Delirium
Looking at the Latin origin of the word “delirium” we get a colourful image of what delirium really is:
The origin of the word “delirium”
- “Lira” – Latin for “furrow”
- “Delirare” means “to jump out of the furrow while ploughing”
- Delirium is a sudden temporary change from the normal steady state that has a specific cause (e.g. your plough hits a rock) and that can be corrected.
Click on the tabs below to see other definitions for delirium, and a mnemonic for remembering the key characteristics of delirium.
Simple Definition of Delirium
An acute confusional state caused by some medical or pharmacological trigger.
Another way to think of it is as a type of organ failure – “Acute Brain Failure.”
We are familiar with the concept of acute renal failure – the kidneys stop doing their job of taking blood, filtering out waste and retaining important electrolytes. Another example is acute heart failure – the pump stops doing is job of pumping blood to organs. We are aware that the main risk factor for ARF or AHF are chronic insufficiency.
The purpose of the brain is to take in information from the environment, process it, and formulate an appropriate response. When a patient has delirium, the brain is acutely unable to process information and stimuli appropriately. The primary risk factor for delirium is a brain that has dementia or “chronic insufficiency.”
DSM-IV Definition
- Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
- Change in cognition that is not better accounted for by a pre-existing, established, or evolving dementia
- Development over a short period of time (usually hours to days) and disturbance tends to fluctuate during the course of the day
- There is evidence from the history, physical exam, or lab findings that the disturbance is caused by the consequences of a general medical condition
Key Characteristics of Delirium
AIDA – This mnemonic is helpful for remembering the key characteristics of delirium based on the DSM-IV definition:
A– Acute and fluctuating
I– Inattention
D– Disorganized thinking: incoherent, rambling,
A-Altered level of consciousness: drowsy, lethargic, stuporous, hyper-alert, agitated
Discussion: Delirium
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yes
good
AIDA acronym helps to simplify and remember more easily
Useful mnemonic
good acronym
good info
Good acronym
I like the acronym.
AIDA is a very helpful mnemonic!
AIDA! Great reminder of a mnemonic for the CAM criteria. THANK you!
I agree
good reminder
Great Acronym!
Delirium needs to always have a full work up as it could be just a symptoms of other pathology.
Good
.
Useful definitions
Useful acronym
agree
Great discussion
cool acronyms
great acronym
didnt know that
great use of acronym!!
good
.
Delirium s/s: acute, fluctuating, inattention, AMS
agreed
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ok
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good
Important to remember that delirium is acute
agree
OK
ok
ok
ok
ok
ok
acronym is useful
Agreed.
agreed
great information
Interesting take.
great
Varga. Thanks for the acronym
Very well done
great
Great information
Agree
Very good definition
Buenos recursos para no olvidar las características
ok
ok
yup
good easy to understand
good info
agreed
good information
all these acronyms are very helpful
I liked the 3 different definitions!
great info, excellent mnemonics to follow when assess geriatric patients.
I agree!
good info
Good info
I agree
agree
a comment
Infection is always considered for delerium. Getting a urine sample proves to be rate limiting step sometimes.
Looking at the comments and for certin I agree that too often infection is over looked. I appreciated that shorter mnemonic especially DIMES.
ok
good video
helpful
IMES:
D-DRUGS
I- INFECTION
M – METABOLIC
E-ENVIRONMENTAL clear, labs normal, it seems that positive urine often warrants iv Abx.
varga June 28, 2013
any and all definitions work I find the acronim
Dementia
Ethanol
Metabolic
Endocrine
Neoplastic
Trauma
Infection, inflammatory
Alcohol, drugs
Social
WFWEFWefvarga June 28, 2013
any and all definitions work I find the acronim
Dementia
Ethanol
Metabolic
Endocrine
Neoplastic
Trauma
Infection, inflammatory
Alcohol, drugs
Social
a very helpful one
🙂
thank
DIMES:
D-DRUGS
I- INFECTION
M – METABOLIC
E-ENVIRONMENTAL
S-S TRUCTURAL
I like that!
Very good
good
helpful
good definition
good description
Thanks for the acronym
great modules
cool
informative
great information
good case
acute brain failure – like that term
Very concise and to the point. Like the acronym.
I think of delirium as new and temporary and dementia as long term and permanent. You can also have a delirious state in a demented patient.
mnemonics help
love the idea of delirium as acute brain failure!
excellent review
Really like the “acute brain failure” analogy and simplifying the brain’s function to input/processing/response.
Really like the “acute brain failure” analogy, and thinking of the brain function as input/process/response.
Helpful to compare the problem to physical symptoms from other organs to understand effects.
interested take on treating delirium much like acute cardiac
I appreciate the mnemonic, it prompts a quick recall for ease of identifying the key features of delirium.
