Delirium & Assessing a Confused Patient

Criteria:

A. A disturbance in attention and awareness (reduced orientation to the environment).

B. The disturbance develops over a short period of time (usually hours to a few days),
represents a change from baseline attention and awareness, and tends to fluctuate in
severity during the course of a day.
C. An additional disturbance in cognition (e.g., memory deficit, disorientation, language,
visuospatial ability, or perception).
D. The disturbances in Criteria A and C are not better explained by another preexisting,
established, or evolving neurocognitive disorder and do not occur in the context of a
severely reduced level of arousal, such as coma.
E. There is evidence from the history, physical examination, or laboratory findings that the
disturbance is a direct physiological consequence of another medical condition, substance
intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies.

Specify if:
− Acute: Lasting a few hours or days.
− Persistent: Lasting weeks or months.
Specify if:
− Hyperactive: hyperactive level of psychomotor activity that may be accompanied by
mood lability, agitation, and/or refusal to cooperate with medical care.
− Hypoactive: hypoactive level of psychomotor activity that may be accompanied by
sluggishness and lethargy that approaches stupor.
− Mixed level of activity: a normal level of psychomotor activity even though attention and
awareness are disturbed. Also includes individuals whose activity level rapidly fluctuates.
Clues from the medical notes:
− Current diagnoses – consider dementia & depression as standalone causes or in
conjunction with delirium
− Medications – perform a medication review – opiates / calcium supplements etc
− Vascular problems – previous Strokes / MI / ischemic limbs ↑ likelihood of vascular
dementia
− Other presenting complaints History of recurrent admissions

Clinical instruments — The Confusion Assessment Method (CAM)

Can be repeated to allow ongoing recognition of improvement / deterioration
Also consider use of a more formal screening tool (MMSE/ACE-III/frontal lobe tests)

Get the best history from the patient as possible – conversation can give big clues to current
mental state.
Reassurance and gentle re-orientation if appropriate – ask the patient what they are
seeing/hearing/experiencing.
Collateral history – What is normal for the patient? How long have they been confused? What is
different?
 I WATCH DEATH: Mnemonic for Differential Diagnosis of Delirium
Infection HIV, sepsis, pneumonia
Withdrawal Alcohol, barbiturate, sedative-hypnotic
Acidosis, alkalosis, electrolyte disturbance,
Acute metabolic
hepatic failure, renal failure
Closed-head injury, heat stroke,
Trauma
postoperative, severe burns
Abscess, hemorrhage, hydrocephalus,
subdural hematoma, infection, seizures,
CNS pathology
stroke, tumors, metastases, vasculitis,
encephalitis, meningitis, syphilis
Anemia, carbon monoxide poisoning,
Hypoxia
hypotension, pulmonary or cardiac failure
Deficiencies Vitamin B12, folate, niacin, thiamine
Hyper/hypoadrenocorticism,
Endocrinopathies hyper/hypoglycemia, myxedema,
hyperparathyroidism
Hypertensive encephalopathy, stroke,
Acute vascular
arrhythmia, shock
Prescription drugs, illicit drugs, pesticides,
Toxins or drugs
solvents
Heavy Metals Lead, manganese, mercury
 Management
Modifying risk factors
− Orientation protocols: Provision of clocks, windows with outside views, and verbally
reorienting patients may mitigate confusion that results from disorientation in unfamiliar
environments.
− Cognitive stimulation: may benefit from activity such as regular visits from family and
friends. At the same time, sensory overstimulation should be avoided, particularly at
night.
− Facilitation of physiologic sleep: Nursing and medical procedures, including the
administration of medications, should be avoided during sleeping hours when possible.
Night-time noise should be reduced.
− Early mobilization and minimized use of physical restraints for patients with limited
mobility.
− Visual and hearing aids for patients with these impairments
− Avoiding and/or monitoring the use of problematic medications.
− Avoiding and treating medical complications: A number of medical conditions are known
to cause or aggravate delirium; these should be managed aggressively and prevented
where possible.
− Managing pain: Pain may be a significant risk factor for delirium. The use of nonopioid
medications should be used where possible, as these are less likely to aggravate delirium.
 Confusion Assessment Method (CAM)
(Adapted from Inouye et al., 1990)

Patient’s Name: Date:

Instructions: Assess the following factors.

