Acute Confusional State

Key facts:

Authors: Damian Mayo and Kris Ghosh
Top Tips: Commonest causes are sepsis (urinary tract and chest) and drugs/alcohol excess or withdrawl. Not TIA/CVA. Don't forget encephalitis and SDH

Key Differential Diagnoses

• Dementia (chronic confusion)
• Learning difficulties

• Hysterical confusion 

Key Investigations

• Glucose (BM)
• Dipstick
• O2 saturation ± ABG if low
• FBC, ESR, CRP

  Key Investigations

• U+E, LFT/GGT, Bone, Glucose, ± B12/folate, TFTs, TPHA
• BC, MSU
• CXR ± CT head (± LP)

Key Treatment

• OXYGEN high flow, if hypoxic
• IV ANTIBIOTICS, if infected (if source unclear, IV BENZYLPENICILLIN 1.2 g qds + IV GENTAMICIN 5 mg/kg od)
• Remove drug cause
• ± IV GLUCOSE, 20 mls 50%, if BG < 4 mmol/L
• ± Alcohol withdrawal regime, if appropriate
• ± O/IM HALOPERIDOL 2-10 mg (start as low as possible,
  even 0.5 mg)

Key Management
Decisions

• CT head (± LP) (encephalitis)

Background

First of all, ascertain whether the confusion is really acute; ie does the patient have chronic confusion (dementia)?; or is this acute on chronic confusion. Not doing this (and recording it) is one of the most medicolegally dangerous things a junior doctor can do

Introduction

• An acute confusion state is a neuropsychiatric syndrome which is difficult to define but involves abnormalities of perception, thought and awareness levels. Patients may appear confused or 'not with it' when talking to them. It may be their family or carer who notice the confusion, alternatively
• It is very common, especially in the elderly, and not a benign syndrome. Many of these patients subsequently do not return to their baseline function and some even require long-term institutionalisation. 20% medical and surgical acute admissions have some confusion; 10% of elderly admissions primarily due to confusion (often due to drugs). 5% in-hospital mortality, 10% mortality (+25% functional decline) at 3 mths. 50% diagnosed dementia in 2y
• It can occur acutely or subacutely. Characteristically symptoms fluctuate
• Sepsis, drugs/alcohol (excess/withdrawal) and metabolic disturbance are the 'big 3' ie three commonest causes of an acute confusional state
• TIA/CVA rarely presents as confusion. But hyponatraemia is a common cause in the frail elderly
• First of all, check the blood glucose. Record Mental Test Score (MTS; partly as baseline)
• Removal from home can cause acute confusion. The skills are not to admit the frail elderly unless its necessary (or make their stay as short as possible), and accident prevention
• Pain and opiates can both cause confusion (think about post-op, especially post #NOF). Think about nursing issues and it's important to sedate only if essential. This is a good review: [Ref]

Medicolegal aspects

• Patients are vulnerable
• It is a common scenario for errors, eg missing the diagnosis and poor management. This is why it has the potential to rapidly become serious
• So, do a full examination, and a full set of bloods, BC, CXR, and CT head, if necessary
• Do not assume confusion is due to long-term dementia or learning difficulties, even in the elderly and those with learning difficulties. In other words, check previous level of function from relative/carer/home circumstances
  Note: if this is not possible treat as acute confusion until proven otherwise; not doing this is medicolegally dangerous; do not go there; you need to make great efforts to find out their baseline mental state; ring family, GP, anyone; 2am, 2pm, anytime

Definitions

• Neuropsychiatric syndrome characterised by disorientation in time and place, impaired short-term memory, and impaired consciousness; occuring over hours/days, with a tendency to fluctuate over the course of the day
• Delirium = in addition, there are disorders of perception (hallucination, illusion, delusion)
• Importantly, confusion and delerium are reversible

DSM-IV Diagnostic Criteria for Delirium Due to a General Medical Condition (2000)

1. Disturbance of consciousness (ie, reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention 
2.  A change in cognition (such as memory deficit, disorientation, language disturbance, or all 3), or development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia 
3.  The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day 
4.  There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition

Epidemiology

• 20% medical and surgical acute admissions have some degree of confusion; 10% of elderly admissions primarily due to confusion often due to drugs: [Ref] ; ie its very common, just ask the questions
  Note: only 10% of admissions with confusion have a primary neurological problem (vs sepsis, drugs and metabolic; which are the most important groups of causes)

Causes

HIDEMAP (from GP notebook):

