Diagnosis of delirium and confusional states DEFINITION AND TERMINOLOGY

Deterioro de la conciencia y de la atencin. Cambio en la cognicin, deteriori perceptual que no corresponde a demencia previa. Inicio rapido, fluctuante. Enfermedad medica subyacente, intoxicacion o efecto adverso.

Hipo o hiperactividad, aumento actividad simptica, cambios en el sueo. Cambios emocionales.

Risk factors Enfermedad cerebral subyacente: demencia, ACV, Parkinson. Edad Deterioro sensorial Precipitating factors Polifarmacia Infeccion Deshidratacion Inmovilidad Malnutricion SV CLINICAL PRESENTATION Disturbance of consciousness Alerta y atencion. Distractibilidad. Somnolencia, letargo, semi coma, hipervigilancia en jovenes. Change in cognition Perdida de memoria, desorientacion, afasia. Fallas en la percepcion, alucinaciones.

 Cambios en el idioma. Temporal course Se desarrolla en horas a dias, persiste dias a meses. DD con demencia. Empeora de noche. Prodromp: cansancio, cambios en el sueo, depresion, ansiedad, etc. Elderly patients Puede ser el unico signo de enfermedad en mayores. Other features EPM, irritabilidad, ansiedad, labilidad emocional, hipersensibilidad a lices. EVALUATION Recognizing the disorder Clinical confirmation Comparar con funcionamiento basal. History HC mediante familiares: enfermedad febril reciente, insuficiencia organiza, medicaciones, alcoholismo, drogas, depresion reciente. General examination SV, hidratacion, piel, foco. Apariencia general (ictericia, estigmas de IR, agujas, aliento). Lengua mordida, signos de TEC, hemorragia retiniana. Abstinencia: TQC, sudor, rubor, pupilas dilatadas. Solo en jovenes. Sepsis. Neurologic examination Nivel de cc, grado de atencin, cambios visuales, PC, deficits motores. Neuroimagenes, PL, EEG. Delirio de causa metabolica toxica: mioclonias multifocales, asterixis, temblor postural.

 Wernicke: nistagmus, paralisis oculares. Clinical instruments Confusion Assessment Method (CAM). Intensive Care Delirium Checklist for Screening (ICDSC). Investigating medical etiologies

DHT, hiponatremia, hipernatremia Infecciones (ITU, neumonia, piel y PB) Toxicidad, drogas, OH (drogas 30%) Abstinencia OH, BT, BDZ, IRSS Hipoglucemia, hipercalcemia, uremia, IH, tirotoxicosis Shoch, IC Postquirurgico

Menos frecuente: hipoxemia, hipercarbia, Wernicke, insuficiencia suprarrenal, infeccin de SNC, convulsiones, trauma, sindrome paraneoplasico. Medication review DIFFERENTIAL DIAGNOSIS Sundowning Deterioro de la conducta al anochecer en dementes e institucionalizados. Focal syndromes Nonconvulsive status epilepticus Requiere EEG. Twitching facial bilateral, movimientos nistagmoides, hipo espontaneo, estado post ictal, automatismos, afasia, neglect sin lesion estructural. Dementia

Comienzo insidioso, no fluctuante. Cuerpos de Lewy: ms fluctuacin y alucinaciones.

Primary psychiatric illnesses Depresin: disforia, menos fluctuante. Delirio hiperactivo.

DIAGNOSTIC TESTS Laboratory tests

Ionograma, FR. glucemia, calcio, HMG, SU, UC. Siempre. Niveles de: digoxina, litio, quinidina. Triage. EAB: alcalosis respiratoria ms frecuente en sepsis, IH, intoxicacin por AAS, causas cardiopulmonares. Acidosis metabolica: uremia, CAD, acidosis lctica, sepsis tarda, metanol. RXTX. HPG si aplica. Funcion tiroidea y B12 en trastornos mas cronicos.

Neuroimaging TAC si no se encuentra causa. No en: enfermedad medica evidente, no trauma, no foco, alerta, vigil, responde a ordenes. Si si no mejora como se espera. RMN ms sensible para ACV, lesiones fosa posterior, materia blanca, leucoencefalopatia posterior reversible, encefalomielitis aguda diseminada. Lumbar puncture - Siempre que no se encuentre la causa del delirio. Tomar TAC en coma, foco, papiledema. EEG testing

Descartar convulsiones y status no convulsivo. Confirmar dx de encefalopatias metabolicas y encefalitis infecciosas con patterns EEG caracteristicos.

Tienen patrn caracterstico: status epilepticus no convulsivo, encefalopata metablica, encefalopata heptica, encefaliti viral, encefalitis por HSV. SUMMARY AND RECOMMENDATIONS

Delirium is a clinical syndrome caused by a medical condition, substance intoxication or withdrawal, or medication side effect that is characterized by a disturbance of consciousness with reduced ability to focus, sustain, or shift attention (See 'Definition and terminology' above.)

Nearly 30 percent of older medical patients experience delirium at some time during hospitalization. The incidence is higher in those with advanced age and pre-existing brain disease (See 'Epidemiology' above.) A disturbance of consciousness and altered cognition are essential components of delirium. Some patients are drowsy and lethargic, others are agitated and confused. Visual hallucinations, tremulousness, and myoclonus/asterixis are variably present (See 'Clinical presentation' above and 'Neurologic examination' above.). Focal or lateralized neurologic findings are not characteristic of delirium. A careful neurologic examination can also distinguish between focal syndromes that can mimic delirium (See 'Focal syndromes' above.) The past medical history, a review of medications, and a physical examination may provide clues as to the underlying etiology (See 'History' above and 'General examination' above.) Laboratory evaluation in patients with delirium should include serum electrolytes, creatinine, glucose, calcium, complete blood count, and urinalysis and urine culture. Drug levels, toxicology screen, liver function testing, and arterial blood gas should follow if the cause remains obscure (See 'Laboratory tests' above.). Neuroimaging, lumbar puncture, and electroencephalogram are not required in most patients with delirium, but are recommended in specific clinical scenarios, including in those whose cause remains obscure after routine testing (See 'Diagnostic tests' above.)

