stroke. N Engl J Med. 2007 Aug 9;357(6):572-9. http://www.ncbi.nlm.nih.gov/pubmed/17687132?tool=bestpractice.com

confusion frequently noted; focal neurologic signs include: unilateral hemiparesis, hemianopia, aphasia, ataxia[90]van der Worp HB, van Gijn J. Clinical practice: acute ischemic stroke. N Engl J Med. 2007 Aug 9;357(6):572-9. http://www.ncbi.nlm.nih.gov/pubmed/17687132?tool=bestpractice.com

history of risk factors for CAD (e.g., smoking, hyperlipidemia, diabetes, family history of CAD); chest pain (often described as heavy, or tight) radiating to arms, back, neck, or jaw; chest pain may be absent in older adults and people with diabetes; dyspnea; nausea; diaphoresis

delirium is often the only identifiable sign in older patients; other signs may include hypotension; diaphoretic appearance; pallor; tachycardia; bradycardia; new abnormal pulse rhythm; distended jugular veins; other signs of heart failure (e.g, dyspnea, crackles at lung bases); new heart murmur

cough, sputum production, dyspnea, chest pain, and urinary incontinence; common causes, especially in older people, are pneumonia and urinary tract infections; systemic infections and sepsis can cause delirium separate from their hypoxic effect[92]Johnson JC, Jayadevappa R, Baccash PD et al. Nonspecific presentation of pneumonia in hospitalized older people: age effect of dementia? J Am Geriatr Soc. 2000 Oct;48(10):1316-20. http://www.ncbi.nlm.nih.gov/pubmed/11037021?tool=bestpractice.com [93]Warshaw G, Tanzer F. The effectiveness of lumbar puncture in the evaluation of delirium and fever in the hospitalized elderly. Arch Fam Med. 1993 Mar;2(3):293-7. http://www.ncbi.nlm.nih.gov/pubmed/8252150?tool=bestpractice.com [94]Manepalli J, Grossberg GT, Mueller C. Prevalence of delirium and urinary tract infection in a psychogeriatric unit. J Geriatr Psychiatry Neurol. 1990 Oct-Dec;3(4):198-202. http://www.ncbi.nlm.nih.gov/pubmed/2073307?tool=bestpractice.com [95]Siami S, Annane D, Sharshar T. The encephalopathy in sepsis. Crit Care Clin. 2008 Jan;24(1):67-82, viii. http://www.ncbi.nlm.nih.gov/pubmed/18241779?tool=bestpractice.com [96]Seaman JS, Schillerstrom J, Carroll D, et al. Impaired oxidative metabolism precipitates delirium: a study of 101 ICU patients. Psychosomatics. 2006 Jan-Feb;47(1):56-61. http://www.ncbi.nlm.nih.gov/pubmed/16384808?tool=bestpractice.com

pyrexia, rigors, rales, and crackles on auscultation of chest, cloudy urine with offensive odor, hypotension

confusion, sweating, nausea, headache, drowsiness, and seizures; usually a history of taking medication for diabetes, or alcohol abuse

tremor, sweating, tachycardia

polyuria, polydipsia, weakness, nausea, vomiting, drowsiness, and weight loss, developing rapidly over a day or less; may be precipitated by infection, MI, stroke, or other endocrine disorders

signs of volume depletion, including tachycardia and hypotension, Kussmaul respiration, acetone breath, stupor, or coma

usually secondary to underlying disease such as sepsis, pneumonia, pulmonary embolism, severe asthma attack, COPD, cardiac failure or arrhythmia, or carbon monoxide poisoning; symptoms include incoordination, confusion, poor judgment, seizures, myoclonic jerks, euphoria, nausea, visual impairment, coma

increased respiratory rate, tachycardia, cyanosis, poor coordination

history of abnormal respiratory function (e.g., COPD)

dyspnea, cyanosis; may have a flapping tremor of the hands, warm peripheries, bounding pulse, and occasionally papilledema

inability to urinate, abdominal pain; may be history of poor urinary stream, hesitancy, dribbling, nocturia, dysuria