• H = hypoxia (CCF, Respiratory Failure, ARF) + head trouble (head injury, SOL (SDH? Brain abscess?); meningitis; rarely .. encephalitis, cerebral malaria)
• I = infection (UTI, chest, wound, line, post-op, neutropenic sepsis, especially if immunosuppressed)
• D = DRUGS DRUGS DRUGS = recreational or prescribed, excess or withdrawal, eg: benzodiazepines, analgesics (especially opiates), Anticholinergics, Anticonvulsants, anti-parkinsonism medication, steroids
• E = endocrine (hyper/hypoglycaemia, hypothyroidism (especially elderly))
• M = metabolic (ARF, ALF, hypercalcaemia, hyponatraemia)
• A = alcohol (excess or withdrawal) + anaemia (B12/folate deficiency)
• 3Ps = psychosis + postictal + postop (especially post #NOF; often multifactorial, eg septic, dry and drugs)
  Notes: TIA/CVA does not usually present as confusion; steroids can cause 'steroid psychosis'
  [Ref]

Risk factors

• Dementia (ie worsening confusion)
• Alcohol + recreational drugs
• Recent surgery (especially neurosurgery); look on back of drug card

Symptoms

• History has limited value

Key Questions

• Vital to get history from witnesses (relative, carer, ambulanceman):
• Depression (?overdose); epilepsy; drug/medical history; recent head and neck infection (brain abscess); recent surgery (especially neurosurgery); cerebral shunt?
  Note: pick up the phone if necessary. Remember, the 'poor historian' is you

Signs

• Record mental test score (partly as baseline)
  Note: if you are in a hurry, do at least the first three, ie is the patient orientated in time, place and person?. If they know the date, they are not confused
• Look for needle tracks, and signs of head injury and alcohol
• Check for bladder (retention can cause confusion in elderly)
  Note: patient may be a danger to you (aggression or HIV/Hep B/C positive, ie wear gloves)

Investigation

First of all, check the blood glucose. Don't forget the '3 Treatable Ts' = Thyroid(hypo), TPHA + BTwelve deficiency

Blood

• FBC, ESR, CRP
• U+E, LFTs, GGT, Bone (?calcium), Glucose
• B12/folate,TFTs, TPHA/VDRL
  Note: don't forget the '3 Ts' (Thyroid(hypo), TPHA + BTwelve deficiency. Even though these are rare causes of acute confusion, they (and subdural haemorrhage) are 4 of the important reversible causes of chronic confusion ie dementia. In fact, many dementia clinics will not take a referral from a GP, unless those 4 things have been excluded
• O2 saturation (± ABG, if low), BC
• ± CK, if has been on floor for long
• ± Thick/thin films (malaria)
• ± SLE serology

Other

• Urinalysis: leucocytes? nitrites? (catheterise slowly if cannot get sample)
• ?Urinary toxin screen (overdose?)
• MSU
• CXR (pneumonia, ?carcinoma if patient hyponatraemic)
• AXR: ?constipation (can cause confusion in elderly)
• CT head ± LP , if no obvious diagnosis, or not improving at 24 hrs

Key Investigations

• Glucose
• CT head ± LP

Specialist investigation

• EEG

Differential Diagnoses

• Learning difficulties, dementia (chronic confusion) - all easy to confuse
• Drunk
• Deafness
• Dysphasia/
• Dysarthria
• DepressionHysterical confusion
• Bipolar disorder
• Other psychoses eg schizophrenia

Treatment

Admitted or not, such patients are a danger to themselves, and others; ie the most important 'treatment' may be making them safe - so think about nursing issues

Treatment
(first line)

Drugs:

• IV GLUCOSE 20 mls 50%, if BG < 4 mmol/L
  Note: GLUCOSE increases risk of Wernicke's encephalopathy, so give IV PABRINEX first, if suspect patient is alcohol dependent and hypoglycaemic
• IV PABRINEX 2 vials tds, if ?Wernicke's or alcohol withdrawal possible
• PO CHLORDIAZEPOXIDE 20-40 mg qds, reducing over 5d; if alcohol withdrawal; but benzodiazepines can make confusion worse; so, only Rx with benzodiazepine if sure
  Note: larger doses are used in severe withdrawal-eg 40 mg qds, reducing over 10 days
• IV NALOXONE 400 mcg, if small pupils (?opiate OD)
• IV FLUMAZENIL 200 mcg, over 15 secs, if ?benzodiazepine OD; then 100 mcg every 60 secs; max 1mg (2mg ITU)
  Note: flumazenil is contraindicated in patients with epilepsy on longterm benzodiazepines; you may need to give further doses of naloxone and flumazenil (see BNF)
  

Procedures: (see supportive measures below)

• IV (+IV fluids, if dry)
• OXYGEN, in hypoxic patient (this can quickly calm patient, and reduce confusion); if pulling mask off, try nasal cannulae
• Warm up/cool down, as necessary