I like the comparison to acute renal or acute heart failure, this simplifies and draws attention to it’s categorization as Emergencies Medicine.
I like provided acronyms which help nurses easy to rmb
Acute brain Failure, I like it
Dx can be challenging in someone with dementia. Dr. clearly needs to determine if there has been an acute change from baseline
changes in neuro status could indicate a multitude of issues. good patient interview and history taking is the key to ruling in or out. urosepsis vs delerium
I agree we often thinks it’s UTI, then treat them with antibiotics for seven to ten days, then no follow up after that.
I think that delirium is often overlooked in the ED, though once we approach the diagnosis systematically and lose our fear of talking about mental status issues with patients, it is something that we can diagnose and should be looking for – it affects so much in terms of patient care, disposal and outcome.
Agreed that the hyper & agitated behaviours are more readily dx, often the hypo can be easily missed as delirium.
Often delirium is only recognized in the hyper alert traditional sense, but unfortunately there is the chance it could be hypo alert in nature–important not to overlook delirium in these patients
agreed
i am agree whit that concept, we have to think in delirium every moment when evaluate an older patient
Always allow the patient to communicate fully and also maintain good communication with caregivers
it is important to complete all the information and applying the full test for sader which is the real problem
🙂
xx
Thorough assessments of change in patient status, solid communication with nursing home staff/docs/family will ensure appropriate tests are ordered and management of the cause once determined.
I like the mnemonic posted by Varga, DEMETIAS.
I like the idea of thinking of Delirium as Acute brain failure, really solidifies the concept of an acute and reversible change.
Just like falls prevention, we need to have UTI prevention strategies in LTC. Immobility/wheelchair bound cause urine stasis in the bladder and is an independent risk factor for UTI. Another benefit of physical activity in elderly..
As for treatment, I am liberal towards antibiotic therapy for symptomatic bacteuria + behaviour change, in addition to monitored and measured hysdartion trx and output, in LTC patients. If urine dip (POC) is negative I’d still send it for culture if I suspect UTI
the LTC setting is a good example of jumping to conclusions…if there is any change in behavior they immediately think “UTI” without even a set of vital signs! asymptomatic bacteriauria is often the case as it occurs in 85% of instituitionalized elderly…why…we keep giving them antibiotics over the phone without a thorough assessment
Love thinking of delerium as Acute Brain Failure the way we do with ARF and CHF
Agreed
Dx can be challenging in someone with dementia, and so one clearly needs to determine if there has been an acute change from baseline.
Dehydration is one of my favourite aetiologies, along with acute urinary retention. UTI follows, and I struggle with the discussion in the literature regarding asymptomatic bacteriuria – in a delirious patient, can I necessarily conclude that the delirium is caused by bacteria in the urine (the only abnormality that turns up after labs, ecg, ct head, cxr)?
Yes. We know that leukocyturia and bacteriuria are NORMAL findings in some difficult-to-determine-but-defintiely-significant proportion of the healthy community-dwelling older population — perhaps as much as 50% of the over 75s. So it clearly is foolhardy and just plain wrong to ascribe acute changes (confusion, sepsis) to what may well be normal findings in any given patient. I think the main point we need to keep in mind is that only after a thorough (exhaustive) search elsewhere can you attribute the infective symptoms to the urinary WBCs, or the mild confusion to the bacteria in the urine. You still need to do the CXR to find the pneumonia which is presenting atypically — or the CT head to turn up the atraumatic SDH. But once you’ve done the complete workup and found no other causes — then it certainly is true that SOME confusion and SOME sepsis is caused by urinary infection — more a diagnosis of exclusion.
What about trial of antibiotics. We often get called in the ER from the nursing home with a pt with a pos U/A, change in behaviour,normal vital signs hx of UTI and no other clear organic source for change. I have always consider it reasonable to try antibiotics and monitor the pt – transferring them in the morning if not improved
Sounds like a reasonable approach. Would your approach be different if you were able to confirm that last week, last month, the patient also had a pos U/A? “Watch and wait” is probably a reasonable approach — bearing in mind that life-threatening conditions (ACS, subdural, pneumonia) could also account for the change in behaviour and normal vital signs!
But not everyone( from LTC) sent to ER would get head CT to rule out subdural. Often if chest x ray is clear, labs normal, it seems that positive urine often warrants iv Abx.
any and all definitions work I find the acronim
Dementia
Ethanol
Metabolic
Endocrine
Neoplastic
Trauma
Infection, inflammatory
Alcohol, drugs
Social
a very helpful one
I’ve never seen this acronym but I think it will be useful. Thanks!