Acute Confusional State

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AcuteConfusionalState

• Frederick G. Flynn, DO, FAAN
• Medical Director, TBI Program
• Chief, Neurobehavior
• Madigan Army Medical Center
• Ft. Lewis, WA

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Acute Confusional StateObjectives

• Definition
• Characteristic clinical features
• Etiology / differential diagnosis
• Evaluation
• Management strategies
• Important pearls

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Attentional impairment is the principal
manifestation of the acute confusional state.
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Acute Confusional StateDSM-IV Criteria for
Delirium

• Disturbance in consciousness impairing awareness
  of the environment
• Reduced ability to focus, sustain, or shift
  attention
• Cognitive or perceptual disturbance not
  attributable to dementia

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Acute Confusional StateDSM-IV Criteria for
Delirium

• Acute to subacute onset (hours to days)
• Diurnal fluctuations
• Clinical/laboratory evidence relating the
  disturbance to a general medical condition

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Mental Status Assessment ACS

• Level of alertness
• Digit Span
• A Test
• Confusion Assessment Method (CAM)
• W-O-R-L-D backwards
• Writing a sentence or phrase
• Copying a three dimensional drawing

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Confusion Assessment Method (CAM)

• Acute onset/fluctuating course ?
• Inattention ?
• Disorganized thinking ?
• Altered level of consciousness ?
• Normal alert
• Hyperalert vigilant
• Drowsy, easily aroused lethargic
• Difficult to arouse stupor
• Unarousable coma

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Acute Confusional State Clinical Features

• Attention deficit
• Thought disorder
• Language/speech dysfunction
• Anomia/dysnomia
• Dysgraphia
• Visual Perceptive Dysfunction
• Failure to encode new memory

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Acute Confusional State Clinical Features

• Confabulation
• Disorientation to time and space
• Dyscalculia
• Perseveration (thought, speech, motor)
• Neuropsychiatric features

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Acute Confusional State Clinical Features

• Movement disorders
• Sleep-wake cycle disturbance
• Autonomic dysfunction

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Acute Confusional StateNeuropsychiatric Features

• Hallucinations (visualgttactilegtauditory)
• Delusions (simple/complex)
• Capgras syndrome
• Reduplicative paramnesia
• Persecutory fear

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Acute Confusional StateNeuropsychiatric Features

• Agitation
• Emotional lability
• Hyperexcitability
• Euphoria

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Acute Confusional StateNeuropsychiatric Features

• Depressed
• Apathetic
• Perplexed
• Mixed - hyper hypoactivation

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Acute Confusional StateMovement Disorders

• Seen mostly in toxic-metabolic encephalopathies
• Generalized tremulousness
• Tremor
• Asterixis

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Acute Confusional StateMovement Disorders

• Myoclonus
• Increased motor tone
• Hyperreflexia / extensor plantar responses
• Catatonia

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Acute Confusional StateEpidemiology

• Underreported - 2/3 of cases unrecognized
• Prevalence in elderly hospitalized - 15
• Incidence in elderly hospitalized - 3-31
• Higher incidence and prevalence in surgery
  patients

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Acute Confusional StateRisk Factors

• Advanced age
• Young children
• Underlying brain injury or disease
• Severity of illness- advanced CA
• Dehydration
• Infection
• Fever

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Acute Confusional StateRisk Factors

• Metabolic abnormalities
• Polypharmacy
• Anticholinergic drugs
• Sedative-hypnotic drugs
• Narcotics especially merperidine
• Pain
• Malnutrition
• Immobility (restraints)

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Acute Confusional StateRisk Factors

• Pre-existing dementia (3X risk for delirium)
• 50 of delirious elderly have pre-existing
  dementia or unmask a subclinical dementia
• Post-op in elderly

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Acute Confusional StateRisk Factors

• Post surgery
• Elderly
• Pre-op low HCT
• Burn patients
• Drug toxicity/withdrawal
• Low perfusion states
• Urinary catheters
• Urinary retention/constipation

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Acute Confusional StateEnvironmental Risk Factors

