Tests of attention in context of delirium

Attention in delirium

Impaired attention is the cardinal, defining feature of delirium (distinguishing it from dementia, where attention is often relatively preserved until late stages) - specific bedside tests of attention are therefore central to delirium diagnosis, not just general cognitive screening
Delirium is common and frequently under-recognised in hospitalised older patients, particularly the hypoactive subtype, which lacks the agitation that prompts recognition of hyperactive delirium

Attention (the ability to focus, sustain, and shift concentration) depends on intact, integrated cortical and subcortical arousal networks - delirium's global cerebral dysfunction disrupts this network diffusely, producing the fluctuating inattention characteristic of the syndrome, distinct from the more focal/progressive deficits of dementia

Simple bedside attention tests: digit span (repeating a sequence of numbers forwards, then backwards), months of the year backwards, spelling "WORLD" backwards, or sustained attention tasks (e.g. squeezing a hand on hearing a specific letter in a spoken sequence)
Confusion Assessment Method (CAM) formalises this into a diagnostic algorithm: acute onset/fluctuating course + inattention + (disorganised thinking OR altered level of consciousness) = delirium - inattention is a required, non-negotiable criterion, not just a supportive feature

A positive delirium screen should trigger a systematic search for the underlying precipitant(s) (infection, metabolic derangement, drugs, urinary retention/constipation, pain, unfamiliar environment) rather than symptomatic sedation alone
Serial attention testing can help track resolution (or persistence) of delirium over the course of treatment

Hypoactive delirium (commonly missed), the CAM diagnostic algorithm, dementia vs delirium distinction
A patient can appear calm and cooperative (hypoactive delirium) while still being significantly inattentive and delirious - formal attention testing catches cases that would be missed by simply observing whether the patient seems agitated or distressed

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