Acute confusional

state
Prevention , treatment and prognosis
By
Ahmed Abdelgelil ,MD
 Delirium
Delirium is an acute confusional state characterized by an
alteration of consciousness with reduced ability to focus,
sustain, or shift attention. This results in a cognitive or
perceptual disturbance that is not better accounted for by
a preexisting, established, or evolving dementia. Delirium
develops over a short period of time (usually hours to
days) and tends to fluctuate during the course of the day.
Delirium is typically caused by a medical condition,
substance intoxication, or medication side effect
 Prevalence

10% in older ER patients

1040% in hospitalized older patients
25% in older post-acute care patients
Highest rates (>50%) in ICU, post-hip fracture repair,
post-cardiothoracic surgery
 Subtypes based on level of
consciousness:
Hyperactive delirium (15%): Patients are loud,
rambunctious, and disruptive.
Hypoactive delirium (20%): Quietly confused; may sit and
not eat, drink, or move
Mixed delirium (50%): Features of both hyperactive and
hypoactive delirium
Normal consciousness delirium (15%): Still display
disorganized thinking, along with acute onset, inattention,
and fluctuation.
 Clinical diagnosis
Key diagnostic features comprise the CAM:
Acute change in mental status that fluctuate,Abnormal
attention,and either disorganized thinking or altered level of
consciousness.
Any of the following non-diagnostic symptoms may be
present:Short- and long-term memory problems,Sleep-
wake cycle disturbances,Hallucinations and/or
delusions,Emotional lability,Tremors and asterixis.The
Confusion Assessment Method (CAM) is the most well-
validated and tested tool and has been adapted for ICU
setting in adults.
 Differential Diagnosis

Depression (slow onset, disturbance of mood, normal level

of consciousness, and fluctuates over weeks to months)
Dementia (insidious onset, memory problems, normal level
of consciousness, and fluctuates over days to weeks)
Psychosis (rarely sudden onset in older adults)
 The management of delirium
Includes primary prevention( modifying risk factors )and
pharmacological agents:
A)modifying RFs ( non pharma):1-avoiding multiple
medications, immobilization,dehydration,sensory
impairment and sleep disturbance.2-treating underlying
acute illness 3-supportive care to prevent further physical
and cognitive impairment.
B)pharma:like cholinesterase inhibitors, antipsychotic
agents,gabapentin,melatonin agonist ,and analgesics.
 Interventions designed to
mitigate risk factors for delirium
Orientation protocols - Provision of clocks, calendars,
windows with outside views.Cognitive stimulation -
Patients with cognitive impairment, in particular, may
benefit from activity such as regular visits from family and
friends.sensory overstimulation should be avoided,
particularly at night.Facilitation of physiologic sleep:
Nursing and medical procedures, including the
administration of medications, should be avoided during
sleeping hours when possible. Night-time noise should be
reduced.the use of earplugs at night was associated with a
lower incidence of confusion in ICU patient
 Interventions designed to
mitigate risk factors for
delirium( continued)
Early mobilization and minimized use of physical
restraints for patients with limited mobility early
institution of physical and occupational therapy along with
consequent interruption in use of sedatives, was associated
with a lower rate of hospital days with delirium.Visual and
hearing aids for patients with these
impairments.Avoiding and/or monitoring the use of
problematic medications - Medications are often
implicated in precipitating delirium,benzodiazepines should
be avoided in high risk patients, while caution should be
used in prescribing opioids, dihydropyridines, and
antihistamines
 Interventions designed to
mitigate risk factors for
delirium( continued)
Avoiding and treating medical complications early
volume repletion for patients with delirium.Hypoxemia and
infections are other common complications in high-risk
settings and patients.Managing pain Pain may be a
significant risk factor for delirium. The use of nonopioid
medications should be used where possible, as these are
less likely to aggravate delirium. Clinicians must balance
the benefits of using opioids to treat significant.Cancer
patients with terminal delirium and pain may benefit from
switching from shorter-acting opioids to long-acting agents
such as methadone.
Medications to prevent delirium
A)Cholinesterase inhibitors (e.g., rivastigmine; donepezil)
has been proposed as a means to prevent delirium in
selected patients and high risk settings (eg, older patients
with or without dementia, postoperative and post-stroke
settings)However, clinical trials have not demonstrated a
reduction in the prevalence or incidence of delirium, and
side effects have been greater in patients receiving these
medications.
Medications to prevent delirium
B)Antipsychotic agents, given prophylactically and in low
dose have been studied in the postoperative setting, and
have been associated with inconsistent, and at best,
modest benefits in the incidence, severity, and duration of
delirium treatment was associated with increased severity
and longer duration of delirium.such treatment reduced
the incidence of delirium, but not the severity or duration;
nor were the incidence of associated adverse events
reduced second-generation antipsychotics appeared to be
more beneficial compared to haloperidol
Medications to prevent delirium
Gabapentin, in pilot study, reduced the incidence of
postoperative delirium, perhaps by reducing pain and
opioid administration.
Melatonin shows promise in the prevention of delirium.
The melatonin agonist, ramelteon, Compared to placebo,
ramelteon 8 mg was associated with a lower risk of
delirium (3 versus 32 percent) despite its lack of effect on
sleep parameter.
 Treatment of underlying
conditions
A)Metabolic encephalopathy :Fluid and electrolyte
disturbances (dehydration, hyponatremia/hypernatremia,
hypo/hypercalcemia).Infections (sepsis, urinary tract,
respiratory tract, skin and soft-tissue).Organ failure
(uremia, liver failure,
hypoxemia/hypercarbia).Hypoglycemia.B)Drug toxicity
:Drug toxicity causes or contributes to approximately 30
percent of all cases oClinicians must be aware that
delirium can occur even with "therapeutic" levels of such
agents as digoxin or lithium. C)Withdrawal from alcohol
and sedatives.
 Supportive medical care
The outcome of delirium could be improved by earlier
identification of the disorder and comprehensive
intervention to treat underlying causes and prevent
subsequent complications such as immobility, aspiration,
and skin breakdown.interdisciplinary approach to delirium
should focus upon maintaining adequate hydration and
nutrition, enhancing mobility and range of motion, treating
pain and discomfort, preventing skin breakdown,
ameliorating incontinence and minimizing the risk of
aspiration pneumonitis.
 Supportive medical care
Because delirium may require weeks or months to fully
resolve, management often extends into subacute
settingsTransfers of care to new settings are periods of
particular vulnerability for older patients, and it is
important to effectively communicate information about
mental status to the accepting treatment team.Periods of
disruptive and hyperactive behavior place the patient at
risk for falls, wandering off, or inadvertently removing
intravenous lines and feeding tubes.When delirium is
manifest by agitation, symptom control is occasionally
necessary. a cautious trial of psychotropic medication is
 Supportive medical care
BenzodiazepinesBenzodiazepines have a limited role
in the treatment of delirium; they are primarily indicated
in cases of sedative drug and alcohol withdrawal or when
neuroleptic drugs are contraindicated