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geriatrics.delirium.core.v1

Delirium (older adult)

general_internal_medicineacutegeriatricadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest points at the existing placeholder prisma/seed/manifests/neuro.delirium.v1.ts; a dedicated geriatrics.delirium manifest (CAM/CAM-ICU/4AT scoring, I WATCH DEATH precipitant matrix) is deferred to the deepening pass. RxNav RxCUIs deferred — NO rxcui fields anywhere; haloperidol/quetiapine/risperidone/lorazepam/thiamine/dexmedetomidine need RxNav validation before PRODUCTION. No problem-package folder or atom manifests on disk yet; design brief authored at src/lib/dossiers/_briefs/geriatrics.delirium.core.v1.md. Bayesian likelihood ratios for CAM/4AT/CAM-ICU and the DELIRIUM/I WATCH DEATH precipitant priors to be wired into the manifest in the deepening pass.

Entry points (4)

  • symptom
    Acute confusion / new disorientation / "not themselves" reported by family or staff (NICE CG103 2023)
    acute_confusion
  • symptom
    Fluctuating attention or level of consciousness — positive CAM / 4AT screen (Inouye Ann Intern Med 1990)
    fluctuating_inattention
  • history
    New agitation (hyperactive) OR new lethargy/withdrawal/somnolence (hypoactive — most missed) in older inpatient (DSM-5-TR)
    agitation_or_withdrawal
  • demographic
    Age >=65 post-operative or post-acute-illness cognitive change — postoperative delirium screen (AGS/ADS 2015)
    age_65_postop

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Age >=65 is a core predisposing factor; older brain is delirium-vulnerable; affects drug dosing (start low) (NICE CG103 2023)
  • baseline_cognitionrequired
    history • used at CONTEXT
    Baseline dementia / cognitive impairment is the STRONGEST predisposing factor; needed to separate delirium from dementia and detect delirium-superimposed-on-dementia (DSM-5-TR)
  • onset_and_courserequired
    history • used at ENTRY
    Acute onset (hours-days) + fluctuating course is the definitional pivot vs chronic dementia (DSM-5-TR; CAM)
  • attention_levelrequired
    symptom • used at RED_FLAGS
    Inattention + altered consciousness are the two CAM cardinal features; drive screening and subtype (Inouye Ann Intern Med 1990)
  • current_medsrequired
    medication • used at CONTEXT
    Anticholinergic burden, benzodiazepines, opioids, polypharmacy and abrupt withdrawal (alcohol/benzo) are leading precipitants and the most modifiable (NICE CG103 2023)
  • glucose_pocsrequired
    vital • used at RED_FLAGS
    Point-of-care glucose — hypoglycemia is an immediately reversible life-threatening mimic; check first (AGS/ADS 2015)
  • spo2required
    vital • used at RED_FLAGS
    Hypoxia / hypercapnia is a rapidly reversible precipitant; bedside SpO2 mandatory in RED_FLAGS (NICE CG103 2023)
  • temperaturerequired
    vital • used at RED_FLAGS
    Fever signals infection (UTI/pneumonia/sepsis) — the single most common precipitant in the elderly (NICE CG103 2023)
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    Severe hypo/hypernatremia precipitates and mimics delirium; correction must be controlled (osmotic demyelination) (AGS/ADS 2015)
  • calcium
    lab • used at INITIAL_WORKUP
    Hyper/hypocalcemia is a metabolic precipitant on the I WATCH DEATH hunt (AGS/ADS 2015)
  • creatinine
    lab • used at INITIAL_WORKUP
    Uremia is a metabolic encephalopathy cause; renal function also guides drug dosing (NICE CG103 2023)
  • alcohol_benzo_use
    history • used at CONTEXT
    Alcohol/benzodiazepine dependence flags withdrawal delirium (DTs) — the ONE setting where benzodiazepines are correct (AGS/ADS 2015)
  • sensory_aids
    history • used at CONTEXT
    Sensory impairment (no glasses/hearing aids) is a predisposing factor and a directly correctable HELP-bundle target (Inouye NEJM 1999)
  • focal_neuro_signs
    symptom • used at RED_FLAGS
    Focal deficit / new seizure / meningism redirects to stroke/ICH/NCSE/meningitis pathway and CT/LP/EEG (NICE CG103 2023)

