Acute confusional state.
Any unexplained behavioural change in a hospital patient is likely to be part
of an acute confusional state.
Clinical features: impaired conscious level with onset over hours or days. The patient is likely to be disoriented in time and with greater impairment in place. The patient may be unusually quite and drowsy, and sometimes he/she may be agitated. On other occasions the patient may be deluded (accusing staff of plotting against him/her) or to be hallucinating (seeing things or hearing voices which are not there). In the later two cases the question of primary mental illness is raised e.g. paranoid state and schizophrenia. However if there is no past psychiatric history, and in the setting of a general hospital, i.e. the patient is physically ill or has had recent surgery, mental illness is rare and acute confusional state is common. A confusional state is more likely if the symptoms are worse in the late afternoon and at night.
DD: if agitated consider an anxiety state. If the onset is uncertain consider dementia.
Causes: infection: chest, UTI, surgical wound, IVI sites
Drugs: especially analgesics and sedatives.
*Alcohol withdrawal,
*Metabolic disorder,
*Hypoxia
Vascular: stroke, MI
Head injury, especially subdural haematoma.
Management: find the cause, review the case notes, examine the patient with above causes in mind, do necessary investigations, start relevant treatment.
If hypoxic give oxygen. If agitated and disruptive sedation is necessary, sometimes before examination and investigations are possible.
Use major tranquillizers: haloperidol and chlorpromazine.
In alcohol withdrawal use chlormethiazole.
Nurse in a moderately lit quite room with the same staff in attendance to minimize confusion. Repeated reassurance and orientation.
Refer: Mini mental state.