Key points and practical approach to Delirium.

1. ACUTE CONFUSIONAL
STATE
Prepared by:
Hussam Aldeen Muhammed

2. WHAT IS ACUTE CONFUSIONAL
STATE (ACS) ?
• TRANSIENT AND TYPICALLY REVERSIBLE
DISTURBANCE IN COGNITIVE (NEUROLOGICAL AND
PSYCHOLOGICAL) FUNCTION.

3. HOW SIGNIFICANT IS IT?
• UP TO 10% OF ACUTE MEDICAL ADMISSIONS ARE
COMPLICATED BY ACUTE CONFUSION OR DELIRIUM.
• IT CARRIES A SIGNIFICANT HEALTH RISKS AMONG
AFFECTED PATIENTS BY INITIATING A SERIES OF
EVENTS CULMINATING IN LOSS OF INDEPENDENCE,
INCREASED MORBIDITY AND MORTALITY,
INSTITUTIONALIZATION AND INCREASED HEALTH
COSTS.

4. THE TYPICAL PATIENT
• THE TYPICAL PATIENT IS AN ELDERLY HOSPITALIZED
PATIENT WITH A CHRONIC DISEASE THAT
SUSTAINED AN ADDITIONAL HEALTH BURDEN OR
COMPLICATIONS.
• HOWEVER, IT’S POSSIBLE TO OCCUR IN ANY
SIGNIFICANT DISEASE AMONG ANY AGE GROUP.

5. TRIAD OF PRESENTATION
• 1- ACUTE DISORIENTATION TO TIME AND PLACE
• 2- IMPAIRED SHORT TERM MEMORY
• 3- IMPAIRED CONSCIOUS LEVEL
• ACS + HALLUCINATIONS +- ILLUSIONS = DELIRIUM.

6. APPROACH

7. KEY POINTS
• EMERGENCY MANAGEMENT
• CONFIRM CONFUSION
• EXCLUDE DEMENTIA
• REVIEW THE DRUG CHART
• PERFORM NEUROLOGICAL EXAMINATION
• IDENTIFY THE UNDERLYING ACUTE ILLNESS

8. EMERGENCY MANAGEMENT
• APPROACH AS (DLOC)
• HYPOGLYCEMIA  RBS
• CVA  NEUROLOGICAL EXAM.
• MI  ECG

9. CONFIRM CONFUSION
MINI MENTAL STATE EXAMINATION
Age.
Time (nearest hour).
A sample address for recall at the end of the test (make the patient
repeat the address to check).
Year.
Place (name of hospital).
Recognition of two people (doctor, nurse, etc.).
Date of birth (day and month).
Year of a prominent public event. E.g. Gulf war.
‘Who is the president at the moment?’
Count backwards from 20 to 1.
***
Each correct answer scores 1 point. A healthy elderly scores at least 8.

10. EXCLUDE DEMENTIA
• REVIEW THE PATIENT NOTES
• TAKE HISTORY FROM RELATIVES FRIENDS

11. REVIEW DRUGS CHART
• DRUGS THAT CAUSE ACUTE CONFUSION IN THE
ELDERLY:
• COMMON: BENZODIAZEPINES, NARCOTICS.
• OTHERS: NSAIDS, STEROIDS, BETA BLOCKERS,
PSYCHOTROPIC MEDICATIONS.

12. PERFORM NEUROLOGICAL EXAM
• AIM FOR DETECTING FOCAL NEUROLOGICAL SIGNS.
• MENINGEAL SIGNS.
• EXAMINE THE PUPILS, REFLEXES, PLANTAR
RESPONSE AND MUSCLE POWER OF LIMBS.
• IN ALCOHOLIC PATIENTS, EXAMINE FOR FLAPPING
TREMOR AND SIGNS OF WERNECKE’S
ENCEPHALOPATHY (NYSTAGMUS, ATAXIA,
OPHTHALMOPLEGIA).

13. IDENTIFY THE UNDERLYING ILLNESS
• INVESTIGATE FOR THE CAUSE.
• IT SHOULD BE NOTED THAT DELIRIUM FREQUENTLY
HAS MULTIPLE ETIOLOGIES AND INVESTIGATIONS
SHOULD NOT BE TERMINATED AT THE BASIS OF A
SINGLE CAUSE DETECTION

14. CAUSES OF ACS
I- SYSTEMIC
• Sepsis
• Metabolic disorder:
Increase or decrease in
glucose, Na, or Ca
• Vitamin deficiency (e.g.
thiamine)
• Endocrine disease
(thyroid, adrenal cortex)
• Myocardial ischemia
• Organ failure (renal,
respiratory, liver, cardiac)
• Alcohol withdrawal
• Investigations:
• CBC, RBS, CRP
• RFT, LFT
• Electrolytes
• GUE, Urine culture
• Blood culture
• ABG
• Cardiac markers, ECG
• CXR
• Others when indicated:
Vitamins, TFTs

15. CAUSES OF ACS
II- DRUGS
• Drugs that cause acute
confusion in the elderly:
• Common:
benzodiazepines,
narcotics.
• Others: nsaids, steroids,
beta blockers,
psychotropic
medications.
• Alcohol
• Investigations:
• Check prescribed
medications.
• Serum Alcohol.

