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Acute Confusional State / Delirium

Muhammad Farid Azraai

+Introduction

• The approach requires • knowledge• skill • Experience

• Correct diagnosis & appropriate management can be improve with • careful history taking, examination & observation

• The challenges are :• Is this patient confused and why?• If so, what is the cause?• Can the cause be corrected so the confusion clears?

+Definition

Delirium or acute confusional state Non-specific organic cerebral syndrome, characterised by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion and the sleep-wake cycleIn other words, attention and cognition are impaired.

J Neurol Neurosurg Psychiatry 2001;71:i7-i12 doi:10.1136/jnnp.71.suppl_1.i7

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Prevalence in hospital ranges from 10–20% in medical wards could become higher as the elderly population in hospital

increases

Incidence during hospitalisation ranges from 4–30% about 25% of people over 70 years old admitted to hospital

have delirium.

+Presentations

Range of different behaviours

hyperactive @ agitated delirium hypoactive or quiet delirium can have both or neither subtype

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Reduced attention and distractibility

Impaired memory, paramnesias

Disorientation to place and time

Abnormal language content, agraphia

Calculation impairment

Misperceptions, hallucinations, delusions

Reduced abstract reasoning, insight, judgement

Labile moods, facetiousness

Alterations of the sleep-wake cycle

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Causes @ precipitating factors

+ Infection

• Sepsis : UTI /chest• Meningitis • Encephalitis • Abscess

Metabolic disorder & nutritional hypo @ hypernatraemia hypercalcaemia hypoxia @ hypercapnia cerebral hypoperfusion hypo @ hyperglycaemia acidosis renal failure – uraemia hepatic failure thiamine deficiency vitamin B 12 deficiency

Endocrine hypo @ hyperthyroidism hyperparathyroidism Cushing’s Disease

Neurological disorder Stroke ICB

Subdural hematoma Subarachnoid hemorrhage

Venous thrombosis Neoplastic Epilepsy : non convulsive

status Head injury Inflammatory : multiple

sclerosis Vasculitis

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Cardiovascular disease Ischaemic heart disease

infarct @ ischaemic Arrythmias Hypertensive

encephalopathy

Environmental Hypothermia @

Hyperthermia

Drug abuses alcohol cocaine amphetamines

Pharmacologic Salicylate toxicity Anticholinergic toxicity Medication reaction @

interaction (bleeding-aspirin)

Others pain constipation urinary retention

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How to evaluate a patient with acute confusional

state?

Comprehensive history and physical examination, including cognitive testing

+HistoryOnset of symptoms & associated symptoms

Evaluate for recent & past medical illness and interventions/surgery been done recently

Gather collateral information from family/friends regarding baseline function, personality, psychiatric history

Review drug chart @ medication list including scheduled, recent meds discontinued @ started

+On examinations

ACCESS GCS !Do GCS charting, monitor GCS

*if GCS is full : suggest MMSE

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+On examination

GCS

Pale?Cyanoses?

Vital signs BP Pulse rate –

regular @ irregular tachy @ bradycardia

Temp Pulse oximetry

Bedside glucometer /DXT– hypo@hyperglycaemia

Unequal pupils

Neck stiffness, Kernig's sign

or Brudziński sign

Ear&nose : discharge ( trauma?any raccoon eye?)

Lungs : breath sound, additional sounds

CVS : heart sound, any murmurs

Abdomen : mass ( pulsatile mass : leaking Abnormal Aortic Aneurysm)

Neurological : movement of all limbs,tone, power, reflexes, plantar

+Investigations

ECG AMI, ischemic changes,

arrythmias

Blood Ix FBC – anaemia, infection RP, Ca, Mg, PO4 - electrolyte imbalance ABG - respiratory @ metabolic

@ mixed Cardiac enzyme : ck, ckmb,

troponin t( if available) If fever, to do septic work up LFT TFT Vitamin B12

CXR: pneumonic patches, TB

changes(TB workup), mass

Urinalysis UTI-UFEME

CT scan stroke @ ICB @ mass

with/without midline shift

MRI (if indicated) vasculitis @ inflammatory

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Lumbar puncture if treated for

meningoencephalitis @ meningitis opening pressure FEME / cytology biochem C+S Indian Ink Cryptococcal Ag AFB direct smear, PCR Mycobacterium C+S Viral study

Drug screening & toxicology : if indicated

EEG - if indicated

UPT - childbearing age woman

+CSF normal values..

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+MANAGEMENT

First and foremost treat the underlying cause / precipitating

factors

+Principles of treatment

Find the cause

Treat symptomatically for example, correct fluid and electrolyte balance and

nutritional status; treat infections

Moderate sensory balance not too bright and noisy but not too dark

Social support and visiting Delusions and hallucinations should be neither endorsed

nor challenged

Good night's sleep

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Avoid drugs if possible

Haloperidol 0.5–1.0 mg initially, can be repeated after 30 minutes severe agitated delirium may require doses up to 10 mg

daily, should not be used in the old or frail. should be tapered off and stopped before the patient is

discharged benzodiazepines may be preferred when withdrawal

delirium is causing agitation eg : lorazepam 0.05mg/kg

+Outcome and prognosis

Mortality depends on the patient population & time period covered most series show a significantly increased mortality in

patients who develop delirium.

any recovery may be slow

more likely to develop dementia.

+Thank You