Diagnostic Process

Key Points

Key Points

• Central nervous system immaturity in children and CNS disease in elderly persons may explain the increased prevalence of delirium in these two groups.

• Children generally have a more acute onset of delirium, but a less fluctuating course, than adults.

• Delirium is thought to be caused by an acute cholinergic deficit; other neurotransmitter disturbances are also probably involved.

A stress-diathesis model has been proposed to explain the risk of delirium, depending on the severity of an insult to brain function and the vulnerability of the brain because of immaturity in children and central nervous system (CNS) disease or degenerative disorders most common in elderly persons. This helps explain the highest risk of delirium in the elderly population and more frequent occurrence in children than in young and middle-aged adults.

Although the phenomenology of delirium in adults and in elderly persons differs only in the severity of cognitive symptoms and resilience in recovery, the course and symptomatology in childhood are different. Childhood delirium is often associated with febrile illness and from CNS-toxic medications (anticholinergics) (Lenntjens et al., 2008). Delirium in a child is more likely to have a very acute onset, but a less fluctuating course with less disruption of the sleep-wake cycle, than in adults. Cognitive deficits may be less pronounced in children, whereas hallucinations, delusional thinking, and labile mood may be more pronounced. The different array of causes of delirium in children and adults might explain these differences. In both children and elderly patients with dementia, problematic behaviors caused by delirium are often falsely attributed to irritability associated with illness or oppositional behavior toward caregivers. When a child cannot be comforted by a parent, delirium should be suspected.

The remainder of this discussion focuses on delirium in the elderly patient.

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