Section Two
Assessment of Delirium
Approx Time To Complete: 20 Mins
Recognising Delirium
Delirium is a complex medical condition characterised by sudden and fluctuating changes in mental function. It is essential to recognise the symptoms early, as timely intervention can significantly impact outcomes. Practitioners should be alert to various signs, including abrupt worsened concentration, confusion, visual or auditory hallucinations, and alterations in physical function, such as reduced mobility, restlessness, and changes in appetite or sleep patterns. It’s not uncommon for family members or caregivers to notice these changes before the person affected does. Delirium can manifest in different ways, making it crucial for healthcare providers to listen carefully to reports from those close to the individual. Additionally, practitioners should be vigilant for hypoactive delirium, which may present as withdrawal, slow responses, reduced mobility, worsened concentration, and decreased appetite. Early recognition ensures that appropriate care measures can be implemented promptly.
Identifying Delirium
The identification of delirium involves the use of standardised tools to assess cognitive function and mental state. One such tool is the 4AT, a straightforward and quick test designed for easy clinical use. The 4AT evaluates a person’s level of alertness, cognitive function (assessing orientation and attention), and the presence of acute changes or a fluctuating course in mental status. This tool doesn’t require special training and has demonstrated high sensitivity and specificity in various clinical settings. In critical care scenarios, the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) may be more appropriate. These tools help healthcare professionals work collaboratively to identify delirium accurately. Delirium can sometimes be challenging to detect, especially in cases of hypoactive delirium, where symptoms may be subtle.
Holistic Assessment
Delirium is a complex clinical condition necessitating a thorough diagnostic process, involving a detailed history, comprehensive examination, and targeted investigations. This multifaceted approach aims to determine the complex nature of behavioural changes and identify underlying factors contributing to delirium.
These are highlighted below.
1. History Taking
Click the dropdown boxes to open.
Evaluate the onset, nature, and course of behavioural changes. Acute alterations that fluctuate are indicative of delirium.
Assess baseline cognitive function through tools like the GPCOG (for general practitioners), comparing current and previous scores to distinguish acute from chronic cognitive changes.
Inquire about past intellectual function, including the ability to manage daily activities and medication compliance.
Understand the individual’s social context and care arrangements.
Identify potential triggers, such as new illnesses, recent hospital discharge, falls, pain, poor oral intake, environmental changes, comorbidities, medications, alcohol use, and sensory impairments.
2. Physical Examination
Monitor vital signs to detect anomalies like fever, hypoperfusion
(i.e., reduced amount of blood flow), hyperglycaemia, hypoglycaemia,
or hypoxia.
Conduct a comprehensive physical examination, exploring respiratory (e.g., chest infection),
cardiovascular (e.g., heart failure), abdominal (e.g., constipation), musculoskeletal (e.g., hip fracture),
neurological (e.g., stroke), endocrine (e.g., diabetes) and skin conditions (e.g., pressure injury).
Assess sensory impairments and non-verbal signs of pain,
particularly crucial in individuals with communication
difficulties.
3. Confirmatory Assessment
Confirm the diagnosis using standardised tools such as the 4A’s test.
4. Consultation and Collaboration
In cases of diagnostic uncertainty, seek guidance from an appropriate healthcare specialist, ensuring a collaborative and informed decision-making process.
5. Targeted Investigations
Click the dropdown boxes to open.
Conduct urinalysis to discern potential conditions like infection or hyperglycaemia. If urinalysis yields abnormal results, proceed to arrange a mid-stream urine (MSU) test.
Perform a sputum culture to pinpoint the presence of a chest infection.
Utilise a full blood count to identify potential indicators of infection or anaemia.
Checking B12 levels in delirium helps rule out potential vitamin deficiencies, contributing to a comprehensive understanding of the individual’s overall health and well-being.
Conduct tests for urea and electrolytes to identify signs of acute kidney injury and electrolyte disturbances, such as hyponatremia or hypokalaemia.
Measure HbA1c levels to identify indications of hyperglycaemia.
Evaluate calcium levels to identify potential imbalances, whether hypercalcemia or hypocalcaemia.
Conduct liver function tests to identify potential hepatic failure and rule out hepatic encephalopathy.
Assess inflammatory markers, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), to obtain insights into potential infection or inflammation.
Test drug levels to identify potential toxicity, particularly if the individual has ingested substances like digoxin, lithium, or alcohol.
Employ thyroid function tests to identify indicators of hyperthyroidism or hypothyroidism.
Perform a chest X-ray to identify conditions such as pneumonia and heart failure.
Utilise an electrocardiogram (ECG) to identify potential cardiac conditions, including arrhythmias.
Delirium or Dementia
Healthcare professionals often encounter challenges in distinguishing between delirium and dementia due to overlapping symptoms such as confusion and disorientation. This confusion is exacerbated by the fact that both conditions are prevalent in older individuals, sharing commonalities in their demographic. However, crucial distinctions exist. Dementia is a slow-progressing, long-term brain disease with consistent and gradually worsening symptoms over years. In contrast, delirium is acute and develops rapidly, sometimes within hours. The key for accurate diagnosis lies in recognising the onset—dementia progresses slowly, while delirium manifests as a sudden and fluctuating state of confusion. This distinction can be particularly challenging during initial encounters with patients. Here, family input becomes crucial, understanding the individual’s baseline functioning and identifying any acute changes aids in distinguishing between the two conditions. Delirium might act as a warning sign for underlying dementia, especially in situations like hospitalisation, where older patients are vulnerable to both conditions. The connection between delirium and subsequent dementia emphasises the importance of careful observation and collaboration with family members in healthcare settings. The table below provides an overview of the key differences between delirium and dementia.
Lana Cook explaining differences between delirium and dementia
Lana explains the differences between delirium and dementia.
Test Your Knowledge
You have completed this section
If you feel you have completed all of the learning from this section then you should progress on to the Management of Delirium.