Does dysgraphia determine delirium?

From the Guidelines

No, dysgraphia does not determine delirium, as they are two distinct neurological conditions with different characteristics and causes. Dysgraphia is a learning disorder that affects a person's ability to write coherently, with symptoms including poor handwriting, spelling difficulties, and trouble putting thoughts on paper. Delirium, on the other hand, is an acute confusional state characterized by disturbed consciousness, reduced ability to focus attention, and cognitive changes, as described in the 2024 update of the ACR Appropriateness Criteria for altered mental status, coma, delirium, and psychosis 1. Delirium typically develops rapidly and is often caused by underlying medical conditions such as infections, medication side effects, metabolic imbalances, or substance withdrawal.

Some key points to consider:

• Delirium is a medical emergency that requires early detection and accurate diagnosis, as mortality in patients may be twice as high if the diagnosis of delirium is missed 1.
• The economic impact of delirium in the United States is profound, with total costs estimated at $38 to $152 billion each year 1.
• Delirium can affect anyone, particularly the elderly or hospitalized patients, and its presence is not predicted or caused by dysgraphia, as they have different pathophysiological mechanisms and clinical presentations.
• The diagnosis of delirium is based on the presence of disturbed consciousness, reduced ability to focus attention, and cognitive changes, which are distinct from the symptoms of dysgraphia, as outlined in the clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit 1.

Overall, the presence of dysgraphia does not determine delirium, and these two conditions should be diagnosed and managed separately based on their distinct characteristics and causes. The most recent and highest quality study, the 2024 update of the ACR Appropriateness Criteria, supports this conclusion and emphasizes the importance of early detection and accurate diagnosis of delirium 1.

From the Research

Relationship Between Dysgraphia and Delirium

• Dysgraphia is a recognized clinical finding in delirium, with studies indicating that patients with delirium often exhibit handwriting problems, including abnormalities of omission, illegibility, and spelling 2.
• The presence of dysgraphia, particularly in the form of abnormal signatures, may be an indicator of delirium, with a sensitivity of 0.54 and specificity of 0.88 for detecting delirium as defined by the Confusion Assessment Method (CAM) 2.
• Dysgraphia and constructional apraxia are useful clinical signs of delirium in psychiatric inpatients, with a global rating of writing quality and evidence of jagged or angled letter loops being informative clinical signs 3.

Pathophysiology and Diagnosis of Delirium

• Delirium is an acute confusional state that is common and costly, associated with significant functional decline and distress, and is the manifestation of acute encephalopathy 4.
• The pathophysiologic cause of delirium is not well understood, and it is typically multifactorial, with several physiological and/or pharmacological contributors 5.
• Casual observation is seldom sufficient to detect delirium, and the use of open-ended questions, regular neurocognitive testing, and validated delirium screening instruments can aid in accurately identifying cases of delirium 5.

Management and Treatment of Delirium

• Nonpharmacological management of delirium is first-line, both for prevention and treatment, and psychotropic drugs such as neuroleptics are not recommended for routine use in delirium 5.
• Antipsychotic medications such as haloperidol can be used to reduce agitation and psychosis in delirium, but their use must be judicious and carefully monitored due to the risk of extrapyramidal symptoms (EPSs) 6.
• The development of a physiologically-based pharmacokinetic (PBPK) model for haloperidol can help estimate plasma and unbound interstitial brain concentrations and determine dopamine receptor occupancy and antagonism, which can inform treatment decisions 6.