Assessing the Cause of Delirium
A reasonable diagnostic work-up to investigate the cause of a delirium would include:
- CBC, lytes, urea, creatinine, glucose
- Ca, Mg, PO4
- LFTs, TSH
- Cardiac biomarkers
- Chest x ray
- Urinalysis
- ECG
- CT head if history of trauma, OR if substantially impaired consciousness OR if new focal neurologic findings OR if history is incomplete OR if there is no CLEAR alternative cause.
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Important Note
Failure to find a cause does not mean that delirium is not present, but that the cause has not yet been determined.
Limits in the ED
The cause of a geriatric delirium cannot always be identified in the ED. On occasion, even after a thorough work-up in the ED, it may be necessary to admit the patient to the hospital with the diagnosis “Delirium Not Yet Diagnosed” It is rarely if ever safe to discharge a patient home with an acute mental status change without establishing a cause.
Discussion: Assessing the Cause of Delirium
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UTI, subdural hemorrhage, hypo/hyperglycemia
Certainly simple things like urinary retention esp. in men get overlooked. Also physicians still have reluctance to ask re use of illicit substances in older patients. They forget Etoh and illicit drugs have been around for many years- don’t assume.If you don’t ask you can miss a potentially fatal and treatable cause. Other misses are often due to having a busy department and anchoring on a diagmosis.
medication, withdrawals, electrolytes abnormalities
Electrolyte disturbance, medications.
depression, hypothyroid, infection, elder abuse
lyme disease
Lately it has been COVID-19 again
fall, medication change, dehydratation
Falls, infection
Urinary retention/constipation
decubitus ulcer, tox, and falls
ok
informative discussion
medications
tox, medication side effect, h/o fall
focused on the emergent symptom
Mental health issues, depression, suicidal thoughts or behaviors,
Depression, Seasonal affective disorder, Pain meds, SDH…
good
Withdrawal/med changes
Yes, medication changes.
60 y/o M with hx of multiple visits for chronic alcohol abuse, presented with ataxia and AMS, turned out he now had Wernicke’s encephalopathy
deficiencies
Incomplete med history. Med interactions can also be one too
agree
Agree
the idea that meds, even in a steady state may be causing problems if there is some other insult to homeostasis – like mild dehydration leading to a cascade effect of med interactions and probs, since most of my patients are on 10-40 medications together – – im sure there are WAY more med probs than i give them credit for (even though every time the med list pops up im like “how do they have any room in their stomach for anything else? and also “who on earth is preSCRIBing all these !!??”
Agree!
Incomplete med history
History of fall not always there to justify CT but if no other causes, or no response, CT should be done
etoh
Polifarmacia, estado hidratación, estado de ánimo
Polifarmacia causas endocrinas deshidratación
intoxication
inadeherant to medications
dehydration
polypharmacy, being rushed and not having time to pay attention to the patient holistically
polypharmacy
Agreed, medications are a big one missed
agree
polypharmacy
Agree, this is the one that we miss the most in the ED
I see that very often we miss on chacking for changes in the patient like weight or dehydration that can change their metabolism and therefore change pharmacocynetics
sepsis , poly pharmacy
I agree
Moving too fast, working to get people in and out. failure to listen to what has not been said. Another scenario I family member not giving accurate account or not being involved in pt care.
unintentional apap or asa toxicity
Agree with the above
Hematoma subdural subagudos por mala historia clínica
Dejarnos llevar por lesiones en piel o itus y dejar de lado bacteremias u otras causas
prolonged substance use disorder, typically alcoholism
polypharmacy
Agree, often overlooked
uti
medication overdose
Cam assessment
urinary retention
Constipation, sudden cessation of TCA.
medication withdrawal
polypharmacy
CAM assessment, MMSE, MH history, suicidal risk, recent falls.
CAM assessment, MMSE, MH history, suicidal risk.
Lack of resources in ED, inability to take collateral history, night shift , lots of barriers to make a diagnosis of Delirium in ED
agreed, we are often rushed to rule out and determine safe enough discharges without finding a root cause
subacute subdural
urinary tract infections
Interesting.
Medication overdose.
sepsis. normal all other bloods other than a positive blood culture
No noteworthy misses yet as I am still a resident, but great to read some of these, I will keep them in mind!
Accidental ingestion of medical marijuana
meds
Most common missed causes of delirium in ED could be, medication over dose or withdrawal, early pneumonia, depression.
medication error
One saw case that was hypoxia due to severe anemia
pain, constipation, urinary retention
Constipation
meds, trauma remote
N/A
an interesting one I saw was baclofen withdrawal
A UTI causing delirium in an elderly female.
Some commonly missed causes of delirium are medications. Elderly individuals with multiple co morbidities tend to be on many different medications, making it difficult to pinpoint a specific cause when all other etiologies have been ruled out.
Acute coronary syndrome, hyponatraemia, congestive cardiac failure, stroke
Heart failure; sensory deficits; medication adverse effects or prescribing cascade issues; sleep deprivation
Yes
Poniant and timely. Will definitely incorporate I’m my scope of practice
infection
very good, no comment
very good
ACS, polypharmacy
OTC toxicity
Seratonin syndrome
Patients who lost weight dramatically and then developed lithium toxicity/delirium, patients who had a bought of gastro and became delirious due to electrolyte abnormalitlies, hidden intracranial bleeds, presented as weak and dizzy after starting a new med – found to have a new intracranial tumor. Infected pressure ulcers on buttocks/in vulva were not uncommon.
occult ACS, Subdural hematoma
I think we miss a lot of medication interactions/toxicities/side effects. I have had several cases where the meds we were using to treat delirium actually exacerbated the situation. A consult from geriatric specialists and pharmacists proved useful in identifying such issues and they were able to offer alternative options
superimposed depression of not aware of same
polypharmacy
Poly pharmacy, recent loss, change in environment
urinary tract infections
polypharmacy, urinary tract infections
polypharmacy
Urinary retention and constipation.
polypharmacy, UTI
polypharmacy and urinary retention. simple but often overlooked when imaging en labs are normal.
