Diagnosis and differential diagnosis

The diagnosis of delirium is a two-stage process: first, it is necessary to diagnose the delirium, and second, to identify the underlying cause or causes. The diagnosis of delirium in elderly patients can be problematic, given the predominantly hypoactive clinical picture and the unreliability of 'positive' symptoms. However, it is important to consider the possibility if cognitive decline is rapid, and if any of the recognized signs and symptoms are present. A good informant history from relatives or ward staff is essential to establish the onset and course of the disorder. Routine screening procedures may be useful in identifying patients who develop delirium while in hospital. Brief instruments such as the Mini-Mental State Examination (5) are not diagnostic, but will alert the clinician to any sudden decline in cognitive function. More extended diagnostic instruments are also available, such as the Delirium Rating Scale, (6) the Confusion Assessment Method,(7) and the Delirium Symptom Interview/8.) Another approach to screening for delirium is to identify those at particular risk of developing the disorder. A number of factors have been shown to be predictive:(91°) those related to the patient include visual impairment, severity of illness, cognitive impairment, and a ratio of blood urea nitrogen to creatinine of 18 or more. Hospital- and treatment-related factors include the use of restraints, malnutrition, the use of more than three medications, bladder catheterization, and the number of iatrogenic events. These factors are multiplicative in their effect.

The differential diagnosis of delirium includes most other psychiatric disorders in this age group. These disorders are themselves risk factors for delirium, and so the possibility of a double diagnosis must always be considered. When in doubt, investigate and manage as delirium until the situation is clear.

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