Confusion (delirium) Flashcards
Define confusion
Confusion = acute, treatable or chronic progressive condition
Patient has the inability to think clearly and / or rapidly characterised by:
- Difficulty understanding a situation
- disordered or unclear thoughts
- associated with memory loss and/or disorientation
Can be aggravated by environmental or diurnal changes e.g. sundowning
How common is confusion?
Who is it more common in?
1/10 hospital patients will be confused at some point
More common in:
Elderly
People w:
memory problems
poor hearing/ eyesight
recent surgery
terminal illess
people with a brain disorder e.g. stroke or tumour
Where do we most often see confused patients?
most commonly:
at home
in residential and nursing homes
in hospital –> post op, A & E, wards
Being in hospital makes confused patients more confused, we try and manage them as much as possible in their home
What are some common causes of confusion?
Infections
Head injury
Stroke
Brain or spinal cord tumour
Dementia
Delirium
Alcohol or drug intoxication
Sleep disorder
Chemical/ electrolyte imbalances
Vitamin deficiencies
Medication
Seizure
Hypothermia
What are the pathways implicated in confusion?
What are the two sites of production of this NT?
Where do these sites of NT production project to?
Therefore what is this NT involved in and how would changing its levels change a pt?
The pw’s involved in confusion are the cholinergic pathways.
Cholinergic:
- Nucleus basilis of meynert, (situated under the nucleus accumbens and related to reward pathways) projects to cortical regions and striatum (supplies cortex and limbic system)
- Brainstem pontine nuclei (involved in control of arousal) –> two nuclei produce Ach in the brainstem:
- Lateral tegmentum (Also produces dopamine)
- pedunculopontine nucleus (involved in arousal)
- Intrinsic cholingeric systems are also found within the striatum and hippocampus –> Hippocampus involved in memory, striatum involved in movement as well as neurocognitive behaviours.
- Changing Cholinergic levels will affect motor system, higher cortical functioning, cognition.
- Brainstem regions project up to thalamus (linked to sleep) and down the spinal cord
- Therefore there is both a central and peripheral effect by medications added to this p/w
What role does ACh play in arousal?
- Peripherally controls ANS and muscle function (NMJ)
- Centrally involved in:
- Alertness
- Arousal
- Attention
- Sleep
- Memory
- Learning
- Acetylcholine also modulates a no of NT pw’s including dopamine.
What are the two transmitters involved in the sleep wake cycle? (part of the arousal spectrum).
Transmitters involved in sleep wake cycle:
Histamine
Acetycholine (Ach)
Describe the waking stage of sleep wake cycle
Waking:
- High levels of histamine which activate cholinergic pathways
- Cholinergic pathways activate the thalamic reticular nuclei
- Enables information to flow freely though this area
- Information flow –> awareness and arousal –> conciousness
Describe the changes that occur during slow wave sleep
- Histamine levels start to drop, less activation of cholingergic pw’s, less cortical activity
- Low light and warmth detected by suprachiasmatic and ventrolateral preoptic nuceli (hypothalamus)
- Inhibits the histamine cells in the tuberomamillary bodies and brainstem
- Inhibits the cholinergic pw/s
- reduced activity passing through the thalamus
- Prevents info flow –> low arousal level
Describe the changes in REM sleep
Paradoxical or REM sleep:
- During deep sleep (slow wave sleep) you have slow delta waves that oscillate, controlled by the thalamus which acts as the gatekeeper of activity.
- The thalamus prevents output to the cortex with its own intrinsic rythm
- In REM sleep, cholinergics are activated again, allowing some cortical activity again (dreaming) and allows movement (eye movements):
- Inhibition increases which begins to affect other NT pw’s
- 5HT and NA (which normally dampen cholingergic activity) decrease
- Increased cholinergic input to the thalamus
- Increased cortical activity (active mind in an inactive body).
What is sundowning syndrome?
What sx may a pt present with?
Best approach?
