Importance of Delirium Diagnosis
Why is the diagnosis of delirium important? Because delirium may be the only sign of significant medical illness such as:
- Pneumonia
- Sepsis
- ACS
- Abdominal infection
- Intra-cerebral event
Warning Words
When these words are heard during your practice they should trigger the thought of delirium as a symptom.
- “Not feeling/acting right“
- “Weak“
- “Just not him/herself“
- “Poor historian“
- “Pleasantly confused“
- “Vague complaints“
- “Little old lady in no apparent distress“
- “Well, she looks okay to me…“
Today’s vague historian may be tomorrow’s ICU patient.
Missed Diagnosis
Why do we not notice delirium?
- We don’t think about the time course (“What has changed?”)
- We assume (incorrectly) that most older people have baseline cognitive impairment and don’t look for changes.
- We usually have a static snapshot of a condition that is by definition fluctuating
- We under-estimate the severity of the condition and its consequences
- We believe delirium always means agitation whereas hypoactive form is most common
- The diagnosis overlaps with dementia and depression
- The presentations are almost always atypical
- We rarely use formal assessment methods
Atypical Presentations
We know that the elderly have atypical presentations of common diseases. The following are just a few examples of potential atypical presentations in the older person presenting in the ED. Each of these may result in delirium.
Pneumonia
Frequently does not present with fever (because of altered thermoregulation) or with tachypnea (because a resting tachypnea can be normal) or cough (because of decreased strength of respiratory musculature) or even dyspnea (because of sensory impairment).
Acute Coronary Syndrome
Frequently doesn’t have chest pain (sensory impairment) or tachycardia (decreased adrenergic response or beta-blocked) or ECG changes (already have a LBBB).
Abdo Pain
Diverticulitis/cholecystitis – complaints of pain and findings of tenderness/guarding/rigidity are often not present. A change in mental status may be the only symptom.
Important Take Home Message
Often, the only way to establish the diagnosis is to investigate its symptom – but in this case the symptom is the delirium.
Discussion: Importance of Delirium Diagnosis
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agreeany change needs assessment.
agree any chnage needs assesment.
thanks
yes
great
thanks to much for all
thanks
agreeOctober 24, 2013
I find the static snapshot makes it really hard to prove fluctuation and it’s hard to figure out questions to ask the family to get that information.
agree
Very good notes
Easier for the future if we document the patient’s basal status in our notes
gg
true
agree
Good point, need to catch delirium
agree with above
agree
good info
the ED nurse most assess the pt in detail to help finding the correct cause of delirium
nice reminder
good
– too often the elderly are dismissed with complaints of “weak or tired”- we need to do a better job in the busy ED’s to fully explore what is going on.
ok
knowing the signs of delerium can help get the patient what they need
ok
ok
agreed
have patients elaborate
Mental status changes can be subtle, its important we take out time with the ‘vague’ complaint pt’s
ok
Trying to find the root cause of the delirium could be very challenging and sometimes missed if you don’t have a clear history and baseline for the patient. it’s important to get as much information from family and care takers.
eye opening, great info
good info
we should be broad minded while scanning body systems for diagnosing delerium
We often miss the diagnosis because it presents differently than expected. We often don’t see or recognize, that symptoms present differently in geriatrics.
true
yes
yes
Great
Take time to speak with patient
dig deeper
the importance of having an open mind
great
…
important to treat underlying cause
.
.
I agree
It is a s/s seen often in septic pts as well.
.
I find often elderly people come in fith delirium and every assumes a UTI and then sometimes stop there. others do a CXR and look for pneumonia. Baseline bloodwork is essential on all patients with complaints. If patients come from a facility important to find out their baseline.
true
–
get baseline blood gas
yes
Must call the SNF’s and ALF to find out baseline.
so true
Interesting
ok
Blood sugar and UTI can be causes but, if the patient has delirium, they cannot express their symptoms.
Good hx taking and physical examination with relevant investigations.
Good assessments and medication lists are so important.
good
true
informative
I agree. Sometimes people just accept the fact that they are old and that is how they get (missing things or getting confused etc)
vs can be misleading
base line needs more workup
Don’t ignore people who say their family member is off their baseline even if you don’t think they seem acutely altered.
VS can be very misleading
So AMS can be distracting and sometimes sending down a rabbit hole on why Delirium is missed
Asses changes in mental status, can be acute illness
Finding the underlying cause is essential when addressing patient with delirium
agreed
have seen chole without any pain only AMS
very helpful information as to why we miss aspects of delirium
agree to comments above
very thorough
often difficult to diagnose delirium without a thorough assessment
Too many times, we take for granted our assumptions that older adults cannot function adequately in general. DIMES is a great reminder that we need to probe further
so very accurate and i wish we could increase everyones awareness to avoid such outcomes
Any change or worsening in a geriatric pt normal status should be assessed for delirium and d/dx of underlying issues DIMES with full physical exam and workup plan.
na
finding a list of what medications a patient is actually on can be difficult
over-reliance on physical exam findings, especially tenderness. My father had biliary obstruction and developed cholangitis as lab and imaging abnormalities were overlooked because he had no abdominal tenderness.
baseline changes
The geriatric population as a rule, have more co-morbidities that can confuse or be superimposed on an acute illness, making the presenting symptoms “less classic” which can lead to missed diagnoses’. They can also have sensory & functional changes making their reactions more or less than expected.
Interesting concepts
helpful
it is all about investigation from the medical/nursing perspective. and finding out as much collateral as possible to assertain that there is a significant change from the patients baseline which could = Delerium and +/- something more severe.
