Organic disorders: confusion, infection and trauma

Question 1

What is the appearance of a confused patient?

Answer 1

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.

Question 2

What 2 groups can the causes of confusion be divided into?

Answer 2

Transient causes
Enduring causes

Question 3

What does transient confusion mean?

Answer 3

A confusional state that is likely to recover following resolution/elimination of the underlying cause.

Question 4

Causes of transient confusion?

Answer 4

• Delirium
• Post ictal confusion (usually following tonic clonic seizure)
• Migraine
• Delirium tremens
• Physical ill health and chronic illness
• Medications

Question 5

Delirium can also be referred to as an acute confusional state and is associated with physical insult or injury or environmental factors. True/false?

Answer 5

True

Question 6

Onset of delirium?

Answer 6

Rapid in onset, 1-2 days after precipitating insult.

Question 7

People at risk of delirium?

Answer 7

Older people with previous history of delirium and those with underlying cognitive deficits.

Question 8

Characteristics of delirium?

Answer 8

Disorientation - time, place, person.

Agitation and distress

Auditory or visual hallucinations - often vivid

Inattention

Question 9

The 3 common types of delirium?

Answer 9

Hypoactive - quiet, confused, drowsy, fearful patient.

Hyperactive - driven, wandering, agitated, shouting out and often aggressive.

Mixed - some periods of both of the above.

Question 10

Delirium is regarded as a medical emergency with a 35-40% 1 year survival. True/false?

Answer 10

True since it significantly worsens patient mortality and morbidity.

Question 11

How is delirium treatment usually carried out?

Answer 11

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.

Question 12

What is post-ictal confusion?

Answer 12

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.

Question 13

Characteristics of post-ictal confusion?

Answer 13

• Drowsiness
• Nausea
• Confusion
• Exhaustion

Usually requires supportive management only and health promotion in the form of seizure prevention.

Question 14

How many phases does a migraine have? What are they?

Answer 14

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.

Question 15

What symptoms can be associated with migraines?

Answer 15

Confusion
Visual changes
Irritability
Low mood
De-realisation “nothing is real”
De-personalization “I am not real”
De’ja vu

Question 16

Treatment of delirium tremens?

Answer 16

Can be fatal due to high risk of seizure. Treatment with benzodiazepines regularly and targeted to symptoms.

Consider fluid, electrolyte and vitamin replacement.

Question 16

What is delirium tremens?

Answer 16

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

Question 17

Physical ill-health and chronic illness causes of delirium?

Answer 17

Encephalitis

Hypoglycaemia

Hypothyroidism/Hyperthyroidism

Vit B12 deficiency

Anaemia

Electrolyte disturbances

Question 18

Medication causes of delirium?

Answer 18

Analgesics – particularly opioid medications and gabapentinoids

Steroids

Benzodiazepines

Narcotics – zopiclone, zolpidem

NSAIDS

H2 receptor antagonists – digoxin, beta-blockers

Question 19

What are some enduring causes of delirium?

Answer 19

Acquired brain injury

Dementia – Alzheimer’s disease, Vascular Dementia, mixed presentations

Alcohol related dementia

Question 20

Some causes of acquired brain injury?

Answer 20

Trauma
Hypoxia.
Stroke
Aneurysm
Intracranial tumours
Surgical intervention

Question 21

Definition of dementia?

Answer 21

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.

Question 22

Alzheimer’s dementia subtype?

Answer 22

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).

Question 23

Vascular dementia subtype?

Answer 23

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.

Question 24

Mixed dementia subtype?

Answer 24

Combination of two separate intracranial processes e.g. Mixed Alzheimer’s and Cerebrovascular disease.
- Treatment should be tailored to underlying subtypes.

Question 25

Parkinson’s disease, Parkinson’s plus syndromes and Lewy body dementia?

Answer 25

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.

Question 26

Frontotemporal dementia subtype character?

Answer 26

Specific difficulties in planning, executive function and impulse control.

Question 27

Alcohol-related dementia subtype?

Answer 27

Neuronal damage secondary to long term, excessive alcohol consumption. Predominantly affects the frontal lobes.

Leads to deficits in memory , planning, motivation and executive function.

Question 28

What are Alcohol related brain injuries (ARBI) and can they be reversed?

Answer 28

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.

Question 29

What is temporal lobe epilepsy?

Answer 29

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.

Question 30

Pathology of temporal lobe epilepsy?

Answer 30

Paroxysmal discharges from neurones due to excessive excitation or loss of inhibition.