Alterations in attention or consciousness accompanied by a cognitive change may mean that there is a pathology to be treated. Therefore it is important to make a good diagnosis. In this way, the reason for these changes can be ascertained and an action plan can be implemented. But what kind of disorder can be behind these alterations? For this, the subject will have to be evaluated thoroughly, but one of the disorders that may be behind is delirium.
Delirium is classified into neurocognitive disorders (TNC) in the latest edition of the DSM-V (Diagnostic and Statistical Manual of Mental Disorders, 2014). Throughout the article, following the DSM-V, both the diagnostic criteria, the characteristics that can support the disorder, prevalence and differential diagnosis will be exposed.
- 1 Diagnostic criteria of delirium
- 2 Specifications
- 3 Associated characteristics that support the diagnosis
- 4 Prevalence
- 5 Differential diagnosis of delirium
Diagnostic criteria of delirium
According to the latest update of the DSM-V (2014), the diagnostic criteria for Delirium are as follows:
- They can be observed attention alterations such as the ability to direct, center, maintain or divert attention; as well as alterations of consciousness.
- The alterations appear in a short time (hours or days). They represent changes regarding attention and awareness and their severity has to change throughout the day.
- Presence of a additional cognitive impairment as a deficit of memory, orientation, language, visospatial ability or perception.
- The alterations of criteria 1 and 3 are not better explained by another pre-existing neurocognitive alteration, established or ongoing, nor do they happen in the context of an extremely low level of stimulation, such as coma.
- In the history, physical examination or clinical analysis data are obtained indicating that the alteration is a direct physiological consequence of another medical condition, an intoxication or withdrawal from a substance, an exposure to a toxin or due to multiple etiologies.
- Delirium for substance intoxication. This diagnosis should be established instead of a diagnosis of poisoning by a substance when the symptoms of criteria 1 and 3 predominate in the clinical picture and are severe enough to require clinical attention.
- Delirium for substance withdrawal. This diagnosis should only be carried out instead of a diagnosis of withdrawal syndrome of a substance when the symptoms of criteria 1 and 3 prevail in the clinical picture and are severe enough to require clinical attention. It should be specified if delirium is due to withdrawal from alcohol, opiates, sedatives, hypnotics or anxiolytics or other substances or medications.
- Drug-induced delirium. This diagnosis will be applied when the symptoms of criteria 1 and 3 arise as a side effect of a prescription drug.
- Delirium due to another medical condition. The alteration can be attributed to a physiological consequence of another medical condition.
- Delirium I owe to multiple etiologies. Evidence is obtained that delirium has more than one etiology, for example, more than one medical condition, a medical condition plus a substance poisoning or a drug side effect.
Other delirium specifications
It should be noted if the delirium is acute (lasts a few hours or days) and if it is persistent (lasts weeks or less). On the other hand, it should also be specified if the disorder is:
- Hyperactive. The person suffering from it has a level of hyperactivation of psychomotor activity that can be accompanied by labile humor, agitation or refusal to cooperate with their medical assistance.
- Hypoactive. In this case, the person has a hypoactive level of psychomotor activity that can be accompanied by slowness and lethargy close to stupor.
- Mixed activation level. Normal psychomotor activity but attention and perception are altered. Those individuals whose activity level changes rapidly are also contemplated.
Associated features that support the diagnosis
One of the characteristics associated with delirium is the sleep-wake cycle disturbance. This type of alterations can include daytime sleepiness, difficulty falling asleep, daytime agitation, excessive wakefulness at night or excessive sleep throughout the day. In some cases there may even be an inversion of the cycle, that is, sleeping during the day and being awake at night. These types of alterations are quite frequent in delirium and have been proposed as an important criterion, even essential, in the diagnosis.
Other associated features may also be the emotional disturbances such as anxiety, fear, irritability, anger, depression, apathy or euphoria. These emotional alterations can be expressed in the form of screams, insults, groans, murmurs or other types of noise. Emotional changes can happen quickly. This type of behavior becomes especially relevant at night, when the
The prevalence is observed to a greater extent among hospitalized elderly. Globally, the prevalence is low, between 1% and 2% of the community. However, it increases over the years, being up to 14% in the elderly over 85 years. Delirium can appear in up to 60% of people who are in residences or in care of subagudos and in 83% of those who are at the end of their life.
Differential diagnosis of delirium
Psychotic disorders and bipolar and depressive disorders with psychotic characteristics. Delirium characterized by alterations of language, delusions, vivid hallucinations and agitation, must be distinguished from brief psychotic disorder, schizophrenia, schizophreniform disorder and other psychotic disorders. Similarly, it should be distinguished from bipolar and depressive disorders with psychotic characteristics.
Acute stress disorders The delirium associated with anxiety, fear or dissociative symptoms must be distinguished from acute stress disorder.
Simulation or factitious disorder. Delirium can be differentiated from these disorders based on the appearance - often atypical - that occurs in simulation and factitious disorder, and the absence of another medical condition or substance etiologically related to the apparent cognitive impairment.
Other neurocognitive disorders. A difficulty in differential diagnosis is one in which elderly people with dementias are involved. Distinguishing the symptoms of delirium with those of certain dementias can be expensive. The professional should establish whether the person has a delirium, a delirium superimposed on a previous neurocognitive disorder (TNC) such as Alzheimer's, or a TNC without delirium.
American Psychiatric Association. (2014). Diagnostic and Statistical Manual of Mental Disorders. Madrid: Pan American Medical Editorial.