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Acute Confusional State by Dr Flynn

VIEWS: 68 PAGES: 47

									               Acute
          Confusional
                State

    Frederick G. Flynn, DO, FAAN
    Medical Director, TBI Program
        Chief, Neurobehavior
    Madigan Army Medical Center
            Ft. Lewis, WA
1
            Acute Confusional State
                  Objectives
    •   Definition
    •   Characteristic clinical features
    •   Etiology / differential diagnosis
    •   Evaluation
    •   Management strategies
    •   Important pearls

2
    Attentional impairment is the
    principal manifestation of the
       acute confusional state.




3
        Acute Confusional State
       DSM-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

4
      Acute Confusional State
     DSM-IV Criteria for Delirium


    • Acute to subacute onset (hours to days)
    • Diurnal fluctuations
    • Clinical/laboratory evidence relating the
      disturbance to a general medical
      condition

5
         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
6
        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
           Acute Confusional State
              Clinical Features
    •   Attention deficit
    •   Thought disorder
    •   Language/speech dysfunction
    •   Anomia/dysnomia
    •   Dysgraphia
    •   Visual Perceptive Dysfunction
    •   Failure to encode new memory

8
          Acute Confusional State
             Clinical Features

    •   Confabulation
    •   Disorientation to time and space
    •   Dyscalculia
    •   Perseveration (thought, speech, motor)
    •   Neuropsychiatric features

9
       Acute Confusional State
          Clinical Features


     • Movement disorders
     • Sleep-wake cycle
       disturbance
     • Autonomic dysfunction


10
        Acute Confusional State
       Neuropsychiatric Features

 • Hallucinations (visual>tactile>auditory)
 • Delusions (simple/complex)
     – Capgras syndrome
     – Reduplicative paramnesia
 • Persecutory fear


11
         Acute Confusional State
        Neuropsychiatric Features

•    Agitation
•    Emotional lability
•    Hyperexcitability
•    Euphoria



12
        Acute Confusional State
       Neuropsychiatric Features

 •   Depressed
 •   Apathetic
 •   Perplexed
 •   Mixed - “hyper” &
     “hypoactivation”


13
         Acute Confusional State
          Movement Disorders

     • Seen mostly in toxic-metabolic
       encephalopathies
     • Generalized tremulousness
     • Tremor
     • Asterixis


14
         Acute Confusional State
          Movement Disorders


     • Myoclonus
     • Increased motor tone
     • Hyperreflexia / extensor
       plantar responses
     • Catatonia

15
         Acute Confusional State
              Epidemiology

     • Underreported - 2/3 of cases
       unrecognized
     • Prevalence in elderly hospitalized - 15%
     • Incidence in elderly hospitalized - 3-31%
     • Higher incidence and prevalence in
       surgery patients

16
         Acute Confusional State
              Risk Factors
 •   Advanced age
 •   Young children
 •   Underlying brain injury or disease
 •   Severity of illness- advanced CA
 •   Dehydration
 •   Infection
 •   Fever
17
          Acute Confusional State
               Risk Factors
     • Metabolic abnormalities
     • Polypharmacy
     • Anticholinergic drugs
     • Sedative-hypnotic drugs
     • Narcotics – especially
       merperidine
     • Pain
     • Malnutrition
     • Immobility (restraints)
18
       Acute Confusional State
            Risk 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
19
          Acute Confusional State
               Risk Factors
• Post surgery
     – Elderly
     – Pre-op low HCT
•    Burn patients
•    Drug toxicity/withdrawal
•    Low perfusion states
•    Urinary catheters
•    Urinary retention/constipation
20
      Acute Confusional State
     Environmental 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
21
         Acute Confusional State
               Etiologies

     • Metabolic conditions
       – Cardiac, pulmonary, renal, hepatic disease
       – Glucose and electrolyte disturbances
       – Systemic inflammatory disorders
       – Hypoxia
       – Anemia
       – Porphyria

22
          Acute Confusional State
                Etiologies
     • 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
23
       – Protein-calorie malnutrition
         Acute Confusional State
               Etiologies

• Intoxications
     – Drugs (therapeutic and abused)
     – Alcohol
     – Withdrawal syndromes
     – Heavy metals, industrial
       solvents, pesticides


24
          Acute Confusional State
                Etiologies

• Multifocal / diffuse CNS
     – Head trauma
     – Encephalitis
     – Epilepsy (ictal and postictal)
     – Hypertensive encephalopathy
     – Vasculitis
     – Migraine
25
        Acute Confusional State
              Etiologies

• Multifocal / diffuse
  CNS (continued)
     – Subdural hematoma
     – Neoplasm
     – Stroke (acute
       phase)


26
          Acute Confusional State
                Etiologies

     • Focal CNS
       – Right hemisphere
          • Temporal (medial)
          • Parietal (inferior)
          • Frontal (inferior)
       – Occipitotemporal (bilateral or left)
       – Caudate
27
        Acute Confusional State
              Etiologies

     • Focal CNS (continued)
       – Thalamus (paramedian)
       – Midbrain (rostral)
       – Internal capsule (genu)




28
          Acute Confusional State
                Evaluation
     • Guide- Hx, predisposing factors,
       assessment
     • Medication review
     • Toxicology panel
     • Lytes, Glu, BUN, Creat, LFTs
     • TFTs
     • B12/Folate
     • ESR/ANA/RF
29
     • ABG - if respiratory compromise
          Acute Confusional State
                Evaluation
• 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
30
     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
31
      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



32
          Acute Confusional State
             Management - Medical

     • Lab/Imaging studies - guide to recognition
       and treatment
     • Reduce psychological and behavioral
       symptoms
     • Pharmacological management


33
            Acute Confusional State
            Pharmacological 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

34
                  Acute Confusional State
                   Pharmacological 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


35
      Acute Confusional State
Psychopharmacology 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
36

         Dementia patients
            Acute Confusional State
      Psychopharmacology 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

37
            Acute Confusional State
      Psychopharmacology 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
38
            Acute Confusional State
      Psychopharmacology 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
39
       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?
40
       Acute Confusional State
     Prognosis 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
41
          Acute Confusional State
       Prognosis 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

42
           Acute Confusional State
                   Pearls

     • Often not recognized
     • Common among hospitalized patients
     • Is frequently preventable
     • Accounts for significant morbidity and
       mortality
     • Impaired attention is the hallmark
43
            Acute Confusional State
                    Pearls
     • 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
44
           Acute Confusional State
                   Pearls
     • 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)

45
     Questions?
46
     Bibliography Attached



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