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Hypoactive delirium
Christian Hosker,1 David Ward2
1
Leeds 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
Correspondence to: C Hosker settings and will consequently be encountered by with cancer,7 8 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
acterised by restlessness and agitation (see infographic).1 diagnosis3
Some people experience a mix of these subtypes.2 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).
tend to fluctuate in severity over the course of a day (see box The 4A’s Test (4AT)4 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‑ 2 The disturbance develops over a short period of time
tive study of patients in intensive care units6 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,
c­reate 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
explained by a pre-existing, established, or evolving
•   Cornerstones of supportive care might 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

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 P R AC T I C E P O I N T E R

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:

+
An additional disturbance
Acute change
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
year backwards and current year Language Perception
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
Increased motor activity activity action speed of speech
previous 24 hours
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 http://bmj.co/delirium Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations,
article online conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of
treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own
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Table 1 | Reported proportions of delirious patients with the Box 2 | Factors associated with developing delirium1 15
hypoactive subtype1 10 • 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%
Elderly patients 13-46%
• Increasing age*
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
Setting Prevalence
• Polypharmacy
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?
Available data suggest about 50% of delirium is hypoactive;
Box 3 | Reasons why hypoactive delirium can be missed18 19
this and the mixed motor subtype account for 80% of all
cases of delirium.1‑10 Data on the dominance of the hypo‑ The nature of the condition
active subtypes vary between studies and locations, and • Person too withdrawn to alert a care provider, particularly if
considerable uncertainty about its prevalence exists (table isolated without family or carers
1). Delirium occurs across a range of settings (table 2), and • The condition fluctuates, and periods of near-normality
observational data suggest that at least 1 in 10 people in may coincide with a clinician’s assessment
most healthcare setting who are acutely unwell or admitted • Establishing the diagnosis requires a degree of longitudinal
overview, to capture the shift from baseline, combined with
as inpatients have delirium.
careful assessment
Delirium is associated with a wide range of factors (box
The nature of health care systems
2), and hypoactive delirium is particularly associated with
• A lack of continuity of care, poor access to the latest records
some of them (such as organ failure, prior cognitive impair‑
(such as medication changes, recent admissions, or other
ment, and dehydration). Ultimately, the chance of an event risk factors such as dementia), sensory impairment
triggering delirium varies according to a person’s thresh‑ • Delayed assessment because the patient is not triaged by
old for developing delirium. For young, fit, non-cognitively primary or secondary care services as urgent
impaired people, the precipitant is likely to be more severe
Factors inherent within the population at risk
such as meningitis, traumatic brain injury, or sepsis requir‑
• Elderly patients may be isolated
ing intensive care. For older, frail people with dementia it
Misunderstandings within the workforce
might be minor metabolic disturbance, urinary tract infec‑
• It is normal for older patients to be forgetful or disorientated
tion, or constipation.
• Hyperactive symptoms must be present for a diagnosis to
be made, or these are viewed as a marker of severity
Why is it important to recognise symptoms of hypoactive
• Patients are offended by having their cognition tested
delirium?
• Hypoactive delirium is irreversible
Hypoactive delirium is associated with poorer outcomes
• Hypoactive delirium is somehow beneficial to the patient
compared with mixed or hyperactive delirium,1‑15 includ‑ in protecting them from the reality of having an advanced
ing increased mortality and admission to longer term care disease
(see infographic). This may be because it presents or is diag‑
nosed later. If the poorer outcomes in hypoactive delirium How is hypoactive delirium diagnosed?
are explained by delayed diagnosis then identifying cases A variety of sources offer advice on how to approach diagno‑
sooner, including patients who do not have symptoms but sis. The NICE guidance on delirium recommends first iden‑
are at greater risk, and addressing reversible causes of delir‑ tifying those at risk of delirium before further assessing for
ium in these groups may improve outcomes. fluctuations in behaviour.13
A study which examined 805 consecutive acute medical Risk factors (box 2) for delirium, including those most
admissions reported that 75% of the cases of delirium were associated with hypoactive delirium, are so common in
missed by the admitting teams.16 Patients with hypoactive acutely unwell people that they are of limited predictive
delirium can be missed because those who are docile may value. Box 1 gives an approach to diagnosis based on DSM
not come to the attention of care providers. In one observa‑ 5 (diagnostic and statistical manual of mental disorders,
tional study of 67 elderly inpatients consecutively referred fifth edition).3
to a psychiatric consultation service with suspected depres‑ Numerous validated delirium tools exist, which vary in the
sion, 42% were found to be delirious.17 There are various time required to complete them, the training required, and
reasons why the diagnosis of hypoactive delirium may be their suitability for use in hypoactive patients.20 A recent sys‑
overlooked, as laid out in box 3. tematic review of screening tools in hospitalised inpatients20

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How is hypoactive delirium managed?

