Confusion Flashcards
Define delirium.
An acute impairment in cognitive ability with impaired consciousness
Define dementia.
A chronic, progressive impairment in cognitive ability but with intact consciousness
Define psychosis.
A disorder of thought content/perceptions (e.g. delusions and hallucinations)
NOTE: the patient may NOT be confused
Define receptive dysphasia.
The patient may be cognitively intact but they have difficulty comprehending speech
Due to damage to Wernicke’s area
Define expressive dysphasia.
The patient may be cognitively intact but have difficulty verbalising answers to questions
Due to damage to Broca’s area
What are two important methods of screening confused patients?
Are they oriented in time, space and person? Can they tell you why they are there?
Can they follow a three-step command? Can they identify three common objects?
What abbreviated mental test score would indicate that the patient has a cognitive impairment?
< 6/10
What MMSE score would indicate that the patient has a cognitive impairment?
< 26/30
What does three-step command and naming three common objects test?
Three-step command – tests for receptive dysphasia
Three common objects – tests for expressive dysphasia
If the confused patient has been accompanied by a friend/relative, what are some important details to ascertain?
The patient’s normal state Time course of confusion (acute onset is more likely to be delirium) Drug history (including alcohol) NOTE: a fluctuating course is suggestive of delirium
What are the five most important and common causes of confusion?
Chest infection
UTI
Subdural haematoma
Drugs – diuretics, digoxin, thyroid medication
Sodium and other electrolyte abnormalities
Using the surgical sieve, list some other causes of confusion.
Infection – encephalitis, brain abscess, sepsis
Neoplastic – brain tumour
Vascular – stroke, MI causing hypoperfusion
Immune/Inflammatory – neuropsychiatric lupus, Hashimoto’s encephalopathy
Trauma – extradural haematoma
Endocrine – hypothyroidism, hyperthyroidism, DKA
Drugs – intoxication or withdrawal from alcohol, opiates or psychiatric medications
Metabolic – hypoxia, hypercapnia, hypoglycaemia, hypercalcaemia, thiamine/folate/B12 deficiencies
Degenerative
Explain the importance of checking the following vital signs in a confused patient: PR + RR BP Sats Temp BG
Pulse and Respiratory Rate
Tachycardia and tachypnea indicates infective process
Blood Pressure
Hypotension can lead to hypoperfusion of the brain impaired consciousness
Cushing’s response (to raised ICP): high BP + low HR + irregular breathing
Oxygen Saturation
Hypoxia impairs consciousness
Temperature
Fever indicates infection
Hypothermia can cause confusion in elderly patients
Blood Glucose
Hypoglycaemia and hyperglycaemia can depress consciousness
T1DM: hyperglycaemia may be associated with DKA
T2DM: extreme hyperglycaemia may indicate hyperosmolar hyperglycaemia state (HHS)
List some key features of examination of a confused patient.
Consciousness Septic focus Pupils Focal neurological signs Needle track marks Asterixis Breath Bitten tongue and posterior shoulder dislocation
Describe some pathological variations in the pupils of a confused patient.
Pinpoint + sluggish to react = opiate or barbiturate overdose
Dilated + sluggish to react = drug overdose (e.g. cocaine or TCA), severe hypoxia, hypothermia, post-ictal
Asymmetrical = could be normal variant (anisocoria), but is rarely suggestive of coning secondary to raised ICP
What would a bitten tongue or a posterior shoulder dislocation suggest?
Convulsive seizure
What are the three divisions of the Glasgow Coma Scale and how many points are allocated to each?
Eyes = 4 Verbal = 5 Motor = 6
Which investigations would be performed to find out whether an infection is the cause of the confusion?
FBC – raised WCC
CRP – raised in infection
Blood cultures
Urinalysis – check for features of UTI (leucocyte esterase + nitrites), or DKA (positive glucose + positive ketones)
Urine MC&S
Chest radiograph (check for consolidation caused by chest infection)
Which investigations would be performed in a metabolic screen?
Blood gas – check hypercapnia, acid-base balance
U&Es – check for electrolyte imbalances
TFTs
Liver Enzymes – hepatic encephalopathy can cause confusion
Thiamine, folate and B12 levels – check whether the patient is malnourished
What does disproportionately raised GGT suggest?
Alcohol abuse
Why is it important to perform an ECG in a confused patient?
Exclude ischaemia and arrhythmia that could lead to a low-output state causing hypoperfusion of the brain
Describe the management of a confused patient.
Resuscitation – assess ABC
Antibiotics – if there is an infectious cause
Conservative measures
Make sure the patient isn’t left unattended
Keep them in a quiet side room if possible
Discontinue non-essential medications
Promote good sleep
Consider providing fluids and nutrition if they are unable or unwilling to maintain a good diet
Which sedatives may be used if a confused patient requires sedation?
Haloperidol
Lorazepam
Describe the management of a patient in alcohol withdrawal.
Thiamine is important because it can prevent Wernicke’s encephalopathy
Chlordiazepoxide reduces the symptoms of withdrawal
NOTE: alcohol withdrawal is a medical emergency
List some reasons why post-operative patients may be confused.
Hypoxia Opiates Deranged electrolytes Infection Sleep loss Alcohol withdrawal
Give four reasons why post-operative patients may be hypoxic.
PE
Basal atelectasis
Opiates causing respiratory depression
Anaemia from blood loss
Give two reasons why surgery can lead to derangement of electrolytes.
IV fluids
Renal failure caused by hypoperfusion
What is lithium used to treat? Why is it important to check serum lithium levels?
Bipolar disorder
It has a narrow therapeutic window and high serum lithium levels can cause confusion
Describe the results of a lumbar puncture in a patient with meningococcal meningitis.
High WCC
Gram-positive intracellular diplococci
High protein
CSF: blood glucose ratio < 0.5
What is pseudohyponatraemia and what can it be caused by?
This is an artifact produced by the machine that analysis U&Es in which sodium appears low although it is normal
If sodium is low, plasma osmolality should also be low
Causes of pseudohyponatraemia:
Hyperproteinaemia
Hyperlipidaemia
Hyperglycaemia/mannitol/glycine (associated with HIGH plasma osmolality)
List three causes of hyponatraemia associated with hypovolaemia
Diarrhoea
Vomiting
Diuretics
List three causes of hyponatraemia associated with euvolaemia
SIADH
Hypothyroidism
Adrenal insufficiency (can also be in the hypovolaemic category)
List three causes of hyponatraemia associated with hypervolaemia
Cirrhosis
Cardiac failure
Nephrotic syndrome
List some signs and symptoms of diabetic ketoacidosis.
Polyuria, polydipsia
Decreased mental state due to hyperglycaemia
Nausea/vomiting
Abdominal pain
Shortness of breath or Kussmaul breathing
Hypotension and tachycardia due to dehydration
Ketotic (fruity) breath
Describe features of opiate overdose
‘Chill out’
Pinpoint pupils
Respiratory depression
Check for needle track marks
Describe features of cocaine overdose
‘Buzz’ Dilated pupils Sinus tachycardia Hypotension Pyrexia
Describe features of TCA overdose
Exert both sympathetic and parasympathetic effects
Sympathetic: dilated pupils, sinus tachycardia, brisk reflexes, and urinary retention
Parasympathetic: dry mouth, drowsiness
What triad of symptoms is associated with Wernicke’s encephalopathy?
Confusion
Ataxia
Ophthalmoplegia
What are the two main symptoms of Korsakoff syndrome?
Amnesia
Confabulation