Too many meds and meds not being adjusted for wt changes. Everyone just keeps adding to the list.
Polypharmacy is big. Everyone just keeps adding to the list.
I have seen a lot of undiagnosed bleeds, likely from unwitnessed falls
medication changes/environmental changes can be a cause a well.
drugs
Med rec is so important contributing meds, mistaking meds
look for untreated pain, constipation, urinary retention
Recreational drugs; Older people can still do drugs or occasionally accidentally ingest them. I had a grandma who ate her grandkid’s pot brownies.
One time I was able to determine folate deficiency as contributory.
incarcerated hernia
patient came in with fall but apparently had UTI and had focus in ruling out fracture on top of delirium
Medication withdrawal (bzd).
Lack of medication compliance
adherence to POC
medication withdrawal, a missed injury from a previous fall
MI
polypharmacy
high pressure hydrocephalus
patients starting or stopping meds at home
hard to go through huge differential for dementia
acs
OTC overdose with language barrier. AMS with undiagnosed head injury days after fall with no signs of trauma.
new medication
stroke
stroke, ICH
Improper assessments, rushing assessments, alternative presentations
polypharmacy
The ER is about as delirium provoking an environment as one could design. It also comes with myriad pressures and distractions to remove provider attention from the patient. We have no prior context or baseline, so subtle changes can be missed. Family is not always present to help inform our history. Atypical presentations are also common. I have an 82 year old woman who’s only complaint was ‘tired’ and she had STEMI with massive tombstones on her EKG.
Misuse of medications, infection
Ok
compliance to medications
unsure
unsure
ok
ok
ok
ok
Pain, urinary retention
medications
nothing
Inadequate pain management
occult trauma
too rushed to street a pt
a
medication compliance- difficult to obtain especially if the patient lives alone.
Delirium can most certainly go misdiagnosed if not properly screened for.
Dementia can certainly mask delirium and can go untreated until symptoms of the cause escalate like a uti
non compliance or mismanagement of medications, Etoh/ Etoh withdrawal, urinary retention
acute urinary retentions, fecal impaction
UTI alcohol withdrwal
infections
Polypharmacy
Good
ETOH induced delirium
sensory impairments
unable to self manage medications
Compliance with meds, sometimes difficult to determine.
.
none
medications either changes, missed or double doses
ep
ok
Head trauma
medication mis management: patients getting similar meds by two different providers, then taking them outside of the prescribed parameters.
inaccurate medication list and or inaccurate medical history
agreed
El retiro abrupto de dispositivos como audífonos, prótesis dentales o anteojos que le permiten mantener sus funciones básicas.
Inaccurate medication history, not taking a thorough social history or involving family
doing a detailed exam, taking time to as questions
Missed causes of delirium:
Failure of the MD to recognize delirium early
Insufficient time spent with the patient in the ED
No collateral information for a relative
No enough and effort spent on the Elderly
Delirium assessment tools such as CAM not employed for quick assessment
Lack of identification of causation and investigative procedures
Patient is in unfamiliar noisy fast paced surroundings
Agree
MI
Meds (incorrectly taken, new, withdrawal) , cellulitis, HSV encephalitis etc
Subdural Hemorrhage
NMDA encephalitits
Wound infection and hematoma
Moving too fast, failure to get detailed history from patient and family.
moving too fast is always one that gets people.
Moving too fast, working to get people in and out. failure to listen to what has not been said. Another scenario I family member not giving accurate account or not being involved in pt care.
Not asking the right questions. Fast paced, not taking the time.
A thorough assessment. Failure to listen to primary care givers.
Missed Hemorrhagic stroke as alcohol withdrawal.
Writing narcotic and muscle relaxers to someone who is over 80 years old.
Almost missed a hemorrhagic stroke that was brought in by EMS as “alcohol intoxication”
CVA with no other findings
falls
acs
Falls, dehydration
dehydration, multiple falls, depression
dehydration and vomiting
Addition of OTC medications, particularly anti histamines. Thyroid abnormalities. Occult use of sedative hypnotics or alcohol. Marijuana use.
Falls and medication
infection, virus, post-fall r/t complications, depression
Hyponatremia, urosepsis, Fournier’s gangrene…
you can overlook signs if you do not do a thorough assessment.
need more pt. hx
Spending time reviewing medications to decrease medication cause delirium should be on the priority list of assessments
yes. thorough assessments involving pt hx, medications, falls assessment
Patients can sometimes look “normal” to our assessment, but if you talk to them for more than a few minutes, you realize that their story doesn’t quite make sense. Or their family contradicts what they say.
In my experience, missed causes of delirium are often chalked up to a history of dementia or lack of family member or caregiver to establish baseline and timeframe. Often with no appropriate historian, it is difficult to even obtain an accurate medication list or know if the patient takes any OTC meds.
Med interactions, etoh, vitamin deficiencies
change in weight which impacts medications effect
as patients age they continue on dosages of medications that they may have been on for years;howver, as they age their body fat percentage may change increasing the active levels of mediations. In addition, metabolism slows effectivey increasing the dosage of medications that they are on.
Hypoactive delirium misdiagnosed as depression.
That’s correct as most people assume delirium is hyperactive
Medication overdose and ETOH
DEPRESSion
uti, chronicsubdural
severe hypothyroidism
hyperparathyroidism, hypercalcemia
Posterior circulation stroke, infective endocarditis with cerebral embolization, active B12 deficiency secondary to Nang use.
agreed
medication interactions or side effects, acute depression, subdural hematoma
yea agreed. Also over looking minor stuff when there is a lack of assessment.
b12!
sepsis , lacking assessment to capture details of changes pt exhibiting
UTI in nursing homes
absolutely
UTI, chronic sub dural
urinary tract infections, trauma, bleeding, medications, sleep disturbance, we need check the stop start criteria
great question
Polypharmacy, Constipation, Withdrawel
Chronic subdural hematoma especially in chronic alcoholics, personal experience, drugs, sepsis for which an etiology is not found.
