A brief presentation about confusional states. Difference between coma. This presentation is focused on Pathophysiology, major causes and approach to diagnosis and diagnosis tools.

1. Confusional States
Kadir Sumerkent
Department of Neuroscience, Graduate School of Health Sciences
Bahcesehir University

2. Coma
In order to understand confusional states, we need to
understand “Coma”.

3. Coma
• Coma is a sleep-like state with no purposeful response to the
environment and from which the patient cannot be aroused.
• The eyes are closed and do not open spontaneously. The patient does
not speak. There is no purposeful movement of the face or limbs.
• Verbal stimulation produces no response. Painful stimulation may
produce no response or purposeful reflex movements mediated
through spinal cord or brainstem pathways.
• Coma results from a disturbance in the function of either the
brainstem reticular activating system above the mid pons or both
cerebral hemispheres.

4. Confusional State
• A confusional state, sometimes referred to as encephalopathy or
delirium, is a state in which the level of consciousness is depressed,
but to a lesser extent than in coma.
• In confusional states, responses to stimulation are at least semi-
purposeful, whereas in come, patients fail to respond to even painful
stimulation or do so only reflex fashion.
• Thus, the difference between a confusional state and coma is largely
one of degree, and the causes overlap extensively.

5. Confusional State
• Altered mental status can be divided into two major subgroups;
• Acute (delirium or acute confusional state)
• Chronic (dementia)
• … or maybe three;
• Encephalopathy (subacute organic brain syndrome)
A gray zone between delirium and dementia; its early course may fluctuate
but it is often persistent and progressive.

6. Delirium

7. Synonyms
• Confusional State
• Delirium
• Altered mental status
• Acute organic syndrome
• Acute brain failure
• Acute brain syndrome
• Acute cerebral insufficiency
• Exogenous psychosis
• Metabolic encephalopathy

8. Subtypes
• Hyperactive delirium
This type is characterized by agitation, restlessness and attempts to
remove invasive tools (drug intoxication)
• Hypoactive delirium
This type is characterized by withdrawal, flat affect, apathy, lethargy,
and decreased responsiveness.
• Mixed type
Patient’s symptoms fluctuate between the two conditions.

9. Pathophysiology
• Alteration in cortical brain function, with abnormalities of deep brain
structures.
• An exogenous insult or an intrinsic process that affects cerebral
neurochemical functioning
• Physical or structural damage to the cortex, sub cortex, or to deeper
structures involved with memory
• 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, judgement, and psychomotor activity.

10. Major Causes
• Metabolic
• Toxic
• Infectious
• Neurologic
• Perioperative

11. Major Causes: Neurologic
• Stroke
• Traumatic Brain Injury
• Subdural Hematoma
• Infectious encephalitis
• Meningoencephalitis
• CNS vasculitis
• Limbic encephalitis
• Granulomatous meningoencephalitis (TB, sarcoidosis)
• Non-convulsive status epilepticus
• Migraine

12. Major Causes: Neurologic

13. EEG and Delirium
• Delirious patients showed significant reductions of alpha percentage,
increased theta and delta activity and slowing of the peak and mean
frequencies.
• Engel and Romano (1959) described alpha slowing with delta and
theta intrusions on electroencephalograms (EEGs) and correlated
these changes with clinical severity.
• Treating the medical cause resulted in reversal of EEG changes of
delirium.

14. EEG and Delirium

15. Confusional State
Kadir
Overview of Confusional States
Clinical Diagnosis and Differentiation of Confusional States from Coma and other disorders.
Deniz Zeynep Elif
Drugs Meningitis, Encephalitis, & Sepsis Endocrine Disorders
Organ System Failure Vascular Disorders Electrolyte Disorders
Head Trauma Nutritional Disorders
Common Topics
Seizures
Psychiatric Disorders

16. Approach to Diagnosis
• Characterization is the first step
• Evaluation of a patient with altered consciousness is aimed first aid at
characterizing the nature of the disorder (confusional state, coma, or a more
chronic condition such as dementia) and second at determining the cause.
• Dementia vs Confusional State
• A confusional state is most readily distinguished from dementia by the time
course of impairment.
• Confusional states are acute or subacute in onset, typically developing over
hours to days, whereas dementia is a chronic disorder that evolves over
months or years.
• Early identification of the situation is critical
• Certain causes of confusional state must be identified urgently, because they
may lead rapidly to severe structural brain damage or death, which prompt
treatment can prevent.

17. Approach to Diagnosis
• Characterization is the first step
• Evaluation of a patient with altered consciousness is aimed first aid at
characterizing the nature of the disorder (confusional state, coma, or a more
chronic condition such as dementia) and second at determining the cause.
• Dementia vs Confusional State
• A confusional state is most readily distinguished from dementia by the time
course of impairment.
• Confusional states are acute or subacute in onset, typically developing over
hours to days, whereas dementia is a chronic disorder that evolves over
months or years.
• Early identification of the situation is critical
• Certain causes of confusional state must be identified urgently, because they
may lead rapidly to severe structural brain damage or death, which prompt
treatment can prevent.

