2. Confusion Flashcards
Define delirium.
An acute impairment in cognitive ability with impaired consciousness
Define dementia.
A chronic, progressive impairment in cognitive ability but with intact consciousness
Define psychosis.
A disorder of thought content/perceptions (e.g. delusions and hallucinations)
NOTE: the patient may NOT be confused
Define receptive dysphasia.
The patient may be cognitively intact but they have difficulty comprehending speech
Due to damage to Wernicke’s area
Define expressive dysphasia.
The patient may be cognitively intact but have difficulty verbalising answers to questions
Due to damage to Broca’s area
What are two important methods of screening confused patients?
- Are they oriented in time, space and person? Can they tell you why they are there?
- Can they follow a three-step command? Can they identify three common objects?
What abbreviated mental test score would indicate that the patient has a cognitive impairment?
< 6/10
What MMSE score would indicate that the patient has a cognitive impairment?
< 26/30
What does three-step command and naming three common objects test?
Three-step command – tests for receptive dysphasia
Three common objects – tests for expressive dysphasia
If the confused patient has been accompanied by a friend/relative, what are some important details to ascertain?
The patient’s normal state Time course of confusion (acute onset is more likely to be delirium) Drug history (including alcohol) NOTE: a fluctuating course is suggestive of delirium
What are the five most important and common causes of confusion?
Chest infection
UTI
Subdural haematoma
Drugs – diuretics, digoxin, thyroid medication
Sodium and other electrolyte abnormalities
Using the surgical sieve, list some other causes of confusion
(INVITED MD)
Infection – encephalitis, brain abscess, sepsis
Neoplastic – brain tumour
Vascular – stroke, MI causing hypoperfusion
Immune/Inflammatory – neuropsychiatric lupus, Hashimoto’s encephalopathy
Trauma – extradural haematoma
Endocrine – hypothyroidism, hyperthyroidism, DKA
Drugs – intoxication or withdrawal from alcohol, opiates or psychiatric medications
Metabolic – hypoxia, hypercapnia, hypoglycaemia, hypercalcaemia, thiamine/folate/B12 deficiencies
Degenerative
What vital signs must you check for in a confused patient?
Pulse and Respiratory Rate Blood Pressure Oxygen Saturation Temperature Blood Glucose
Importance of checking pulse and respiratory rate in a confused patient
Tachycardia and tachypnea indicates infective process
Importance of checking blood pressure in a confused patient
Hypotension can lead to hypoperfusion of the brain -> impaired consciousness
Cushing’s response (to raised ICP): high BP + low HR + irregular breathing
Importance of checking oxygen saturation in a confused patient
Hypoxia impairs consciousness
Importance of checking temperature in a confused patient
Fever indicates infection
Hypothermia can cause confusion in elderly patients
Importance of checking blood glucose in a confused patient
Hypoglycaemia and hyperglycaemia can depress consciousness
T1DM: hyperglycaemia may be associated with DKA
T2DM: extreme hyperglycaemia may indicate hyperosmolar hyperglycaemia state (HHS)
List some key features of examination of a confused patient.
Consciousness Septic focus Pupils Focal neurological signs Needle track marks Asterixis Breath Bitten tongue and posterior shoulder dislocation
Describe some pathological variations in the pupils of a confused patient.
Pinpoint + sluggish to react = opiate or barbiturate overdose
Dilated + sluggish to react = drug overdose (e.g. cocaine or TCA), severe hypoxia, hypothermia, post-ictal
Asymmetrical = could be normal variant (anisocoria), but is rarely suggestive of coning secondary to raised ICP
What would a bitten tongue or a posterior shoulder dislocation suggest?
Convulsive seizure
What are the three divisions of the Glasgow Coma Scale and how many points are allocated to each?
Eyes = 4 Verbal = 5 Motor = 6
Which investigations would be performed to find out whether an infection is the cause of the confusion?
FBC – raised WCC
CRP – raised in infection
Blood cultures
Urinalysis – check for features of UTI (leucocyte esterase + nitrites), or DKA (positive glucose + positive ketones)
Urine MC&S
Chest radiograph (check for consolidation caused by chest infection)
Which investigations would be performed in a metabolic screen?
Blood gas – check hypercapnia, acid-base balance
U&Es – check for electrolyte imbalances
TFTs
Liver Enzymes – hepatic encephalopathy can cause confusion
Thiamine, folate and B12 levels – check whether the patient is malnourished
