title: Delirium diagnostic and classification challenges in palliative care: subsyndromal delirium, comorbid delirium-dementia, and psychomotor subtypes.
abstract: BACKGROUND
  Delirium often presents difficult diagnostic and classification challenges in palliative care settings.
  
  
  OBJECTIVE
  To review three major areas that create diagnostic and classification challenges in relation to delirium in palliative care: subsyndromal delirium (SSD), delirium in the context of comorbid dementia, and classification of psychomotor subtypes, and to identify knowledge gaps and research priorities in relation to these three areas of focus.
  
  
  METHODS
  We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant PubMed literature searches as the knowledge synthesis strategy in this review.
  
  
  RESULTS
  We identified six (SSD), 33 (dementia), and 44 (psychomotor subtypes) articles of relevance in relation to the focus of our review. Recent literature data highlight the frequency and impact of SSD, the relevance of comorbid dementia, and the propensity for a hypoactive presentation of delirium in the palliative population. The differential diagnoses to consider are wide and include pain, fatigue, mood disturbance, psychoactive medication effects, and other causes for altered consciousness.
  
  
  CONCLUSIONS
  Challenges in the diagnosis and classification of delirium in people with advanced disease are compounded by the generalized disturbance of central nervous system function that occurs in the seriously ill, often with comorbid illness, including dementia. Further research is needed to delineate the pathophysiological and clinical associations of these presentations and thus inform therapeutic strategies. The expanding aged population and growing focus on dementia care in palliative care highlight the need to conduct this research.
authors.affiliation: Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
authors.forename: Maeve M
authors.initials: MM
authors.lastname: Leonard
authors.affiliation: Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia.
authors.forename: Meera
authors.initials: M
authors.lastname: Agar
authors.affiliation: Palliative Medicine, Marie Curie Hospice, Edinburgh and West Lothian Palliative Care Service, Edinburgh, United Kingdom.
authors.forename: Juliet A
authors.initials: JA
authors.lastname: Spiller
authors.affiliation: Milford Care Centre, University of Limerick, Limerick, Ireland.
authors.forename: Brid
authors.initials: B
authors.lastname: Davis
authors.affiliation: Milford Care Centre, University of Limerick, Limerick, Ireland.
authors.forename: Mas M
authors.initials: MM
authors.lastname: Mohamad
authors.affiliation: Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
authors.forename: David J
authors.initials: DJ
authors.lastname: Meagher
authors.affiliation: Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. Electronic address: plawlor@bruyere.org.
authors.forename: Peter G
authors.initials: PG
authors.lastname: Lawlor
mesh_terms: D015897:Comorbidity; D003693:Delirium / Q000145:classification* / Q000175:diagnosis* / Q000453:epidemiology; D003704:Dementia / Q000145:classification / Q000175:diagnosis / Q000453:epidemiology; D003937:Diagnosis, Differential; D006801:Humans; D010166:Palliative Care / Q000379:methods*; D011596:Psychomotor Disorders / Q000145:classification / Q000175:diagnosis
keywords: Delirium; assessment; classification and hospice; dementia; diagnosis; palliative care; psychomotor; subsyndromal