Mohammad Ameen

Clinical Assistant
August 20, 2014
Acute change in mental state
characterized by confusion and lack of
attention due to changed neurological
function

Prevalence
10% of all old age ED visits
10-40% of all hospitalized old age patients
25% of post acute care old age patients
Physiologic reserve vs. Vulnerability to
stressors

Depends on the balance between the
predisposing factors and the precipitating
factors

Predisposing factors = Precipitating
factors and vise versa
Age
Prior cognitive impairment
Functional impairment
BUN-Creatinine ratio
Dehydration
Malnutrition
Hearing/Vision impairment
Frailty
Severe illness/failure of any
organ system
Need for catheterization
>3 medication use
Specific medications
Long acting BDZ
Opioids (Meperidine)
Anticholinergic
(Diphenhydramine)
Pain
New medication change
Alcohol/Drug withdrawal
Infections (especially lungs, UTI and
meningitis)
Metabolic changes ( Na
+
, Ca
++
, Renal
failure, Hepatic failure etc.)
MI
Stroke
DIMS
Drugs
Medications: Opioids, Anicholinergic, BDZ,
Anesthetics, Steroids, NSAIDs, Digoxin,
Phenytoin, Theophylline
W/D from Alcohol/BDZ, Recreational- Amph.,
LCD, Cannabis
Infections (Lung/UTI/Meningitis/Sepsis)
Metabolic
Basic- O
2
, Hb, Na
+
, Ca
++
, Dehydration
Organ failure- Cardio/resp./renal/hepatic
Endo/other- BG, Thyroid, Adrenal, B12
Structural
SOL- neoplasia, abscess
Seizure, HTN encephalopathy
Stroke/TIA/ICH/SDH/EDH etc.
Trauma (Post op, Head injury, Fat embolism etc.)
Confusion Assessment Method (CAM)

Dx features
Acute mental status change
Inattention
And, Disorganized thinking OR Altered LOC

Additional features are- Memory, Sleep
cycle, Orientation, Misrepresentation,
Psychomotor agitation/retardation
Time scale of mental status change
Presence of predisposing factors
Recent change of any medications
Presence of symptoms of infection
Metabolic diseases SSx
New neurological changes
Exclusion of DDx (Depression, Dementia and
Psychosis)
Comprehensive cardiorespiratory exam
including volume status exam
Signs of other organ failure (Liver/Renal)
Signs of infection (Chest/UTI/CNS etc.)
Neurological exam (CNs, Extremities, Gait)
MMSE for serial follow up
Basics: CBC, Lytes, Creatinine, LFT, UA,
RBG
Toxicology/Drug screening
Infection screen: CXR, Urine/Blood Cx
Endo/Metabolic: TSH, Thiamine/B12
ABG, Troponin, EKG
Focal neurological deficit on Hx/PE
Hx of recent fall
Hx of anticoagulant use
Dx unclear from work up
Need to exclude ICP before Lumber
puncture when needed
Stabilization: ABC
6 important risk factor modification
Cognitive impairment
Hearing impairment
Vision impairment
Sleep deprivation
Dehydration
Immobility
Post op monitoring and Mx of
MI
Lung complication/Pneumonia
PE
Urinary retention
Maintain CNS O
2
delivery
SaO
2
> 90%
SBP > 90mm Hg
Hct > 30%
Maintain fluid/electrolyte balance
Dehydration or fluid overload
Na/K/Glucose level
Pain Mx
Use round the clock Acetaminophen
Use Morphine/Oxycodone for breakthrough
Treat specific causes that are treatable
1
st
Line:
Haloperidol 0.25-0.5mg PO/IV/IM q1h prn
Quetiapine 25-50mg PO BID
Avoid neuroleptics in long QT, Parkinson's
Short acting BDZs (Lorazepum/Ativan 0.25-0.5mg
PO q6-8h ( sedation, FALL risk)
2
nd
Line: Olanzapine
For sleep: Zolpidem/Trazodone
Discharge if- symptoms resolve, or if not safe
discharge place available (e.g. RCTP/LTC etc.)

Follow up- family doctor in 1-2 wk after resolution

Prognosis- Delirium usually improves with Rx of
definitive cause. But may become chronic.

Increases chance of dying from causative disease
if caused by medical illness