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Delirium–Acute Confusional State

  • Dementia          
  • Delirium            
  • Amnestic syndrome

DELIRIUM – Acute confusional State

Clinical features:

  1. Clouding of consciousness: May be from disorientation to dullness of alertness to deep coma
  2. Disorientation: Memory disturbance. All aspects of memory registration, retention and recall are affected. One of the earliest manifestations is disorientation in time and place, resulting from an inability to register the sequence of events and to learn new surroundings.
  3. Perceptual abnormalities – Visual Hallucinations (Frightening , Fragmentary,  Lilliputian), illusions.  Objects may be seen as larger (macropsia) or smaller (micropsia) than they are. They maybe perceived as distorted in shape or be misinter­preted (illusions). Hallucinations are the most striking perceptual disturbance. Generalised organic reactions are characteristically associated with visual and tactile perceptual disturbances. Focal lesions in the temporal lobe can cause disturbances in taste and smell.
  4. Disturbance of sleep or reversal of sleep wake cycle  
  5. Psychomotor changes. Mental and motor activity is usually retarded. There is little spontaneity, speech is sparse and responses to questions are slow in forthcom­ing. However in some cases the reverse is true.
  6. Thinking delusions are Transient and frightening. But the hall mark of delirium is transient delusion. There is subjective difficulty in think­ing clearly. Speed of thought is slowed, mental fatigue soon occurs and the pattern of thinking becomes muddled. The patient has difficulty grasping the essential features of his environment so that events are misin terpreted and secondary delusional ideas develop, often of paranoid nature.
  7. Emotional changes. Anxiety, irritability and de­pression may accompany the other   fea tures. In severe case the emotional response becomes apathetic.
  8. SundowningQ, phenomenon ie. worsening of symptoms after ‘sunset’.
  9. EEG – generalized slowing of activity.
  10. Floccillations (Picking movements at clothes and cover sheets)
Causes of Acute Confusional States (Delirium)
  1.   Intra-cranial
    1. Trauma
    2. Vascular
      1. TIA
      2. Cerebral haemorrhage
      3. Cerebral thrombosis
      4. SAH                    
      5. Subdural haemorrhage
    3. Epilepsy Post-ictal state
    4. Infection
      1. Encephalitis
      2. Cerebral abscess
      3. Meningitis
      4. AIDS
    5. Tumour: Primary or secondary lesion
  2.  Extra-cranial
    1. Infection
      1. Exanthemata             
      2. Septicaemia               
      3. Pneumonia        
      4. Urinary infection
    2. Toxic
      1. Alcohol
      2. Many therapeutic drugs (e.g. anticholinergics, beta-blockers, L-Dopa, isoniazid)
    3. Endocrine
      1. Hyperthyroidism                 
      2. Hypothyroidism          
      3. Hypoglycemia
      4. Addisonian crisis        
      5. Hypopituitarism
    4. Metabolic
      1. Uraemia                     
      2. Liver failure               
      3. Remote effects of carcinoma
      4. Electrolyte imbalance  
      5. Porphyria
    5. Hypoxia
      1. Respiratory failure             
      2. Cardiac failure
      3. Acute heart block                
      4. Carbon monoxide poisoning
Once the cause is established specific treatment is given for the underlying cause.
I / V therapy may be required to correct fluid and electrolyte imbalance. Sedative drugs should not be given unless the patient’s behaviour is disruptive; chlorpromazine or haloperidol are the drugs of choice, except in delirium tremens when benzodiazepines (e.g. diazepam ) are preferred.

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