Step 1: History
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History and physical exam form the cornerstone of evaluation of a patient with delirium.
Begin by obtaining history from the patient if possible.
Precipitating factors
- recent illness, new medication, substance use or withdrawal, environmental changes
- post-fall, post-hospitalization, recent change of medication
Gather collateral history from caregivers, family, or facilities
Focus on:
- Onset
- Waxing/Waning characteristics
- Baseline functioning
- Associated symptoms
- Falls
- Recent medication changes or adherence
- Recent changes of living environment
- Loss of support system
Symptoms
Onset and course
- acute, chronic or acute on chronic, waxing/waning, or constant
- pattern: Same intensity through the day or waxing and waning through the day, variation from day-to-day
Duration of symptoms
Intensity, extent, or severity of symptoms
Associated signs and symptoms
- nausea, vomiting, chest pain, dyspnea, headaches, weakness, numbness, abdominal pain
- Associated symptoms: sob, rash, pain, increased somnolence, fever, delusions, hallucinations
Detailed medication review
- Current medication list
- Over-the-counter or herbal medications
- Adherence to medication prescriptions
- Any overdose or missed doses
Find out if symptoms started after initiation of a new medication.
NOTE: In the setting of dehydration or initiation of a new drug, a previously well-tolerated drug can have a deliriogenic effect as a result of reduced clearance or drug-drug interaction.
Substance abuse history
- Alcohol
- Illicit drug use
- Opioid or benzodiazepine use
- History of drug overdose or withdrawal