Things We Do for No Reason: Neuroimaging for Hospitalized Patients with Delirium

Inspired by the ABIM Foundation’s Choosing Wisely® campaign, the “Things We Do for No Reason” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

A 67-year-old woman with a history of hypertension and osteoarthritis was hospitalized for fever, flank pain, and dysuria with pyuria on urinalysis. She was diagnosed with acute pyelonephritis and started ceftriaxone, ondansetron for nausea, and oxycodone for pain. On hospital day two, she developed acute confusion that waxed and waned in severity throughout the day. On examination, she appeared mildly agitated, inattentive, and was noted to pick at her linens and garment. She was oriented to person only and had a nonfocal neurologic examination. Her nurse reported no recent falls or trauma. As part of the patient’s evaluation, her attending physician ordered a head computed tomography (CT) scan.

Delirium is commonly diagnosed in hospitalized patients. It has a prevalence of 29%-64% and is associated with longer lengths of stay, higher mortality, and costs of over $164 billion per year in the United States.¹ While a number of practice guidelines have been created to help guide delirium diagnosis and management, there is not a clear consensus on when neuroimaging should be performed during the evaluation.^2-4 It should also be noted that numerous guidelines for delirium management exist, with variable quality and a heavy reliance on expert opinion.⁵ Perhaps due to this lack of consensus, neuroimaging is performed in 33% to 67% of hospitalized patients with delirium.^6,7

Delirium is known to be associated with intracranial processes. For example, delirium occurs in 13% to 48% of patients with acute stroke⁸ and conversely 7% of patients with new confusion evaluated in emergency departments or inpatient settings were found to have an acute stroke.⁹ The inclusion of neuroimaging as part of a delirium evaluation is supported in certain circumstances, such as in patients with recent falls, focal neurologic signs (including papilledema), systemic anticoagulation,² or increased risk of intracranial processes such as metastatic malignancy.⁴

A number of studies have evaluated the diagnostic yield of neuroimaging in hospitalized patients with delirium (Table).^6,7,10,11 Two studies included patients with delirium that developed after hospitalization^10,11 and two included patients with delirium at admission.^6,7