12-phase flow (12)

  1. 1FRAME
    Frame delirium as an acute brain emergency in a vulnerable (often demented/frail) older adult: predisposing vulnerability x precipitating insult; goal is the reversible-cause hunt, not symptom suppression (NICE CG103 2023)
    inputs: age, baseline_cognition
    advance: Older adult with possible acute cognitive change identified; scope confirmed (NICE CG103 2023)
  2. 2ENTRY
    Capture trigger: acute confusion, fluctuating inattention/consciousness, new agitation OR new withdrawal (hypoactive), or postoperative/post-acute cognitive change (DSM-5-TR)
    inputs: onset_and_course
    advance: Acute, fluctuating presentation captured against a known/inferable baseline (DSM-5-TR)
  3. 3CONTEXT
    Establish predisposing factors (baseline dementia/cognitive impairment — strongest, age, frailty, sensory impairment, comorbidity, prior delirium) and the medication context (anticholinergic burden, benzodiazepines, opioids, polypharmacy, alcohol/benzo use); reconcile baseline cognition with collateral history (NICE CG103 2023)
    inputs: age, baseline_cognition, current_meds, alcohol_benzo_use, sensory_aids
    actions: workup.beers_screen, calc.acb_scale
    advance: Predisposing vulnerability profile and full medication/withdrawal context characterized (NICE CG103 2023)
  4. 4RED_FLAGS
    Immediate life-threatening reversible causes — check and treat NOW: hypoglycemia (POC glucose), hypoxia/hypercapnia (SpO2/ABG), sepsis, Wernicke encephalopathy (give IV thiamine before glucose), non-convulsive status epilepticus, acute stroke/ICH, opioid/sedative toxicity, severe hyper/hyponatremia, alcohol/benzodiazepine withdrawal (AGS/ADS 2015; NICE CG103 2023)
    inputs: glucose_pocs, spo2, temperature, attention_level, focal_neuro_signs
    actions: calc.qsofa, calc.news2
    advance: Immediately reversible/dangerous causes screened and empirically treated (thiamine, glucose, oxygen, naloxone, anticonvulsant as indicated) (AGS/ADS 2015)
  5. 5INITIAL_WORKUP
    Confirm delirium with CAM/4AT and run the first-line reversible-cause panel: glucose, CBC, CMP/electrolytes (Na, Ca, Mg, PO4), renal/hepatic, TSH, B12, urinalysis + culture, CXR, ECG, drug levels/toxicology screen; structured medication review (NICE CG103 2023)
    inputs: attention_level, sodium, calcium, creatinine
    actions: workup.delirium, panel.cbc, panel.cmp, panel.metabolic, panel.ua, panel.tsh
    advance: CAM/4AT positive (or strongly suspected) AND first-line precipitant panel resulted (NICE CG103 2023)
  6. 6BRANCHING_WORKUP
    Targeted next-step diagnostics by finding: CT head if focal deficit / trauma / anticoagulated / depressed consciousness / no cause found; LP if meningism or unexplained fever; EEG if non-convulsive status epilepticus suspected; quantify reversible drug drivers (anticholinergic burden) (NICE CG103 2023)
    inputs: focal_neuro_signs, current_meds
    actions: calc.acb_scale, workup.encephalopathy, workup.first_seizure, workup.hyponatremia
    advance: Targeted imaging/LP/EEG completed where indicated; drug-driver burden quantified (NICE CG103 2023)
  7. 7DIFFERENTIAL
    Resolve etiology and subtype: motor subtype (hyperactive vs HYPOACTIVE — most common in elderly, worst prognosis, frequently missed; vs mixed); precipitant(s) via DELIRIUM / I WATCH DEATH (Infection, Withdrawal, Acute metabolic, Trauma/Toxins, CNS, Hypoxia, Deficiencies, Endocrine, Acute vascular/MI, Heavy metals/drugs); distinguish from dementia, depression (pseudodementia), primary psychiatric disease, and non-convulsive status (DSM-5-TR)
