The phenotype of delirium based on a close reading of diagnostic criteria.

Oldham, Mark A.; Weber, Miriam T.

Objective: Although delirium is well known to acute care clinicians, the features required for its diagnosis and how to understand and operationalize them remain sticking points in the field. To clarify the delirium phenotype, we present a close reading of past and current sets of delirium diagnostic criteria. Methods: We first differentiate the delirium syndrome (i.e., features evaluated at bedside) from additional criteria required for diagnosis. Next, we align related features across diagnostic systems and examine them in context to determine intent. Where criteria are ambiguous, we review common delirium instruments to illustrate how they have been interpreted. Results: An acute disturbance in attention is universally attested across diagnostic systems. A second core feature denotes confusion and has been included across systems as disturbance in awareness, impaired consciousness, and thought disorganization. This feature may be better understood as a disturbance in thought clarity and operationalized in terms of neuropsychological domains thereby clearly linking it to global neurocognitive disturbance. Altered level of activity describes a third core feature, including motor and sleep/wake cycle disturbances. Excluding stupor (wherein mental content cannot be assessed due to reduced arousal) from delirium, as in DSM‐5‐TR, is appropriate for a psychiatric diagnosis, but the brain injury exclusion in ICD‐11 is unjustified. Conclusions: The delirium phenotype involves a disturbance in attention, qualitative thought clarity, and quantitative activity level, including in relation to expected sleep/wake cycles. Future diagnostic systems should include a severity threshold and specify that delirium diagnosis refers to a 24‐h period. Key points: Disturbance in attention is a hallmark feature of delirium and may manifest in any number of attentional domains (e.g., directed, focused/selective, shifting, sustained, or attention span).The second hallmark feature of delirium, disturbance in thought clarity, has met with considerable confusion and been included variously across diagnostic systems as a disturbance in awareness, impaired consciousness, or thought disorganization.Altered level of activity, either cross‐sectionally or in relation to sleep/wake patterns, represents a third core feature of delirium.Excluding stupor from delirium is justified for a psychiatric diagnosis, but acute confusion after brain injury that otherwise meets delirium criteria should be regarded as delirium.

DIAGNOSIS of delirium; COGNITION disorders; SLEEP-wake cycle; NOSOLOGY; NEUROPSYCHOLOGY; NEUROPSYCHOLOGICAL tests; SLEEP disorders; ATTENTION-deficit hyperactivity disorder; DECISION making; DIAGNOSIS; SELECTIVITY (Psychology); CLASSIFICATION of mental disorders; CONSCIOUSNESS disorders; PHENOTYPES; MENTAL illness

International Journal of Geriatric Psychiatry, 2023, Vol 38, Issue 12, p1

0885-6230

Academic Journal

10.1002/gps.6046