Table 3 | An overview of the screening tools 4A’s Test (4AT)4 and Nursing Delirium Screening
Checklist (NuDESC)21 suitable for the detection of hypoactive delirium use in a busy clinical setting There is insufficient evidence to support the routine use
4AT NuDESC
of drugs, including antipsychotics, to prevent or treat
Rating by Any member of staff Nurses d­elirium.15 22
Time to complete 2-3 minutes 1-2 minutes Several evidence based guidelines on the manage‑
No of items Four: Five: ment of delirium exist, and all broadly recommend
• Alertness  • Disorientation the following approaches.13‑24 Clinicians may consider
• Cognition (4 sub-items) • Inappropriate behaviour of­fering:
• Attention • Inappropriate communication
• Acute change or fluctuations • Illusions or hallucinations •   An explanation for symptoms and a diagnosis to
• Psychomotor retardation patients who may be frightened by their experience,
Sensitivity 89.7% 85.7% including written information
Specificity 84.1% 86.8% •   Treatment for reversible causes
•   Supportive nursing care in a suitable environment
recommended the 4A’s Test (4AT)4 and the Nursing Delirium to ensure that complications that can arise from
Screening Checklist (NuDESC)21 due to their validity in hypo‑ patients being withdrawn and unable to self
active patients and their suitability for incorporation into care (dehydration, infections, bed sores, etc) are
busy clinical practice without specific training (see table 3). monitored for and managed
Ensure history taking includes information about medi‑ •   Reorientation on a regular basis by explaining who
cation use, the presence of comorbid conditions, and any you are, as well as communicating the day, date,
alcohol or illicit drug use. Perform a thorough physical time, and location.
examination and appropriate investigations (see box 4). •   An opportunity to discuss their experiences once
they are recovered.
What is a differential diagnosis for hypoactive delirium? Delirium can leave patients confused and frightened.
Distinguish hypoactive delirium from other causes of with‑ Distress can be even higher in the carers and spouses.7
drawn, apathetic behaviour. Major depressive episodes can The ability of hypoactive patients to engage with informa‑
present with reductions in activity levels, but not with reduc‑ tion can be limited while they are unwell. After patients
tions in consciousness, fluctuations, or abrupt onsets.
Pre-existing dementia can be a cause of withdrawal and Box 5 | A multi-component approach to prevention of
delirium15 25
apathy. However, hypoactive delirium can be superimposed
upon dementia. Use a collateral history to establish the Cognition and orientation
baseline state and determine whether the changes are acute • Cognitive stimulation activities, such as reminiscing
(suggestive of delirium) or chronic (suggestive of dementia). • Orientation board with names of care team members and
An abrupt step-change in the patient’s mental state, sug‑ daily schedule
gests the presence of delirium. • Talking to the patient to re-orientate them
Early mobility
Box 4 | Investigations to consider when assessing a patient
• Ambulation or active range-of-motion exercises
with suspected hypoactive delirium
• Minimising use of immobilising equipment
The choice of tests will depend on the individual patient
Hearing
Questions
• Portable amplifying devices and special communication
• Bowel habit inquiry
techniques, with daily reinforcement
• Medication review (to identify and discontinue those that
• Ear wax clearing as needed
are contributory or causative)
• Pain control Sleep-wake cycle preservation
• Warm milk or herbal tea, relaxation tapes or music, and
Simple tests
back massage to encourage sleep
• Full blood count—For anaemia, infection
• Unit-wide noise reduction strategies and schedule
• Urea and electrolytes—For renal failure adjustments to allow uninterrupted sleep
• C reactive protein—For inflammatory process
Vision
• Bone profile—For hypercalcaemia
• Visual aids (glasses, magnifying lenses) and adaptive
• Liver function tests—For liver failure equipment (large illuminated telephone keypads, large
• Thyroid function tests—For hyperthyroidism or print books, fluorescent tape on call bell), with daily
hypothyroidism reinforcement of their use
• Blood glucose Hydration
• Drug levels of prescribed medications • Encourage fluid intake
• Urine analysis—For infection • Feeding assistance and encouragement during meals
• Electrocardiography—For cardiovascular causes
Examples of service delivery
More specialist tests • Programmes of education for ward nursing staff
• Blood cultures • Protocols targeting specific risk factors delivered by a
• Chest x ray trained interdisciplinary team
• Arterial blood gas • Specialist nursing interventions to educate nursing
• Computed tomography of head staff, review and change medication, encourage patient
• Consider lumber puncture mobilisation, and improve patient environment

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doi:10.1371/journal.pone.0153775. pmid:27096605. bmj.com/group/rights-licensing/permissions

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