Delirium

1. A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
2. The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
3. An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception).
4. The disturbances in Criteria 1 and 3 (listed above) are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.
5. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.

Dementia, “Major Neurocognitive Disorder”

1. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:
   • Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and
   • A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.
2. The cognitive deficits interfere with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications).
3. The cognitive deficits do not occur exclusively in the context of a delirium.
4. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).

Depression, “Major Depressive Episode”

1. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition.
   • Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
   • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
   • Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
   • Insomnia or hypersomnia nearly every day.
   • Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
   • Fatigue or loss of energy nearly every day.
   • Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
   • Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
   • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
2. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3. The episode is not attributable to the physiological effects of a substance or to another medical condition.
   

   Note: Criteria 1–3 represent a major depressive episode.
   Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.

4. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
5. There has never been a manic episode or a hypomanic episode. Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.

Distinguishing the 3D’s

Key Points

• Delirium is a medical emergency – it may be the only manifestation of a life-threatening illness.
• Delirium is missed in 60% of cases.²
• The prevalence and incidence of delirium in post-acute/long-term care (PALTC) is 14% and 20-22% respectively. Up to 4 out of 5 persons will have delirium at the time of death.³
• Delirium that begins in hospital can continue for weeks to months.⁴
• Patients with delirium have a higher risk of dying – risk ratio (RR) of 4.9 in PALTC, and RR of 2 after a stroke or 5.4 if there is also a diagnosis of dementia.²
• Delirium can also lead to long-term functional decline, cognitive impairment, permanent nursing home placement, and increased costs.²
• Delirium superimposed on dementia tends to last longer and is associated with accelerated cognitive and functional decline, recurrent and longer hospitalizations, nursing home placement and death.⁵
• At the onset of any changes in mental status from baseline a validated delirium screening assessment should be performed. The Confusion Assessment Method (CAM) is included in the MDS 3.0.
• Delirium is preventable in 30-40% of cases. Since delirium occurs as a result of the interaction of multiple predisposing and precipitating risk factors, a multi-component non-pharmacologic approach for primary prevention is most effective.²
• Antipsychotics do not prevent delirium, shorten the dura