Confusion Flashcards
What syndromes can cause a patient to appear confused?
- Delirium
- Dementia
- Mental Impairment
- Psychosis
- Receptive dysphasia
- Expressive dysphasia
What is delirium?
an acute impairment in cognitive ability together with impaired consciousness
What is dementia?
a chronic, progressive impairment in cognitive ability but with intact consciousness - you cannot diagnose dementia from a single mental status assessment
What is dementia?
a chronic, progressive impairment in cognitive ability but with intact consciousness - you cannot diagnose dementia from a single mental status assessment
What is mental impairment?
a permanent impairment in cognitive ability
What is psychosis?
the patient may not be confused, but have a disorder of thought content/perception (e.g. delusions and/or hallucinations)
What is receptive dysphasia?
the patient may have difficulties comprehending your questions (e.g. due to damage to Wernicke’s area of the brain)
What is expressive dysphasia?
the patient may be cognitively intact but have difficulties verbalizing an answer to your questions (e.g. damage to Broca’s area of the brain)
Can these conditions coexist?
yes
After ABCs before taking a history what should you ask for someone with confusion?
- Are they orientated to time, place and person? Can they tell you why they are here?
- Can they follow a three-step command? Can they name three common objects?
- Other symptoms: in pain?
How can you tell if they are orientated in time and place? What tests can you use?
- AMTS is 10q screening tool for assessing confusion: score less than 6/10 indicates cognitive impairment
- MMSE score of less than 26/30 indicates cognitive impariement
- CAM and MoCA other option
What does the 3 step command test for?
receptive and expressive dysphasia
What other symptoms would you enquire about?
- breathlessness
- cough
- urinary symptoms
What infections can cause confusion?
chest and UTI
If you can get a collatoral history what is important to check?
- Normal state
- Time course
- Drugs history
What would acute confusion suggest?
delirium over dementia
What would fluctuating confusion suggest?
delirium
What is important to check in drugs history?
both introduction and cessation of drugs can cause confusion esp in elderly who may have dementia / or on lots of medications some of which may have changed recently
What are the possible infectious causes of confusion?
- chest
- urinary
- encephalitis
- brain abcess
- sepsis
What are the possible neoplastic causes of confusion?
brain tumour
What are the vascular causes of confusion?
- stoke
2. MI causing hypoperfusion
What are the immune causes of confusion?
- neuropsychiatric lupus
2. Hasimoto’s encephalopathy
What are the trauma causes of confusion?
- subdural haematoma
2. extradural haematoma
What are the endocrine causes of confusion?
- hypothyroidism
- hyperthyroidism
- diabetic ketoacidosis
What are the drug causes of confusion?
intoxication or withdrawal of alcohol, opiates, or psychiatric medication or use of diuretics, digoxin, thyroid medication) Drug toxicity accounts for 30% of delirium
What are the metabolic causes of confusion?
- hypoxia
- hypercapnia
- hypoglycaemia
- hypercalcaemia
- sodium or other electrolyte imbalances
- thiamine
- folate, Vitamin B12 deficiencency
What are the degeneritive causes of confusion?
chronic and not cause delirium but will predispose patients to becoming delirious
What vital signs need to be taken in confusion?
- Pulse and resp rate
- BP
- Oxygen sat
- Temp
- Blood glucose
Why do you take pulse and resp rate in confusion?
tachycardia or tachypnoea could occur secondary to infection
Why do you measure BP in confusion?
- hypoperfusion of the brain (due to systemic hypotension) decreases patient consciousness 2. if hypertension and bradycardia is Cushing response indicative of raised ICP
Why do you take oxygen sats in confusion?
hypoxia also affects consciousness
Why do you take temperature in confusion?
fever may indicate underlying infective process and hypothermia also causes confusion
Why do you measure blood glucose in confusion?
hypoglycaemia or hyperglycaemia can depress consciousness
What happens with T1 diabetes confusion?
T1 hyperglycaemia assoicated with ketoacdisosis
What happens in T2 diabetes confusion?
T2 extreme hyperglycaemia may indicate hyperosmolar hyperglycaemic syndrome (HHS)
What do you look for on examination of patient with confusion?
- Conciousness
- Septic focus
- Pupils
- Focal neurological sings
- Needle track signs
- Asterixs (metabolic flap)
- Breath (for alcohol)
- Bitten tongue and/or posterior shoulder dislocation
How do you assess consciousness?
GCS (allows you to track progress as well)
What do you look for on the chest with septic focus?
Infection:
- dull percussion
- bronchial breathing crackles
What do you look for on the urine with septic focus?
- check for suprapubic tenderness -atheter bag check if urine is cloudy
- peform urine analysis
- send off specimen for MC&S
What do you look for on the cellulitis with septic focus?