Timeline is important to assess either via the patient or family
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
agree with any baseline change.
COMPLETE ASSESSMENT NEEDED.
helpful
I’m pretty stokked that delirium is finally getting the recognition that it deserves. Im actully so shocked at how little many health care providers know about it. I was in mini work shop on delirium at a nursing home and its forever kept my eyes aware and open to it
informative
understanding and treating some of these causes will help these patients be at home and not instutionalized
AEIOU tips
morbidity
interesting information
Language difficulties add to the complexity for our patient group,
high morbidity
As a paramedic and an er nurse I see both sides of the pt assessment. I see the pt in their homes and have to try and figure out what the chief complaint is. Mental status is crucial in determining this as well as contributing factors. How is the this normally? What has changed?
It takes collaborative effort by involving the different care providers to look at the bigger picture (e.g., GEM, SW, PT/OT, Pharm, Nsg, MD, etc)
Patient’s from the nursing home with no aide or family member present who have very little complaints > needs further eval. I had an older gentleman who came in for head injury not on blood thinner after falling while getting out of the tub. Patient answered all of my questions appropriately and had a h/o dementia and no caregiver. No complaints, just wanted his head checked. Negative CT and normal vitals. Normal neuro exam. No pain anywhere. No fevers. Patient became diaphoretic, so we investigated. Acute cholangitis with a lactic of 4.1.
any significant change
usually a person with dementia can always be missed diagnosis. but its always important to medically clear them first.
Good to establish baseline ADL, LOA, solid and fluid intake, when change in cognitive function these may help provide pathways for differential diagnosis.
It is extremely important to consider the diagnosis of delirium in any geriatric patient in ED. I came across a large number of junior medical staff who consider inattention and change in mentality of the patient as normal process due to their age. It is of paramount importance to consider family discussion and gaining collateral history.
it is all about investigation from the medical/nursing perspective. and finding out as much collateral as possible to assertain that there is a significant change from the patients baseline which could = Delerium and +/- something more severe.
good to review this information
poor bed mobility is often a good sign of delirium
altered change from normal needs thorough assessment
Detailed history from multiple sources in addition to patient especially regarding any recent change in behavior and a detailed evaluation of every symptom.
there is often findings during investigations that are surprising in that the clinical suspicion of that condition was low at the outset
Collateral information is key (family, GP)
often ER is criticized for doing cardiac biomarkers without symptoms, but this clearly indicates these test are indicated in these presentations of patients.
having family members that are involved in the patient’s care can provide good baseline information.
Coming from a rural hospital with a fairly static patient population, it is somewhat easier to identify behavioural changes or mentation changes. We have ready access to patient medical records. Also, nursing staff are a valuable resource when assessing for changes from baseline.
why most of the time we think wrongly that is something age
Altered cognition is not an inevitable component of ageing.
Altered cognition is NOT a normal part of aging
Listening to the patient, checking medication changes and drug interactions, and reviewing the patients past medical history may be a good start to this process
Collateral information is key – review of previous notes/visits.
I see how this can be missed
Importance of investigating conditions in terms of causes and effect.
Early assessment or reassessment can avoid later big problems
good point
vague seems the word of the day when it comes to what delirium is defined as. any change in mentation is delirium? why use the word at all? why not just change of mentation?
A valuable observation. BUT the delusions of schizophrenia, the agitation of mania, and the forgetfulness of dementia are all “changes in mentation” — but none of them are acute AND fluctuating AND marked by inattention AND have an underlying MEDICAL cause that can be treated. So identifying one kind of “change in mentation” from a different kind of “change in mentation” can be quite important for the patient.
when patient complaint of a symptom doesn’t add up to their story further investigation should always be done
we treat all elderly patients as if their cognitive baseline has a normal variant from the rest of our patient population. Largely, we are inattentive!!
Family history of pts. normal neuro status is key. These may be very subtle clues to underlying issues.
baseline from family and past medical hx notes.
we need to look closely at why there s a change in mental status and delirium should not be ignored as a symptom
To detect delirium we need to think about it and then look for it. Painful conditions are often overlooked in older patients, because the are less liable to complain of pain than younger people.
look at baseline and use family as help
Comprehensive history needed!
Very informative
i totally agree, we need to interrogate better our patients
as it is such a common diagnosis in the emergency services must be aware of the differences of these two diseases
why most of the time we think wrongly that is something age
Important to consider delirium as a symptom.
Delirium is a very nonspecific symptom that we will put all our attention to determine its origin.
🙂
I agree to above comments
Agree to above comments
definitely need to assess changes from baseline. and trust the family
xx
cc
agree, more thorough assessment of changes from baseline. but you must be able to accurately establish baseline as well
I find family very helpful in understanding baseline
Better communication from NH and family members
From the NH we need better documentation when patients are transferred specifically why are they being sent and how is this a change from their baseline?
do you know the worst group of patients to be assessed for delirium in emerg-nurseying home patients they are all demented all confused so why are you sending them!Delirium is equated with dementia and obviously not.
There is definitely a lack of communication between LTC staff and ER staff! if they shared information there would be better care, better use of resources and less waste/repeat tests
In frail seniors, one must be very vigilant for changes in baseline due to underlying delirium.
I find the static snapshot makes it really hard to prove fluctuation and it’s hard to figure out questions to ask the family to get that information.
As a small ER with one primary care group we have access to the primary care notes in the ER. It has been really helpful in picking up changes in patients condition.
agree any change from the baseline needs to have a thorough assessment of the medical surgical status and meds old and new