Acute Confusional State

Dr.Hisham Abid AldabaghMedical Specialist

Kingdom of Saudi ArabiaMinistry of HealthDirectorate of Health Affairs in Gurayat Gurayat General Hospital

• Delirium, dementia, amnesia, and certain other alterations in cognition, judgment, and/or memory are subsumed under more general terms such as mental status change, acute confusional state, or altered mental status.

• Altered mental status can be divided into 2 major subgroups:

• Acute (delirium or acute confusional state), and chronic (dementia).

• A third entity, encephalopathy (subacute organic brain syndrome), denotes a gray zone between delirium and dementia; its early course may fluctuate, but it is often persistent and progressive.

Pathophysiology

• The final common pathway of all forms of organically based mental status change is

• an alteration in cortical brain function, with abnormalities of deep brain structures.

• These conditions result from • (1) an exogenous insult or an intrinsic process that

affects cerebral neurochemical functioning and/or • (2) physical or structural damage to the cortex,

subcortex, or to deeper structures involved with memory.

• The end result of these disruptions of function or structure is impairment of cognition that affects some or all of the following:

• Alertness, orientation, emotion, behavior, memory, perception, language, praxis, problem solving, judgment, and psychomotor activity.

Epidemiology

• Delirium accounts for or develops during 10-15% of all admissions to acute-care hospitals but is seen much more frequently in elderly persons (up to >50%, particularly following major surgery or trauma).

• Alzheimer disease (AD) accounts for most patients with dementia who are older than 55 years (50-90% of all cases).

Epidemiology• Race• Delirium is seen more commonly in whites than in

other races.• Sex• Delirium is seen more commonly in females than in

males. • Age• Delirium due to physical illness is more frequent

among the very young and those older than 60 years. • Delirium due to drug and alcohol intoxication or

withdrawal is most frequent in persons aged mid teens to the late 30s.

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History• Delirium presents with acute onset of impaired

awareness, easy distraction, confusion, and disturbances of perception (e.g, illusions, misinterpretations, visual hallucinations).

• Recent memory is usually deficient, and the patient is typically disoriented to time and place.

• The patient may be agitated or obtunded, and the level of awareness may fluctuate over brief periods.

• Speech may be incoherent, pressured, nonsensical, perseverating, or rambling, which may make the taking of an accurate history from the patient impossible.

• Patients with delirium have difficulty maintaining attention and/or changing the focus of their attention.

• Attempt to obtain a current and past history from other sources, including prehospital workers, family or friends, and past medical records.

• Look specifically for street drug, alcohol, and medication use; preexisting endocrine disorders; and recent activities that may have resulted in exposure to toxins or environmental injury.

• Ask about prior psychiatric illness and similar episodes of confusion in the past, to uncover a treatable or modifiable cause for the cognitive impairment.

Physical• The delirious or obtunded patient should be

evaluated for pupillary, funduscopic, and extraocular abnormalities; nuchal rigidity; thyroid enlargement; and heart murmurs or rhythm disturbances.

• Other clues include a pulmonary examination that reveals wheezing, rales, or absent breath sounds;

• an abdominal examination that reveals hepatic or splenic enlargement; or a cutaneous examination that shows rashes, icterus, petechiae, ecchymoses, track marks, or cellulitis.

Look for track marks.• Smell for alcohol, the musty odor of fetor hepaticus, or the fruity

smell of ketoacidosis.• Icterus and asterixis point to liver failure with an elevation of the

serum ammonia level.• Agitation and tremulousness suggest sedative drug or alcohol

withdrawal.• Fever may point to infection, heat illness, thyroid storm, aspirin

toxicity, or the extreme adrenergic overflow of certain drug overdoses and withdrawal syndromes (in particular, delirium tremens). Extreme hyperthermia (with pinpoint pupils) may be seen in pontine strokes.

• In patients with a rapid respiratory rate, consider diabetic ketoacidosis (ie, Kussmaul respiration), sepsis, stimulant drug intoxication, and aspirin overdose.

• In patients with a slow respiratory rate, consider narcotic overdose, CNS insult, or various sedative intoxications.

• A rapid pulse rate is seen in patients with fever, sepsis, dehydration, thyroid storm, and various cardiac dysrhythmias and in overdoses of stimulants, anticholinergics, quinidine, theophylline, tricyclic antidepressants, or aspirin.

