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Acute Confusional State

Introduction

Delirium = an acute confusional state.

A state of fluctuating mental disturbance characterised by global disturbance of cerebral function, usually of abrupt onset and short duration.

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Clinical features

Disorders of:

Consciousness
- alertness
- arousal
- memory

Orientation
- time
- place
- person

Behaviour
- inactivity / hyperactivity
- perseveration
- day-night sleep reversal

Mood
- fear / agitation
- depression

Thought
- bradyphrenia
- delusions

Perception
- tactile hallucinations
- visual hallucinations

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Risk factors

Age
- elderly / children

Brain damage
- pre-existing dementia

Transient
- post-op
- drugs
- burns

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Differential diagnosis

Extra-cranial vs Intra-cranial causes.

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Investigation

Cardiac causes
- ECG

Septic causes
- urine cultures
- blood cultures
- CRP / ESR
- CXR

Metabolic causes
- BM
- U&Es
- Ca²⁺
- LFTs / INR
- TFTs
- ABGs

Intracranial causes
- CT head
- LP

Treat the cause
e.g. EtOH withdrawl - chlordiazepoxide, Pabrinex

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Management

Conservative
- Nursing: moderate lighting, quiet room, same staff

Drugs
- review sedation chart & cut out non-essential drugs
- sedation: haloperidol (T1/2 = 60 hours, start low and go slow, watch for extra-pyramidal side effects)
- also consider a benzodiazepine (nocte)

Don't forget to treat the cause!

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