bladder distension, may be enlarged prostate

overdoses with anticholinergics, tricyclic antidepressants, stimulants, opiates, steroids, analgesics, cardiac glycosides, and anti-Parkinson drugs can be associated with delirium; there may be a history of known illicit drug abuse[52]Oh ES, Li M, Fafowora TM, et al. Preoperative risk factors for postoperative delirium following hip fracture repair: a systematic review. Int J Geriatr Psychiatry. 2015 Sep;30(9):900-10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4465414 http://www.ncbi.nlm.nih.gov/pubmed/25503071?tool=bestpractice.com

may be signs of underlying illnesses requiring predisposing medication; may be signs of illicit drug overdose (e.g., agitation, tachycardia, hyperthermia, mydriasis with amphetamine or cocaine overdose; decreased respiratory rate and miosis with opiate overdose)

may be history of recent heavy consumption of alcohol; symptoms of ketoacidosis include nausea and vomiting, abdominal pain, fatigue, poor appetite, lethargy and confusion

alcoholic ketoacidosis causes reduced consciousness, agitation, rapid ventilation rate, and signs of dehydration

history of hepatitis infection, alcohol use and/or drug use may be present

hallmark finding in metabolic encephalopathies is asterixis; features of chronic liver disease, encephalopathy, jaundice, hepatomegaly, and ascites may be present

historical findings might include a change in the quantity or quality of urine output, anorexia, and/or NSAID use

hallmark finding in metabolic encephalopathies is asterixis; myoclonic jerks may be evident in uremia; pallor, edema, pleural effusion, pericarditis, neuropathy, and hypertension may be found

recent changes in hypertensive medications, dehydration, inability to obtain water (e.g., as evident with stroke, dementia)[22]Singer GG, Brenner BM. Fluid and electrolyte disturbances. In: Kasper DL, Fauci AS, Longo DL, et al. eds. Harrison's Principles of Internal Medicine, 16th ed. New York, NY: McGraw Hill; 2005:252-63.

mental status changes, weakness, neuromuscular irritability, and or coma/seizures[22]Singer GG, Brenner BM. Fluid and electrolyte disturbances. In: Kasper DL, Fauci AS, Longo DL, et al. eds. Harrison's Principles of Internal Medicine, 16th ed. New York, NY: McGraw Hill; 2005:252-63.

recent infection, recent medication change and/or free water intoxication, history of hypotonic intravenous infusions; symptoms of headaches, nausea, confusion, lethargy[22]Singer GG, Brenner BM. Fluid and electrolyte disturbances. In: Kasper DL, Fauci AS, Longo DL, et al. eds. Harrison's Principles of Internal Medicine, 16th ed. New York, NY: McGraw Hill; 2005:252-63.

confusion, seizures, coma[22]Singer GG, Brenner BM. Fluid and electrolyte disturbances. In: Kasper DL, Fauci AS, Longo DL, et al. eds. Harrison's Principles of Internal Medicine, 16th ed. New York, NY: McGraw Hill; 2005:252-63.

history of hyperparathyroidism, malignancy, and/or thiazide diuretic use; symptoms of fatigue, anorexia, nausea, constipation, and polyuria[99]Potts JT Jr. Diseases of the Parathyroid gland and other hyper- and hypocalcemic disorders. In: Kasper DL, Fauci AS, Longo DL, et al. eds. Harrison's Principles of Internal Medicine, 16th ed. New York, NY: McGraw Hill; 2005:2252.

confusion[99]Potts JT Jr. Diseases of the Parathyroid gland and other hyper- and hypocalcemic disorders. In: Kasper DL, Fauci AS, Longo DL, et al. eds. Harrison's Principles of Internal Medicine, 16th ed. New York, NY: McGraw Hill; 2005:2252.

headache, neck stiffness, photophobia, and acute mental status changes; fevers, chills, nausea, and other evidence of illness also common; mental status changes acute or subacute

findings associated with meningeal inflammation: acute fulminant illness and triad of fever, headaches, and nuchal rigidity; in meningococcemia, maculopapular rash and/or petechial rash[100]van de Beek D, de Gans J, Spanjaard L, et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med. 2004 Oct 28;351(18):1849-59. http://www.nejm.org/doi/full/10.1056/NEJMoa040845#t=article http://www.ncbi.nlm.nih.gov/pubmed/15509818?tool=bestpractice.com

