DSM-5: Delirium.

This post is the most recent addi­tion to my DSM-5 e-mail list. I include it here only because I appar­ently have a fond­ness for delir­ium; it was one of my favorite teach­ing top­ics when work­ing with med­ical stu­dents. If you’d like to read my other DSM-5 sum­maries, let me know.

(724 words = 5 min read)

How rarely, par­tic­u­larly out­side of hos­pi­tal set­tings, do we remem­ber to think of delirium!

DSM-5 lists five cri­te­ria for delirium:

A. There is a dis­tur­bance in atten­tion and awareness.

Because peo­ple who are deliri­ous have prob­lems with focus and sus­tain­ing atten­tion, this means you might find your­self ask­ing the same ques­tions over and over. The deliri­ous patient may end up pro­vid­ing the same answer over and over, even though you’re ask­ing a dif­fer­ent question.

Fur­ther­more, if patients have severe inat­ten­tion, they might not be able to have a con­ver­sa­tion with you at all.

B. Delir­ium devel­ops over a short period of time, typ­i­cally hours to days. There is a change in base­line atten­tion and aware­ness. It fluc­tu­ates through­out the day.

Atten­tion and aware­ness often worsen at night (some­times referred to as “sun­down­ing”).

C. There is also another dis­tur­bance in cog­ni­tion, such as in mem­ory, ori­en­ta­tion, lan­guage, and perception.

Deliri­ous patients might think that a pair of socks is an opos­sum (illu­sion), the nurse is try­ing to sell his blood (misinterpretation/delusion), or that he can hear the con­ver­sa­tions that are hap­pen­ing in the cafe­te­ria (hallucinations/delusions).

D. The dis­tur­bances in (A.) and (C.) are not bet­ter explained by another pre-existing, estab­lished, or evolv­ing neu­rocog­ni­tive dis­or­der. (Hav­ing a neu­rocog­ni­tive dis­or­der, how­ever, increases the risk of the devel­op­ment of delirium.)

You also can’t diag­nose delir­ium is some­one is comatose. Essen­tial to the diag­no­sis of delir­ium is that the patient can respond to “ver­bal stimulation”.

E. There must also be evi­dence that the delir­ium is due to a direct phys­i­o­log­i­cal con­se­quence of another med­ical con­di­tion, sub­stance intox­i­ca­tion or with­drawal, or expo­sure to a toxin, or is due to mul­ti­ple etiologies.

This means that delir­ium always has a cause. Your job is to find that cause (or work with some­one who can help you find that cause).

There are many spec­i­fiers for delir­ium (which clar­ify the cause):

(1) sub­stance intox­i­ca­tion delir­ium
(2) sub­stance with­drawal delir­ium
(3) medication-induced delir­ium
(4) delir­ium due to another med­ical con­di­tion
(5) delir­ium due to mul­ti­ple eti­olo­gies
(6) acute
(7) per­sis­tent (how ter­ri­ble!)
(8) hyper­ac­tive (more fre­quently rec­og­nized, because these are the peo­ple who are shout­ing that they are on a boat and think that the IVs are snakes)
(9) hypoac­tive (this is often missed because these are the peo­ple who seem to be the most “com­pli­ant” patients ever)
(10) mixed level of activity

DSM-5 spends a fair amount of time dis­cussing the record­ing pro­ce­dures. If you are a consult-liaison psy­chi­a­trist, you should look those over.

DSM-5 states that, in hos­pi­tal set­tings, delir­ium usu­ally lasts about one week. Some symp­toms, though, per­sist even after indi­vid­u­als are dis­charged from the hospital.

Delir­ium is con­sid­ered a “great imi­ta­tor” amongst psy­chi­a­trists. Peo­ple who are deliri­ous can look psy­chotic, depressed, manic, anx­ious, or a com­bi­na­tion of all four. Delir­ium also messes with sleep-wake cycles and may man­i­fest more at night because there is less envi­ron­men­tal stim­u­la­tion present.

DSM-5 pro­vides some preva­lence num­bers:
(1) peo­ple in the com­mu­nity: 1–2% (that num­ber ide­ally should be 0%)
(2) hos­pi­tal­ized peo­ple: 6% to 56% (this is not a com­fort­ing range)
(3) peo­ple who just had surgery: 15% to 53%
(4) peo­ple in ICUs: 70% to 87%
(5) peo­ple in nurs­ing homes: 60% (yikes!)
(6) peo­ple who are at “end of life”: 83%

Thank­fully, the major­ity of peo­ple with delir­ium expe­ri­ence a full recov­ery, though delir­ium is a har­bin­ger of death: About 40% of peo­ple who are diag­nosed with delir­ium in the hos­pi­tal are dead within a year. Delir­ium also increases the like­li­hood of “insti­tu­tional place­ment” and “func­tional decline”.

In addi­tion to neu­rocog­ni­tive dis­or­ders, other risks for delir­ium include extremes of age, drug use, polyphar­macy, a his­tory of falls, and func­tional impairment.

Delir­ium is a clin­i­cal diag­no­sis (there is no test for it), though EEGs might show “gen­er­al­ized slowing”.

I have never thought about the dif­fer­en­tial for delir­ium, as that is what I always con­sider first (but that may be due to my past work as a consult-liaison psy­chi­a­trist). DSM-5 includes psy­chotic dis­or­ders, acute stress dis­or­der, malin­ger­ing, fac­ti­tious dis­or­der, and other neu­rocog­ni­tive dis­or­ders in the dif­fer­en­tial for delir­ium. Rarely, though, do those con­di­tions have the “wax­ing and wan­ing” in level of con­scious­ness and atten­tion that is seen in delirium.

I’ll resume send­ing [DSM-5] posts out after Jan­u­ary 1st. May you all recall fond mem­o­ries from 2013. May 2014 bring you good health, mirth, and ongo­ing learning.