The Rational Clinical Examination
David L. Simel, Drummond Rennie
Delirium
David L. Simel
Make the Diagnosis: Delirium
Topics Discussed:
cognition, confusion assessment method, criterion standard comparisons (diagnostic tests), delirium, global attentiveness rating, make the diagnosis, prior probability, reference standards
Excerpt:
"Delirium describes a state where patients have a reduced ability
to focus or to sustain or shift attention with an associated change
in cognition. Patient may also develop perceptual disturbances.
These events occur over a short period of time, and they fluctuate
during the course of a day. The diagnosis is primarily clinical
and based on careful observation of key features. Consensus from
an expert panel identified several clinical features of delirium:
acute onset and fluctuating course, inattention, disorganized thinking,
altered level of consciousness, disorientation, memory impairment,
perceptual disturbances, increased or decreased psychomotor activity,
and disturbance of the sleep-wake cycle.1 The key
diagnostic feature that helps to distinguish delirium from dementia
is that delirium has an acute and rapid onset, whereas dementia
is much more gradual in progression. Alternations in attention and
changes in level of consciousness also favor a diagnosis of delirium.
A hypoactive form of delirium is characterized by lethargy and reduced
psychomotor functioning, while a hyperactive form is more easily
recognized because patients are agitated or hypervigilant, or they have
hallucinations.2 Patients may fluctuate between
the 2 forms...."
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