16. CAUSES OF ACS
III- CNS DISORDER
• Cerebrovascular accident
(CVA)
• Intracranial bleed (SAH,
subdural)
• Infection (encephalitis,
meningitis)
• Trauma
• Malignancy (primary or
secondary)
• Post- ictal; non- convulsive
status
• Cerebral vasculitis (SLE,
PAN)
• Dementia
• Consider CT scan with
contrast, LP, EEG
• Blood cultures, CRP
• Syphilis serology, Lyme
serology

17. CAUSES OF ACS
IV- MALIGNANCY
• CNS malignancy
• Malignancy elsewhere
• Check CXR ± CT chest
• Serum Ca
• CT brain

18. DEFINITIVE
MANAGEMENT

19. DEFINITIVE MANAGEMENT
• TWO CORNERSTONES:
• 1- TREATING THE UNDERLYING CAUSE.
• 2- OPTIMIZING THE PATIENT’S CARE.

20. TREATING THE CAUSE
• SOMETIMES, SIMPLE MEASURES ARE ADEQUATE TO
RESTORE COGNITION:
• - O2 FOR HYPOXIA.
• - HYPERTONIC DEXTROSE FOR HYPOGLYCEMIA.
• - THIAMINE FOR WE.
• - DEXAMETHASONE FOR INTRACRANIAL SOL.
• OTHER CAUSES ARE MANAGED ACCORDINGLY.

21. OPTIMIZING THE PATIENT’S CARE
I – GENERAL
• - COOPERATION WITH THE PSYCHIATRIST.
• - COMMUNICATION WITH THE PATIENT SHOULD BE
IN SIMPLE LANGUAGE AND SHOULD ONLY INCLUDE
THE INFORMATION THAT ARE RELEVANT.
• - THE TREATING PHYSICIAN SHOULD BE KIND AND
UNDERSTAND THE EMOTIONAL STATE OF THE
PATIENT.
• IT’S BETTER TO ENSURE INVOLVEMENT OF FAMILY
MEMBERS TO GIVE A FEELING OF SECURITY

22. - REPEATED REASSURANCE.
• - REORIENTATION OF THE PATIENT BY FREQUENT
REMINDING ABOUT TIME, DATE, LOCATION, INSTALLING A
CALENDAR, CLOCK AND IDENTIFYING KEY INDIVIDUALS
SHOULD BE ATTEMPTED.
• COGNITION-ENHANCING ACTIVITIES MAY HELP THE
PATIENT BUT MULTI-TASKING IS BETTER AVOIDED. USING
TELEVISION, RADIO, SMARTPHONES…ETC IS AS NEEDED
BY THE PATIENT.
• - MAINTAINING ADEQUATE SLEEP AT NIGHT IS A CRUCIAL
STEP OF DELIRIUM MANAGEMENT.

23. OPTIMIZING THE PATIENT’S CARE
II – THE ENVIRONMENT
• - NURSING IN A MODERATELY LIT ROOM WITH
REMOVAL OF POTENTIALLY HARMFUL OBJECTS,
AVOIDANCE OF SENSORY DEPRIVATION OR
SENSORY OVERLOAD.
•
• IT’S BETTER TO ADMIT ONLY ONE PATIENT PER
ROOM. THE ROOM SHOULD BE QUIET AND HAVE
PROPER TEMPERATURE.
• FAMILIAR OBJECTS FROM PATIENT’S HOME MAY BE
BROUGHT TO HOSPITAL TO ELICIT ORIENTATION
AND SECURITY.

24. AGITATION ATTACKS
• DURING AGITATION ATTACKS, THE POSSIBLE
AGITATING TRIGGERS SHOULD BE REMOVED,
BEHAVIORAL THERAPY IS ATTEMPTED AND
DELUSIONS SHOULD NOT BE DIRECTLY
CONFRONTED AND DISAGREED WITH.
• PHYSICAL RESTRAINTS ARE RESERVED FOR
UNCONTROLLABLE CASES AND THEY ARE BETTER
USED FOR THE SHORTEST POSSIBLE DURATION
AND REMOVED REGULARLY.

25. PHARMACOLOGICAL THERAPY
• - SEDATION IS ONLY INDICATED IN:
• * HIGHLY AGITATED PATIENTS.
• * RISK OF CAUSING HARM TO SELF OR TO OTHERS.
• * FACILITATING TESTS AND TREATMENTS.
• THE MOST COMMONLY USED CLASS OF DRUGS FOR DELIRIUM
IS ANTIPSYCHOTIC GROUP, MOST NOTABLY HALOPERIDOL IN
PARENTERAL FORM.
• ATYPICAL ANTIPSYCHOTICS (E.G. RISPERIDONE,
OLANZAPINE) MAY ALSO BE USED AND THEY HAVE THE
ADVANTAGE OF LOWERING THE RATE OF SIDE EFFECTS IN
COMPARISON TO HALOPERIDOL.
• BENZODIAZEPINES SHOULD BE AVOIDED OWING TO THEIR
MENTAL STATUS CHANGING AND UNNECESSARY SEDATION
EFFECTS.

26. THANK YOU