Delirium diagnostic criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Pratik Bahekar, MBBS [3]; Vishal Khurana, M.B.B.S., M.D. [4]; Ahmed Zaghw, M.D. [5]; Jesus Rosario Hernandez, M.D. [6]


The DSM V, and ICD-10 have provided diagnostic criteria for delirium. Definition based on DSM-5 include disturbance in attention and awareness (reduced ability to direct, focus, shift attention and reduced orientation to envinment), initiation of disturbance over a short period of time during several hours or days with fluctuation in severity over a day, disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, [[perception, disturbance other than evolving neurocognitive disorder, disturbance due to medical condition, substance intoxication, or withdrawal. Other definitions of delirium include disturbance in cognition, impairment of immediate recall and recent memory, disorientation to time, place, person, disturbance in sleep wake cycle, Psychomotor disturbances,emotional disturbances in a period of less than 6 months.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Paranoid Personality Disorder[1]

  • 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.
  • D. The disturbances in Criteria A and C 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.

Specify whether:

Substance intoxication delirium: This diagnosis should be made instead of substance intoxication when the symptoms in Criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention.
Substance withdrawal delirium: This diagnosis should be made instead of substance withdrawal when the symptoms in Criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention.
Medication-induced delirium: This diagnosis applies when the symptoms in Criteria A and C arise as a side effect of a medication taken as prescribed.
Delirium due to another medical condition: There is evidence from the history, physical examination, or laboratory findings that the disturbance is attributable to the physiological consequences of another medical condition.
Delirium due to multiple etiologies: There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiology (e.g. more than one etiological medical condition; another medical condition plus substance intoxication or medication side effect).

Specify if:

Acute: Lasting a few hours or days.
Persistent: Lasting weeks or months.

Specify if:

Hyperactive:: The individual has a hyperactive level of psychomotor activity that may be accompanied by mood lability, agitation, and/or refusal to cooperate with medical care.
Hypoactive:: The individual has a hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy that approaches stupor.
'Mixed level of activity: The individual has a normal level of psychomotor activity even though attention and awareness are disturbed. Also includes individuals whose activity level rapidly fluctuates.

ICD-10 Diagnostic Criteria

To make a definite diagnosis, symptoms (mild, moderate, or severe) must be present in the following criteria:

  1. Curtailment in the consciousness and consciousness (as a result of clouding to coma; ( inability to direct, keep, transfer focus)
  2. Universal disruption in faculties of cognition (clouding of perception, illusions, and hallucinations— mostly visual; clouding of abstract thinking and comprehension, may or may not be accompanied by delusions, some degree of incoherence is likely to be present; the reduced ability of immediate recall and of disturbance in the recent memory and relatively intact remote memory; lack of orientation to time and in more severe cases, to place and person)
  3. Impairment in psychomotor activity (increased or decreased, which may shift from increased to decreased activity; raised reaction time; change in the flow of speech, and an enhanced startle reaction)
  4. Disruption of the sleep-wake cycle (which may range from complete loss of sleep, insomnia or reversal of the sleep - wake cycle; drowsiness during the day, nocturnal worsening of symptoms, nightmares, sometimes continuing as hallucinations after waking up)
  5. Disruption in emotional state , e.g. depressed mood, apathy to euphoria, anxiety or fear, irritability, or wondering perplexity.[2]

Diagnosis in ICU

  • Patients admitted in the ICU should be screened for delirium twice a day.
  • The two most widely used are the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC)..[3][4]
  • These tools can be easily administered at bedside by caregivers, even if patient is not able to follow commands[5]
  • This has resulted in focused care and better outcomes to patients suffering from delirium.

Confusion Assessment Method for the ICU (CAM-ICU)

Patient is accessed on following 4 features:

  1. Onset of symptoms, is acute(change from baseline) or fluctuating as calibrated by Richmond Agitation Sedation Scale or Glasgow Coma Scale
  2. Inability to focus as measured by Attention Screening Examination
  3. Thinking is not organized
  4. Altered level of consciousness if Vigilant, Lethargic, Stupor, Coma

If feature 1 and 2 are present along with 3 or 4 then patient is assessed to have delirium by CAM-ICU scale.[6]

Intensive Care Delirium Screening Checklist (ICDSC)

The criteria of the scoring system:

  1. Inability to focus
  2. Altered level of consciousness
  3. Not oriented to time, place and person
  4. Hallucination/ delusions/ psychosis
  5. Psychomotor agitation
  6. Speech or mood is not appropriate
  7. Disturbance in sleep-awake cycle
  8. Fluctuation of symptoms.