• Stay in ICU
• Stay in long term care unit
• Increased number of room changes
• Absence of clock or watch
• Absence of glasses or hearing aid
• Use of physical restraints

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Acute Confusional StateEtiologies

• Metabolic conditions
• Cardiac, pulmonary, renal, hepatic disease
• Glucose and electrolyte disturbances
• Systemic inflammatory disorders
• Hypoxia
• Anemia
• Porphyria

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Acute Confusional StateEtiologies

• Infection
• Systemic with fever
• UTI, pneumonia, sepsis-esp. in elderly
• Endocrine dysfunction
• Thyroid, parathyroid, adrenal, pituitary
• Nutritional deficiency
• Thiamine (Wernicke encephalopathy)
• B12, folate, biotin, niacin
• Protein-calorie malnutrition

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Acute Confusional StateEtiologies

• Intoxications
• Drugs (therapeutic and abused)
• Alcohol
• Withdrawal syndromes
• Heavy metals, industrial solvents, pesticides

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Acute Confusional StateEtiologies

• Multifocal / diffuse CNS
• Head trauma
• Encephalitis
• Epilepsy (ictal and postictal)
• Hypertensive encephalopathy
• Vasculitis
• Migraine

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Acute Confusional StateEtiologies

• Multifocal / diffuse CNS (continued)
• Subdural hematoma
• Neoplasm
• Stroke (acute phase)

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Acute Confusional StateEtiologies

• Focal CNS
• Right hemisphere
• Temporal (medial)
• Parietal (inferior)
• Frontal (inferior)
• Occipitotemporal (bilateral or left)
• Caudate

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Acute Confusional StateEtiologies

• Focal CNS (continued)
• Thalamus (paramedian)
• Midbrain (rostral)
• Internal capsule (genu)

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Acute Confusional StateEvaluation

• Guide- Hx, predisposing factors, assessment
• Medication review
• Toxicology panel
• Lytes, Glu, BUN, Creat, LFTs
• TFTs
• B12/Folate
• ESR/ANA/RF
• ABG - if respiratory compromise

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Acute Confusional StateEvaluation

• CT - if acute severe headache or trauma
• MRI if focal neurological findings or if no
  clear etiology for ACS sans focal findings
• LP - if no focal findings and fever is present
• EEG
• May help in determining etiology
• Important if complex partial seizures are
  suspected

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General Management of ACS

• Hydration
• Nutrition
• Adequate sleep
• Appropriate sensory and social stimulation
• Avoid constipation and urinary retention
• Proper sedation
• especially when agitation prevents evaluation and
  management of the underlying condition

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General Management of ACS

• Environmental manipulation
• Reassurance and gentle touch
• Verbal orientation
• Glasses/hearing aids if prescribed
• Avoid physical restraints
• Use as last resort
• Increases agitation
• Increases morbidity

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Acute Confusional StateManagement - Medical

• Lab/Imaging studies - guide to recognition and
  treatment
• Reduce psychological and behavioral symptoms
• Pharmacological management

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Acute Confusional StatePharmacological Management

• Thiamine (100 mg IV) before Dextrose (50-50 ml
  IV) Naloxone (2 mg IV)
• Specific pharmacotherapy of underlying etiology
• BZD overdose/Hepatic encephalopathy
• flumazenil 0.2 mg IV over 30 sec
• then 0.3 mg at 1 min
• then 0.5 mg q 1 min up to 3 mg total
• Anticholinergic Toxicity - physostigmine 0.5 -
  2.0 mg IV over 2 min. q 30-60 min. prn cardiac
  monitoring

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Acute Confusional StatePharmacological Management

• ETOH/Sedative Withdrawal - Thiamine 100 mg IV or
  IM once a day
• minor Chlordiazepoxide 25-100 mg po q6h or
  Lorazepam 2-5 mg po bid
• Delirium Tremens
• Chlordiazepoxide - 100 mg IV q2-6h, max 500 mg/24
  hr then taper dose to maintenance OR
• Diazepam 5-10 mg IV q 5-10 min until sedate then
  maintenance OR
• Lorazepam 2-4mg IV q 15-20 min until sedate
  then maintenance (can be used in hepatic failure)
• Refractory DTs
• Intubate
• IV phenobarbital or propofol