delirium can occur in people with malignant disease either because of structural brain lesions, infection, drugs (especially opioids), or metabolic encephalopathy; symptoms include lethargy, coma, agitation, disorientation, delusions, hallucinations, and seizures[55]Doriath V, Paesmans M, Catteau G et al. Acute confusion in patients with systemic cancer. J Neurooncol. 2007 Jul;83(3):285-9. http://www.ncbi.nlm.nih.gov/pubmed/17225935?tool=bestpractice.com [56]Leonard MM, Nekolaichuk C, Meagher DJ, et al. Practical assessment of delirium in palliative care. J Pain Symptom Manage. 2014 Aug;48(2):176-90. http://www.ncbi.nlm.nih.gov/pubmed/24766745?tool=bestpractice.com

lateralizing neurologic signs, papilledema

loss of consciousness, observed seizure activity, urinary incontinence, tongue trauma may be reported; premonitory symptoms or signs

observed tonic-clonic seizure or abnormal movements followed by drowsiness

thirst; fatigue; muscle cramps; abdominal pain; chest pain; confusion; loss of weight; underlying cause of volume loss including diarrhea, vomiting, burns, poor oral intake, severe sweating, severe pancreatitis, GI or intra-abdominal hemorrhage; polyuria from diabetes; crush injury, intestinal obstruction

dry mucous membranes; orthostatic hypotension; postural tachycardia; shock; decreased skin turgor; decreased urine output

altered bowel habits; abdominal pain; pain on defecation

tender abdomen; mass on palpation

loss of consciousness, anterograde and retrograde amnesia, vomiting, headache

deformity of skull or open fracture, reduced Glasgow coma scale (based on eye, verbal, and motor response), abnormal or unequal pupil reflexes, bruising around eyes or ears, bleeding or leakage of CSF from nose or ears, associated injuries to other parts of the body

caused by stress, trauma, or infection in a patient with Addison disease, or damage to the adrenal gland or pituitary; symptoms include headache, weakness, nausea, vomiting, fatigue, confusion, sweating, joint pain, abdominal pain, and weight loss

tachycardia, increased respiratory rate, hypotension, rash or darkening of the skin

change in appetite, weight loss, anxiety, palpitations, sweating and heat intolerance, oligomenorrhea, mood change, and fatigue

goiter, lid lag, exophthalmos, tachycardia, proximal muscle weakness, and tremor; thyroid storm also causes high fever and coma

reduced consciousness, usually in older patient with infection or oversedation; may also be weight gain, depression, lethargy, feeling cold, forgetfulness, and constipation

coma, hypothermia, bradycardia, signs of cardiac and respiratory failure, dry skin, facial and eyelid edema, and thick tongue

fever, headache, motor weakness, neck stiffness, vomiting, visual disturbance, seizures, impaired consciousness[102]Hsieh MJ, Chang WN, Lui CC, et al. Clinical characteristics of fusobacterial brain abscess. Jpn J Infect Dis. 2007 Feb;60(1):40-4. https://www.niid.go.jp/niid/images/JJID/60/40.pdf http://www.ncbi.nlm.nih.gov/pubmed/17314424?tool=bestpractice.com

pyrexia, hemiparesis, focal neurologic abnormalities, septic shock, meningism, papilledema[102]Hsieh MJ, Chang WN, Lui CC, et al. Clinical characteristics of fusobacterial brain abscess. Jpn J Infect Dis. 2007 Feb;60(1):40-4. https://www.niid.go.jp/niid/images/JJID/60/40.pdf http://www.ncbi.nlm.nih.gov/pubmed/17314424?tool=bestpractice.com

personality change, gait impairment, incontinence, headache, lightning pains, blurred vision, photophobia, reduced color perception

hyporeflexia, ataxia, anisocoria, Argyll Robertson pupils, cranial neuropathy, dementia, paranoia, Charcot joint

may be history of long-term, heavy consumption of alcohol or recent withdrawal; Wernicke encephalopathy and Korsakoff syndrome can be caused by thiamine deficiency and can contribute to delirium; symptoms include loss of coordination, confusion, memory impairment, change in vision, anxiety, delusions, insomnia, and delirium

confusion, nystagmus, conjugate gaze palsy, ataxia, short-term memory loss, hypothermia, hypotension, peripheral neuropathy, confabulation