- in between toes of diabetics and skin
- check venous or arterial lines that may be focus for infection
What do you look for on the cellulitis with septic focus?
- in between toes of diabetics and skin
- check venous or arterial lines that may be focus for infection
What do you look for on the cellulitis with septic focus?
- in between toes of diabetics and skin
- check venous or arterial lines that may be focus for infection
What do you look for on the cellulitis with septic focus?
- in between toes of diabetics and skin
- check venous or arterial lines that may be focus for infection
What do you look for on the meningitis with septic focus?
- neck stiffness
- photophobia
- purpuric rash (suggestive of meningococcal septicaemia)
What do you look for on the meningitis with septic focus?
- neck stiffness
- photophobia
- purpuric rash (suggestive of meningococcal septicaemia)
What do you look for in the pupils?
- symmetry
- size
- direct and consensual response to light
What does it mean if the pupils are dilated and sluggish to react?
drug overdose (cocaine, tricyclic antidepressant, severe hypoxia, hypothermia, postical)
What can it means if the pupils are assymetrical?
- normal variant (anisocoria)
2. rarely suggestive of coning secondary to raised ICP or 3rd nerve palsy)
What are the focal neurological signs you look for in confusion?
- signs suggestive of stroke or SOL
- dysphasia
- visual field deficits
- nystagmus
- tone and reflex symmetry
- plantar responses
- focal weakness
- ataxia
- sensory or visual inattention
What would needle track marks suggest?
suggestive of IV drug abuse
What would asterixis (metabolic flap) suggest?
- hypercapnia
- hepatic encaphalopathy
- ureamia
What would a bitten tongue and/or posterior shoulder dislocation?
suggest convulsive seizure
What do you measure in the septic screen?
- FBC
- CRP
- Blood cultures
- Urine analysis
- Urine MC&S
- Chest radiograph
What do you look at in the FBC for a septic screen?
- WCC elevated in systemic infection
- Anaemia can contribute to hypoxia
What would CRP be in the septic screen?
elevated: inflammatory but non-specific
Why do you get blood cultures in a septic screen?
- Check infection and identify organism and its sensitivity to antibitoics
- Time consuming
What sort of sample do you get for urine analysis?
MSU
What urine analysis is suggestive of UTI?
- positive leucocyte esterase
- positive nitrate
What urine analysis is suggestive of diabetic ketoacidosis?
- positive glucose
- ketones
What is seen in a chest x ray with a chest infection?
consolidation
What is seen in a chest x ray with a chest infection?
consolidation
What would be seen on a chest x ray with heart failure (could be cause of cerebral hypoperfusion)?
enlarged heart
What do you measure on the metabolic screen for confusion?
- Blood gas
- U+Es+Calcium
- TFTs
- Liver enzymes
- Thiamine, folate and vitamin B12 levels
Why do you take a blood gas?
provide info about hypercapnia and acid base balance
What can cause metabolic acidosis?
- uraemia
- diabetic ketoacidosis
- some toxins
When do you do a venous gas?
if patient not hypoxic on oxygen sat monitoring or drowsy with hypercapnia a possible cause
Why do you measure U+E+Calcium?
-Low sodium
-High calcium
-Uraemia
in renal failure can lead to acute confusional state
Why would you do TFTs?
if clinical signs or history suggests hypo- or hyperthyroidism, should investigate T3/T4 and TSH levels
Why do you measure liver enzymes?
-liver failure can result in hepatic encephalopathy and suggested by deranged liver enzyme
Why do you measure liver enzymes?
-liver failure can result in hepatic encephalopathy and suggested by deranged liver enzyme
What raised liver enzyme can suggest alcohol abuse?
GGY
When do you do thiamine, folate and vitamin B12 levels with confusion?
if you suspect patient is malnourished (homeless, alcohol or drug abuser, elderly patient living alone who appears cachexic) look for these deficiencies as these are treatable
What other tests can you do in confusion?
- toxicology screen
- ECG
Why is a toxicology screen not great?
only for specific drugs and do not say when taken etc
Why do you do an ECG with confusion?
to exclude ischaemia or arrhythmia leading to a low-output state and hypoperfusion
How do you manage UTI acutely?
- ABC
- Antibiotics
- Confusion management
What is the confusion management?
- Don’t leave unatteneded
- Put in quiet side room
- Make sure have glasses hearing aids that work
- Discontinue non-essential medication as may be contributing
- Promote good sleep hygiene
- Fluid and nutrition - if suspect thiamine deficiency secondary to malnutrition or alcoholism must treat asap
- Sedation (LAST resort as can exacerbate confusional state)
What medications can you use for sedation?
- Haloperidol: (30-60 mins to work and can have extrapyramidal side effects so use in caution with Parkinson’s or Lewy body dementia)
- Lorazepam: (5-10 mins to act) and useful in restoring sleep
