Farid's Presentation Acs

of 24 /24
+ Acute Confusional State / Delirium Muhammad Farid Azraai

Embed Size (px)



Transcript of Farid's Presentation Acs

Page 1: Farid's Presentation Acs


Acute Confusional State / Delirium

Muhammad Farid Azraai

Page 2: Farid's Presentation Acs


• 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?

Page 3: Farid's Presentation Acs


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

Page 4: Farid's Presentation Acs


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


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

have delirium.

Page 5: Farid's Presentation Acs


Range of different behaviours

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

Page 6: Farid's Presentation Acs


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

Page 7: Farid's Presentation Acs


Causes @ precipitating factors

Page 8: Farid's Presentation Acs

+ 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

Page 9: Farid's Presentation Acs


Cardiovascular disease Ischaemic heart disease

infarct @ ischaemic Arrythmias Hypertensive


Environmental Hypothermia @


Drug abuses alcohol cocaine amphetamines

Pharmacologic Salicylate toxicity Anticholinergic toxicity Medication reaction @

interaction (bleeding-aspirin)

Others pain constipation urinary retention

Page 10: Farid's Presentation Acs


How to evaluate a patient with acute confusional


Comprehensive history and physical examination, including cognitive testing

Page 11: Farid's Presentation Acs

+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

Page 12: Farid's Presentation Acs

+On examinations

ACCESS GCS !Do GCS charting, monitor GCS

*if GCS is full : suggest MMSE

Page 13: Farid's Presentation Acs


Page 14: Farid's Presentation Acs

+On examination



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

Page 15: Farid's Presentation Acs


ECG AMI, ischemic changes,


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

Page 16: Farid's Presentation Acs


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

Page 17: Farid's Presentation Acs

+CSF normal values..

Page 18: Farid's Presentation Acs


Page 19: Farid's Presentation Acs


Page 20: Farid's Presentation Acs


First and foremost treat the underlying cause / precipitating


Page 21: Farid's Presentation Acs

+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

Page 22: Farid's Presentation Acs


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

Page 23: Farid's Presentation Acs

+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.

Page 24: Farid's Presentation Acs

+Thank You