Acute Confusional States

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Acute Confusional States

• 6th Year Medical Camp
• UWA
• 19th July 2008
• Vera Sistenich

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Content

• Overview of terminology
• 4 cases of confusion presenting to ED
• Assessment, diagnosis management
• Differentiate delirium, dementia, amnesia
• Summary
• You should not be confused by the end!

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Overview of terminology

• ACS can just Delirium
• Another context all confusion which presents
  acutely
• - Delirium
• - Dementia
• - Amnesia
• ACS also called
• - Mental State Changes (MSC)
• - Organic Brain Syndromes (OBS)
• Physical (organic) v Psychiatric (functional)
• But beware some organic components to some ?

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OBS / MSC / ACS

• Diagnosis may be clear-cut
• They may exacerbate each other / co-exist
• Diagnosis may be v challenging in these cases

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Case 1

• 79 y.o. ?
• Previously well, lives alone
• Neighbour usually chats to her over fence
• Today finds her dithery in movements confused
• Just not making sense
• Called ambulance

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Assessment

• Looks anxious with coffee stain on dress
• Doesnt smell good
• Disorientated in time place
• Asking to go home
• Not answering your questions appropriately, not
  concentrating on your questions, babbling about
  feeding her dog

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• Temp 37.9ºC
• HR 102/min, BP 100/76mmHg
• RR 20/min, Sats 98 RA
• Dry lips tongue
• No evidence head injury / trauma
• Heart sounds normal, chest clear
• Abdomen normal, wet underpants
• What Ix would you like to do?

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• BSL 5.4
• ECG LBBB which is old
• FBC, UE pending
• Urine Blood , Nitrites
• What is your provisional ??
• Delirium secondary to UTI

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Delirium (DSM-IV Criteria)

• Disturbance of consciousness ? ability to
  focus, sustain or shift attention
• Changes in cognition not better explained by
  pre-existing, established or evolving dementia
• Disturbance develops rapidly fluctuates
• Evidence from Hx, Ex, Ix that disturbance due to
  direct physiologic consequences of general
  medical condition, intoxicating substance,
  medication or gt 1 cause

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Causes of Delirium

• Drugs
• Emotion Environment
• Low O2
• Infection Infarction
• Retention
• Ictal states
• Undernutrition
• Metabolic
• Stroke

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Management

• Further Ix to consider
• - LFT, Ammonia, Coags, Ca
• - TFT, VDRL, Synacthen test
• - CXR
• - CT Head
• - LP

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• Treat the underlying cause
• Drugs to help control agitation
• - Nothing if possible
• - Midazolam 1 5mg IV
• - Lorazepam 1 2mg PO
• - Haloperidol 1 5mg PO / 0.5 2mg IV
• - Droperidol 2.5 5.0mg IM/IV
• - Risperidone 0.5 1mg PO
• - Olanzapine 2.5 10mg PO/IM

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Case 2

• 23 y.o. ?
• Brought in by mother who found her crying in her
  room, acting bizarrely
• Empty packet of Promethazine
• Thinks she has taken 20 x 25mg tablets
• Recent break-up with boyfriend and failed exam
• No PMHx / P?Hx except allergic urticaria

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Assessment

• Confused disorientated in time place
• Fluctuating mental state
• Restless fidgeting
• Visual hallucinations plucking at air
• Mumbled speech not directed at questions
• Disruptive behaviour

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• Temp 38.0ºC, HR 120/min, BP 130/70mmHg
• RR 22/min, Sats 100 RA
• Flushed complexion
• Dry mouth
• Dry skin
• Dilated pupils
• Tremulous ankle clonus
• What is your d??

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• Anticholinergic delirium
• Serotonin syndrome
• Neuroleptic malignant syndrome
• Neurotrauma
• Encephalitis / sepsis
• SAH
• Ictal state
• Hypoglycaemia / hyponatraemia
• Wernickes encephalopathy

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Anticholinergic delirium

• Inhibition of central peripheral ACh MusR
• Hot as a hare, red as a beet, blind as a bat,
  dry as a bone, mad as a hatter
• Manifests lt 12hrs from time of ingestion
• Can last for days
• Differentiate from other toxidromes by type of
  drug ingested clinical signs

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• Injury to self / others
• Hyperthermia
• Dehydration
• Rhabdomyolysis
• Pre-renal RF
• Pulmonary aspiration atelectasis
• Seizures / coma
• Multi-organ failure

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Management

• Ix to consider
• Paracetamol level
• ECG
• UE, CK
• Urinalysis ßHCG
• Address d? as needed

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• A, B, C
• Treat seizures with benzodiazepines
• Treat agitation with Diazepam 10mg PO/IV PRN
• Correct hyperthermia
• Correct hypoglycaemia
• IDC for retention
• Supportive care
• Physostigmine

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• If patient presents to ED with psychosis, all
  drugs worn off / not present / causes of delirium
  excluded ? ? assessment
• Patients with underlying ? ? may present with
  drug-induced psychosis / drug non-compliance /
  causes of delirium

