Farid's Presentation Acs
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Acute Confusional State / Delirium
Muhammad Farid Azraai
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+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?
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+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 cycleIn other words, attention and cognition are impaired.
J Neurol Neurosurg Psychiatry 2001;71:i7-i12 doi:10.1136/jnnp.71.suppl_1.i7
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Prevalence in hospital ranges from 10–20% in medical wards could become higher as the elderly population in hospital
increases
Incidence during hospitalisation ranges from 4–30% about 25% of people over 70 years old admitted to hospital
have delirium.
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+Presentations
Range of different behaviours
hyperactive @ agitated delirium hypoactive or quiet delirium can have both or neither subtype
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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
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Causes @ precipitating factors
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+ 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
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Cardiovascular disease Ischaemic heart disease
infarct @ ischaemic Arrythmias Hypertensive
encephalopathy
Environmental Hypothermia @
Hyperthermia
Drug abuses alcohol cocaine amphetamines
Pharmacologic Salicylate toxicity Anticholinergic toxicity Medication reaction @
interaction (bleeding-aspirin)
Others pain constipation urinary retention
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How to evaluate a patient with acute confusional
state?
Comprehensive history and physical examination, including cognitive testing
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+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
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+On examinations
ACCESS GCS !Do GCS charting, monitor GCS
*if GCS is full : suggest MMSE
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+On examination
GCS
Pale?Cyanoses?
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
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+Investigations
ECG AMI, ischemic changes,
arrythmias
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
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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
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+CSF normal values..
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+MANAGEMENT
First and foremost treat the underlying cause / precipitating
factors
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+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
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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
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+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.
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+Thank You