Delirium – History and Physical

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Delirium – History and Physical

geriguidesOctober 13, 2021List of Guides 0

History:

Get recent history from a knowledgeable collateral source (family or facility staff)

Focus on:

  • Onset and character of change in mental status
  • New diagnoses
  • New medications
  • New change in habits
Perform focused geriatric review of systems as needed
  • Falls in past 3 months?
  • Assistive devices (cane, walker, rollator, wheelchair)?
  • Constipation?
  • Urinary incontinence?
  • Chronic pain?
  • Weight changes/nutrition
Determine baseline functional status

Is the patient independent, need assistance, or dependent on?

Instrumental Activities of Daily Living (IADLs)

  • Using the telephone?
  • Shopping?
  • Preparing food?
  • Cleaning?
  • Laundry?

Activities of Daily Living ADLs

  • Bathing?
  • Dressing?
  • Toileting?
  • Transferring?
  • Feeding?

Functional impairment at baseline is a strong predisposing factor for developing delirium

Determine baseline cognitive status
  1. Does the patient have a preexisting diagnosis of mild cognitive impairment or dementia (includes Alzheimer’s, Parkinson, Lewy Body, Frontotemporal, Vascular Contributions, and others)?
  2. Has the patient ever had a cognitive evaluation before?
    -Can include MiniCog, MoCA, SLUMS, neuropsychiatric testing, memory clinic evaluation, and others
  3. If unknown, determine if any impairments of IADLs/ADLs exist as a result of their cognition

Cognitive impairment or dementia at baseline is a strong predisposing factor for developing delirium

Evaluate for sensory impairments

Does the patient wear or need glasses or hearing aids?

Not only are vision and hearing impairment risk factors for delirium, but ensuring glasses/hearing aids are used in the hospital is key to preventing and treating delirium.

Evaluate risk for intoxication vs withdrawal

Especially focus on:

  • Alcohol
  • Illicit drug use
  • Benzodiazepines
  • Opioids
Perform medication review

Search for potentially deliriogenic medications with focus on medication changes, and potential interactions, over the past two weeks.

Physical:

Vital signs (+/- orthostatic vitals) and fingerstick/serum glucose

Physical Exam:

General

General exam as guided by history with focus on evaluating for acute illness, infection, pain

Neurologic

looking for focal deficits, muscle tone, meningeal signs

MSK

Passive range of motion for upper/lower extremities

Integument

looking for ulceration, erythema

Laboratory/Imaging

The laboratory and imaging work up should be guided suspicion based on history and physical.

At a minimum, obtain CBC, CMP (basic metabolic panel, liver function panel, calcium).

Also consider, magnesium, phosphorus, VBG, EKG +/- troponin, BNP, CRP, blood cultures, urine culture, chest radiograph as clinically indicated.

Pearls:

In the absence of fever/leukocytosis, hemodynamic, and localizing urinary symptoms, delirium is not a sign of UTI and other etiologies should be evaluated. Any bacteriuria should be viewed as asymptomatic and not subject to antibiotics per the Infectious Disease Society of America (IDSA) and Journal for Post-Acute and Long-Term Care (JAMDA).

  • “Nonspecific symptoms — including change in cognition, agitation, decreased appetite, and falls – are not symptoms of UTI, especially when genitourinary tract specific signs and symptoms are absent” (JAMDA – Role of Behavioral Change)
  • In older patients with functional and/or cognitive impairments with bacteriuria and without local genitourinary symptoms or other signs of infection (fever, hemodynamic instability) who experience delirium or a fall, we recommend assessment for other causes and careful observation rather than antimicrobial treatment.” IDSA Asymptomatic Bacteriuria Guidelines 2019 – Recommendations V1 and V2

Head imaging is not recommended in the initial evaluation unless there are neurologic deficits or recent head trauma (such as due to a fall).

The role of B12/Folate, thiamine, thyroid studies, EEG, MRI, drug levels, toxin screen, and lumbar puncture in the initial evaluation of a patient with delirium is very limited unless there is high clinical suspicion.