Acute Onset
1. Is there evidence of an acute change in mental status from the patient’s baseline?
YES NO UNCERTAIN NOT APPLICABLE

Inattention
(The questions listed under this topic are repeated for each topic where applicable.)
2A. Did the patient have difficulty focusing attention (for example, being easily distractible or having difficulty
keeping track of what was being said)?
Not present at any time during interview
Present at some time duri ng interview, but in mild form
Present at some time dur ing interview, in marked form
Uncertain
2B. (If present or abnormal) Did this behavior fluctuate during the interview (that is, tend to come and go or
increase and decrease in severity)?
YES NO UNCERTAIN NOT APPLICABLE
2C. (If present or abnormal) Please describe this behavior.

Disorganized Thinking
3. Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear
or illogical flow of ideas, or unpredictable, switching from subject to subj ect?
YES NO UNCERTAIN NOT APPLICABLE

Altered Level of Consciousness

4. Overall, how would you rate this patient’s level of consciousness?
Alert (normal)
Vigilant (hyperalert, overly sensitive to environmental stimuli, startled very easily)
Lethargic (drowsy, easily aroused)
Stupor (difficult to arouse)
Coma (unarousable)
Uncertain

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Disorientation
5. Was the patient disoriented at any time during the interview, such as thinking that he or she was somewhere
other than the hospital, using the wrong bed, or misjudging the time of day?
YES NO UNCERTAIN NOT APPLICABLE

Memory Impairment
6. Did the patient demonstrate any memory problems during the interview, such as inability to remember
events in the hospital or difficulty remembering instructions?
YES NO UNCERTAIN NOT APPLICABLE

Perceptual Disturbances
7. Did the patient have any evidence of perceptual disturbances, such as hallucinations, illusions, or
misinterpretations (for example, thinking something was moving when it was not)?
YES NO UNCERTAIN NOT APPLICABLE

Psychomotor Agitation
8A. At any time during the interview, did the patient have an unusually increased level of motor activity, such as
restlessness, picking at bedclothes, tapping fingers, or making frequent, sudden changes in position?
YES NO UNCERTAIN NOT APPLICABLE

Psychomotor Retardation
8B. At any time during the interview, did the patient have an unusually decreased level of motor activity, such as
sluggishness, staring into space, staying in one position for a long time, or moving very slowly?
YES NO UNCERTAIN NOT APPLICABLE

Altered Sleep-Wake Cycle

9. Did the patient have evidence of disturbance of the sleep-wake cycle, such as excessive daytime sleepiness
with insomnia at night?
YES NO UNCERTAIN NOT APPLICABLE

Scoring:
For a diagnosis of delirium by CAM, the patient must display:
1. Presence of acute onset and fluctuating discourse
AND
2. Inattention
AND EITHER
3. Disorganized thinking
OR
4. Altered level of consciousness

Source:
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion
assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948.

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 Confusion Assessment Method (CAM) Diagnostic Algorithm

Feature 1: Acute Onset and Fluctuating Course

This feature is usually obtained from a family member or nurse and is shown by positive
responses to the following questions: Is there evidence of an acute change in mental status
from the patient's baseline? Did the (abnormal) behavior fluct uate during the day; that is, did it
tend to come and go, or increase and decrease in severity?

Feature 2: Inattention
This feature is shown by a positive response to the following question: Did the patient have
difficulty focusing attention; for example, being easily distractible, or having difficulty keeping
track of what was being said?

Feature 3: Disorganized Thinking

This feature is shown by a positive response to the following question: Was the patient's
thinking disorganized or incoherent, such as ramb ling or irrelevant conversation, unclear or
illogical flow of ideas, or unpredictable switching f rom subject to subject?

Feature 4: Altered Level of Consciou sness

This feature is shown by any answer other than "alert" to the following question: Overall, how
would you rate this patient's level of consciousness? (alert [normal], vigilant [hyperalert],
lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])

Source:
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion
assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948.

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Reference:
- UpToDate.com
- James L. Levenson MD. “The American Psychiatric Association Publishing Textbook of
Psychosomatic Medicine and Consultation-Liaison Psychiatry.” 3rd edition
- DSM5