Acute confusional state Flashcards
What are the 3 types of delirium
Hypoactive
Hyperactive
Mixed
hyperactive CF
Agitation Delusions Hallucination Wandering Aggression
hypoactive CF
Lethargy
Slowness with everyday tasks
Excessive sleeping
Inattention
Nemonic for confusion
CHIMPS PHONED
Whats does CHIMPS PHONED stand for
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)
What to looks for in notes
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
What quick assessment tool - more formal scores
AMTS
MOAC, ACEIII
How to get Hx
Collateral
What is included in the confusion screen
• 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
FBC
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.)
U+E
deranged electrolytes can cause confusion (consider sodium, but relative to what is normal for the patient).
LFT
confusion can be caused by liver failure, malnutrition or be based on the background of alcohol abuse.
INR
can be useful to know if the patient is on Warfarin & you are concerned about intracranial bleeding
TFT
confusion is more common in hypothyroid states.
Calcium
Hypercalcaemia often causes confusion/delirium – Bones, moans, psychotic groans ring a bell?
B12/folate + macrocutic anaemia
macrocytic anaemias, and B12/folate deficiency can compound confusion
Glucose
hypoglycaemia is a common cause of confusion – it’s also potentially life threatening, so don’t miss it!
Mgmt
Tx underling problem → it is a symptom
• Conservative: consistent nursing team, introductions
• Environmental - familiar objects, see clock and date
• Medication → last resort - bentos, haloperidol
Differentials to delirium
Dementia
Depression
Bipolar disorder
function psychosis
Complications
Hospital acquired infection pressure sore injuries residual psychiatric + cognitive impairment malnutrition
Prevention
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!
Tx for B12 deficiency
IM hydroxocobalamin 1mg on alternative days until improved
Korsakoff
confabulation, anterograde and retrograde amnesia
