Table 4 Diagnostic algorithm for DSM-5 delirium
DSM-5 criteria | Tests to be performed or information needed | DSM-5 criteria fullfilled? | |||
|---|---|---|---|---|---|
YES | NO | ||||
A. Disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment). | Evaluation | TEST | Cut off (definition of inattention) | ||
Daily | Digit span forward | Less than 5 forward | |||
Daily | Digit span backward | Less than 3 backwards | |||
Daily | SAVEAHAART | 2 or more errors | |||
Initial diagnosis only | Days of the week in reverse order | Any error | |||
Initial diagnosis only | Months of the year in reverse order | Unable to reach July | |||
Initial diagnosis only | Count backwards from 20 to 1 | Any error | |||
Observation (by the examiner): | |||||
Distractibility. Comprehension. Tendency to lose the tread of conversation | |||||
The “DelApp” [level of arousal test followed by counting of serially-presented lights. Cut-off 7/8 out of 10] | |||||
B. 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. | Informant history from patient´s carers and nursing staff | ||||
Questions to carer/ nursing staff or derived from clinical notes: | |||||
Has there been a sudden change in the patient´s mental state? | |||||
Does the patient seem to be better at any period in the day compared to other times? | |||||
Has the level of consciousness been altered (drowsy/not interacting or agitated)? | |||||
Sleep-wake cycle disturbances? | |||||
C. An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception). | Questions to the patient: | ||||
Orientation to time, place and person | |||||
Recall (3 words) | |||||
Why are you in hospital? Will a stone float in water? Are there fish in the sea? (any error = disorganised thinking) | |||||
Questions to carer/ nursing staff or derived from clinical notes: | |||||
Has there been any…: | |||||
Perceptual disturbances? Sleep-wake cycle disturbances? Memory disturbances? Psychotic symptoms? | |||||
Psychomotor abnormalities? | |||||
D. The disturbances in criteria A and C are not 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. | Information from history/chart/clinical assessment | ||||
E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiologic consequence of another medical condition, substance intoxication or withdrawal (i.e., because of a drug of abuse or to a medication), or exposure to a toxin or is because of multiple etiologies. | Information from history/chart/clinical assessment | ||||
Delirium based on the tests and information above? | All DSM-5 criteria fulfilled | Yes □ | No □ | ||
Subsyndromal delirium based on the tests and information above? | Defined as evidence of change, in addition to any one of these: (a) altered arousal, (b) attentional deficits, (c) other cognitive change, (d) delusions or hallucinations. | Yes □ | No □ | ||
Criteria D and E must be met. | |||||