Confusion ( Delirium )

Prof. Kareem AL-Tameemi

Objectives of learning :
Be familial with clinical presentation of delirium . ( must to know )
Learn the differential diagnosis of delirium . ( must to know )
Describe how to evaluate a patient with delirium .
Important causes .
Case scenario
A 63 year old woman is brought to the ER with altered mental status . Her family tell
you that she was normal until 3 days ago and since she become sleepiness and
confused. She has no medical problem. Her family concede that the patient was
alcoholic for many years but recently she stopped drinking . On interview , the patient
answer most questions inappropriately and with anger , however she denied
experiencing any headache , neck pain , visual symptoms , or loss of balance . On
Examination she was afebrile , her BP 130 /70 mmHg , pulse rate 100 BPM , she was
awake but inattentive and her focus waxes and wanes throughout the examination .
Her general was notable for the absence on nuchal rigidity , no obvious head trauma or
distended abdomen . Her mini mental state examination ( MMSE) was 24 /30 and she
was having difficulty with orientation , concentration and recall . She fluctuated with
being appropriate throughout the examination . She didn’t have any aphasia or
dysarthria , but was circumstantial and tangential . Her neurological exam was
significant for grossly contact cranial nerves and intact pinprick sensation of the face .
The reminder of the sensory , motor and cerebellar examination can't be fully assessed
she was uncooperative with much of the exam . The tests she did tolerate were largely
normal , however , when asked to bend her wrist upward , she found it difficult due to
involuntary flapping with loss of tone in the wrist extremities .

QUESTIONS
1.What is the most likely diagnosis ?
2.What is the next diagnostic step ?

Delirium from hepatic encephalopathy

Summary
 A 63 year old woman with history of alcoholic abuse presents with an alteration in
mental status ,which developed over 3 days . Her mental status shows : attention
deficits , disorganized thinking , altered psychomotor activity , difficult focusing ,
memory deficits and disorientation . Additionally , it seems that there has been some
fluctuations of her symptoms . The examination is notable absent nuchal rigidity ,
distended abdomen and flapping tremor at rest .

ANSWER

1.Most likely diagnosis , delirium from hepatic encephalopathy

2.Next diagnostic step , CT of the head , CBC , comprehensive metabolic panel , Blood
alcohol level , and urine toxicology screen .

ANALYSIS
Considerations
This 63 year old women presents with acute fluctuating level of attention , confusion ,
and altered psychomotor activity developing over 3 days . the findings of attention
deficits , disorganized thinking , altered psychomotor activity , difficulty focusing ,
memory deficit , and disorientation are characteristics of delirium when there is
waxing and waning of symptoms and a relatively acute onset . Important not all
patients with altered mental status have delirium . The hallmark of delirium are
cognitive impairment , impairment attention and fluctuating course . The differential of
altered mental status can be quite broad and must be first accurately defined . Giving
the history of alcoholism , distended abdomen ( ascites ) and flapping hand ( likely
asterixis ) , her presentation is suggestive of hepatic encephalopathy . This occurs
when there is accumulation of harmful neurotoxic substance such as ammonia and
manganese that would otherwise be removed by healthy liver .

DEFINITIONS

Delirium : a neurobehavioral disorder with fluctuating course including inattention and

acute alteration in mental status .

Attention : the ability to focus on specific stimuli while excluding other , such as
spelling words backward .
Asterixis : a type of negative myoclonus or loss of muscle tone in the wrist extensors
result in characteristics flapping movement . It is classically caused by hyper ammonia
in liver diseases and can be related to various metabolic conditions .

Coma : sleepy state from which you cannot arouse the patient .

Dementia : impairment of memory and at least one other cognitive function ( e.g.
visual – special orientation , judgment ) without alteration in the level of consciousness
. reprehensive a decline from previous level of ability and interfering with daily
functioning and independent living .

Difference between Acute confusion state and dementia:

Feature ACS Dementia

Level of consciousness Impaired Not impaired , except

occasionally late
Course Acute to sub-acute Chronic , steadily
fluctuating progressive
Autonomic hyperactivity Often present Absent

Prognosis Reversible Irreversible

Clinical approach
The presentation of acute mental state changes + abnormal attention + fluctuating
course .
SHOULD ALERT CLINICIAN TO DELIRIUM .
It is the most common neurobehavioral disorder in the hospital .
40% of ICU patients have delirium .
10 – 24 % of all admission are due to delirium .
26 % of admitted cases result in death .

Pathophysiology

1. Decrease neurotransmitter lead to impairment of oxidative metabolite

2.
Risk factors for delirium
1. Elderly > 80 years old .
2. Preexisting cognitive disorder .
3. Dehydration / electrolytes disturbance .
4. Hypoxemia / cardiorespiratory failure
5. Drugs abuse / EtOH or hypotonic dependency .
6. Fever / hyperthermia .
7. Depression .
8. Physical trauma .
9. Sleep disturbance .
10. EtOH , alcohol consumption .
11. Gender male > female .
12. Number and severity of medical illnesses .
13. Infection : urinary / pulmonary .
14. Malnutrition .
15. Poly pharmacy ananalgesic use .
16. Fractures .
17. Burns .
18. Visual , auditory impairment .