acute confusional state

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2. Acute Confusional State Objectives. DefinitionCharacteristic clinical featuresEtiology / differential diagnosisEvaluationManagement strategiesImportant pearls. 3. Attentional impairment is the principal manifestation of the acute confusional state.. 4. Acute Confusional State DSM-IV Criteria for Delirium.

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1. 1 AcuteConfusionalState Frederick G. Flynn, DO, FAAN Medical Director, TBI Program Chief, Neurobehavior Madigan Army Medical Center Ft. Lewis, WA

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3. 3 Attentional impairment is the principal manifestation of the acute confusional state.

4. 4 Acute Confusional StateDSM-IV Criteria for Delirium Disturbance in consciousness impairing awareness of the environment Reduced ability to focus, sustain, or shift attention Cognitive or perceptual disturbance not attributable to dementia

5. 5 Acute Confusional StateDSM-IV Criteria for Delirium Acute to subacute onset (hours to days) Diurnal fluctuations Clinical/laboratory evidence relating the disturbance to a general medical condition

6. 6 Mental Status Assessment ACS Level of alertness Digit Span “A” Test Confusion Assessment Method (CAM) W-O-R-L-D backwards Writing a sentence or phrase Copying a three dimensional drawing

7. Confusion Assessment Method (CAM) Acute onset/fluctuating course ? Inattention ? Disorganized thinking ? Altered level of consciousness ? Normal = alert Hyperalert = vigilant Drowsy, easily aroused = lethargic Difficult to arouse = stupor Unarousable = coma 7

8. 8 Acute Confusional State Clinical Features Attention deficit Thought disorder Language/speech dysfunction Anomia/dysnomia Dysgraphia Visual Perceptive Dysfunction Failure to encode new memory

9. 9 Acute Confusional State Clinical Features Confabulation Disorientation to time and space Dyscalculia Perseveration (thought, speech, motor) Neuropsychiatric features

10. 10 Acute Confusional State Clinical Features Movement disorders Sleep-wake cycle disturbance Autonomic dysfunction

11. 11 Acute Confusional StateNeuropsychiatric Features Hallucinations (visual>tactile>auditory) Delusions (simple/complex) Capgras syndrome Reduplicative paramnesia Persecutory fear

12. 12 Acute Confusional StateNeuropsychiatric Features Agitation Emotional lability Hyperexcitability Euphoria

13. 13 Acute Confusional StateNeuropsychiatric Features Depressed Apathetic Perplexed Mixed - “hyper” & “hypoactivation”

14. 14 Acute Confusional StateMovement Disorders Seen mostly in toxic-metabolic encephalopathies Generalized tremulousness Tremor Asterixis

15. 15 Acute Confusional StateMovement Disorders Myoclonus Increased motor tone Hyperreflexia / extensor plantar responses Catatonia

16. 16 Acute Confusional StateEpidemiology Underreported - 2/3 of cases unrecognized Prevalence in elderly hospitalized - 15% Incidence in elderly hospitalized - 3-31% Higher incidence and prevalence in surgery patients

17. 17 Acute Confusional StateRisk Factors Advanced age Young children Underlying brain injury or disease Severity of illness- advanced CA Dehydration Infection Fever

18. 18 Acute Confusional StateRisk Factors Metabolic abnormalities Polypharmacy Anticholinergic drugs Sedative-hypnotic drugs Narcotics – especially merperidine Pain Malnutrition Immobility (restraints)

19. 19 Acute Confusional StateRisk Factors Pre-existing dementia (3X risk for delirium) 50% of delirious elderly have pre-existing dementia or unmask a subclinical dementia Post-op in elderly

20. 20 Acute Confusional StateRisk Factors Post surgery Elderly Pre-op low HCT Burn patients Drug toxicity/withdrawal Low perfusion states Urinary catheters Urinary retention/constipation

21. 21 Acute Confusional StateEnvironmental Risk Factors Stay in ICU Stay in long term care unit Increased number of room changes Absence of clock or watch Absence of glasses or hearing aid Use of physical restraints

22. 22 Acute Confusional StateEtiologies Metabolic conditions Cardiac, pulmonary, renal, hepatic disease Glucose and electrolyte disturbances Systemic inflammatory disorders Hypoxia Anemia Porphyria

23. 23 Acute Confusional StateEtiologies Infection Systemic with fever UTI, pneumonia, sepsis-esp. in elderly Endocrine dysfunction Thyroid, parathyroid, adrenal, pituitary Nutritional deficiency Thiamine (Wernicke encephalopathy) B12, folate, biotin, niacin Protein-calorie malnutrition

24. 24 Acute Confusional StateEtiologies Intoxications Drugs (therapeutic and abused) Alcohol Withdrawal syndromes Heavy metals, industrial solvents, pesticides

25. 25 Acute Confusional StateEtiologies Multifocal / diffuse CNS Head trauma Encephalitis Epilepsy (ictal and postictal) Hypertensive encephalopathy Vasculitis Migraine

26. 26 Acute Confusional StateEtiologies Multifocal / diffuse CNS (continued) Subdural hematoma Neoplasm Stroke (acute phase)

27. 27 Acute Confusional StateEtiologies Focal CNS Right hemisphere Temporal (medial) Parietal (inferior) Frontal (inferior) Occipitotemporal (bilateral or left) Caudate

28. 28 Acute Confusional StateEtiologies Focal CNS (continued) Thalamus (paramedian) Midbrain (rostral) Internal capsule (genu)

