This document provides information about acute confusional state (delirium) including its pathophysiology, epidemiology, history, physical exam findings, assessment tools, causes, differential diagnosis, laboratory and imaging studies, and emergency department care. It describes how delirium involves an acute alteration in mental status due to changes in brain function or structure. Common causes include infection, metabolic disturbances, drugs/toxins, and brain insults. The document emphasizes safety, treatment of reversible factors, and minimizing sedation in delirium management.

1. Acute Confusional State
Dr.Hisham Abid Aldabagh
Medical Specialist
Kingdom of Saudi Arabia
Ministry of Health
Directorate of Health
Affairs in Gurayat
Gurayat General Hospital

2. • Delirium, dementia, amnesia, and certain
other alterations in cognition, judgment,
and/or memory are subsumed under more
general terms such as mental status change,
acute confusional state, or altered mental
status.

3. • Altered mental status can be divided into 2
major subgroups:
• Acute (delirium or acute confusional state),
and chronic (dementia).
• A third entity, encephalopathy (subacute
organic brain syndrome), denotes a gray zone
between delirium and dementia; its early
course may fluctuate, but it is often
persistent and progressive.

4. Pathophysiology
• The final common pathway of all forms of
organically based mental status change is
• an alteration in cortical brain function, with
abnormalities of deep brain structures.
• These conditions result from
• (1) an exogenous insult or an intrinsic process
that affects cerebral neurochemical functioning
and/or
• (2) physical or structural damage to the cortex,
subcortex, or to deeper structures involved with
memory.

5. • The end result of these disruptions of function
or structure is impairment of cognition that
affects some or all of the following:
• Alertness, orientation, emotion, behavior,
memory, perception, language, praxis,
problem solving, judgment, and psychomotor
activity.

6. Epidemiology
• Delirium accounts for or develops during 10-
15% of all admissions to acute-care hospitals
but is seen much more frequently in elderly
persons (up to >50%, particularly following
major surgery or trauma).
• Alzheimer disease (AD) accounts for most
patients with dementia who are older than
55 years (50-90% of all cases).

7. Epidemiology
• Race
• Delirium is seen more commonly in whites than
in other races.
• Sex
• Delirium is seen more commonly in females
than in males.
• Age
• Delirium due to physical illness is more frequent
among the very young and those older than 60
years.
• Delirium due to drug and alcohol intoxication or
withdrawal is most frequent in persons aged
mid teens to the late 30s.

8. History
• Delirium presents with acute onset of impaired
awareness, easy distraction, confusion, and
disturbances of perception (e.g, illusions,
misinterpretations, visual hallucinations).
• Recent memory is usually deficient, and the patient is
typically disoriented to time and place.
• The patient may be agitated or obtunded, and the
level of awareness may fluctuate over brief periods.
• Speech may be incoherent, pressured, nonsensical,
perseverating, or rambling, which may make the
taking of an accurate history from the patient
impossible.
• Patients with delirium have difficulty maintaining
attention and/or changing the focus of their attention.

9. • Attempt to obtain a current and past history from
other sources, including prehospital workers,
family or friends, and past medical records.
• Look specifically for street drug, alcohol, and
medication use; preexisting endocrine disorders;
and recent activities that may have resulted in
exposure to toxins or environmental injury.
• Ask about prior psychiatric illness and similar
episodes of confusion in the past, to uncover a
treatable or modifiable cause for the cognitive
impairment.

10. Physical
• The delirious or obtunded patient should be
evaluated for pupillary, funduscopic, and
extraocular abnormalities; nuchal rigidity; thyroid
enlargement; and heart murmurs or rhythm
disturbances.
• Other clues include a pulmonary examination
that reveals wheezing, rales, or absent breath
sounds;
• an abdominal examination that reveals hepatic or
splenic enlargement; or a cutaneous examination
that shows rashes, icterus, petechiae,
ecchymoses, track marks, or cellulitis.

11. Look for track marks.
• Smell for alcohol, the musty odor of fetor hepaticus, or the
fruity smell of ketoacidosis.
• Icterus and asterixis point to liver failure with an elevation
of the serum ammonia level.
• Agitation and tremulousness suggest sedative drug or
alcohol withdrawal.
• Fever may point to infection, heat illness, thyroid storm,
aspirin toxicity, or the extreme adrenergic overflow of
certain drug overdoses and withdrawal syndromes (in
particular, delirium tremens). Extreme hyperthermia (with
pinpoint pupils) may be seen in pontine strokes.
• In patients with a rapid respiratory rate, consider diabetic
ketoacidosis (ie, Kussmaul respiration), sepsis, stimulant
drug intoxication, and aspirin overdose.
• In patients with a slow respiratory rate, consider narcotic
overdose, CNS insult, or various sedative intoxications.

