Assessment of delirium

chronic impairment of memory with 1 or more of the following criteria: aphasia, apraxia, agnosia, and disturbances in executive function; usually not acute and not associated with changes in attention; chronic confusion not associated with changes in alertness and coherence except in the most severe cases; history of long-term cognitive decline from carers

previous cognitive status examination (e.g., Folstein Mini-Mental Examination, Montreal Cognitive Assessment) helpful to establish the chronicity of confusional states; chronic confusion more likely dementia; acute on chronic changes can occur in mixed delirium/dementia states​

pain; may be history of falls or trauma (e.g., causing hip fracture)

tachycardia, tachypnoea, sweating, reluctance to move and distress on movement

acute changes in mental status likely; associated with neurological symptoms: unilateral weakness or numbness; change in vision (unilateral or bilateral); difficulty with speech, comprehension; loss of co-ordination, difficulty walking; severe headache

confusion frequently noted; focal neurological signs include: unilateral hemiparesis, hemianopia, aphasia, ataxia

history of risk factors for CAD (e.g., smoking, hyperlipidaemia, diabetes, family history of CAD); chest pain (often described as heavy, or tight) radiating to arms, back, neck, or jaw; chest pain may be absent in older adults and people with diabetes; dyspnoea; nausea; diaphoresis

delirium is often the only identifiable sign in older patients; other signs may include hypotension; diaphoretic appearance; pallor; tachycardia; bradycardia; new abnormal pulse rhythm; distended jugular veins; other signs of heart failure (e.g., dyspnoea, crackles at lung bases); new heart murmur

symptoms of localised infection, non-specific symptoms include fever or shivering, dizziness, nausea and vomiting, muscle pain, feeling confused or disoriented; may be history of risk factors: for example, immunosuppression, pregnancy or postpartum period, frailty, recent surgery or invasive procedures, intravenous drug use or breach of skin integrity; cough, sputum production, dyspneoa, chest pain, and urinary incontinence; common causes, especially in older people, are pneumonia and urinary tract infections; systemic infections and sepsis can cause delirium separate from their hypoxic effect

tachycardia, tachypnoea, hypotension, fever >38°C (>100.4°F) or hypothermia <36°C (<96.8°F), prolonged capillary refill, mottled or ashen skin, cyanosis, low oxygen saturation, newly altered mental state, reduced urine output; rigours, rales and crackles on auscultation of the chest, cloudy urine with offensive odour

confusion, sweating, nausea, headache, drowsiness, and seizures; usually a history of taking drug for diabetes, or alcohol misuse

tremor, sweating, tachycardia

polyuria, polydipsia, weakness, nausea, vomiting, drowsiness, and weight loss, developing rapidly over a day or less; may be precipitated by infection, MI, stroke, or other endocrine disorders

signs of volume depletion, including tachycardia and hypotension, Kussmaul's respiration, acetone breath, stupor, or coma

usually secondary to underlying disease such as sepsis, pneumonia, pulmonary embolism, severe asthma attack, COPD, cardiac failure or arrhythmia, or carbon monoxide poisoning; symptoms include inco-ordination, confusion, poor judgement, seizures, myoclonic jerks, euphoria, nausea, visual impairment, coma

increased respiratory rate, tachycardia, cyanosis, poor co-ordination

history of abnormal respiratory function (e.g., COPD)

dyspnoea, cyanosis; may have a flapping tremor of the hands, warm peripheries, bounding pulse, and occasionally papilloedema

inability to urinate, abdominal pain; may be history of poor urinary stream, hesitancy, dribbling, nocturia, dysuria

bladder distension, may be enlarged prostate

overdoses with anticholinergics, tricyclic antidepressants, stimulants, opioids, corticosteroids, analgesics, cardiac glycosides, and anti-Parkinson's drugs can be associated with delirium; there may be a history of known illicit drug misuse

may be signs of underlying illnesses requiring predisposing drug; may be signs of illicit drug overdose (e.g., agitation, tachycardia, hyperthermia, mydriasis with amphetamine or cocaine overdose; decreased respiratory rate and miosis with opioid overdose)

may be history of recent heavy consumption of alcohol; symptoms of ketoacidosis include nausea and vomiting, abdominal pain, fatigue, poor appetite, lethargy, and confusion

alcoholic ketoacidosis causes reduced consciousness, agitation, rapid ventilation rate, and signs of dehydration