29. 29 Acute Confusional StateEvaluation Guide- Hx, predisposing factors, assessment Medication review Toxicology panel Lytes, Glu, BUN, Creat, LFTs TFTs B12/Folate ESR/ANA/RF ABG - if respiratory compromise

30. 30 Acute Confusional StateEvaluation CT - if acute severe headache or trauma MRI – if focal neurological findings or if no clear etiology for ACS sans focal findings LP - if no focal findings and fever is present EEG May help in determining etiology Important if complex partial seizures are suspected

31. 31 General Management of ACS Hydration Nutrition Adequate sleep Appropriate sensory and social stimulation Avoid constipation and urinary retention Proper sedation especially when agitation prevents evaluation and management of the underlying condition

32. 32 General Management of ACS Environmental manipulation Reassurance and gentle touch Verbal orientation Glasses/hearing aids if prescribed Avoid physical restraints Use as last resort Increases agitation Increases morbidity

33. 33 Acute Confusional StateManagement - Medical Lab/Imaging studies - guide to recognition and treatment Reduce psychological and behavioral symptoms Pharmacological management

34. 34 Acute Confusional StatePharmacological Management Thiamine (100 mg IV) before Dextrose (50%-50 ml IV); Naloxone (2 mg IV) Specific pharmacotherapy of underlying etiology BZD overdose/Hepatic encephalopathy flumazenil 0.2 mg IV over 30 sec then 0.3 mg at 1 min then 0.5 mg q 1 min up to 3 mg total Anticholinergic Toxicity - physostigmine 0.5 - 2.0 mg IV over 2 min. q 30-60 min. prn; cardiac monitoring

35. 35 Acute Confusional StatePharmacological Management ETOH/Sedative Withdrawal - Thiamine 100 mg IV or IM once a day minor: Chlordiazepoxide 25-100 mg po q6h or Lorazepam 2-5 mg po bid Delirium Tremens: Chlordiazepoxide - 100 mg IV q2-6h, max 500 mg/24 hr then taper dose to maintenance OR Diazepam: 5-10 mg IV q 5-10 min until sedate then maintenance OR Lorazepam : 2-4mg IV q 15-20 min until sedate then maintenance (can be used in hepatic failure) Refractory DTs: Intubate IV phenobarbital or propofol

36. 36 Acute Confusional StatePsychopharmacology of Acute Agitation Haloperidol is drug of choice should be administered IM or IV severely agitated should receive drug IV Cardiac monitor for prolonged QT Dosages: ( ) = elderly dose Initial: mild agitation: 2.0 mg (0.5 mg) moderate agitation: 5.0 mg (1.0 mg) severe agitation: 10 mg (2.0 mg) Do not use in Parkinsonian or Lewy Body Dementia patients

37. 37 Acute Confusional StatePsychopharmacology of Acute Agitation Haloperidol repeat dose q. 30 min until patient is sedate maintenance doses may be given parenterally or p.o. after confusion clears gradually taper med over 3-5 days before D/C

38. 38 Acute Confusional StatePsychopharmacology of Acute Agitation Atypical Antipsychotics Risperidone* – dis. tab or liq. conc. 1-2 mg q ½-2h MAX 4 mg/d Olanzapine* – IM 5-10 mg q 2-4h MAX 30 mg/d or dis. Tab 5-10 mg q ½-2h MAX 20 mg/d Ziprasidone – IM 10-20 mg q 2-4h MAX 40 mg/d Rapid onset but most likely to cause prolong QT Aripiprazole – IM 10 mg q 2 h MAX 30mg/d or dis. tab po 10-15 mg q 2h MAX 30 mg/d *preferred in elderly for acute agitation Doses listed should be 1/2 for elderly

39. 39 Acute Confusional StatePsychopharmacology of Acute Agitation Benzodiazepines Lorazepam most commonly used and can be used in hepatic failure Midazolam has rapid onset but short half life so be cautious of withdrawal effects used for DTs adjunct to neuroleptics Try to avoid use of phenothiazines

40. 40 ACS – Ethical Considerations “Implied consent” Auerswald, Charpentier, and Inouye, 1997: 173 procedures in patients with delirium No documented assessments of decision capacity No documented competency assessment Cognitive assessment – only 4% No informed consent – 19% Surrogates used in only 20% Is “implied consent” what the patient would want or what the physician or surrogate wants to have done to the patient?

41. 41 Acute Confusional StatePrognosis if Diagnosis is Unrecognized or Delayed Increased morbidity Increased mortality - 15-30%/1 mo. rate Longer hospitalizations Increased number of medical complaints Accelerated cognitive decline in dementia patients Increased cost of care

42. 42 Acute Confusional StatePrognosis if Diagnosis is Unrecognized or Delayed More likely to be D/C to nursing home Recovery may be protracted & incomplete Two years post-delirium 2/3 of pts. cannot live independently (Francis and Kapoor, 1992) Neuropsychiatric sequelae > 6 mos. in majority If further deterioration remotely - think underlying dementia being unmasked

43. 43 Acute Confusional StatePearls Often not recognized Common among hospitalized patients Is frequently preventable Accounts for significant morbidity and mortality Impaired attention is the hallmark

44. 44 Acute Confusional StatePearls In elderly think meds/polypharmacy first Consider underlying dementia in elderly who develop ACS Known dementia patients may develop ACS due to a treatable cause – it is not always deterioration due to dementia! Common irritants such as constipation or urinary retention may cause ACS in the elderly

45. 45 Acute Confusional StatePearls Consider capacity, competency, and surrogate issues in informed consent of ACS patients – write it in the record! There is often a time lag of days to weeks between effective Rx and clinical response (most significant lag in the elderly)

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47. Bibliography Attached 47

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