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Case 3

• 81 y.o. ?
• Brought in by Police
• Walked into department quite normally
• Found wandering streets, didnt know way home
• He tells you he wasnt sure why he went out but
  suddenly realised he was lost
• Is terribly sorry to cause you trouble

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Assessment

• Looks well
• Well dressed but dirty clothes
• Missed a few bits of beard shaving
• You hold a very pleasant conversation with him
• He knows he is in hospital but not which one
• Orientated in person, not time or place

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• Temp 36.4ºC, HR 72/min, BP 162/90mmHg
• RR 16/min, Sats 97 RA
• No evidence trauma
• You hear a PSM
• Nothing else of note
• He hands you little notebote from pocket with
  family members tel nos.
• What would you like to do?

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• BSL 7.2
• ECG NSR
• Urinalysis clear
• FBC, UE pending

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• You call patients daughter for collateral Hx
• She is distraught he is lost (again)
• Has happened before but he wants to live alone
• He takes Donezepil (Aricept)
• Your ? is
• Alzheimers dementia

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Dementia (DSM-IV Criteria)

• Syndrome due to disease of the brain
• Usually chronic or progressive
• Disturbance of multiple higher cortical functions
• Consciousness not clouded
• Commonly accompanied by deterioration in
  emotional control, social behaviour or motivation

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Main types of Dementia

• Alzheimers disease
• Vascular dementia
• Parkinsons dementia with Lewy bodies
• Others
• - Picks frontal temporal lobe dementia
• - Prion-related disease (CJD)
• - Progressive supranuclear gaze palsy

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• Diagnosis is clinical
• Need first to exclude delirium
• Subtle differences in order and degree of
  cognitive loss e.g. memory, language personality
• Folsteins MMSE
• - 25/30 normal
• - 20 24 mild dementia
• - 10 19 moderate dementia
• - lt 10/30 severe dementia

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Management

• Exclude causes of delirium
• Patients with dementia at ? risk delirium
• May need higher level care
• Behavioural therapy
• Drugs
• - Cardiovascular drugs if vascular dementia
• - Centrally acting acetylcholinesterase
  inhibitors
• - Memantine NMDA-R blocker (glutamate
  antagonist)

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Delirium vs Dementia
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Case 4

• 73 y.o. ?
• Referred by GP with ? Psychosis
• Went to vet this morning
• Told cat had ESRF needed dialysis
• Son noticed she was not right when returned
• Seemed to have forgotten events of past yr
• Kept asking for husband who died 9 months ago
• Burst into tears when told, then asked again
  later

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Assessment

• History
• - Medications / precipitants
• - PMHx / P?Hx
• - Vascular RF
• - Previous episodes
• - Focal neurological symptoms / seizure activity
• Examination
• - Trauma / infection / focal neurological
  deficit
• - Memory personal, immediate, recent, remote
• - Concentration / attention / higher functions

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• Patient looks well, but anxious something is
  wrong
• Afebrile, all vital signs normal
• No focal neurological deficit
• You detect anterograde amnesia
• Keeps bursting into tears when told husband dead
• Retrograde memory loss for past 1 yr
• Recalls prior events lucidly
• All bedside blood tests normal
• CT head normal
• What is your d??

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• Transient global amnesia (TGA)
• Trauma (concussion)
• Transient epileptic amnesia (TEA)
• Transient ischaemic attack (TIA)
• Transient neurological attack (TNA)
• Migraine
• Psychiatric (functional)
• Korsakoffs
• Encephalitis
• Tumours
• Hippocampal infarction

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Transient Global Amnesia

• Self-limited, sudden, severe anterograde amnesia
• Autobiographical, verbal non-verbal memory N
• Immediate recall N
• Repetititive questioning, behaviour otherwise N
• Retrograde amnesia of hrs yrs
• Often anxious about episode
• Episode lasts 1 8 hrs
• Rapid return anterograde, slower retrograde

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• Episode must be witnessed
• Acute onset anterograde amnesia hallmark
• No altered conscious state
• No other cognitive impairment
• No focal neuro deficit / epileptic features
• No other causes of delirium
• Episode largely resolved in 24 hrs

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Precipitants of TGA

• Valsalva manoeuvre
• Emotional stress
• Physical activity
• Medical procedures / interventions

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? Causes

• Hypoxic / ischaemic
• Paradoxical emboli
• Seizure
• Migraine
• Transient venous hypertension
• Psychogenic
• All Ix essentially N

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Management

• Exclude other causes delirium as needed
• Reassure during episode
• Safe environment
• Often diagnosed in retrospect

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Summary

• Terminology ACS, MSC, OBS
• Physical (organic) v Psychiatric (functional)
• Some organic components to some ? conditions
• Delirium acute onset, altered consciousness,
  fluctuates, reversible
• Dementia insidious onset, normal consciousness,
  progressive, irreversible
• Amnesia may be isolated or secondary
• Diagnosis may be clear-cut or may overlap

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• Enjoy rest of camp!