12. • A rapid pulse rate is seen in patients with fever,
sepsis, dehydration, thyroid storm, and various
cardiac dysrhythmias and in overdoses of
stimulants, anticholinergics, quinidine,
theophylline, tricyclic antidepressants, or aspirin.
• Patients with a slow pulse rate may have elevated
intracranial pressure, asphyxia, or complete heart
block. Calcium channel blockers, digoxin, and
beta-blockers also may produce altered mental
status and bradycardia.
• Blood pressure elevation is common in delirium
because of resulting adrenergic overload.

13. • In pregnant patients with a diastolic pressure
greater than 75 mm Hg in the second trimester or
greater than 85 mm Hg in the third trimester,
consider preeclampsia (ie, hyperreflexia, edema,
proteinuria).
• In patients with hypertension and bradycardia,
consider an elevated intracranial pressure.
• With delirium and hypotension, the differential
diagnosis includes dehydration, diabetic coma,
hemorrhage due to trauma, aneurysmal rupture,
or GI bleeding. Also, consider adrenergic depletion
secondary to cocaine; amphetamine; or tricyclic
overdose. Addisonian crisis, particularly in those
who are steroid dependent, should be considered.

14. • Pupillary dilation is seen in anticholinergic
overdose (diphenhydramine), stimulant use,
and hallucinogen use. A common feature of
diphenhydramine and other antihistamine
overdoses is picking at imaginary objects in
the air.
• Pupillary constriction is seen in narcotic
intoxication

15. • Serious head trauma is usually obvious.
However, occult trauma may be discovered
by findings of basilar skull fracture.
• At times, it may be difficult to distinguish
between acute delirium, psychiatric crisis, or
a chronic process with exacerbation such as
dementia. It is safest to presume delirium
until an alternative process can be proven
through testing and/or clinical observation.

16. Assessment
• The Mini-Mental Status Examination (MMSE) is a formalized
way of documenting the severity and nature of mental status
changes: (The maximum score per item is indicated in parentheses).
• Orientation (5): What are the year, season, date, day, and
month?
• Orientation (5): Where are we (ie, state, county, town,
hospital, and floor)?
• Registration (3): Name 3 objects (ask the patient to repeat
these 3 objects).
• Attention and calculation (5): The serial 7 test awards 1 point
for each correct answer. Stop after 5 answers. Spelling
"word" backwards is optional.

17. • Recall (3): Ask for the 3 objects (from
Registration) to be repeated. One point is scored
for each correctly recalled object.
• Language (2): Name a pencil and a watch.
• Repetition (1): Repeat the following: "No ifs,
ands, or buts."
• Complex commands (6): Follow a 3-stage
command, such as "Take a paper in your right
hand, fold it in half, and put it on the floor" (3
points). Next, read and follow these printed
commands: "Close your eyes" (1 point); "Write a
sentence" (1 point); and "Copy design" (1 point)

18. • A score of less than 24 suggests the presence
of delirium, dementia, or another problem
affecting the patient's mental status and may
indicate the need for further evaluation.
• In addition, or as an alternative to the MMSE,
correctly drawing the face of a clock (to include
the circle, numbers, and hands) is a sensitive
test of cognitive function. To perform this test,
ask the patient to draw a clock with the hands
at 8:20. Two or more errors significantly
correlate with dementia. No errors rule against
dementia.

19. Causes
High fever seen with infection or
heat stroke
Renal failure
Liver failure
Neoplasia
Inflammation (eg, systemic lupus
erythematosus)
Cerebral vascular accident (CVA)
Respiratory dysfunction (eg,
hypoxia, hypercarbia)
Shock
Chronic neurological disorders
such as dementia and Parkinson
disease
“Sundowning”
Intoxication with a substance (eg,
hallucinogens, alcohol, medications,
toxins)
Polypharmacy, most often with
psychoactive medications
Major surgery, orthopedic trauma,
prolonged immobility, and “ICU
psychosis”
Occult infection (e.g, UTI, meningitis,
encephalitis, neurosyphilis, sepsis)
Head trauma
Seizure disorder
Acute mania or other psychiatric
etiology
Endocrine crisis (eg, thyroid, adrenal,
diabetic) .