UTI probably most common but have been surprised by chronic subdurals
UTI
Under staffed LTC facilities with overworked caregiver tends to lead to poor history intake. Results sometimes leading to misdiagnosed “worsening dementia” when labs and scans return normal.
medications interaction, UTI, and head injury
.
.
Sepsis
.
ETOH
great info
Cellulitis from bed sores
Patient presented with delirium – identified UTI and HHS, but also discovered a previously unidentified systolic murmur radiating to the neck. May have been contributing as well in some ways.
.
polypharm
.
yes
I concur
Polypharmacy.
Minimal experience with same but EtOH withdrawal, ACS
.
UTI, medications
Polypharmacy. Way to many doctors prescribing medications. Patients being prescribed medications and not being told when to take them and taking all of them at the same time so they get dizzy and fall.
.
hypoactive delirium, polypharmacy
polypharmacy
Polypharm
Lack of sleep or change in sleep patterns or recent medication changes are probably what I see overlooked most often, and these are the first two things I ask about.
Hypoglycemia
stroke
dehydration, malnutrition, change in or addition of new medication
SDH
Spontaneous SDH on patient on warfarin.
Dehydration, altered renal Fx leading to reduced drug metabolism,
missed or changed drug doses
incident of polypharm
meds, uti, pneumonia
polypharm
medication; toxic doses 2nd to dehydration or withdrawal (acute change in dosing)
UTI, electrolyte abnormalities.
agree
med error
Psychosis, alocohol intoxication and sepsis
ok
Medications. ACS.
cns pathology or medications
yes, meningitis due to fungi has been something I’ve seen before
Cardiac causes.
medications
In my limited experience, I think the easiest to miss is polypharmacy. We go looking for a pathology when often patients are on medications that could be deprescribed.
I agreee with the polypharmacy cause. We recently had one that was recently prescribed oxybutynin and it caused inucrease in confusion.
Working EMS and Er you see a lot of the older patients with medication problems, and the big one UTI’s.
WE work to fast.
Medication, electrolyte imbalance, infection
unrecognized changes in baseline condition
I think that a lot of times in our department, its either a withdrawl or medication that we miss as a cause of delirium
infections and change to an unfamiliar enviroment
sespis is socommon in delirium
constipation, urinary retention are often overlooked
patients with sepsis of unknown origin typically presents with delirium
sepsis often has altered LOC compnent
Soft tissue infections (missed decubiti)can cause sepsis and delirium.
good
Covering up the actual baseline or changes by the family members.
In my case I ahave observed that infections alone or usually associated with fluid and electrolyte imbalance are in between the most common causes of overlooked delirium in medical settings
ok
Medication, stress, dehydration
Medications, falls/trauma, head bleeds
medications is a big one
In your experience what are some of the “missed causes” of delirium that you have seen? Participate in the discussion by posting your answers below
I have seen several infections that have led to acute delerium. In my experience this is by far the most common cause I have run into.
Stress
Abuse ( DV, emotional, sexual, physical)
Also a lot of Work cover issue – bulling at work
Also allergies
Polypharmacy is a common cause of delirium but easily overlooked – new OTC or prescribed medications, also acute coronary syndrome and thyroid disease are often missed as well due to vague, nonspecific complaints. Most will not miss electrolyte abnormalities, PNA, or UTI.
I agree.
Very well done
lack of time
yes
Subtle or hidden skin issues such as a wound between the toes or under the breast.
underlying diseases and disorders, overwhelmed or not enough staff
.
Not enough time
Lack of time, overwhelmed ER, burned out staff can all be contributing factors to missing this.
failure to listen to family and patient
Gangrenous gallbladder; STEMI
cellulitis/septic joints
facts
I find often if the infection is found the delirium is resolved; however, often delirium is not investigated further if there is no known or identified infection. I had a patient’s wife stop her husband’s medications because his blood pressure was normal (not realizing it was normalized by the medications. The result was a delirium. Pharmacy review helped.
Levaquin
b12 deficiency
elevated ammonium
UTI and vitamin B deficiency
Stroke without focal deficits seen only on MRI
Subdural Hematoma, polypharmacy where medicines interacting with each other and potentiating the effect, and off all the things drug abuse which is a real problem also.
ACS
Stroke without focal deficits seen only on MRI
Definately! I have had a few patients that presented with weakness and confusion that end up with elevated cardaic markers.
uti missed too often
depression
Seperation of loved once
Siginicnat change surrouding social life
I think Sepsis, and dementia.
Sepsis, depression, CO poisoning
I attributed delirium to institution of a new medication (steroid), but the patient bounced back and was diagnosed with a viral meningitis.
hepatic encephalopathy, hypercarbia
UTI, baseline assessment, dehyration. pts in long term care facility that behavior changed but no work up
En mí entorno lo más frecuentes la uti y los trastornos electrolíticos,una paciente de 76 años con síntomas depresivos y deterioro cognitivo producto de una colelitiasis y muy buena tolerancia al dolor
UTI, normal initial workup, severe dementia with superimposed delirium
Hypercalcemia, infection and dehydration
meds, dehydration
Dehydration, UTI
Meds, change in patient’s environment, change in caregivers.
Medication
Meds, infection
polypharmacy
medications/polypharmacy
We constantly get patient’s with “AMS” as a complaint, more so from Nursing Homes Or ECF’s, I don’t think they understand delirium vs baseline dementia, often times we end up admitting these patients and they decline even more while in the hospital
heat stroke in summer
spouse absenteism (sudden loss of caretaker)
Herbal use
limitations of delirium
antibiotics
Cases where delirium is not the main presenting cognitive issue. Though cognition may play a role. Delirium can be masked by other mental health disorder specialists.