Supportive measures

• Room: don't move about unecessarily, moderately lit side room preferable). Avoid excess noise, avoid over- or under-stimulation
• Communication: clear. Avoid speciality jargon. Staff consistency (both doctors and nurses). Use health advocates (eg interpreters) where needed
• Orientatation: reminders of the day, time, location and identification of surrounding persons; have a clock visible
• Relaxation: eg watch television. Involve family and carers.
• Familiarity: have familiar objects from home around patients especially glasses, walking aids and hearing aids. Maintain competence eg maintain walking in ambulant patient
• Accident prevention: nurse on floor if necessary (to prevent falls and fractures). Only use restraints if essential (patient may pull out essential line and exsanguinate)

Stop

• Drug cause (especially hyponatraemia secondary to diuretics and/or SSRIs)
• Alcohol
• Any sedative drug (if in doubt, stop almost everything)

Treatment
(second line)

Drugs

• Have low threshold for broad spectrum IV antibiotics (± antivirals ± antimalarials):
• IV BENZYLPENICILLIN 1.2 g qds + GENTAMICIN 5 mg/kg od; before CT ± LP, if meningitis possible
• ± IV ACICLOVIR 10 mg/kg tds (infused over 60 mins) for 10-14 days, if encephalitis possibility (reduced dose in renal insufficiency)
• ± IV QUININE DIHYDROCHLORIDE: loading dose 20 mg/kg (maximum 1.4 g) over 4 hrs; then 8 hrs after loading dose, 10 mg/kg tds (also infused over 4 hrs); doses diluted in 250 mls N Saline, if cerebral malaria possible; watch for toxicity (QT prolongation)
• Avoid sedation, unless absolutely necessary. But if extremely agitated/aggressive (ie danger to themselves or others) consider O/IM HALOPERIDOL 2-10 mg (start as low as possible, even 0.5 mg); maximum 18 mg/d; or PO QUETIAPINE 12.5-200 mg od. Start with 12.5mg od especially in elderly; and if more needed than 25 mg bd, please consult psychiatrist-on-call
  
  

Procedures

• If unwell, urinary catheter, CVP, arterial line
• Note: but may pull out any of these; so can make situation worse

Prescribing issues

• If drugs might be the cause (and no other diagnosis made), consider stopping all but essential ones - and inform GP when they go home. Polypharmacy is a problem in the elderly

Admit?

• Usually
  Note: but if frail elderly, consider alternative management plan, in community; ring GP, if you are doing this plan

Bed plan

• Medical admission ward
• ± ITU

Referrals

Medical

• Depends on cause
• ± ITU
  

Other

• SALT team etc, if CVA (pneumonia, 2^o to aspiration?); does patient need NG feed? PEG?

The Rest

Maxim

• "Sedating a confused patient may make them worse"

Complications

• Hospital acquired infections, eg Clostridium difficile and MRSA
• Pressure sores 
• Accidents: eg fractures (femoral or hip fractures from falls) 
• Residual psychiatric and cognitive impairment 
• Some progress to stupor, coma and eventual death
  Note: patient may be a danger to you (aggression or HIV/Hep B/C positive, ie wear gloves)

Follow-up

• Nil, usually
• But consider HCE follow-up, if thought to be first presentation of dementia
  Note: confusion may last longer than the underlying condition, sometimes for up to a year: [Ref] . This means that some patients will be discharged with persisting abnormalities. It is good idea to warn the family (and GP) about this issue. Quicker inpatient recovery is associated with a better outcome

Prognosis

• Good, if confusion is mild. 5% in-hospital mort, 10% mort (25% functional decline) at 3 mths. 50% diagnosed dementia in 2y

2° Prevention
+ Health promotion

• If alcohol or recreational drugs all/part of problem, refer to appropriate community services

Don't forget

• Encephalitis; DO NOT MISS THIS DIAGNOSIS; it's treatable
• SDH; so is this
• DRUGS DRUGS DRUGS (and look on back of card). If in doubt, stop almost everything. Ring GP, if necessary
• Find out whether this is acute, chronic (dementia), or acute-on-chronic confusion. Not doing this (ie making assumptions in Acute Confusion) is medicolegally dangerous
• Look at vital signs (including oximetry) and glucose
• Record mental test score (important baseline; like GCS in coma; note if fluctuating)
• CT head/LP if no obvious diagnosis, or no better at 24h
• Check for retention and constipation, in the elderly
• '3 treatable Ts' = Thyroid(hypo), TPHA + BTwelve deficiency

Red flags

• Pulling at lines, catheter etc
• Falling out of bed .. ie, may be danger to him/herself (protect them)

Synonyms: acute confusion, acute brain failure, acute organic reaction, delirium, post-operative confusion

References