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Hypoactive Delirium PRACTICE POINTER Hypoactive delirium Christian Hosker,1 David Ward2 1Leeds Liaison Psychiatry Service, Hypoactive delirium tends to capture less clinical Patients’ and their carers’ experiences of delirium are Becklin Centre, Leeds LS9 7BE, UK attention than hyperactive delirium. Like all variable. Two studies, both of which systematically exam‑ 2 Acute Medicine, Hinchingbrooke delirium, it can occur in a variety of patients and ined the experience of delirium in samples of inpatients Hospital, Huntingdon PE29 6NT, UK 7 8 Correspondence to: C Hosker settings and will consequently be encountered by with cancer, suggest that the level of distress experi‑ [email protected] many groups of doctors. It can be more difficult to enced in those with hypoactive delirium is similar to that Cite this as: BMJ 2017;357:j2047 recognise, and is associated with worse outcomes, experienced by those with the other forms. However, care doi: 10.1136/bmj.j2047 than hyperactive delirium. This article outlines givers in one of the studies found hyperactive symptoms when to suspect, assess, and appropriately more distressing.8 The other study7 suggested that those manage patients with hypoactive delirium. with hypoactive delirium were less likely to recall the epi‑ sode (43% compared with 66% of those with hyperactive What is hypoactive delirium? delirium). Hypoactive delirium is dominated by symptoms of drowsi‑ ness and inactivity, whereas hyperactive delirium is char‑ Box 1 | DSM 5 classification of delirium and techniques for 3 acterised by restlessness and agitation (see infographic).1 diagnosis 2 Some people experience a mix of these subtypes. All forms In order for a patient to be diagnosed with delirium they of delirium are a syndrome characterised by acute changes must display all of the following: from baseline in a patient’s ability to maintain attention and 1 Disturbance in attention (reduced ability to direct, focus, awareness, accompanied by other disturbances in cognition sustain, and shift attention) and awareness (reduced that develop over a short period of time (hours to days) and orientation to the environment). 4 tend to fluctuate in severity over the course of a day (see box The 4A’s Test (4AT) incorporates two simple elements to 1).3 It can arise as a physiological consequence of a medi‑ aid in the assessment of this: cal condition, substance withdrawal or intoxication state, – Attention is assessed by asking patients to name the months of the year backwards exposure to toxins, or a combination of these. – Awareness is assessed by asking patients their age, A recent literature review reveals that patients with hypo‑ date of birth, place (name of the hospital or building), active delirium may report incomprehensible experiences, and current year strong emotional feelings, and fear.5 An additional qualita‑ 6 2 The disturbance develops over a short period of time tive study of patients in intensive care units reported on the (usually hours to a few days), represents an acute change “overwhelming sense of complete bewilderment and fear from baseline attention and awareness, and tends to expressed in nightmares, altered realities, and false explana‑ fluctuate in severity during the course of a day tions” and found that those affected “often do not internal‑ Establishing this often requires the use of collateral ise the rational account of what they are seeing and instead information—such as other staff who know the patient, c reate their own stories to fit their perceived situation.” case notes containing reference to previous cognitive states, or carers WHAT YOU NEED TO KNOW 3 An additional disturbance in cognition (such as memory deficit, disorientation, language, visuospatial ability, or • Hypoactive presentations of delirium are perception). more common than the classically agitated, If necessary, a cognitive assessment tool can be used hyperactive forms and may be overlooked to assess for disturbance of cognition beyond that • A collateral history can distinguish revealed by the 4A’s Test. There are several to choose hypoactive delirium from other causes of from which vary in length and therefore ease of use and behaviour change such as dementia and acceptability depression 4 The disturbances in criteria 1 and 3 are not better Cornerstones of supportive care might explained by a pre-existing, established, or evolving • neurocognitive disorder and do not occur in the context of include reorientation and a chance to debrief a severely reduced level of arousal such as coma on experiences once the patient is recovered Again, this will require the use of a collateral history