A man on palliative care unit with overdose on morphine began to experience delirium. Poor hydration and output along with overuse of pain meds
really good module
subacute SDH…diagnosis was missed due to no clear h/o falls reported, plus no focal neuro changes (which is usually the case with subacute/chronic SDH).
Medications, UTI
Agreed
Pain, pressure sores
multiple comorbids, medications, underlying factors, SDH
UTI’s, medication’s, undiagnosed mental illness
Medications, UTI
The underlying symptom can be masking the delirium
polypharmacy
I almost sent a pt home with a major head bleed, and very minor but present AMS, also dx with Pneumonia, CT of head is important even without obvious trauma
Agreed! This should always be looked at
Medications and UTI
medications and UTI
UTI and medication changes
I have see UTI and infections as common reasons
Question for Discussion: In your experience what are some of the “missed causes” of delirium that you have seen?
dehydration, electrolytes, when a pt is frequently seen due to high utilization the recurrent visits are not screened due to preconceptions. Dizziness weakness are vague and have seen missed dx many times with that. pharmacy causes are common due to poly pharmacy or inaccurate reporting of current med list.
I have not been practicing long enough yet to have seen many missed causes of delirium. I would say the most common I’ve seen overlooked is medications.
usually medication but also unaddressed pain or constipation/bowel/bladder concerns
also change in environment in the recent past
old timer was super confused, after the million dollar workup he had salicylates and had attempted suicide by ASA
very thorough
ACS
discomfort and unaddressed pain
when people administer medications without knowing the purpose, many may not be aware that they are inf act working with patient’s with such diagnosis
medications.
Asymptomatic UTI
extreme heat
Polypharmacy – not thoroughly assessed
medications
over prescription of antipsychotics
ok
Polypharmacy and UTI’s that are otherwise asymptomatic
Dehydration,hyponatraemia,Assymptomatic UTI, unwitnessed fall
hyponatremia, MI, fournier’s gangrene
seen TIAs/CVA, medications, hypoxia, UTIs, ACS, substance abuse.
also seen low bs, pt acute aggressive behaviour, altered LOC/ or LOA.
Infections, medication interactions
confusion about medications and noncompliance but defiant that they can manage them their selves
otc meds
alcohol withdrawal due to decreased access b/c of a medical issue
MS pt who couldn’t communicate well..family rarely saw them & were no help. NH staff came by & adv of “normal status” to ICU staff.
withdrawal in pts who severely underreport their ETOH/other drug use
medications, subtle or missed skin infections (e.g. dependent areas, groin)
UTIs and medications
UTIs
Medications
medication
uti
yep
common medications in the ED especially gravol or tramadol
not really knowing what a baseline makes it tough to identify temporary confusion
medications and withdrawl
medication, even medication error-had a pt from nursing home who got another resident’s medication
med error
great
UTI is very common and not always assessed – have seen this missed.
Sick sinus syndrome with pauses of up to 12 seconds, where UTI was incorrectly diagnosed because ER collected it in a bedpan from a female patient. Urines aren’t always collected with proper technique in community hospitals.
Pain, in a patient who could not verbally communicate.
A gastric perforation in a patient not complaining about pain and trying to resist medical care. Withdrawal is another ddx that can be overlooked.
Medications
Medications or dehydration
Acs
Antihistamine induced delirium
medication withdrawal is not often thought about
Withdrawal from alcohol or benzodiazepines. Undiagnosed heart failure.
Also stroke.
drug abuse, UTI, infection
infection, CNS pathology,
TIA, urosepsis
death of caregiver spouse; new environment; urinary retention; occult MI
Electrolyte, UTI, and accedental withdrawal. With drugs the focus is most often placed on overdose. The W in I WATCH DEATH struck me!
Urinary retention, fecaloma
Urinary retention is a great one, so tough to spot! Another I saw was abd perforation, on chronic steroids which masked tenderness
Incomplete medication history frequently the cause either medications not being taken or OTC medications like Tylenol PM being taken but not mentioned
herbal supplements, THC, substance use
narcotics, long stays in the hospital, getting hospital infectious diseases like c-Diff
Medication toxicity of patient’s long standing medications that are above therapeutic levels due to recent weight loss, dehydration and/or decreased kidney function seen in the geriatric population that causes the medication clearance to be less than for a younger patient or one with better kidney function.
hearing aid batteries dead.
Usually attributed to old age.
A patient that recently had a stroke, but her children were concerned that when she talked her answers didn’t make sense so she was tested for infection.
agtree
Pt taking Levoquin for a PNA in acute delirium. Took days to realize it was the med
an older client post stroke rehab, with new baseline with speech difficulty/ apraxia ; now with new diagnosis OSA – difficult to know if A+Ox3 and CAM ass’t as nearest kin away and writer returning to work after a few weeks absence – so difficult to obtain baseline; in the end appeared to have had altered LOC d/t lack of O2 at night and not delirium, was difficult to figure out, discussion with colleagues re:baseline and timeline trends.
helpful video
helpful
.
Medications
medications are most likely to be messed, especially given the frequency with which patient’s transfer between health systems, and do not carry medication lists
interesting
Medication issues seem to be the most frequently missed, maybe because it requires careful history rather than testing.
infection
Missed causes are from being too focused on the physical issues
postoperative delirium, unresolved
great section
often medication change, or in one case I had experience it was due to blood work and dialysis – so affect of kidney, blood and toxins
medication
infection
I have seen many elderly be miss diagnosed with delirium caused by a UTI simply because a doctor is blaming their symptoms on a diagnosis of dementia and not doing a complete work up
This is sad
Medication change/ unintentional missed doses. Very important to check MAR from nursing homes.
