Organic disorders: confusion, infection and trauma Flashcards
What is the appearance of a confused patient?
Disorientation - to time, place or person.
Misinterpretation - of events and information.
Misidentification - of people and places.
Auditory or visual hallucinations - depending on underlying cause of confusion.
Possible association with agitation, distress or aggression.
What 2 groups can the causes of confusion be divided into?
Transient causes
Enduring causes
What does transient confusion mean?
A confusional state that is likely to recover following resolution/elimination of the underlying cause.
Causes of transient confusion?
- Delirium
- Post ictal confusion (usually following tonic clonic seizure)
- Migraine
- Delirium tremens
- Physical ill health and chronic illness
- Medications
Delirium can also be referred to as an acute confusional state and is associated with physical insult or injury or environmental factors. True/false?
True
Onset of delirium?
Rapid in onset, 1-2 days after precipitating insult.
People at risk of delirium?
Older people with previous history of delirium and those with underlying cognitive deficits.
Characteristics of delirium?
Disorientation - time, place, person.
Agitation and distress
Auditory or visual hallucinations - often vivid
Inattention
The 3 common types of delirium?
Hypoactive - quiet, confused, drowsy, fearful patient.
Hyperactive - driven, wandering, agitated, shouting out and often aggressive.
Mixed - some periods of both of the above.
Delirium is regarded as a medical emergency with a 35-40% 1 year survival. True/false?
True since it significantly worsens patient mortality and morbidity.
How is delirium treatment usually carried out?
Ideally carried out in a medical environment to allow for physical health treatment. ALWAYS TREAT THE UNDERLYING CONDITION.
Can involve:
- Reassurance and reorientation
- Low stimulus environment
- Assistance with medications
- Assistance with activities of daily living during recovery.
- Pharmacological interventions to assist with distress, agitation and aggression.
What is post-ictal confusion?
An abnormal condition following a seizure (mainly Tonic Clonic seizure).
Begins when seizure ends and ends when patient has returned to baseline. Usually resolves in 30 mins but can last for hours or days.
Characteristics of post-ictal confusion?
- Drowsiness
- Nausea
- Confusion
- Exhaustion
Usually requires supportive management only and health promotion in the form of seizure prevention.
How many phases does a migraine have? What are they?
4 phases of migraine:
Prodrome (pre-headache) - problems concentrating, depression, nausea, fatigue.
Aura - seeing bright flashing dots/lights/sparkles, blind spots in vision, tinnitus, numb or tingling skin.
Headache - sensitivity to light, sound and/or odours. Loss of appetite, nausea+vomiting, speech changes, feeling tired.
Postdrome (migraine hangover) - feeling depressed, fatigue, euphoria, unable to concentrate.
What symptoms can be associated with migraines?
Confusion
Visual changes
Irritability
Low mood
De-realisation “nothing is real”
De-personalization “I am not real”
De’ja vu
Treatment of delirium tremens?
Can be fatal due to high risk of seizure. Treatment with benzodiazepines regularly and targeted to symptoms.
Consider fluid, electrolyte and vitamin replacement.
What is delirium tremens?
Severe alcohol withdrawal leading to:
Auditory hallucinations
Visual hallucinations - often of insects of tiny things (e.g. ants, spiders, tiny people)
Tactile hallucinations – things crawling on the skin
Confusion
Disorientation
Sweating
High blood pressure
Physical ill-health and chronic illness causes of delirium?
Encephalitis
Hypoglycaemia
Hypothyroidism/Hyperthyroidism
Vit B12 deficiency
Anaemia
Electrolyte disturbances
Medication causes of delirium?
Analgesics – particularly opioid medications and gabapentinoids
Steroids
Benzodiazepines
Narcotics – zopiclone, zolpidem
NSAIDS
H2 receptor antagonists – digoxin, beta-blockers
What are some enduring causes of delirium?
Acquired brain injury
Dementia – Alzheimer’s disease, Vascular Dementia, mixed presentations
Alcohol related dementia
Some causes of acquired brain injury?
Trauma
Hypoxia.
Stroke
Aneurysm
Intracranial tumours
Surgical intervention
Definition of dementia?
Loss of cognitive function - thinking, memory and reasoning - to an extent which interferes with a person’s daily life and functioning. Several subtypes with specific differences but overall stays the same.
Alzheimer’s dementia subtype?
Most common subtype
- Gradual decline in memory and function
- Long term memory (things that happened further in the past) often fairly well preserved but short term memory impaired.
- Patients often have difficulty with word finding “Where is the ……….. TV thingy (remote control)”
- CT brain findings show a pattern of atrophy, which can be most notable at the temporal lobe.
- Progression can be slowed but
NOT ceased with Acetylcholinesterase Inhibitors (e.g. DONEPEZIL, GALANTAMINE).
Vascular dementia subtype?
Caused by impaired blood flow to the brain leading to chronic vascular injury/TIAs or stroke events.
- Associated with a step-wise decline in memory and function, with cognitive functions not fully regained after each step.
- No specific pattern of pathology/loss of function. Impairments will be seen in the areas most affected by vascular injury e.g. Balance with cerebellar issues, memory and visual processing with the occipital lobe.
- CT brain shows a pattern of small vessel disease or stroke.
- No specific medications for vascular dementia but secondary prevention to protect against further vascular injury is essential.
Mixed dementia subtype?
Combination of two separate intracranial processes e.g. Mixed Alzheimer’s and Cerebrovascular disease.
- Treatment should be tailored to underlying subtypes.
Parkinson’s disease, Parkinson’s plus syndromes and Lewy body dementia?
Specialist dementias
- Associated with dopamine pathway disorders
- Associated movement disorders, visual hallucinations and periods of lucidity.
- Very sensitive to psychotropic medications so should be used with care.
Frontotemporal dementia subtype character?
Specific difficulties in planning, executive function and impulse control.
Alcohol-related dementia subtype?
Neuronal damage secondary to long term, excessive alcohol consumption. Predominantly affects the frontal lobes.
Leads to deficits in memory , planning, motivation and executive function.
What are Alcohol related brain injuries (ARBI) and can they be reversed?
Severe end of a spectrum of disorders collectively named Alcohol related Brain Injuries (ARBI).
If a patient with ARBI remains abstinent from alcohol from 9-12 months then some degree of the damage may be reversed.
What is temporal lobe epilepsy?
The most common cause of focal epilepsy. Some characteristics include:
Not being aware of the people and things around you.
Staring.
Lip smacking.
Repeated swallowing or chewing.
Finger movements, such as picking motions.
Pathology of temporal lobe epilepsy?
Paroxysmal discharges from neurones due to excessive excitation or loss of inhibition.