    inputs: onset_and_course, baseline_cognition
    actions: workup.dementia
    advance: Motor subtype assigned and one or more precipitants identified (or "multifactorial" declared) (NICE CG103 2023)
  8. 8RISK_STRATIFICATION
    Stratify severity and prognosis: hypoactive subtype + delirium-superimposed-on-dementia + sepsis carry the worst outcomes; anticholinergic burden (ACB) as a quantifiable reversible driver; qSOFA/NEWS2 to grade the precipitating illness and disposition acuity (AGS/ADS 2015)
    inputs: attention_level, current_meds
    actions: calc.acb_scale, calc.qsofa, calc.news2
    advance: Severity, subtype-prognosis and illness acuity stratified; level of care decided (AGS/ADS 2015)
  9. 9TREATMENT
    Treat the cause(s) FIRST. Deploy the non-pharmacologic multicomponent bundle (HELP) as FIRST-LINE and preventive: reorientation, sleep hygiene, early mobilization, sensory aids, hydration/nutrition, minimize tethers/catheters, family presence, treat pain/constipation/urinary retention, deprescribe deliriogenic drugs. Pharmacologic therapy ONLY for severe agitation endangering self/others or preventing essential care, after non-pharm — lowest-dose, shortest-duration low-dose antipsychotic with QTc/EPS caution; AVOID benzodiazepines EXCEPT alcohol/benzo withdrawal or seizure; AVOID antipsychotics in Lewy body/Parkinson (quetiapine cautiously). Antipsychotics do NOT shorten delirium or improve mortality (NICE CG103 2023; AGS/ADS 2015)
    inputs: current_meds, attention_level, alcohol_benzo_use
    advance: Precipitant(s) treated + HELP bundle running + deliriogenic drugs deprescribed; pharmacologic agent used only if dangerous agitation (NICE CG103 2023)
  10. 10DISPOSITION
    Level of care by precipitant acuity and safety: ICU if airway/sepsis/NCSE/severe metabolic derangement or ventilated; ward with delirium-friendly environment and 1:1 if unsafe; do NOT discharge active delirium without resolution and a safe environment — high in-hospital mortality, functional decline, and long-term dementia risk (NICE CG103 2023)
    actions: calc.news2
    advance: Care setting matched to precipitant severity and patient safety; ICU triggers screened (NICE CG103 2023)
  11. 11MONITORING
    Reassess CAM/4AT and RASS/agitation at least once per shift (more often if pharmacologically treated); track cause-resolution (repeat electrolytes, infection markers, oxygenation); QTc on any antipsychotic; daily review to deprescribe sedatives and stop antipsychotic as soon as agitation resolves; CIWA-Ar cadence if withdrawal (NICE CG103 2023)
    inputs: attention_level, current_meds
    actions: calc.ciwa_ar, panel.metabolic
    advance: Delirium resolving (CAM/4AT trending negative), precipitant corrected, antipsychotic stopped or tapering (NICE CG103 2023)
  12. 12FOLLOWUP
    Document the delirium episode and resolution status; explicit cognitive follow-up because delirium predicts new/accelerated dementia, functional decline and mortality; medication reconciliation with deprescribing carried forward; carer education + return precautions; outpatient cognitive (MoCA) reassessment once acute illness resolved (AGS/ADS 2015)
    inputs: baseline_cognition
    actions: calc.moca, workup.cga
    advance: Episode documented, cognitive follow-up arranged, deprescribing plan handed off, carer educated (AGS/ADS 2015)