Medication change missed doses. Very important to check MAR from nursing homes.
helpful1
1
helpful
infections
medications and infections
also by disregarding acute problems and saying it’s part of dementia
infections especially utis
Previous history, medications
Not knowing all the medications, prescribed and non-prescribed, taken by the patients at home.
Infections and medication
not knowing all of the medications a pt is on.
Mediation, past experiences
Medication. Anticholinergics, norcotics, benzos.
Infections. Electrolytes abnormalities.
New onset heart failure with low perfusion.
and many more.
Often missed: adrenal insufficiency.
the client being triggered by past experience.
medication
Medications
Medications, infections
great answer! infections, especially UTIs, can cause confusion which can be misdiagnosed as delirium.
Medications
Pain not beurre recognized
Discomfort of any sort
I remember a woman, 80 yo or so, a new patient at Baycrest at the old home for the aged (full care wing) who was admitted from being previously taken care of by a hired Caregiver, a non-professional, at home. She was “getting progressively demented” to the point of incontinence and practically no verbal response. Within a week in the Nursing Home, she was getting better and better, communicating to the point of being totally lucid. Eventually she complained of hip pain and was asking for “her” pain killers. It was recognized that her previous home care giver was giving her her own Tylenol 3 for “pain”, because “no one was listening to the old lady and no one gave her any pain Meds”. So she was just terribly overdosed on codeine
Medications & infection
Infected pressure ulcer
UTI
alread answerwed
Reply
DonM May 7, 2013
I think it’s not uncommon for cellulitis to go unnoticed both by a patient and by caregivers — I have occasionally pulled back the sheets to discover a huge swollen leg or buttock which is clearly the infectious cause of the confusion.
Reply
bharatbahl April 15, 2013
A woman admitted on the psychiatry floor with depression kept talking about her marriage breaking up 4 months ago. After talking to family we realized it was 2 years ago. Turns out she had a massive intracranial tumour compressing her hippocampus! And was alt
medications – without best possible medication history or collateral information
true
subdural hematomas medication
Drugs
nice
yes
UTI
medications, missed falls, infections
stroke with normal neurologic exam
Meds, UTI
Missed cause of hypoactive delirium – both UTI and pneumonia present without much symptoms other than decreased LOC and PO intake. Pt denied feeling unwell, had no cough, no dysuria. This was superimposed with known dementia which made dx harder.
Often it’s the failure to have an accurate medication list and complete med rec. Despite the promise of the EHR, this is an area that it often falls short in.
Medication ; fecalome
MANY FACTORS.
medications, multifactorial
medications, infections, unknown trauma like falls, and incomplete assessment
Medication
Constipation
Urinary retention or infection
Hepatic encephalopathy – did not check ammonia levels, was thought to be intoxicated
Missed causes: Infections in unlikely places. I once took over a patient who was being evaluated by cardiology for a fast atrial fibrillation and he became confused and agitated while awaiting a bed. Turns out he was septic from a large soft tissue infection by his groin and anterior thigh.
Another missed one might be medications. In my country, I have found that there are many elderly patients on benzodiazepines and TCAs as sleeping aids.
too often we rush to get pt out of the ER, we don’t pay attention to the ones who need to be there.
medications changes, acute cholecystitis in a old male with mildly elevated white cells and ‘just not feeling right’
great discussion
Infection, Chronic SDH, Medicatiob
UTI, medications, intracerebral bleed.
elderly patients with dementia who have what appears to be an innocuos uti o rcommunity acquired pneumonia and their altered mental status is labeled as dementia prgression vs delirium
I am not sure how many missed cases I have seen as I am still a resident. A lot of times I see staff playing down mental status changes and they don’t look to obtain collateral history to determine if it is an acute and fluctuating course consistent with delirium. I have seen one chronic subdural hematoma that presented as delirium.
space occupying lesion
subdural hematoma
NSAIDS
Its very important to rule out all other contributing factors before referring pt to psych facility
UTI
missed cause of acute delirium in a case of hypothyroid
Urinary tract infection, dehydration, constipation, opioids, alcohol withdrawal
dehydration
medication, fall
Soft tissue infection especially early cellulitis on lower limb with venous insufficiency, drugs- prescribed, OTC and alternative, myocardial ischaemia
Stroke. Sometimes all the patient has is delirium with no focal neurological signs.
OTC meds, poor sleep (environmental factors), ACS, cellulitis, NPH
Unintentional overdose
Taking partner’s pain meds
Infected decubitus ulcers.
ACS.
unwitnessed fall
Acute weight loss leading to medication-induced delirium
usually a UTI, but meds often overlooked.
ACS, soft tissue infections
Polypharmacy and nutritional deficiencies.
polypharmacy
alcohol withdrawal
medication changes
polypharmacy
gabapentin toxicity second to dehydration
NPH
benzo/ alcohol withdrawal when history not initially not apparent
Missed causes of delirium that I have encountered so far: medication changes, loss of hearing aids/glasses, cellulitis, dehydration.
neuroinfections
Soft tissue infection
medications and withdrawal syndormes
medications
ACS and Meds are commonly missed causes.
As a nurse in a very small hospital we often have to wait for the more invasive procedures. Things take a while to gather but it all gets done.
I have observed patients with delayed diagnosis due to subdural haematoma, myocardial infarction (no pain but presentation of weakness and “not right”) and commonly small pneumonias or evolving soft tissue infections
New onset UTI, patient already with dementia seen as having a “bad day”, polypharmacy or new analgesic medication
people often miss the multifactorial causes and put the delirium down to leucocytes in the urine without a proven UTI. Other missed causes, post ictal state, septic arthritis,
Polypharmacy and changes to medications are frequently not considered as causes for change in mental status in the elderly.