Sundowning syndrome –> the closer to evening and sundown the more confused and agitated the client becomes (those with dementia feel they should be busy at this time)
Late day confusion
Link between arousal levels and diurnal rhythm
Sx: agitatation and increased movement
Most important thing to do is to find out their normal routine, keep them busy and it will eventually reside.
What contributes to sundowning?
1) Cholinergic abnormalities –> reduced input of Ach from Nucleus basalis of meynert (NBM) to cortex
2) Disrupted sleep patterns –> reduced sleep efficienct, frequent awakenings, daytime napping
3) Reduced zeitgebers (light sent to suprachiasmatic N in hypothalamus to control diurnal rhythm)–> dim daytime light, disruptive light at night, lack of daily routine
4) reduced physical activity
5) reduced melatonin –> decreased production, reduced receptor sensitivity
6) SCN (suprachiasmatic nucleus) degeneration –> loss of cell, loss of diurnal rhythm, AVP and VIP
What can you suggest to reduce sundowning syndrome?
- Routine
- reduce light interferences
- regular wake-sleep cycles
- Regular eating patterns
- Exercise / activity
- reduce stress
Describe the link between DA and Ach?
- ACh can modulate activity in dopamine pathways (and vice versa) –> nigrostriatal (movement), mesocortical and mesolimbic pathways (cognition, emotion, reward pathways), tuberohypophyseal
- This will also have knock on effects on other monamines: NA and 5HT –> changes arousal levels as involved in keeping you awake/ alert
- ACh neurons in striatum modulate PFC and are abundant in the hippocampus
- Striatum releases Ach which affects the cortical input before its fed into the motor system
- Affects pw’s from prefrontal cortex (higher cog) and to the limbic system
- Affects input from the midbrain, where most of the DA pw’s come from (VTA and substantia nigra).
What is the reward pw?
How can Ach control the reward pw?
- Reward pw= mesocortical pw –> involves DA from the VTA –> nucleus accumbens –> prefrontal cortex, positive emotional pw
- Ach acts at all levels of the reward pathway:
- Nucleus basilis of meynert (NBM) acts on the nucleus accumbens
- Ach also produced in the brainstem ( pontine centres) and therefore can act on the ventral tegmental area
- Therefore Ach affects how DA reaches the midbrain and how it reaches the cortex.
- NBM and local interneurons act within the prefrontal cortex
How can Ach control motor activity?
Ach acts to alter activity in the striatum via interaction with GABAergic pathway
It does the exact opposite of dopamine:
–> dopamine normally activates the direct pw
–> Ach inhibits the direct pw (Reduces movement)
–> Dopamine normally activates the indirect pw
–> Ach inhibits the indirect pw
Degeneration of cholingeric interneurons can lead to increased or decreased motor activity and changes in motivation
How does Ach relate to confusion?
Reduced levels of Ach lead to imbalance in limbic system, prefrontal cortex, basal ganglia and brainstem
This leads to:
- Slower reduced recall, memory
- Changes in decision making
- Altered motor function
- Altered arousal states and orientation
What is delerium?
Delirium = Acute confusional state
Medical emergency, usually transient, reversible but it CAN have a poor outcome.
Develops over a couple of days
What is delerium characterised by?
What can it often be misdiagnosed as?
- Decreased attention span
- Waxing and waning confusion
- Plus a wide range of other neuropsychiatric abnormalities
Often misdiagnosed as dementia, depression, schizophrenia, mania or normal ageing.
What are the types of delerium?
Three types of delerium:
1) Hyperactive –> pts have heightened arousal, can be restless, agitated, aggressive
2) Hypoactive –> pts become withdrawn, quiet, sleepy
3) Mixed –> combination of hyper and hypoactive
What are the characteristics of hyperactive delerium?
- Confusion
- Pereceptual changes –> auditory, visual hallucinations
- Sleep disturbance
- Agitation
- Restlessness
- Lack of cooperation
- Changes in communication
- Mood/ attitude changes
What are the key indicators of hypoactive delerium?
- Worsening concentration
- Slowness of responses
- Reduced movement and or mobility
- Appetite changes
- Reduced social interaction/ withdrawal