Acute Delirium - Diagnosis

7/01/02

How is acute delirium definitively diagnosed?

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Unique Identifier:7858369

Authors: Johnson J. Sims R. Gottlieb G.

Institution: University of Pennsylvania, Philadelphia.

Title: Differential diagnosis of dementia, delirium and depression. Implications for drug therapy. [Review] [43 refs]

Source: Drugs & Aging. 5(6):431-45, 1994 Dec.

Abstract: Dementia, delirium and depression are the 3 most prevalent mental disorders in the elderly. While dementia and depression are prevalent in the community, hospitals and nursing homes, delirium is seen most often in acute care hospitals. Much of the management of these syndromes is undertaken by primary care physicians rather than psychiatrists. Therefore, it is imperative that generalist physicians be adept at recognising, evaluating and managing patients with these syndromes. Because no diagnostic tests are pathognomonic of these syndromes, the differential diagnosis hinges on a careful clinical evaluation. The first step is to recognise which of the syndromes is present. Dementia is defined by a chronic loss of intellectual or cognitive function of sufficient severity to interfere with social or occupational function. Delirium is an acute disturbance of consciousness marked by an attention deficit and a change in cognitive function. Depression is an affective disorder evidenced by a dysphoric mood, but the most pervasive symptom is a loss of ability to enjoy usual activities. It is important to recognise that these syndromes are not mutually exclusive, as dementia frequently coexists with delirium and depression. Furthermore, physical diagnoses, such as chronic obstructive lung disease, congestive heart failure, stroke and endocrine disorders, are frequently associated with depressive symptoms. Given this, a comprehensive evaluation is mandatory. Laboratory tests are necessary to exclude concurrent metabolic, endocrine and infectious disorders, and drug effects. Imaging studies should be obtained selectively in patients with signs and symptoms, such as focal neurological findings and gait disturbances, which are suggestive of structural lesions: stroke, subdural haematoma, normal pressure hydrocephalus and brain tumours. Appropriate management involving pharmacological and nonpharmacological measures will result in significant improvement in most patients with these syndromes. Potentially offending drugs should be discontinued. In delirious patients the underlying illness must be treated concomitantly with the use of psychotropics, if necessary. Although no current medications have been shown to have a significant effect on the functional status of patients with the 2 most common causes of dementia, Alzheimer's disease and multi-infarct dementia, the management of concomitant illness in these patients may result in improved function for as long as a year. Tacrine, an anticholinesterase inhibitor, improves cognitive function slightly in selected patients with Alzheimer's disease over short periods. Finally, the treatment of depression with medications or electroconvulsive therapy (ECT) results in significant reductions in mortality and morbidity. [References: 43] CAS Registry/EC Number 0 (Psychotropic Drugs).

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Unique Identifier:2910973

Authors: Rockwood K.

Institution: Department of Medicine, University of Alberta, Edmonton, Canada.

Title: Acute confusion in elderly medical patients.

Source: Journal of the American Geriatrics Society. 37(2):150-4, 1989 Feb.

Abstract: The acute confusional state (delirium) is a common presentation for a wide variety of medical conditions in the elderly. This paper reports a prospective study of acute confusion in elderly people admitted to general medical services in two acute care hospitals in Edmonton, Alberta. Eighty patients were studied, ranging in age from 65-91. Acute confusion was seen in one-fourth of these patients, who tended to be older, more ill, more likely to have chronic cognitive impairment and a higher mortality rate. In patients admitted with confusion, infection and congestive heart failure predominated. In those who developed confusion after hospitalization, iatrogenic disease was more common. Confusion was a sensitive sign of physical illness, and its resolution accompanied recovery. A diagnosis of the cause of the confusion state could be made in 22 of 24 cases. These findings support the aggressive investigation and treatment of acute confusion in the elderly.

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Unique Identifier:3625989

Authors: Lipowski ZJ.

Title: Delirium (acute confusional states).

Source: JAMA. 258(13):1789-92, 1987 Oct 2.

Abstract: Delirium (acute confusional states), a common and often overlooked psychiatric disorder, can occur at any age, but elderly persons are especially prone to develop it. In later life, it is often a conspicuous feature of systemic or cerebral disease and drug (notably anticholinergic) toxicity, and it may constitute a grave prognostic sign. Its development in a hospitalized patient may interfere with his or her management, disrupt ward routine, and cause medicolegal complications as a result of patient injury. Acute onset of a fluctuating level of awareness, accompanied by sleep-wake cycle disruption, lethargy or agitation, and nocturnal worsening of symptoms, are diagnostic. Early recognition of delirium and treatment of its underlying cause are essential.

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Unique Identifier:6624987

Authors: Lipowski ZJ.

Title: Transient cognitive disorders (delirium, acute confusional states) in the elderly.

Source: American Journal of Psychiatry. 140(11):1426-36, 1983 Nov.

Abstract: Transient cognitive disorders (delirium and pseudodelirium) are highly prevalent among the elderly, especially those with brain damage. Delirium is a common feature of physical illness or drug intoxication in elderly patients and requires prompt medical attention. While potentially reversible, delirium may herald death. Pseudodelirium may be induced by psychosocial stress or accompany a functional mental disorder. Transient cognitive disorders must not be confused with dementia, a chronic syndrome. The author discusses clinical features, etiology, pathogenesis, diagnosis, and treatment of delirium and related transient disorders of cognition in the elderly.

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