18. Most Urgent Causes of Confusional States
Cause Clinical Evidence Laboratory Confirmation Treatment
Hypoglycemia Tachycardia, sweating, and
dilated pupils, sometimes
progressing to mimic
herniation, with or without
lateralized signs
Low plasma glucose IV glucose
Bacterial meningitis Headache, fever, Brudzinski
or Kernig sign
Positive CSF Gram stain, low
CSF glucose, and increased
CSF protein
IV antibiotics
Subarachnoid hemorrhage Headache, hypertension,
retinal hemor- rhages,
Brudzinski or Kernig sign
Non-clearing red blood cells
in CSF; subarachnoid blood
and aneurysm or other
vascular malformation on CT
scan
Surgical ablation of
aneurysm or other vascular
malformation
Traumatic intracranial
hemorrhage
Headache, hypertension,
lateralized neurologic signs
Epidural, subdural, or
intracerebral hemorrhage on
CT scan
Surgical evacuation of
epidural or subdural (or in
some cases intracerebral)
hematoma
Wernicke encephalopathy Ophthalmoplegia, ataxia Macrocytic anemia may
coexist
IV thiamine and dextrose

19. History is important
• History of Present Illness
• The history should establish the time course of the disorder and provide clues
to its nature and cause.
• Confusional states are acute to subacute in onset, whereas dementias are
chronic disorders.
• In either case, a relative or friend may be the best source of information
about the patient’s previous level of functioning, the time when dysfunction
became evident, and the nature of observed changes.

20. History is important
• Past History
• Preexisting conditions that predispose to confusional states should be noted,
such as alcoholism (intoxication or withdrawal, or Wernicke encephalopathy),
other drug abuse (intoxication or infection), diabetes (hypo- or
hyperglycemia), heart disease (stroke), epilepsy (seizures or postictal state),
and head trauma (concussion, intracranial hemorrhage).
• A thorough medication history is also important, because many therapeutic
drugs can impair consciousness as a side effect.

21. General Physical Examination
Finding Most Suggestive of Finding Most Suggestive of
Fever Infectious meningitis, anticholinergic or
sympathomimetic intoxication, ethanol or sedative drug
withdrawal, sepsis
Neck stiffness Meningitis, subarachnoid hemorrhage
Hypothermia Ethanol or sedative drug intoxication, hepatic
encephalopathy, hypoglycemia, hypothyroidism, sepsis
Battle sign or
raccoon eyes
Head trauma
Hypertension Anticholinergic or sympathomimetic intoxication,
ethanol or sedative drug withdrawal, hypertensive
encephalopathy, subarachnoid hemorrhage
Hemotympanum Head trauma
Tachycardia Anticholinergic or sympathomimetic intoxication,
ethanol or sedative drug withdrawal, thyrotoxicosis,
sepsis
CSF otoorrhinorrhea Head trauma
Bradycardia Hypothyroidism
Hyperventilation Hepatic encephalopathy, hyperglycemia, sepsis Heart murmur Infection, stroke
Abdominal mass Infection, tumor, hepatic encephalopathy
Jaundice Hepatic encephalopathy Rectal bleeding Hepatic encephalopathy
Petechial rash Meningococcal meningitis
Vital Signs Head & Neck
Chest & abdomen
Skin and mucous membranes

22. Mental Status Examination
• Wakefulness
In confusional states, the patient often appears sleepy; this may
alternate with apparent hyperalertness.
• Arousability
In mild confusional states, the patient may be arousable when spoken
to or lightly shaken. As consciousness is further impaired, the
intensity of stimulation required for arousal increases, the duration of
arousal declines, and the responses elicited become less purposeful.
• Orientation
With a confusional state, the patient loses orientation to time and
later to place.

23. Mental Status Examination
• Attention
Confused patients are inattentive, as demonstrated by the inability to
immediately repeat a list of numbers or words.
• Memory
Confusion impairs short-term memory so that the patient cannot
remember a short list of items when asked to repeat them after a
delay of several minutes.

24. Mental Status Examination
• One pitfall to avoid is to mistake receptive or fluent (Wernicke)
aphasia for confusion.
• Although patients with receptive aphasia cannot comprehend written
or spoken language and may speak incomprehensibly, they appear
normally awake and alert, can respond appropriately to nonverbal
commands (such as gestures), and usually have associated right-sided
neurologic abnormalities such as hemiparesis, hemisensory deficit,
and visual field deficits.

