Acute Confusional State/ Delerium

Question 1

Acute confusional state affects what % of elderly patients admitted to hospital?

Answer 1

Up to 30%

Question 2

What may you get in a question regarding acute confusional state?

Answer 2

An elderly confused patient.

If they are a threat to themselves or other - give haloperidol rather than sectioning under the mental health act.

Question 3

What are some risk factors for acute confusional state?

Answer 3

• Age >=65 years
• Cognitive impairment (e.g dementia)
• Drug use - (half of cases) - Benzodiazepines common, morphine.
• Substance misuse (e.g. alcohol)
• Visual or hearing problems (Charles Bonnet Syndrome)
• Current hip fracture
• Severe illness

Question 4

What are some prescribed medications that can cause delerium?

Answer 4

• Benzodiazepines
• Analgesics (morphine)
• Anticholinergics
• Anticonvulsants
• Steroids
• Anti-Parkinsonism medications - (Levodopa, Carbidopa)

Question 5

What are some causes of delerium?

Answer 5

• Acute infections - UTI, Pneumonia, Viral infection, Cerebral abscess.
• Vascular disorders - stroke, subdural haemorrhage, miraines, Vasculitis.
• Metabolic causes - hypoxia, Blood sugar, liver or renal problems. Electrolyte abnormalities.
• Vitamin deficiences - thiamine, vitamin B12
• Endocrinopathies - Thyroid, parathyroid, pituitary, Cushing’s, Porphyria
• Trauma - head injury
• Epilepsy - post-ictal
• Neoplasm - cerebral malignancy, paraneoplastic syndromes.
• Urinary retention
• Faecal impaction

Question 6

What are the 3 most common causes of delerium?

Answer 6

• Infections
• Medications
• Drug withdrawal

Question 7

What are the 3 subtypes of delerium and which is most easily missed?

Answer 7

1. Hypoactive - apathy and quiet confusion. Most easily missed.
2. Hyperactive - agitation, delusions and disorientation.
3. Mixed - Both hypo- & hyper-active.

Question 8

What is tranditionally used in hospital to screen for confusion/dementia?

Answer 8

AMTS

Question 9

What scoring tool is used particularly for delerium ^ what does it encompass?

Answer 9

The Short CAM.

Acute onset & fluctuating couse + Inattention

AND EITHER

1. Disorganized thinking/incoherent speech
2. Changed level of consciousness

Question 10

How is it managed?

Answer 10

• Treatment of underlying cause
• Modification of environment
• First line sedative- haloperidol 0.5 mg
• The 2010 NICE delirium guidelines advocate the use of haloperidol or olanzapine

Question 11

In what sorts of dementia should you not use antipsychotics (Haloperidol) if you think they have acute on chronic confusional state?

Use lorzepam instead.

Answer 11

• Lewy body dementia
• Parkinson’s disease

Question 12

What is a good acronymn to remember the causes of delerium?

Answer 12

CONFUSION

• CON - stipated
• F - fluids/dehydration
• U - underlying disease
• S - Sensory - visual or auditory problems.
• I - Infection
• O - Opiods and other drugs (Benzos)
• N - Nutrition

Question 13

What are the screening investigations for acute confusional state?

Answer 13

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