Key facts:
Authors: Damian Mayo and Kris Ghosh
Top Tips: Commonest cause is sepsis (urinary tract and chest). Not TIA/CVA. Don't forget encephalitis
| Key differential diagnoses |
Dementia (chronic confusion) |
| Key investigations |
Glucose (BM), dipstick |
|
Key Treatment |
OXYGEN high flow, if hypoxic |
|
Key Management |
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
|
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 |
| Medicolegal aspects |
• Patients are vulnerable |
|
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 |
| 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 |
|
Causes |
HIDEMAP (from GP notebook) |
|
Risk factors |
Dementia (ie worsening confusion) |
|
Symptoms |
History has limited value |
|
Key questions |
Vital to get history from witnesses (relative, carer, ambulanceman): |
|
Signs |
Record mental test score (partly as baseline) |
Investigation
First of all, check the blood glucose. Don't forget the '3 Treatable Ts' = Thyroid(hypo), TPHA + BTwelve deficiency
|
Blood |
FBC, ESR, CRP |
|
Other |
Urinalysis: leucocytes? nitrites? (catheterise slowly if cannot get sample) |
|
Key investigations |
Glucose |
|
Specialist investigation |
EEG |
|
Differential diagnoses |
Learning difficulties, dementia (chronic confusion) - all easy to confuse (!) |
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 |
Drugs: |
| Supportive measures |
Room: don't move about unecessarily, moderately lit side room preferable). Avoid excess noise, avoid over- or under-stimulation |
|
Stop |
Drug cause (especially hyponatraemia secondary to diuretics and/or SSRIs) |
|
Treatment |
Drugs: |
| 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 |
|
Bed plan |
Medical admission ward |
|
Referrals |
Medical: |
The Rest
| Maxim | "Sedating a confused patient may make them worse" |
|
Complications |
• Hospital acquired infections, eg Clostridium difficile and MRSA |
|
Follow-up |
Nil, usually |
|
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 |
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 |
|
Red flags |
• Pulling at lines, catheter etc |