• Patients with a slow pulse rate may have elevated intracranial pressure, asphyxia, or complete heart block. Calcium channel blockers, digoxin, and beta-blockers also may produce altered mental status and bradycardia.

• Blood pressure elevation is common in delirium because of resulting adrenergic overload.

• In pregnant patients with a diastolic pressure greater than 75 mm Hg in the second trimester or greater than 85 mm Hg in the third trimester, consider preeclampsia (ie, hyperreflexia, edema, proteinuria).

• In patients with hypertension and bradycardia, consider an elevated intracranial pressure.

• With delirium and hypotension, the differential diagnosis includes dehydration, diabetic coma, hemorrhage due to trauma, aneurysmal rupture, or GI bleeding. Also, consider adrenergic depletion secondary to cocaine; amphetamine; or tricyclic overdose. Addisonian crisis, particularly in those who are steroid dependent, should be considered.

• Pupillary dilation is seen in anticholinergic overdose (diphenhydramine), stimulant use, and hallucinogen use. A common feature of diphenhydramine and other antihistamine overdoses is picking at imaginary objects in the air.

• Pupillary constriction is seen in narcotic intoxication

• Serious head trauma is usually obvious. However, occult trauma may be discovered by findings of basilar skull fracture.

• At times, it may be difficult to distinguish between acute delirium, psychiatric crisis, or a chronic process with exacerbation such as dementia. It is safest to presume delirium until an alternative process can be proven through testing and/or clinical observation.

Assessment• The Mini-Mental Status Examination (MMSE) is a formalized

way of documenting the severity and nature of mental status changes: (The maximum score per item is indicated in parentheses).

• Orientation (5): What are the year, season, date, day, and month?

• Orientation (5): Where are we (ie, state, county, town, hospital, and floor)?

• Registration (3): Name 3 objects (ask the patient to repeat these 3 objects).

• Attention and calculation (5): The serial 7 test awards 1 point for each correct answer. Stop after 5 answers. Spelling "word" backwards is optional.

• Recall (3): Ask for the 3 objects (from Registration) to be repeated. One point is scored for each correctly recalled object.

• Language (2): Name a pencil and a watch. • Repetition (1): Repeat the following: "No ifs, ands, or

buts." • Complex commands (6): Follow a 3-stage command,

such as "Take a paper in your right hand, fold it in half, and put it on the floor" (3 points). Next, read and follow these printed commands: "Close your eyes" (1 point); "Write a sentence" (1 point); and "Copy design" (1 point)

• A score of less than 24 suggests the presence of delirium, dementia, or another problem affecting the patient's mental status and may indicate the need for further evaluation.

• In addition, or as an alternative to the MMSE, correctly drawing the face of a clock (to include the circle, numbers, and hands) is a sensitive test of cognitive function. To perform this test, ask the patient to draw a clock with the hands at 8:20. Two or more errors significantly correlate with dementia. No errors rule against dementia.

CausesHigh fever seen with infection or heat stroke Renal failure Liver failure Neoplasia Inflammation (eg, systemic lupus erythematosus) Cerebral vascular accident (CVA) Respiratory dysfunction (eg, hypoxia, hypercarbia) Shock Chronic neurological disorders such as dementia and Parkinson disease “Sundowning”

Intoxication with a substance (eg, hallucinogens, alcohol, medications, toxins) Polypharmacy, most often with psychoactive medications Major surgery, orthopedic trauma, prolonged immobility, and “ICU psychosis” Occult infection (e.g, UTI, meningitis, encephalitis, neurosyphilis, sepsis) Head trauma Seizure disorder Acute mania or other psychiatric etiology Endocrine crisis (eg, thyroid, adrenal, diabetic) .