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Acute Confusional StatePsychopharmacology of
Acute Agitation

• Haloperidol is drug of choice
• should be administered IM or IV
• severely agitated should receive drug IV
• Cardiac monitor for prolonged QT
• Dosages ( ) elderly dose
  
  
• Initial mild agitation 2.0 mg (0.5 mg)
• moderate agitation 5.0 mg (1.0 mg)
• severe agitation 10 mg (2.0 mg)
• Do not use in Parkinsonian or Lewy Body Dementia
  patients
• 
  
  

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Acute Confusional StatePsychopharmacology of
Acute Agitation

• Haloperidol
• repeat dose q. 30 min until patient is sedate
• maintenance doses may be given parenterally or
  p.o.
• after confusion clears gradually taper med over
  3-5 days before D/C

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Acute Confusional StatePsychopharmacology of
Acute Agitation

• Atypical Antipsychotics
• Risperidone dis. tab or liq. conc. 1-2 mg q
  ½-2h MAX 4 mg/d
• Olanzapine IM 5-10 mg q 2-4h MAX 30 mg/d or
  dis. Tab 5-10 mg q ½-2h MAX 20 mg/d
• Ziprasidone IM 10-20 mg q 2-4h MAX 40 mg/d
• Rapid onset but most likely to cause prolong QT
• Aripiprazole IM 10 mg q 2 h MAX 30mg/d or dis.
  tab po 10-15 mg q 2h MAX 30 mg/d
• preferred in elderly for acute agitation
• Doses listed should be 1/2 for elderly

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Acute Confusional StatePsychopharmacology of
Acute Agitation

• Benzodiazepines
• Lorazepam most commonly used and can be used in
  hepatic failure
• Midazolam has rapid onset but short half life so
  be cautious of withdrawal effects
• used for DTs
• adjunct to neuroleptics
• Try to avoid use of phenothiazines

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ACS Ethical Considerations

• Implied consent
• Auerswald, Charpentier, and Inouye, 1997
• 173 procedures in patients with delirium
• No documented assessments of decision capacity
• No documented competency assessment
• Cognitive assessment only 4
• No informed consent 19
• Surrogates used in only 20
• Is implied consent what the patient would want
  or what the physician or surrogate wants to have
  done to the patient?

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Acute Confusional StatePrognosis if Diagnosis is
Unrecognized or Delayed

• Increased morbidity
• Increased mortality - 15-30/1 mo. rate
• Longer hospitalizations
• Increased number of medical complaints
• Accelerated cognitive decline in dementia
  patients
• Increased cost of care

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Acute Confusional StatePrognosis if Diagnosis is
Unrecognized or Delayed

• More likely to be D/C to nursing home
• Recovery may be protracted incomplete
• Two years post-delirium 2/3 of pts. cannot live
  independently (Francis and Kapoor, 1992)
• Neuropsychiatric sequelae gt 6 mos. in majority
• If further deterioration remotely - think
  underlying dementia being unmasked

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Acute Confusional StatePearls

• Often not recognized
• Common among hospitalized patients
• Is frequently preventable
• Accounts for significant morbidity and mortality
• Impaired attention is the hallmark

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Acute Confusional StatePearls

• In elderly think meds/polypharmacy first
• Consider underlying dementia in elderly who
  develop ACS
• Known dementia patients may develop ACS due to a
  treatable cause it is not always deterioration
  due to dementia!
• Common irritants such as constipation or urinary
  retention may cause ACS in the elderly

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Acute Confusional StatePearls

• Consider capacity, competency, and surrogate
  issues in informed consent of ACS patients
  write it in the record!
• There is often a time lag of days to weeks
  between effective Rx and clinical response (most
  significant lag in the elderly)

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Questions?
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Bibliography Attached