25. Signs of Diffuse vs Focal Disorders Causing
Confusional States
• Certain neurologic findings help distinguish diffuse (including
metabolic) from focal (including mass) lesions as the likely cause of a
confusional state.
• Diffuse disorders
Suggestive findings include fever or hypothermia, nystagmus, tremor,
asterixis, and myoclonus.
• Focal disorders
Suggestive findings include signs of head trauma, papilledema,
hemiparesis, focal seizures, asymmetric hyperreflexia, and unilateral
Babinski signs.

26. Signs of Specific Disorders Causing Confusional
States
Finding Most Suggestive of
Cranial Nerves
Papilledema Hypertensive encephalopathy,
intracranial mass
Dilated pupils Head trauma, anticholinergic
intoxication, withdrawal from
ethanol or sedative drugs,
sympathomimetic intoxication
Constricted pupils Opioid intoxication
Nystagmus or ophthalmoplegia Intoxication with ethanol,
sedative drugs, or
phencyclidine; vertebrobasilar
ischemia; Wernicke
encephalopathy
Coordination
Ataxia (especially gait) Ethanol or sedative drug
intoxication, Wernicke
encephalopathy,
vertebrobasilar ischemia
Finding Most Suggestive of
Motor Function
Tremor Withdrawal from ethanol or
sedative drugs,
sympathomimetic intoxication,
thyrotoxicosis
Asterixis Metabolic encephalopathy
Hemiparesis Cerebral infarction, head
trauma, hyperglycemia,
hypoglycemia
Other
Seizures Ethanol or sedative drug
withdrawal, hypoglycemia,
hyperglycemia, head trauma

27. Laboratory Studies in Confusional States
Test Finding Most Suggestive of
Blood
WBC Increased Meningitis, encephalitis, sepsis
PT and PTT Increased Hepatic encephalopathy
Arterial blood gases Metabolic acidosis Diabetic ketoacidosis, lactic acidosis (postictal, shock, sepsis), toxins
(methanol, ethylene glycol, salicylates, paraldehyde), uremia
Respiratory acidosis Pulmonary insufficiency, sedative drug overdose
Respiratory alkalosis Hepatic encephalopathy, pulmonary insufficiency, salicylates, sepsis
Sodium Decreased Hyponatremia
Urea nitrogen and
creatinine
Increased Uremia
Glucose Increased or decreased Hyperglycemia, hypoglycemia
Osmolality Increased Alcohol intoxication, hyperglycemia
Liver enzymes,
ammonia
Increased Hepatic encephalopathy
Thyroid hormones Increased or decreased Hyperthyroidism, hypothyroidism

28. Laboratory Studies in Confusional States
Test Finding Most Suggestive of
Blood
Calcium Increased or decreased Hypercalcemia, hypocalcemia
Drug screen Positive Drug intoxication
Cultures Positive Meningitis, sepsis
FTA or MHA-TP Positive Syphilitic meningitis
HIV antibody titer Positive HIV infection
Urine, gastric aspirate
Drug screen Positive Drug intoxication
Stool
Occult blood Positive Hepatic encephalopathy
ECG
Tachyarrhythmia Anticholinergic or sympathomimetic intoxication

29. Laboratory Studies in Confusional States
Test Finding Most Suggestive of
Cerebrospinal Fluid
Glucose Decreased Bacterial or tuberculous meningitis, leptomeningeal metastases
WBC Increased Meningitis, encephalitis
RBC Present Subarachnoid hemorrhage
Gram stain Positive Bacterial meningitis
AFB stain Positive Tuberculous meningitis
India ink stain Positive Cryptococcal meningitis
Cultures Positive Infectious meningitis
Cytology Positive Leptomeningeal metastases
Glutamine Increased Hepatic encephalopathy
VDRL Positive Syphilitic meningitis
Cryptococcal antigen Positive Cryptococcal meningitis
Polymerase chain
reaction
Positive Meningitis, encephalitis (various etiologic agents)

30. Laboratory Studies in Confusional States
Test Finding Most Suggestive of
CT brain scan or MRI
Various Cerebral infarction, intracranial hemorrhage, head trauma,
toxoplasmosis, herpes simplex encephalitis, subarachnoid
hemorrhage
EEG
Epileptiform activity Complex partial seizures, postictal state
Periodic complexes Herpes simplex encephalitis

31. CSF Profiles in Confusional States

32. Conclusion
• Search for delirium. Use different monitoring tools.
• Preventing is better than curing: prevention is the most effective way
to reduce delirium incidence.
• Search for early risk factors.
• Always try to use the lowest effective doses of neuroactive drugs,
especially sedatives: less is better.
• Treat delirium as a medical emergency aggressively search for
underlying metabolic / organic causes, use of deliriogenic drugs.

33. Confusional States
Kadir Sumerkent
Department of Neuroscience, Graduate School of Health Sciences
Bahcesehir University