Differential DiagnosisSchizophreniaStatus EpilepticusSubarachnoid HemorrhageSubdural HematomaTick-Borne Diseases, LymeToxicity, AmphetamineToxicity, AnticholinergicToxicity, AntidepressantToxicity, AntihistamineToxicity, CocaineToxicity, Cyclic AntidepressantsToxicity, HallucinogenToxicity, LeadToxicity, LithiumToxicity, Mushroom - HallucinogensToxicity, Nonsteroidal Anti-inflammatory AgentsToxicity, Thyroid HormoneToxicity, TolueneToxicity, ValproateVariant Creutzfeldt-Jakob Disease and Bovine Spongiform EncephalopathyWernicke EncephalopathyWithdrawal Syndromes

Brain AbscessConversion DisorderDelirium TremensDepression and SuicideDiabetic KetoacidosisEncephalitisEpidural and Subdural InfectionsHeat Exhaustion and HeatstrokeHerpes SimplexHerpes Simplex EncephalitisHIV Infection and AIDSHypercalcemiaHypernatremiaHyperosmolar Hyperglycemic Nonketotic ComaHypertensive EmergenciesHypoglycemiaHypothyroidism and Myxedema ComaNeoplasms, BrainNeuroleptic Malignant SyndromePanic DisordersPlant Poisoning, Alkaloids - Isoquinoline and QuinolinePlant Poisoning, Alkaloids - TropanePlant Poisoning, Glycosides - Cardiac

Laboratory Studies• Oxygen saturation and, in some cases, ABG with

a carbon monoxide level are helpful. • CBC count, electrolytes level, blood glucose level,

BUN level, and creatinine level should be checked.

• In older patients, consider vitamin B-12 and folate levels.

• Consider calcium level, magnesium level, and liver function tests (LFTs), including serum ammonia, prothrombin time (PT), and activated partial thromboplastin time (aPTT).

• Urinalysis is also indicated

• When alcohol, drugs, and/or toxins are suspected, consider the following:

• Serum ethanol, salicylate, acetaminophen, carbon monoxide, and other specific drug or toxin levels as indicated

• Comprehensive drug analyses of blood and urine• Such toxic screens are generally not helpful in the

acute setting unless turnaround time is rapid.

• In a suspected endocrine emergency, the following are required:

• A bedside fingerstick blood glucose determination followed by serum glucose and serum acetone

• Thyroid-stimulation hormone (TSH), possibly thyroid panel

• Serum cortisol• Serum calcium, phosphorus, and parathyroid levels

• In suspected CNS infection, the following may be ordered:

• Lumbar puncture may be done for CSF studies, including cryptococcal antigen or India ink prep, and VDRL.

• CT scan of head should be done before lumbar puncture to rule out toxoplasmosis or abscess, especially in patients with HIV who present with headache

Imaging Studies• A head CT scan without intravenous (IV) contrast

should be obtained if CNS infection, trauma, or a cerebral vascular accident (CVA) is suspected.

• Although not typically part of the workup in the ED, a brain MRI may be considered if readily available and the need confirmed by neurologist and/or radiologist. MRI helps distinguish between Alzheimer disease and vascular causes of dementia.

• Plain abdominal radiographs may reveal swallowed bags that contain drugs of abuse ("body packing") or radiodense substances such as iron tablets.

Emergency Department Care

• ED physicians caring for the patient with agitation, confusion, or delirium, must ensure the safety of both the patient and the staff while attending to issues of airway protection and immediate recognition and treatment of rapidly reversible problems (eg, hypoxia, hypoglycemia, narcotic overdose).

• Provide supplemental oxygen unless oxygen saturation is above 93% on room air.

• When carbon monoxide poisoning is suspected, ignore the oxygen saturation, obtain a carboxyhemoglobin level, and provide 100% oxygen.

• In cases of airway compromise, coma, or poor gag reflex, the ED physician should have a low threshold for intubation. Use rapid sequence intubation (RSI), particularly in the settings of possible head trauma, elevated ICP, or a combative patient. RSI/intubation may be necessary to facilitate imaging studies.

• Treat suspected overdose-induced delirium based on ingestion history and/or toxidromes. Such treatment may range from simple observation and supportive care, activated charcoal, lavage (rarely performed), sedation, specific antidotes to intubation/life support.

• Behavioral control of a patient with delirium who is agitated and combative should be primarily medication-based with physical restraining kept at a minimum and for protection of both the patient and staff .

• Conversely, inpatient prevention and management of delirium should strive to avoid or minimize use of sedating medications. These medications increase confusion, reduce attentiveness, and impair orientation, thereby exacerbating delirium.

I wish God protect you from delirium

Great thanks for your interest