Confusion

Koech KM
Fri Feb 12, 2010
 Confusion
• There’s no clear medical definition for confusion,
• it’s a general term for a problem with coherent
thinking
• Confused patients are unable to think with
normal speed, clarity, or coherence
• Confusion is typically associated with a depressed
sensorium and a reduced attention span, and it is
an essential component of delirium
Delirium vs acute confusional state
• No generally accepted consensus on distinction,
generally the terms "acute confusional state" and
"encephalopathy" are often used synonymously
with delirium
• The term "acute confusional state" refers to an
acute state of altered consciousness characterized
by disordered attention along with diminished
speed, clarity, and coherence of thought
• This definition encompasses delirium
• Some experts use "confusional state" to
convey the additional meaning of reduced
alertness and psychomotor activity . In this
paradigm, delirium is a special type of
confusional state characterized by increased
vigilance, with psychomotor and autonomic
overactivity; the delirious patient displays
agitation, excitement, tremulousness,
hallucinations, fantasies, and delusions
Delirium and acute confusional
states
 Delirium
• aka encephalopathy, acute confusional state
• transient disorder of cognition and attention
accompanied by disturbances of the sleep-
wake cycle and psychomotor behavior
• The key feature of delirium is the inability to
maintain a coherent stream of thought or
action, along with an impairment in attention
and/or arousal
• Patients cannot keep attention focused, and
this attentional disorder underlies many of the
other cognitive deficits
• Delirious patients are distractible, may be
hypersensitive to stimuli, and cannot prioritize
important from irrelevant environmental
sounds or sights
 DSM-IV-TR
• Disturbance of consciousness (ie, reduced clarity of
awareness of the environment) with reduced ability to focus,
sustain, or shift attention
• A change in cognition (such as memory deficit, disorientation,
language disturbance) or the development of a perceptual
disturbance that is not better accounted for by a preexisting,
established, or evolving dementia
• The disturbance develops over a short period of time (usually
hours to days) and tends to fluctuate during the course of the
day.
• Evidence from the history, physical examination, or laboratory
findings shows that the disturbance is caused by the direct
physiological consequences of a general medical condition
 Additional features
• Psychomotor behavioral disturbances such as
hypoactivity, hyperactivity with increased
sympathetic activity, and impairment in sleep
duration and architecture.
• Variable emotional disturbances, including
fear, depression, euphoria, or perplexity.
 Motoric subtypes
• Hypoactive delirium with low psychomotor
behavioral activity
• Hyperactive delirium with high psychomotor
activity
• Mixed delirium with features of both hypo-
and hyperactivity
• Delirium without psychomotor behavioral
changes
 Epidemiology
• Locally, no figures
• West – mostly on hospitalised patients
• ~30% of older medical patients
• ~10-50% among older surgical patients, the
higher being fracture and cardiac surgery
patients, ICU upto 70%
• Tends to affect older males more
 Risk factors
• Divided into
– Those that increased baseline vulnerability
– those that precipitate the disturbance
• Increased baseline vulnerability
– underlying brain diseases- dementia, stroke,
Parkinson disease
– Advanced age
– Sensory impairment
• (Inouye et al- 5 independent risk factors)
 Precipitating factors
• Drugs and toxins
• Infections
• Metabolic derangements
• Brain disorders
• Systemic organ failure
• Physical disorders
 AEIOU TIPS
• A-alcohol
• E-epilepsy or exposure(heat stroke, hypothermia)
• I-insulin
• O-overdose or oxygen deficiency
• U-uremia
• T-trauma(shock, head injury)
• I-infection
• P-psychosis or poisoning
• S-stroke
 Pathophysiology
• Poorly understood
• Generally:
– Neurobiology of attention
– Cortical versus subcortical mechanisms
– Neurotransmitter and humoral mechanisms
 Neurobiology of attention
• Arousal and attention -brain lesions involving
the ascending reticular activating system
(ARAS) from the mid-pontine tegmentum
rostrally to the anterior cingulate regions.
• Attention -"nondominant" parietal and frontal
lobes
• Insight and judgment-higher order integrated
cortical function
Cortical vs subcortical mechanisms
• 1940s EEG studies-slowing of the dominant posterior
alpha rhythm and appearance of abnormal slow-
wave activity
• correlated with the level of consciousness and other
observed behaviors regardless of the underlying
etiology, suggesting a final common neural pathway
• major exception appeared to be that of delirium
accompanying alcohol and sedative drug withdrawal,
in which low voltage, fast-wave activity
predominated
 Cont…
• brainstem auditory evoked potential,
somatosensory evoked potentials, and
neuroimaging studies suggest an important
role for subcortical (eg, thalamus, basal
ganglia, and pontine reticular formation) as
well as cortical structures in the pathogenesis
of delirium
• Explains subcortical strokes and basal ganglia
abnormalities (eg Parkinson)
Neurotransmitter and humoral mechanisms

• Acetylcholine plays a key role- anticholinergic drugs

even on healthy volunteers induce delirium
• Medical condns precipitating delirium (hypoxia,
hypoglycemia, and thiamine deficiency) reduce
ACh synthesis
• Serum anticholinergic activity relates with severity
• Alzheimer’s disease-loss of cholinergic neurons
• Other neurotransmitters possible
• Cytokines- ILs, IFNs, may explain sepsis
 Presentation
• disturbance of consciousness
• altered cognition
• typically develops over a short period of time
and tends to fluctuate during the course of the
day
• Others-psychomotor agitation, sleep-wake
reversals, irritability, anxiety, emotional lability,
and hypersensitivity to lights and sounds
 Investigations
• CBC
• U E C, LFTs, BGAs
• Blood sugar
• LPs
• Cultures
• Toxic screen, drug levels
• EEG
• CT, MRI
 Management
• ABCDE
• Evaluate for possible cause
• Supportive
– Correct abnormalities
– Hydration, nutrition
– Enhance mobility
– Pain, skin, incontinence
– Interpersonal and envtal manipulation
– Restraint as last resort
• Specific management(dependent on cause)
– Thiamine, glucose
– Naloxone
– Flumazenil
– Antibiotics, antivirals
– Low-dose haloperidol
• Preventive measures
• Outcomes: variable, high mortality