Polypharmacy. Medication reconciliation is very important!!!!
Patient’s with previous dementia or psychiatric history (esp schizophrenia) who have no family, friends, or caregivers to provide input and provide very little themselves. Hepatic encephalopathy in a patient who has normal to low LFTs.
medication error
cellulitis
Loss of spousal support system and subsequent dehydration and medication non-compliance
New place
Breaking of routine
Constipation
Urinary retention
Alcohol withdrawal
ACS
Missed Medications
new environment, falls
medication, liver failure with ascites, infections ( without fever)
Infections (UTI)
CNS (chronic subdural)
Electrolyte abnormality (hyponatremia)
I find urinary retention and skin infections are often overlooked. Many will quickly scan the arms and legs, but missed areas are the coccyx, gluteal folds, between toes.
I think polypharmacy is often an overlooked potential cause of delirium in ED, and as others have said ICH/masses that are missed because there may not be a clinical indication to do one depending on the presentation.
CT sometimes my best friend
UTI
medication
Dementia in family members and caregivers are very difficult to deal with but you always have to make sure its not anything else before diagnosing them with dementia, ex tumor, brain bleed, infection etc.
Some of the “missed causes” of delirium seen in my practice are: deficiencies (e.g. vitamins), endocrinopathies (e.g. hypo/hyper-cortisol) and heavy metals. It can be quite taxing to to ask questions about specific causes of delirium, but you may miss some important causes if you’re not being thorough.
skin infections
I do health assessment in the community and a pt came who had been treated x 1 mth for ungoing in and ot of ER for chest infections and 3 ED visits in just over 1 wk. Pt was on steroids and antibiotics. when she identified she was insulin dependent diabetic and couldn’t recite her daily insulin doses it identified inappropriate cognitive changes. Bld sugars where extremely elevated and then looking at her averages on the glucometer you could see the decline in regularity of her BS monitoring. Pt didn’t want to go back to Er because they weere not helping. Once I identified and assured her it wasn’t just pnuemonia but her diabetes that would be addressed she agreed to return to the ED.
Electrolyte abnormalites very commonly cause delirium
Medications, CNS
– CNS: subacute, chronic subdural bleeding
– Infections: Skin and ST infections
– Medication: interaction of medications and medication side effects
My mother died from an undiagnosed delirium 3 hours post op possibly from hypoxia because the recovery nurse did not recognize her confusion was acute. She kept charting pt confused – has dementia. No family member was brought to Recovery or asked about prior mental status. The am floor nurse charted pt A +O x3, smiling and said goodbye to nurses upon leaving floor to OR, but recovery room staff did not read those notes, as well. My mother also was allergic to some anaesthetics which was clearly noted on chart.
Lesson here: DON’T ASSUME THE DEMENTIA IS CAUSE FOR THE CONFUSION.
Another overlooked cause of delirium is CONSTIPATION!!! My father also had vascular dementia but everytime he asked to be put on toilet for BM nurses said it was in his head. They kept giving him enemas. He was impacted high up in rectum. I disempacted him for huge amounts of soft stool that he could not push out himself. Very painful for him. Delirium subsided shortly thereafter.
OTC medications or herbal remedies
Occult infection or Ca
Severe constipation
medication induced can be missed. sub dural haematomas when no fall on hx. change of environment situation at home.
Skin infections, sub dural hematomas, polypharmacy,overdose/toxins
falls
medications – while easy to review i think we probably don’t consider this often enough as a cause for delirium. Especially those people who aren’t on any classically implicated medications.
Most often missed is atypical presentations of infection and infarction, because these do not present in the same was as their 40 year old counterparts. They also do not always have the skill to describe non-specific symptoms.
Frequently missed cases of elder abuse and neglect.
Missed subdural hematoma, brain malignancy, missed/concealed trauma due to spousal abuse are cases I have encountered
TBI, CHF, and elimination issues such as urinary retention and constipation
subdural
Some of the common missed out causes of delirium are drug interactions, medication errors, constipation, urinary retention and recent change in medications.
constipation, cellulitis causing low grade fever
Infected bed sores esp. of lower back & perineal region & lower legs, CNS pathologies esp. on younger pts
I have seen many patients incorrectly diagnosed as having a UTI as their source of delerium or a lack of cns investigations in a fall, or lack of appreciation for drug interactions as a source of delirium as well as the under appreciation of the use of alcohol in the geriatric population
I often saw delirium after cardiac surgery, especially after prolonged anesthesia & heart-lung bypass machine
polypharmacy
ASA toxicity
Medications, infections (UTI’s), OTC’s, changes in environment.
Urinary retention is the one I find is often missed. And so embarrassing when it is diagnosed by the radiologist.
Also so important to make sure patient is properly undressed and look at all the skin. I have found medication patches that did not belong there!!
Constipation.
medication
UTI, dehydration, CVA
Medication, dehydration, infection, pain
medication
Elderly dementia patient with metastatic lung cancer admitted for pain management and palliative care. Became progressively more agitated, often hallucinating, with aggression and insomnia. Symptoms resolved and returned to baseline after his fentanyl patch dosing was reduced.
Medication
Medications
Medications ! either side effect or interaction including withdrawal.
ACS is another commonly missed causes
Occult ACS, medications. The latter frequently because the patient can’t recall her/his meds
polypharmacy
infection
dehydration
Pressure ulcers are often missed as a source for infection causing delirium
As a surgical nurse we often see post op delirium but cannot always determine the cause as it could be so many reasons and it usually sorts itself out in a couple of days. Main goal is patient safety and constant re-evaluations. The usual blood work is assessed but sometimes it is a full bladder causing the problem or a urinary tract infection not realized. It can also be from narcotics. Often a pre-existing mild dementia is missed until it evolves into a delirium.
medication changes is often missed
Great discussion. I unfortunately am guilty of “failure to cope” diagnosis. This segment has been great
Recent medication changes, especially when the pt or family does not really know what medications they are on, or if they accidentally took an extra dose or forgot one.
