Delirium Diagnosis and Management
Introduction to Delirium
- The American College of Radiology recommends immediate evaluation for delirium in elderly patients with dementia presenting with worsening confusion, as it represents a medical emergency 1, 2, 3
Diagnostic Features
- Delirium is characterized by acute onset and fluctuating course of confusion, which distinguishes it from progression of underlying dementia 3
- The Confusion Assessment Method (CAM) is the most widely used and validated diagnostic instrument for delirium 4
- A two-step screening process using the Delirium Triage Screen and the Brief Confusion Assessment Method (bCAM) can be used to diagnose delirium 5, 2
Critical Pitfalls
- Hypoactive delirium is the most commonly overlooked subtype in elderly patients and carries a higher mortality risk than hyperactive delirium 3, 4, 5
Diagnostic Workup
- Fingerstick glucose, vital signs with oxygen saturation, and medication review should be done immediately to identify underlying precipitants of delirium 6, 2, 3
- Laboratory evaluation should include comprehensive metabolic panel, complete blood count, urinalysis, and culture 6, 2
- Neuroimaging should be considered when focal neurologic deficits are present, there is a history of recent trauma, or significantly elevated blood pressure 1, 6
Management Priorities
- Non-pharmacological interventions, such as avoiding physical restraints, ensuring sensory aids are used, normalizing sleep-wake cycle, and early mobilization, should be used as first-line treatment 5, 2
- Pharmacological management, such as low-dose antipsychotics, should be used sparingly and with caution due to the risk of increased mortality in elderly patients with dementia-related psychosis 2