20. Differential Diagnosis
Schizophrenia
Status Epilepticus
Subarachnoid Hemorrhage
Subdural Hematoma
Tick-Borne Diseases, Lyme
Toxicity, Amphetamine
Toxicity, Anticholinergic
Toxicity, Antidepressant
Toxicity, Antihistamine
Toxicity, Cocaine
Toxicity, Cyclic Antidepressants
Toxicity, Hallucinogen
Toxicity, Lead
Toxicity, Lithium
Toxicity, Mushroom - Hallucinogens
Toxicity, Nonsteroidal Anti-inflammatory
Agents
Toxicity, Thyroid Hormone
Toxicity, Toluene
Toxicity, Valproate
Variant Creutzfeldt-Jakob Disease and Bovine
Spongiform Encephalopathy
Wernicke Encephalopathy
Withdrawal Syndromes
Brain Abscess
Conversion Disorder
Delirium Tremens
Depression and Suicide
Diabetic Ketoacidosis
Encephalitis
Epidural and Subdural Infections
Heat Exhaustion and Heatstroke
Herpes Simplex
Herpes Simplex Encephalitis
HIV Infection and AIDS
Hypercalcemia
Hypernatremia
Hyperosmolar Hyperglycemic Nonketotic Coma
Hypertensive Emergencies
Hypoglycemia
Hypothyroidism and Myxedema Coma
Neoplasms, Brain
Neuroleptic Malignant Syndrome
Panic Disorders
Plant Poisoning, Alkaloids - Isoquinoline and
Quinoline
Plant Poisoning, Alkaloids - Tropane
Plant Poisoning, Glycosides - Cardiac

21. Laboratory Studies
• Oxygen saturation and, in some cases, ABG
with a carbon monoxide level are helpful.
• CBC count, electrolytes level, blood glucose
level, BUN level, and creatinine level should be
checked.
• In older patients, consider vitamin B-12 and
folate levels.
• Consider calcium level, magnesium level, and
liver function tests (LFTs), including serum
ammonia, prothrombin time (PT), and
activated partial thromboplastin time (aPTT).
• Urinalysis is also indicated

22. • When alcohol, drugs, and/or toxins are suspected,
consider the following:
• Serum ethanol, salicylate, acetaminophen, carbon
monoxide, and other specific drug or toxin levels
as indicated
• Comprehensive drug analyses of blood and urine
• Such toxic screens are generally not helpful in the
acute setting unless turnaround time is rapid.

23. • In a suspected endocrine emergency, the following
are required:
• A bedside fingerstick blood glucose determination
followed by serum glucose and serum acetone
• Thyroid-stimulation hormone (TSH), possibly
thyroid panel
• Serum cortisol
• Serum calcium, phosphorus, and parathyroid levels

24. • In suspected CNS infection, the following may
be ordered:
• Lumbar puncture may be done for CSF studies,
including cryptococcal antigen or India ink
prep, and VDRL.
• CT scan of head should be done before lumbar
puncture to rule out toxoplasmosis or abscess,
especially in patients with HIV who present
with headache

25. Imaging Studies
• A head CT scan without intravenous (IV) contrast
should be obtained if CNS infection, trauma, or a
cerebral vascular accident (CVA) is suspected.
• Although not typically part of the workup in the ED,
a brain MRI may be considered if readily available
and the need confirmed by neurologist and/or
radiologist. MRI helps distinguish between
Alzheimer disease and vascular causes of dementia.
• Plain abdominal radiographs may reveal
swallowed bags that contain drugs of abuse ("body
packing") or radiodense substances such as iron
tablets.

26. Emergency Department Care
• ED physicians caring for the patient with agitation,
confusion, or delirium, must ensure the safety of
both the patient and the staff while attending to
issues of airway protection and immediate
recognition and treatment of rapidly reversible
problems (eg, hypoxia, hypoglycemia, narcotic
overdose).
• Provide supplemental oxygen unless oxygen
saturation is above 93% on room air.
• When carbon monoxide poisoning is suspected,
ignore the oxygen saturation, obtain a
carboxyhemoglobin level, and provide 100%
oxygen.

27. • In cases of airway compromise, coma, or poor
gag reflex, the ED physician should have a low
threshold for intubation. Use rapid sequence
intubation (RSI), particularly in the settings of
possible head trauma, elevated ICP, or a
combative patient. RSI/intubation may be
necessary to facilitate imaging studies.

28. • Treat suspected overdose-induced delirium based
on ingestion history and/or toxidromes. Such
treatment may range from simple observation and
supportive care, activated charcoal, lavage (rarely
performed), sedation, specific antidotes to
intubation/life support.
• Behavioral control of a patient with delirium who
is agitated and combative should be primarily
medication-based with physical restraining kept at
a minimum and for protection of both the patient
and staff .

29. • Conversely, inpatient prevention and
management of delirium should strive to avoid
or minimize use of sedating medications. These
medications increase confusion, reduce
attentiveness, and impair orientation, thereby
exacerbating delirium.

30. I wish God protect you from delirium
Great thanks for your interest