Delirium(Acute confusion)

Full Confusion Screen ( Ix)
1. Quick screen of confusion + Hx
  1. Are they oriented to time, place and person? Can they tell you why they are here?
  2. Can they follow a 3-step command?
    1. Receptive dysphasia
      1. The pt may have difficulties comprehending your qns( eg due to damage to Wernicke's area of the brain)
  3. Can they name three common objects?
    1. Expressive dysphasia
      1. The pt may be cognitively intact but have difficulties verbalising an ans to your qns( eg due to damage to Broca's area of the brain)
  4. Other symptoms?
    1. Are they in pain?
    2. SOB?
    3. Cough?
    4. Dysuria, nocturia?
  5. If pt came with someone who knows them, try to find out:
    1. Their normal state( maybe they already have dementia, psychosis, mental impairment)
    2. Time course of confusion
      1. If acute, delirium>dementia
    3. Pt's drug Hx( including alcohol)
      1. Consider both intro and cessation of drugs
2. Septic screen:( FBC, CRp, bld cultures, urine dips and MC+S, CXR) & Toxicology screen
3. Metabolic screen: ( ABG, UE, TFts, LFTs, thiamine, folate, Vit B12)
4. ECG
Causes (INVITED MD)
1. Degenerative Conditions (eg, chronic, but will not cause the delirium, but will predispose pts to becoming delirious
2. Neoplastic( eg, brain tumour)
3. Vascular( eg, stroke, MI causing hypoperfusion)
4. Immune( eg, rare conditions such as neuropsychiatric lupus, Hashimoto's encephalopathy)
5. Trauma( eg, subdural haematoma, extradural haematoma)
6. Endocrine( eg, hypothyroidism, hyperthyroidism, DKA)
7. Drugs( eg, intoxication or withdrawal of alcohol, opiates or psychiatric medications; or use of diuretics, digoxin, thyroid medication). Drug toxicity = 30% of delirium
8. Metabolic( eg, hypoxia, hypercapnia, hypoglycaemia, Na or other electrolyte imbalances, thiamine, folate, or vit B12 def)
9. Infectious( eg, chest, urinary, encephalitis, brain abscess, sepsis)
10. Other causes: hypothermia
Definition: An acute impairment in cognitive ability together with impaired consciousness
1. 4 main features of delirium
  1. disturbance of consciousness( reduced awareness of environ and reduced attention)
  2. change in cognition
  3. hx, exam, Ix suggest that disturbance is due to direct physio result of a general medical condition, subst. intox. or withdrawal
  4. rapid development over a short period of time ( hrs to days) with tendency to fluctuate during day
Risk factors
1. Elderly(>65)
  1. Dementia
    1. Alcohol problems
      1. Impaired vision or hearing
        Current hip fracture
        Severe illness( eg. previous head injury or stroke)
        Dislocation to an unfamiliar environment ( eg hospital admission)
Physical Examination( what to look for?)
1. Vital signs
  1. HBR and RR?
    1. Tachycardia?tachypnoea
      1. Sepsis or haemorrhage
  2. BP
    1. hypoperfusion of the brain( due to systemic hypotension) drops pt consciousness
      1. Is there hypertension and bradycardia?
        Aka Cushing response( indicative of raised ICP)
  3. O2 Saturation
    1. hypoxia affects consciousness
  4. Temp
    1. Fever = infection / hypothermia also causes confusion
  5. Blood glucose
    1. hypoglcaemia/hyperglycaemia can depress consciousness
      1. Type 1 DM hyperglycaemia can be linked to DKA ( which affects mental state)
      2. Type 2 DM hyperglycaemia can indicate HONK state
  6. Consciousness( GCS scale)
2. Septic focus
  1. Signs of chest infection, urine infection( suprapubic pain, catheter bag check), cellulitis esp if diabetes, meningitis
3. Pupils: looking for symmetry, size, and direct and consensual response to light
4. focal neurological signs
5. Needle track signs
6. Cherry red lips( CO poisoning)
7. Asterixis( metabolic flap)
8. Breath ( alcohol, liver failure, DKA)
9. Bitten tongue/post shoulder dislocation=seizure

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Delirium(Acute confusion)

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	Created by sicilia_sp over 10 years ago