to determine whether cognitive changes are longstanding SOURCES AND SELECTION CRITERIA and therefore more likely to be due to dementia, which We searched Medline, Clinical Evidence, and the Cochrane may or may not have been diagnosed previously Library using the terms “delirium, hypoactive.” Where 5 There is evidence from the patient’s history, physical possible, we have used systematic reviews and have examination, or laboratory findings that the disturbance referenced these rather than the individual trials of which is a direct physiological consequence of another medical they are comprised. The search was limited to citations from condition, substance intoxication or withdrawal (that is, 1990 to October 2016. due to a drug of misuse or a medication), or exposure to a We also searched the National Institute for Health and toxin, or is due to multiple causes Care Excellence and the Scottish Intercollegiate Guidelines This is assessed by careful history taking and Network. examination and the use of appropriate investigations No commercial reuse: See rights and reprints http://www.bmj.com/permissions 1 of 5 PRACTICE POINTER Visual summary Quietly delirious Hypoactive delirium can be more difficult to recognise than hyperactive delirium, and is associated with worse outcomes. This infographic summarises the main differences between the two forms of delirium. Delirium According to the DSM-5* classification, to be diagnosed with delirium a patient must display all of the following: + Acute change An additional disturbance Disturbance Disturbance Develops over a short period of time in attention in awareness Such as defecit in: Sudden change from baseline Ask patient to name Ask patient their age, Memory Visuospatial ability the months of the date of birth, place Fluctuates during the course of a day Language Perception year backwards and current year May require information from other staff, carers, or case notes Evidence of cause No better explanation Evidence that disturbance is a consequence of one or more of: Another medical Substance Substance Exposure These disturbances are not better explained by a pre-existing, condition intoxication withdrawal to a toxin established or evolving neurocognitive disorder or coma state Hyperactive delirium Hypoactive delirium Commonly Mixed motor mistaken for depression or Predominantly type Predominantly dementia restless and drowsy and inactive agitated Evidence of both subtypes in the Decreased Decreased Decreased speed of speech Increased motor activity previous 24 hours activity action speed Loss of control of activity Decreased amount Reduced awareness of speech of surroundings Restlessness Wandering Listlessness Withdrawal All types of delirim Adverse consequences Hypoactive delirium Reduced functional ability Onset of dementia Increased mortality + Greater mortality Less reversibility Admission to long term care Distress Increased length of stay + Greater length of stay Worse quality of life Hospital acquired complications Pressure sores Incontinence Falls + Greater frequency of falls * DSM-5 = Diagnostic and Statistical Manual of Mental Disorders (fifth edition) © 2017 BMJ Publishing group Ltd. Read the full Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, http://bmj.co/delirium conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of article online treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: http://www.bmj.com/company/legal-information/ No commercial reuse: See rights and reprints http://www.bmj.com/permissions 2 of 5 PRACTICE POINTER Table 1 | Reported proportions of delirious patients with the Box 2 | Factors associated with developing delirium1 15 1 10 hypoactive subtype • Metabolic disturbance* Proportion with • Organ failure* Setting or patient group hypoactive subtype • Prior cognitive impairment* Consultation liaison psychiatry referrals 6-32% • Dehydration* Intensive care units 36-100% • Increasing age* Elderly patients 13-46% Hip fractures 12-41% • Sensory deprivation Palliative care 20-53% • Sleep deprivation • Social isolation • Physical restraint Table 2 | Delirium prevalence across different healthcare settings • The presence of a bladder catheter • Polypharmacy Setting Prevalence General hospitals11 11-42% • Three or more comorbid diseases Care homes12 14% • Severe illness (especially fracture, stroke, sepsis) Emergency departments13 10-11% • Temperature abnormality Community within one month of hospital discharge (elderly 45% • Malnutrition patients diagnosed with delirium when hospitalised)14 • Low serum albumin *Factors particularly associated with hypoactive delirium1 How common is hypoactive delirium?
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