Patients on regular Metoclopramide who develop akathesia but present as agitation.
Cardiac cause
male in his forties admitted with an abdominal stab wound. Within hours became delirious- first started as making inappropriate comments but then would be back to normal within seconds, then progressed to VH, giving answers that did not make sense, became suspicious and would some times lash out at staff. Focus was on the trauma. Along the line( as in very acutely,in less than 1 day) developed high fevers, sweating, excessive salivation + developed airway compromise. We were begininning to wonder if the weapon he was stabbed with was laced with some form of poison. Lesson learnt- think very broadly, any change from baseline should be a flag for delirium and maybe a pointer to a diagnosis that may have otherwise been missed.
Unfortunately, I have seen pts with delirium misdiagnosed as a “dementia nyd”. Other missed cases: significantly abcessed tooth causing pain and infection, B12 deficiency, medications interactions and inappropriate medication administration, alcohol and benzo withdrawl
“Failure to cope” to frequently assigned without proper investigation
multiple mini brain infarcts on CT
infections mainly but also hyponatraemia, SDH
Lack of knowledge on how to asses and what the causes could be.
lack of awareness of delirium ,
Mental Health – A homeless man brought to the ER by police in the winter time because they did not know what else to do with him. After 5 days of being monitored in ER he developed sepsis.
miss leading assessment from traige or new dx, changes thought process and can miss delirium
This is an interesting one! We can accidentally tunnel vision our care/diagnostics and miss what could have been a classic/easily identified case of delirium/other mental health issue.
Medications
Tunnel vision, thinking it is one specific issue, rather than exploring all options
infection
Lack of awareness of delirium, thinking there was something else.
Hypercalcemia in elderly patient with CRF. ( Moans, Groans, Boans and Stones )
Infections – UTI specifically
medication, infections
infection
Medication overdose, withdrawal, interaction, chronic subdural hematoma
Missed cases due to medication interactions/assuming it was medication induced
TSH. I was told by a staff as a resident that this test was a waste of time in the emerg. NOT. Hypothyroid found.
medication
infection
tunnel vision of chronic conditions and not investigating possible other causes ie UTI
Assumptions by the attending physician that their patient’s condition is the most evident one, uni-factorial.
Urinary track infection are so common in the elderly as a mistaken dx when D shows up
occult infection masked by drug OD
INFECTION
prior medical history and current medications
.
Narrow minded approach with care giver or practitioner goal. If care giver or practitioner can find a rational for cognitive change than they are content with the outcome.
Missed causes like chronic overdosing, then a sudden withdrawal presentation appears puzzling at first until factors such as no support network, lives alone, state of confusion are revealed. And by connecting these subtle changes you’re able to add to your differential Dx of dementia
.
–
easily language/cultural barriers. even those who know the patient well may have a cultural barrier to telling a health professional that they think their charge is acting strangely.
UTI, Dehydration
Medication overdose and alcohol withdrawal
UTI, pneumonia, CVA
cardiac, chest infection, lytes
UTI, dehydration, CVA
UTI in dementia patient
UTI in a dementia patient
Loss of family doctor resulting in non compliance with normal medications
drugs
drugs
the missed ones
bioaccumulation of medication, uti, hypoglycemia
etoh withdraw in an 86 year old who had fallen and been admitted for a broken hip.
hyponatremia
Failure to recognize hypoglycemia in an elderly patient with seeming confusion.
Acute, on chronic subdural hematomas
–
Infection, particularly UTIS
Polypharmacy.
Pain is a big one. Also polypharmacy. Normal pressure hydrocephalus and Wernicke’s once.
tumors , uti , drug interactions , environment , dehydration , pain . infection
Medication interactions/Dosage errors
Deciding when to do a CT can be difficult. I agree with the list of indications. I also think the threshold for doing one should be lower in patients on oral anticoagulants, as the history of trauma may not be forthcoming.
Polypharmacy is a big one. Lots of elderly people on lots of medications with high risks of adverse effects and drug/drug interactions.
change in environment
Missed dx of sepsis. Often UTI is the go to dx in LTC.
Polypharmacy and drug interactions
infection/sepsis, brain tumor, Subdural hematoma
rhabdomyolosis
acute spinal hematoma secondary to anticoagulants
pain!
Dehydration, Overdose, Infections (UTI)
Medications, uti and dehydration as causes missed
UTI, polypharmacy, dehydration
dehydration, medications
meds or substance withdrawal. need to have collateral information to have adequate hx to determine cause if not obvious on initial work up
Language barriers have been an issue when there is reliance on other members of the family to determine the History. Familys acceptance of the presentation of confusion as normal and the reluctance to convey the true events, somewhat as a method of characheter aslvation.
Sepsis
Many of the elderly patients at our institution often come from homes for the aged and often do not have adequate family support, as a result when they present to the ED they are often dehydrated, malnourished, may have been prone to falls without supervision, poly-pharmacy is often an issue. Alcohol and substance abuse is another issue.
medication interactions is the more important for me
we could think of infections Dehydration or malnutrition
Very frequently it associated to infectious porcesos or deibratacion
nice mnemonic
trauma, polypharmacy, strange environment, prolonged ED stay, metabolic abnormalities
Another important cause of delirium are the psychiatric disorders which often do not think and do not give it the importance that we should.
Delirium caused by constipation or hunger with out hypoglycemia
One common mistake I see is that physicians look for major/obvious health problems as the cause for delirium (infection, cardiac, etc), and fail to recognize that is may be something as simple as dehydration in the setting of a vulnerable brain.
Medication withdrawal
Interesting life ED experiences. Added a lot context to my understanding of delirium in ED. thnx
I see my friend, who is in a long term psychiatric facility get very confused every time he is moved from room to room. The care givers have not noticed the association between the room change and confusion, the change is considered to be part of his psychiatric diagnosis.