The interpretation of the scoring system:

  • A score of ≥ 4 is considered positive for the delirium
  • Score more than 4 shows severity.
  • Scores between 1 and 3 is termed as Subsyndromal Delirium.[7][8]

Screening Instruments

Most screening tools are designed in a way nursing staff can use them, as an availability of physician can be an issue.[9]

  • Clinical Assessment of Confusion–A (CAC-A)
  • Confusion Rating Scale (CRS)
  • MCV Nursing Delirium Rating Scale (MCV-NDRS)
  • NEECHAM Confusion Scale.

Lay Interviewers and for Epidemiological Studies

Delirium Diagnostic Instruments

  • Confusion Assessment Method (CAM)
  • Delirium Scale (Dscale)
  • Global Accessibility Rating Scale (GARS)
  • Organic Brain Syndrome Scale (OBS)
  • Saskatoon Delirium Checklist (SDC).[10]

Delirium Symptom Severity Rating Scales

Often based both on behavioral symptoms and on confusion and cognitive impairment. They may be useful for monitoring the effect of an intervention or plotting the course of a delirium over time. These scales have also been used for the diagnosis of delirium.


  1. Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  2. "Delirium in elderly people. [Lancet. 2013] - PubMed - NCBI".
  3. Ely EW; Inouye SK; Bernard GR; et al. (December 2001). "Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU)". JAMA. 286 (21): 2703–10. doi:10.1001/jama.286.21.2703. PMID 11730446. Unknown parameter |author-separator= ignored (help)
  4. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y (May 2001). "Intensive Care Delirium Screening Checklist: evaluation of a new screening tool". Intensive Care Med. 27 (5): 859–64. doi:10.1007/s001340100909. PMID 11430542.
  5. Ely, E.W.; et al. "ICU Delirium and Cognitive Impairment Study Group".
  6. Khan BA, Perkins AJ, Gao S, Hui SL, Campbell NL, Farber MO, Chlan LL, Boustani MA (May 2017). "The Confusion Assessment Method for the ICU-7 Delirium Severity Scale: A Novel Delirium Severity Instrument for Use in the ICU". Crit Care Med. 45 (5): 851–857. doi:10.1097/CCM.0000000000002368. PMC 5392153. PMID 28263192.
  7. Boettger S, Garcia Nuñez D, Meyer R, Richter A, Rudiger A, Schubert M, Jenewein J (2018). "Screening for delirium with the Intensive Care Delirium Screening Checklist (ICDSC): a re-evaluation of the threshold for delirium". Swiss Med Wkly. 148: w14597. doi:10.4414/smw.2018.14597. PMID 29537480.
  8. Reade, MC.; Finfer, S. (2014). "Sedation and delirium in the intensive care unit". N Engl J Med. 370 (5): 444–54. doi:10.1056/NEJMra1208705. PMID 24476433. Unknown parameter |month= ignored (help)
  9. Grover S, Kate N (August 2012). "Assessment scales for delirium: A review". World J Psychiatry. 2 (4): 58–70. doi:10.5498/wjp.v2.i4.58. PMC 3782167. PMID 24175169.
  10. Beishuizen SJ, Festen S, Loonstra YE, van der Werf HW, de Rooij SE, van Munster BC (December 2020). "Delirium, functional decline and quality of life after transcatheter aortic valve implantation: An explorative study". Geriatr Gerontol Int. 20 (12): 1202–1207. doi:10.1111/ggi.14064. PMC 7756254 Check |pmc= value (help). PMID 33098368 Check |pmid= value (help).
  11. Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N (2001). "Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium". J Neuropsychiatry Clin Neurosci. 13 (2): 229–42. doi:10.1176/jnp.13.2.229. PMID 11449030.

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