Evidence for the Diagnostic Criteria of Delirium

An Update

Dan G. Blazer; Adrienne O. van Nieuwenhuizen

Disclosures

Curr Opin Psychiatry. 2012;25(3):239-243. 

In This Article

Abstract and Introduction

Abstract

Purpose of review Since the publication of DSM-III in 1980, the essential criteria for delirium have been reduced progressively through DSM-III-R to DSM-IV. As the field moves toward DSM-V and ICD-11, new data can shed light on the nosological changes that are needed so that diagnostic criteria can reflect empirical data. In this study, we reassess the existing or potential criteria for delirium.
Recent findings Phenomenological studies in recent years have informed the criteria for delirium, including the appropriateness of the term 'consciousness' as a core symptom of the diagnosis, additional symptoms of delirium that are frequent but are not currently part of the diagnostic criteria, subsyndromal delirium, motoric subtypes of delirium (hyperactive, hypoactive), and the association of delirium with dementia.
Summary Recent studies suggest that motoric subtypes should be included as a subtype for delirium but that subsyndromal delirium, although a useful research construct, should not be included in clinical diagnostic criteria given the frequent fluctuation in symptoms over short periods. In addition, though the core symptoms are probably adequate to make the diagnosis, clinicians must be aware of the frequency of other symptoms, for symptoms such as profound sleep disturbance or psychotic symptoms may dominate the clinical picture.

Introduction

Since the publication of DSM-III in 1980, the essential criteria for delirium have been modified and consequently abbreviated progressively through DSM-III-R to DSM-IV.[1–3] As the field moves toward DSM-V (and ICD-11), new data can shed light on the nosological changes that are needed. The core diagnostic symptoms of delirium include a disturbance in attention and awareness that develops over a short period and represents an acute change from baseline, tends to fluctuate in severity, and is characterized specifically by a change in cognition, such as memory deficit, disorientation, or language disturbance.[3] However, many additional symptoms may accompany these core symptoms[4,5] ICD-10, for example, also includes psychomotor disturbance, disturbance of the sleep– wake cycle, and emotional disturbance (such as irritability) as core diagnostic symptoms of delirium.[4]

In this study, we reassess the existing or potential criteria for delirium that have been informed by phenomenological studies in recent years. Issues to be considered include the appropriateness of the term 'consciousness' as a core symptom of the diagnosis, additional symptoms of delirium that are frequent but are not currently included in the diagnostic criteria, subsyndromal delirium, motoric subtypes of delirium (hyperactive, hypoactive), and the association of delirium with dementia. We will not focus on the pathophysiology, treatment, or prognosis of delirium except as they inform the phenomenological issues above. We also limit our focus to delirium in adults, while acknowledging that delirium may present differently in children and is a problem of great clinical concern. Similarly, we do not consider the location of the patient with delirium, although recent studies have highlighted the unique characteristics and prognosis of delirium in ICUs and other critical care units.[6]

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