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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 cycle
In other words, attention and cognition are impaired.

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

Prevalence

in hospital

ranges from 1020% in medical wards

could become higher as the elderly population in hospital

increases

Incidence

during hospitalisation

ranges from 430%

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

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

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
Cushings Disease

Neurological disorder

Stroke

ICB

Subdural hematoma

Subarachnoid hemorrhage

Venous thrombosis

Neoplastic

Epilepsy : non convulsive

status

Head injury

Inflammatory : multiple
sclerosis

Vasculitis

Cardiovascular disease

Drug abuses

Ischaemic heart disease

infarct @ ischaemic

Arrythmias

Hypertensive
encephalopathy

Pharmacologic

Environmental

Hypothermia @
Hyperthermia

alcohol
cocaine
amphetamines

Salicylate toxicity
Anticholinergic toxicity
Medication reaction @
interaction (bleeding-aspirin)

Others

pain
constipation
urinary retention

How to evaluate a patient

with acute confusional
state?
Comprehensive history and physical
examination, including cognitive testing

+ History
Onset

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

On examination

GCS

Unequal pupils

Pale?Cyanoses?

Neck stiffness, Kernig's sign

Vital signs

BP

Pulse rate

or Brudziski sign

regular @ irregular

Ear&nose : discharge ( trauma?any

raccoon eye?)

Lungs : breath sound, additional

tachy @ bradycardia sounds
Temp
CVS : heart sound, any murmurs
Pulse oximetry

Abdomen : mass ( pulsatile mass :

Bedside glucometer /DXTleaking Abnormal Aortic Aneurysm)
hypo@hyperglycaemia
Neurological : movement of all
limbs,tone, power, reflexes, plantar

Investigations
ECG

AMI, ischemic changes,

arrythmias

Blood Ix

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

pneumonic patches, TB
changes(TB workup), mass

Urinalysis

FBC anaemia, infection

CXR:

UTI-UFEME

CT scan
stroke @ ICB @ mass

with/without midline shift

MRI (if indicated)

vasculitis @ inflammatory

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..

MANAGEMENT

First and foremost treat the

underlying cause / precipitating
factors

Principles of treatment

Find the cause

Treat symptomatically

Moderate sensory balance

not too bright and noisy but not too dark

Social support and visiting

for example, correct fluid and electrolyte balance and

nutritional status; treat infections

Delusions and hallucinations should be neither endorsed

nor challenged

Good night's sleep

Avoid drugs if possible

Haloperidol

0.51.0 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