Identification of underlying problems

In every patient with new onset of delirium, exclude life-threatening conditions, check the vital signs (temperature, blood glucose, etc), and perform a clinical examination. After a fall, check for symptoms of intracranial bleeding (with a CT scan if in doubt).

Is the patient in pain?
Perform a pain assessment (eg, Verbal Rating Scale or Numeric Rating Scale) [Note: please refer to the Perioperative pain module]; look for indirect signs
Are there symptoms of infection?
Clinical examination, laboratory tests (eg, blood count, renal parameters, C-reactive protein), samples (urine, blood cultures, possibly lumbar puncture), chest x-ray. Start early antibiotic therapy.
Is the patient dehydrated?
Heart rate, respiratory rate, clinical examination: inspect oral mucous membranes/ tongue for longitudinal furrows, tissue turgor/skin folds.
Are there signs of bleeding?
Heart rate, respiratory rate, look for drainages, look for hemoglobin/hematocrit
Is there a possibility of a withdrawal syndrome? (consider benzodiazepines and alcohol)
Benzodiazepine withdrawal or alcohol withdrawal: refer for advice
Was there a recent medication change (started, stopped, or dose adjusted)?
Evaluate for benzodiazepine, tricyclic antidepressants (TCA), anticholinergic medications, and other psychoactive agents. Review medications with a geriatrician or psychiatrist.
Does your patient have urinary retention?
Check for recent opioid use. Bladder examination (ultrasound), insert catheter, look for UTI (and urine samples). If there is infection, start the patient on early antibiotic therapy.
Is your patient constipated?
Review the patient's chart. Examine the bowel and give a laxative if required or requested.
Did the patient sustain a (another) fall? (also ask the nurses)
Look for bruises or marks from a recent fall; consider a CT scan of the head.
Are there signs of an acute cardiac problems/pulmonary embolism?
Give oxygen 2L, ECG, cardiac enzymes, arterial blood gas analysis; if positive, refer to a cardiologist.
Are there electrolyte abnormalities?
Test for hypo/hypernatremia, hypercalcemia

Other: If you cannot find a cause, also consider hypothyroidism (TSH), intoxication, eg, digoxin, theophylline, lithium; check blood levels of medications.

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