Acute Confusion

Question 1

You are asked to review a 68-year-old gentleman who was admitted to intensive care 3 days ago following an emergency laparotomy for small bowel obstruction. He has a history of hypertension, diverticular disease and is a smoker. He is confused and trying to climb out of his bed.

What are the potential causes of confusion in this patient?

Answer 1

• Pre-existing comorbidities e.g. dementia.
• Alcohol ± nicotine withdrawal.
• Electrolyte disturbances.
• Infection.
• Hypoglycaemia.
• Hypoxaemia.
• Encephalopathy (hepatic, uraemic, sepsis).
• Drug side effects (anaesthetic/sedatives).
• Postoperative cognitive decline.
• Cerebrovascular event.

Question 2

What is delirium?

Answer 2

• An acute disturbance of consciousness and altered cognitive state that may demonstrate a fluctuating course over a short period of time.
• Delirium can be hyperactive, hypoactive or mixed.

Question 3

What are the risk factors for the development of delirium in this patient?

Answer 3

Patient factors:
* Increased age.
* History of hypertension.
* Smoker.
* May have visual or hearing impairment due to his age.

Illness factors:
* Potential for electrolyte or metabolic disturbance postoperatively.
* Possible pyrexia or sepsis.
* Postoperative anaemia.
* Side effects of medication.
* Poor sleep as inpatient.
* Decreased mobility in hospital.
* Pain.

Question 4

How would you assess and treat this patient?

Answer 4

Assessment:
* Carry out a rapid initial assessment to determine whether the patient or staff is at risk; if so, an urgent intervention may be required to prevent injury.

• The CAM-ICU scoring system (confusion assessment method for ICU) can be used to assess the patient. This includes the following aspects:

1. Determining whether the confusion is acute or fluctuating.
2. Assessing patient inattention.
3. Establishing conscious level.
4. Assessing for presence of disorganised thoughts.

For a patient to be CAM-ICU positive (and therefore have a diagnosis of delirium), the first two criteria must be met, together with either the 3rd or 4th criterion.

Question 5

How would you assess and treat this patient?

Continued…

Answer 5

Treatment:
* Avoidance of, and minimising risk factors for delirium. Measures can include:
- Daily sedation hold.
- Drug chart review.
- Treat infection or metabolic disturbances if present.
- Offer hearing or visual aids if appropriate.
- Aim for optimal diurnal sleep-wake cycle.
- Physiotherapy.

• If the above measures fail, pharmacological agents can be considered:
• 1st line: haloperidol.
• 2nd line (or if haloperidol contraindicated): olanzapine.

Note that benzodiazepines should be avoided in these patients.

Question 6

What are the complications in this patient should his delirium remain untreated?

Answer 6

• Overall increase in morbidity and mortality.
• Increased length of hospital stay/duration on intensive care.
• Increased risk of infection.
• Cognitive decline (long-term).