Acute confusional state

Question 1

What are the 3 types of delirium

Answer 1

Hypoactive
Hyperactive
Mixed

Question 2

hyperactive CF

Answer 2

Agitation
Delusions
Hallucination
Wandering
Aggression

Question 3

hypoactive CF

Answer 3

Lethargy
Slowness with everyday tasks
Excessive sleeping
Inattention

Question 4

Nemonic for confusion

Answer 4

CHIMPS PHONED

Question 5

Whats does CHIMPS PHONED stand for

Answer 5

Constipation
Hypoxia
Infection
Metabolic disturbance
Pain
Sleeplessness

Prescriptions - benzos, opioids
Hypothermia/pyrexia
Organ dysfunction (hepatic or renal impairment)
Nutrition
Environmental changes
Drugs (, OTC, illicit, recreational, their partner/neighbour/pets’, alcohol and smoking)

Question 6

What to looks for in notes

Answer 6

Current diagnoses – consider dementia & depression as standalone causes or in conjunction with delirium

Medications – perform a medication review – opiates / calcium supplements etc

Vascular problems – previous Strokes / MI / ischaemic limbs ↑ likelihood of vascular dementia

Other presenting complaints
History of recurrent admissions

Question 7

What quick assessment tool - more formal scores

Answer 7

AMTS

MOAC, ACEIII

Question 8

How to get Hx

Answer 8

Collateral

Question 9

What is included in the confusion screen

Answer 9

• Observations
• BloodsBloods:
FBC 
U&E 
LFTs 
CRP
INR
TFTs 
Calcium
B12 + folate/haematinics 
Glucose

CT head
CXR/AXR
Cultures if sepsis + VBG
Urine dipstick 
PR

Question 10

FBC

Answer 10

white cells for signs of infection, anaemia, increased MCV (macrocytic anaemia can be caused by B12 or folate deficiency which can have a variety of origins: leukemias, alcohol use, lack of intake, lack of absorption (i.e. post-gastrectomy), pernicious anaemia; hypothyroidism, liver disease.)

Question 11

U+E

Answer 11

deranged electrolytes can cause confusion (consider sodium, but relative to what is normal for the patient).

Question 12

LFT

Answer 12

confusion can be caused by liver failure, malnutrition or be based on the background of alcohol abuse.

Question 13

INR

Answer 13

can be useful to know if the patient is on Warfarin & you are concerned about intracranial bleeding

Question 14

TFT

Answer 14

confusion is more common in hypothyroid states.

Question 15

Calcium

Answer 15

Hypercalcaemia often causes confusion/delirium – Bones, moans, psychotic groans ring a bell?

Question 16

B12/folate + macrocutic anaemia

Answer 16

macrocytic anaemias, and B12/folate deficiency can compound confusion

Question 17

Glucose

Answer 17

hypoglycaemia is a common cause of confusion – it’s also potentially life threatening, so don’t miss it!

Question 18

Mgmt

Answer 18

Tx underling problem → it is a symptom
• Conservative: consistent nursing team, introductions
• Environmental - familiar objects, see clock and date
• Medication → last resort - bentos, haloperidol

Question 19

Differentials to delirium

Answer 19

Dementia
Depression
Bipolar disorder
function psychosis

Question 20

Complications

Answer 20

Hospital acquired infection
pressure sore
injuries
residual psychiatric + cognitive impairment 
malnutrition

Question 21

Prevention

Answer 21

Avoid drugs known to precipitate delirium – benzodiazepines etc

Highlighting patients more ‘at risk’ and observing them closely for signs of delirium.

Assessment of other factors which may induce or exacerbate delirium – pain control, drugs etc 6.

Employing supportive/environmental management approaches for all patients, regardless of delirium risk.

Increased awareness!

Question 22

Tx for B12 deficiency

Answer 22

IM hydroxocobalamin 1mg on alternative days until improved

Question 23

Korsakoff

Answer 23

confabulation, anterograde and retrograde amnesia