Searching for the Cause of Delirium

Delirium Symptom list, from Confusion Assessment Method (CAM). Suspect if patient presents with both 1. & 2. and either 3. OR 4.

1. Sudden change in mental status
2. Change in behaviour that fluctuates from normal to abnormal over a 24-hr period
3. Difficulty in focusing attention
4. Disorganized thinking and/or altered level of consciousness

Always consider patient’s trajectory in the disease process, wishes and goals of care. Discuss treatment with care team and Substitute Decision Maker.

Symptom Assessment Consideration
  • 6 or more medications, especially:
    • Narcotics
    • Antipsychotics
    • Anticholinergics
    • Antidepressants
    • Anticonvulsants
  • Age 75 or older receiving a medication for more than 5 years
  • Order drug chemistry
Electrolyte Disturbances
  • Gastrointestinal problems
  • Immobility for more than 1 day in persons previously mobile
  • Abdominal distention
  • Decreased number of bowel movements or constipated stool
  • Decreased fluid intake – dehydration
  • Decreased food intake, especially bulk
  • Hyperglycemia / Hypoglycemia/ Hypercalcemia
  • Initiate appropriate bowel regimen, e.g. enema
  • Order blood test as indicated



Lack of Drugs?
  • Long-term sedatives (including alcohol and sleeping pills) are stopped
  • Pain drugs are not being given adequately.
  • Pain management team
  • Family support/ education
  • Elevation in baseline temperature
  • History of chronic infection
  • Recent episode of falling
  • Appropriate diagnostic tests as indicated:
    • urinalysis, / chest X-ray, / sputum cultures
Reduced Sensory Input
  • What is the baseline normal sleep pattern?
  • Psychosocial/Environmental?
  • Grief/loss
  • Alteration in personal space
  • Recently admitted to hospital
  • Increase or decrease in sensory stimulations
  • Identify causes of sleep disturbances, e.g. medications / pain / environment
  • Initiate assessment:
    • ADLs / Safety / User-friendly environment / Supports
    • Encourage family involvement
  • Changes in chronic illness?
    • Diabetes Mellitus
    • COPD/Hypoxia
    • Cancer
    • Dementia
    • Substance Misuse
  • Request appropriate diagnostic tests (Exacerbation may be accompanied by increased levels of pain and/or decreased functional abilities)
Urinary Problems
  • History of incontinence, retention, or indwelling catheter
  • Signs or symptoms of dehydration, tenting, increased BUN
  • Decreased urinary output
  • Taking anticholinergic medication
  • Abdominal distention
  • Request in-out catheterization for postvoid residual and/or incontinence assessment, or both.
  • New disease process?
  • Silent MI / CHF
  • GI bleed
  • Other
  • Request appropriate diagnostic tests (e.g., PE, pulse oximetry, EKG, hemoglobin and hematocrit, chemistry screen, electrolytes, TSH, specific test for cancer detection, CAT)
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PDF – Searching for the Cause of Delirium