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of consciousness (i.e., reduced clarity of awareness of the environment)
with reduced ability to focus, sustain, or shift attention.
B. A change
in cognition (such as memory deficit, disorientation, language disturbance)
or the development of a perceptual disturbance that is not better
accounted for by a preexisting, established, or evolving dementia.
C. The disturbance
develops over a short period of time (usually hours to days) and
tends to fluctuate during the course of the day.
is evidence from the history, physical examination, or laboratory
findings that the disturbance is caused by the direct physiological consequences
of a general medical condition.
note: If delirium is superimposed on a preexisting
vascular dementia, indicate the delirium by coding 290.41 vascular
dementia, with delirium.
note: Include the name of the general medical condition
on Axis I, e.g., 293.0 delirium due to hepatic encephalopathy; also
code the general medical condition on Axis III (see DSM-IV-TR Appendix G for
Clouding of consciousness
Disorganized thinking/thought disorder
Diffuse cognitive impairment
with permission from Meagher DJ, Trzepacz PT: "Delirium
Phenomenology Illuminates Pathophysiology, Management, and Course." Journal
of Geriatric Psychiatry and Neurology 11:150–156,
1998. Includes data from Voyer et al. 2006.
review: recent past and current
testing: months of the year backward (5), verbal Trails B (10),
clock drawing, A-test for vigilance
As clinically warranted
work: complete blood count, electrolytes, blood urea nitrogen, creatinine,
glucose, calcium, pulse oximetry or arterial blood gas, urinalysis,
drug screen, liver function test with serum albumin, cultures, HIV
screening, cerebrospinal fluid examination
X-ray, electrocardiogram, brain imaging, electroencephalogram
Intact (except Lewy body dementia and end-stage disease)
No (except Lewy body dementia)
Intact attention, insidious, EEG
Hypo- or hyperactive, odd behavior, limited or no speech
Motor findings, resolves with lorazepam/ECT,
Responsive to ECT, other manic symptoms and history,
Disorganized, poor attention, diffuse cognitive dysfunction
Young age, no precipitants, persistent psychotic symptoms
after confusion cleared, EEG
Drug/alcohol intoxication or withdrawal
Hypo- or hyperactive, hallucinations, poor attention
Positive drug screen or history, EEG
Note. ECT = electroconvulsive
therapy; EEG = electroencephalogram.
Preexisting cognitive impairment
Vision or hearing impairment
Impaired functional status
Orthopedic, thoracic, or aortic aneurysm surgery
Lower education level
Blood urea nitrogen/creatinine >18
Abnormal Na+, K+,
or blood glucose levels
Windowless intensive care unit
Hyper- or hypothermia
Perioperative and intraoperative hypotension
Disseminated intravascular coagulation
More than three new medications begun
Benzodiazepines >2 mg lorazepam equivalents
Corticosteroids >15 mg dexamethasone equivalents
Opioids >90 mg morphine equivalents
Many chemotherapy and immunosuppressive agents
Many medications with strong anticholinergic activity
Several Parkinson's disease medications
Numerous isolated reports of varying medications
Source. Benoit et al. 2005; Brown and Stoudemire 1998; Centeno et al. 2004; Culp et al. 2004; Edlund et al. 2001; Foy et al. 1995; Francis et al. 1990; Gaudreau et al. 2005; Gustafson et al. 1988; Henon et al. 1999; Inouye and Charpentier 1996; Inouye et al. 1993; Leung et al. 2005; Lundstrom et al. 2003; Marcantonio et al. 1994; Minden et al. 2005; Pompei et al. 1994; Rockwood 1989; Rogers et al. 1989; Schor et al. 1992; Williams-Russo et al. 1992; L. M. Wilson 1972.
All patients, protocol once daily; patients with baseline MMSE
score of <20 and orientation score of <8, protocol three
Orientation protocol: board with names of care-team members
and day's schedule; communication to reorient to surroundings
Therapeutic activities protocol: cognitively stimulating activities
three times daily (e.g., discussion of current events, structured
reminiscence, word games)
All patients; need for protocol assessed once daily
Nonpharmacological sleep protocol: at bedtime, warm
drink (milk or herbal tea), relaxation tapes or music, and back massage
Sleep-enhancement protocol: unitwide noise-reduction strategies
(e.g., silent pill crushers, vibrating beepers, and quiet hallways)
and schedule adjustments to allow sleep (e.g., rescheduling of medications
All patients; ambulation whenever possible, and range-of-motion
exercises when patient is chronically nonambulatory, bed- or wheelchair-bound,
or immobilized (e.g., because of an extremity fracture or deep venous thrombosis)
or has been prescribed bed rest
Early mobilization protocol: ambulation or active range-of-motion
exercises three times daily; minimal use of immobilizing equipment
(e.g., bladder catheters, physical restraints)
Patients with <20/70 visual acuity on binocular
Vision protocol: visual aids (e.g., glasses or magnifying lenses)
and adaptive equipment (e.g., large illuminated telephone keypads,
large-print books, fluorescent tape on call bell), with daily reinforcement
of their use
Patients with <7 of 12 whispers on Whisper Test
Hearing protocol: portable amplifying devices, earwax disempaction,
and special communication techniques, with daily reinforcement of
Patients with ratio of blood urea nitrogen to creatinine
of >17, screened for protocol by geriatric nurse–specialist
Dehydration protocol: early recognition of dehydration
and volume repletion (e.g., encouragement of oral intake fluids)
score consists of first 10 items on the Mini-Mental State Exam (MMSE).
with permission from Inouye SK, Bogardus ST Jr, Charpentier PA,
et al.: "A Multicomponent Intervention to Prevent Delirium
in Hospitalized Older Patients." New England
Journal of Medicine 340:669–676, 1999.
Copyright 1999, Massachusetts Medical Society. All rights reserved.
Number of reports
Number of RPCDBs
Average daily dosage*
Average dosage range
Average days to response**
Note. RPCDB = randomized,
double-blind study with a control group.
aReports for quetiapine: K. Y. Kim et al. 2003; Lee et al. 2005; Pae et al. 2004; Sasaki et al. 2003; Schwartz and Masand 2000; Torres et al. 2001.
bReports for risperidone: C. S. Han and Kim 2004; Horikawa et al. 2003; J. Y. Kim et al. 2005; Liu et al. 2004; Mittal et al. 2004; Parellada et al. 2004; Toda et al. 2005.
cReport for aripiprazole: Straker 2005.
dReports for olanzapine: Breitbart et al. 2002b; Gupta et al. 2004; K. S. Kim et al. 2001; Sipahimalani and Masand 1997; Skrobik et al. 2004.
*Weighted by sample size.
**Weighted by N, best
estimates for some reports, response equal to or below scale cutoff.
from Seaman J: "Diagnosis and Treatment of Delirium in
2006." Psychiatric Times 23(6):1–2,
2006. Copyright 2006, CMP Media LLC. Used with permission.