history of hepatitis infection, alcohol use, and/or drug use may be present

hallmark finding in metabolic encephalopathies is asterixis; features of chronic liver disease, encephalopathy, jaundice, hepatomegaly, and ascites may be present

historical findings might include a change in the quantity or quality of urine output, anorexia, and/or NSAID use

hallmark finding in metabolic encephalopathies is asterixis; myoclonic jerks may be evident in uraemia; pallor, oedema, pleural effusion, pericarditis, neuropathy, and hypertension may be found

recent changes in hypertensive drugs, dehydration, inability to obtain water (e.g., as evident with stroke, dementia)

mental status changes, weakness, neuromuscular irritability, and or coma/seizures

recent infection, recent drug change and/or free water intoxication, history of hypotonic intravenous infusions; symptoms of headaches, nausea, confusion, lethargy

confusion, seizures, coma

history of hyperparathyroidism, malignancy, and/or thiazide diuretic use; symptoms of fatigue, anorexia, nausea, constipation, and polyuria

confusion

headache, neck stiffness, photophobia, and acute mental status changes; fevers, chills, nausea, and other evidence of illness also common; mental status changes acute or subacute

findings associated with meningeal inflammation: acute fulminant illness and triad of fever, headaches, and nuchal rigidity; in meningococcaemia, maculopapular rash and/or petechial rash

delirium can occur in people with malignant disease either because of structural brain lesions, infection, drugs (especially opioids), or metabolic encephalopathy; symptoms include lethargy, coma, agitation, disorientation, delusions, hallucinations, and seizures​

lateralising neurological signs, papilloedema

loss of consciousness, observed seizure activity, urinary incontinence, tongue trauma may be reported; premonitory symptoms or signs

observed tonic-clonic seizure or abnormal movements followed by drowsiness

thirst; fatigue; muscle cramps; abdominal pain; chest pain; confusion; loss of weight; underlying cause of volume loss including diarrhoea, vomiting, burns, poor oral intake, severe sweating, severe pancreatitis, GI or intra-abdominal haemorrhage; polyuria from diabetes; crush injury, intestinal obstruction

dry mucous membranes; orthostatic hypotension; postural tachycardia; shock; decreased skin turgor; decreased urine output

altered bowel habits; abdominal pain; pain on defecation

tender abdomen; mass on palpation

loss of consciousness, anterograde and retrograde amnesia, vomiting, headache

deformity of skull or open fracture, reduced Glasgow coma scale (based on eye, verbal, and motor response), abnormal or unequal pupil reflexes, bruising around eyes or ears, bleeding or leakage of CSF from nose or ears, associated injuries to other parts of the body

caused by stress, trauma, or infection in a patient with Addison's disease, or damage to the adrenal gland or pituitary; symptoms include headache, weakness, nausea, vomiting, fatigue, confusion, sweating, joint pain, abdominal pain, and weight loss

tachycardia, increased respiratory rate, hypotension, rash or darkening of the skin

change in appetite, weight loss, anxiety, palpitations, sweating and heat intolerance, oligomenorrhoea, mood change, and fatigue

goitre, lid lag, exophthalmos, tachycardia, proximal muscle weakness, and tremor; thyroid storm also causes high fever and coma

reduced consciousness, usually in older patient with infection or over-sedation; may also be weight gain, depression, lethargy, feeling cold, forgetfulness, and constipation

coma, hypothermia, bradycardia, signs of cardiac and respiratory failure, dry skin, facial and eyelid oedema, and thick tongue

fever, headache, motor weakness, neck stiffness, vomiting, visual disturbance, seizures, impaired consciousness

pyrexia, hemiparesis, focal neurological abnormalities, septic shock, meningism, papilloedema

personality change, gait impairment, incontinence, headache, lightning pains, blurred vision, photophobia, reduced colour perception

hyporeflexia, ataxia, anisocoria, Argyll Robertson pupils, cranial neuropathy, dementia, paranoia, Charcot's joint

may be history of long-term, heavy consumption of alcohol or recent withdrawal; Wernicke's encephalopathy and Korsakoff's syndrome can be caused by thiamine deficiency and can contribute to delirium; symptoms include loss of co-ordination, confusion, memory impairment, change in vision, anxiety, delusions, insomnia, and delirium

confusion, nystagmus, conjugate gaze palsy, ataxia, short-term memory loss, hypothermia, hypotension, peripheral neuropathy, confabulation