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Common causes of delirium and confusional states

Drugs and toxins
Prescription medications (eg, opioids, sedative-hypnotics, antipsychotics, lithium, skeletal muscle relaxers, polypharmacy) Non-prescription medications (eg, antihistamines) Drugs of abuse (eg, ethanol, heroin, hallucinogens, nonmedicinal use of prescription medications) Withdrawal states (eg, ethanol, benzodiazepines) Medication side effects (eg, hyperammonemia from valproic acid, confusion from quinolones, serotonin syndrome) Poisons:
Atypical alcohols (ethylene glycol, methanol) Inhaled toxins (carbon monoxide, cyanide, hydrogen sulfide) Plant-derived (eg, Jimson weed, salvia)

Infections
Sepsis Systemic infections; fever-related delirium

Metabolic derangements

Electrolyte disturbance (elevated or depressed): sodium, calcium, magnesium, phosphate Endocrine disturbance (depressed or increased): thyroid, parathyroid, pancreas, pituitary, adrenal Hypercarbia Hyperglycemia and hypoglycemia Hyperosmolar and hypoosmolar states Hypoxemia Inborn errors of metabolism: porphyria, Wilson's disease, etc. Nutritional: Wernicke's encephalopathy, vitamin B12 deficiency, possibly folate and niacin deficiencies

Brain disorders
CNS infections: encephalitis, meningitis, brain or epidural abscess Epileptic seizures, especially nonconvulsive status epilepticus* Head injury* Hypertensive encephalopathy Psychiatric disorders*

Systemic organ failure

Cardiac failure Hematologic: thrombocytosis, hypereosinophilia, leukemic blast cell crisis, polycythemia Liver failure: acute, chronic Pulmonary disease, including hypercarbia and hypoxemia Renal failure: acute, chronic

Physical disorders
Burns Electrocution Hyperthermia Hypothermia Trauma: with systemic inflammatory response syndrome, *head injury, fat embolism

Drugs commonly causing delirium or confusional states*

Analgesics
Nonsteroidal anti-inflammatory agents Opioids (especially meperidine) Bromocriptine

Corticosteroids Dopamine agonists

Amantadine

Antibiotics and antivirals

Acyclovir Aminoglycosides Amphotericin B Antimalarials Cephalosporins Cycloserine

Levodopa Pergolide Pramipexole Ropinirole

Gastrointestinal agents
Antiemetics Antispasmodics

Fluoroquinolones Histamine-2 receptor blockers Isoniazid Loperamide Interferon Linezolid Macrolides Metronidazole Nalidixic acid Penicillins Rifampin Sulfonamides

Herbal preparations
Atropa belladonna extract Henbane Mandrake Jimson weed St. John's Wort Valerian

Anticholinergics
Atropine Benztropine Diphenhydramine Scopolamine Trihexyphenidyl

Hypoglycemics Hypnotics and sedatives

Barbiturates Benzodiazepines

Muscle relaxants
Baclofen Cyclobenzaprine

Anticonvulsants
Carbamazepine Levetiracetam Phenytoin Valproate Vigabatrin

Other CNS-active agents

Disulfiram Donepezil Interleukin-2 Lithium Phenothiazines

Antidepressants
Mirtazapine Selective serotonin reuptake inhibitors Tricyclic antidepressants

Cardiovascular and hypertension drugs

Antiarrhythmics Beta blockers Clonidine Digoxin Diuretics Methyldopa

Bedside tests of attention

Test
Digit span

Directions
Ask the subject to listen carefully and repeat a series of random numbers. Begin with a string of 2 digits, then increase. Read each number in a normal tone of voice at a rate of one digit per second, taking care not to group digits in pairs or sequences that could aid repetition; eg, 3 - 52 - 8 - 18 - 4 - 9 - 36 - 3 - 8 - 5 - 15 - 7 - 2 - 9 - 4 - 68 - 1 - 9 - 2 - 7 - 5 - 6

Vigilance "A" test

Read a list of 60 letters, among which the letter "A" appears with greater than random frequency. The subject is required to indicate (eg, by tapping on the desk) whenever the target letter is spoken by the examiner. The letter list is read in a normal tone at a rate of one letter per second; eg, L T P E A O A I C T D A L A A N I A B F S A M R A E O Z D P A K A L U C J T A E O

Confusion assessment method (CAM) for the diagnosis of delirium*

Feature
1. Acute onset and fluctuating course

Assessment
Usually obtained from a family member or nurse and shown by positive responses to the following questions: "Is there evidence of an acute change in mental status from the patient's baseline?"; "Did the abnormal behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?" Shown by a positive response to the following: "Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?" Shown by a positive response to the following: "Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?" Shown by any answer other than "alert" to the following: "Overall, how would you rate this patient's level ofconsciousness?" Normal = alert Hyperalert = vigilant Drowsy, easily aroused = lethargic Difficult to arouse = stupor Unarousable = coma

2. Inattention

3. Disorganized thinking

4. Altered level of consciousness