Had patient returned from hospital lately,who had been told he did not need a CT scan, who later had his subdural haematoma confirmed!
Environmental causes
ACS I think is missed often because patients don’t complain of chest pain or SOB. I have also seen polypharmacy missed or the addition of more medications to treat the symptoms of the delirium, which was due to a medication in the first place.
Withdrawal from medications (Effexor, benzo), OTC medications and exacerbation of chronic disease (CHF, COPD, angina)
Alcohol poisoning
Alcohol
Poisoning
constipation, altered sleeping or eating patterns, ACS
Pienso que la sepáis y las interacciones medicamentosas
medication
too many meds, uti’s , post op, etc
UTIs, Medication changes, Change in environment, Post surgical pain, changes in sleep pattern, constipation are all causes of delirium
medication withdrawal, endocrinopathies, electrolyte imbalances (especially calcium)
infection/medication interactions
polypharm
infection
xx
injury not seen if a head to toe wasn’t thoroughly performed
neuro / infection / various etiology
med interaction
med interactions, polypharm, infectious processes
Medication change/ unintentional missed doses. Very important to check MAR from nursing homes.
Ulcers – people never turn the patients over – cause of serious infection
subdural hematoma
benzo overdose
brain metastasis and medication overdose
Med errors, med interactions
Medication errors – sometimes when our drug profile is printed out, it only goes back 3 mos, but when you go back 6 months, you can see double dosing, patients fail to stop one med when starting a new one.
infected ulcers on LTC patients
when working as a resident in general internal medicine the cause turned out to be syphylis, same patient was discharged from another hospital with delirium nyd
Intentional medicine withdrawal without discussing with Family Dr or family is something we may miss,as we gathered information we took it by gratis that pt is taking this list but in one case we encountered this scenario in a delirium presentation.
alcohol and drug withdrawal
subdural hematoma
nicotine withdrawal
Incomplete med history
I always ask about ETOH intake and OTC Rx . I find many patients self medication with Gravol for sleep or using herbal/naturophathic substances which unless you ask they will not report as they don’t consider them medications.
anemia, GI bleed, aortic stenosis
medications side effects, non-convulsing sezuire, hypothyroidism
medication interactions
ACS, missed and then double dose parkinsons, mild depression ,
infected pressure ulcer to coccyx
Medication errors are by far the easiest to be missed. While the patient may bring in their medication list, it’s often really difficult to determine whether or not they’re being taken appropriately. Detailed histories about how medications are taken, who’s organizing them, are there any interactions, etc. are key. Pharmacists are excellent resources in this case.
pharmacy med error, caregiver med error, patient med error
patient has a diagnosis of “chronic anemia” so we don’t get concerned with HB in the 90’s had colonoscopy 6 months previously as an out patient. CT colonography picked up the missed CA of colon.
Urinary retention. Constipation. Bowel obstruction. Confused patients can’t tell you when they last voided or had a bowel movement and Nursing home charts and family members rarely know!
unreported OTC Rx
I missed a tylenol overdose in an elderly women a few months ago. She presented with confusion and was admitted for delirium NYD / acute on chronic renal failure. Now, I routinely order a ‘coma panel’ including ASA, Tylenol, Ethanol on all my delirium NYD patients in the emerg. The family came the next day to the hospital with an empty tylenol pill bottle that she had taken.
A lady discharged from our ED post fall, big postural B/P drop but no fracture and could walk. Paramedics home follow up revealed not eating, big weight loss, sleeping all day. She ended up back in ED- admitted and they found a brain tumor on CT the next day.
medication “lending” in retirement home where there we patients that needed LTC and there was no nursing staff.
ACS. Those elderly don’T have to present with chest pain
I have found a change in environment (transfer from acute care to rehab setting for e.g.)can cause delerium and takes a few days to settle, also undiagnosed pain, bladder/bowel retention and the like.
hypoxia (PE), overdose, encephalitis, thyrotoxicosis
And were they detected in the ED — or during subsequent admission. I find the trickiest patients to get admitted are then ones who “just aren’t right” but after a thorough assessment in the ED you can’t find the cause. Internists/hospital-based physicians sometimes are reluctant to admit them even though a cause often becomes more obvious over a short admission.
my most dramatic case was a frontal glioma that presented as failure to thrive
I remember a woman “just not herself” according to her family — couldn’t find anything after a thorough investigation including a CT head because they thought she might have fallen — days later once she started clearing a bit (probalby because of pain meds) she started also complaining of neck pain — a CT neck showed an odontoid fracture!! Imagine if I had sent her home!
I remember a woman, 80 yo or so, a new patient at Baycrest at the old home for the aged (full care wing) who was admitted from being previously taken care of by a hired Caregiver, a non-professional, at home. She was “getting progressively demented” to the point of incontinence and practically no verbal response. Within a week in the Nursing Home, she was getting better and better, communicating to the point of being totally lucid. Eventually she complained of hip pain and was asking for “her” pain killers. It was recognized that her previous home care giver was giving her her own Tylenol 3 for “pain”, because “no one was listening to the old lady and no one gave her any pain Meds”. So she was just terribly overdosed on codeine
I think it was nice of the caregiver to take it upon herself to control the pain. but we can see the negative part of giving prescriptive medication. Interesting case.
I think it’s not uncommon for cellulitis to go unnoticed both by a patient and by caregivers — I have occasionally pulled back the sheets to discover a huge swollen leg or buttock which is clearly the infectious cause of the confusion.
A woman admitted on the psychiatry floor with depression kept talking about her marriage breaking up 4 months ago. After talking to family we realized it was 2 years ago. Turns out she had a massive intracranial tumour compressing her hippocampus! And was altered in several subtle ways.