Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Confusion – a systematic approach PRODROMOS ANASTASIADIS – ST4 NEUROLOGY REGISTRAR, HEE SWP MIND THE BLEEP TEACHING SESSION – 31/03/2022Vevox poll link https://vevox.app/#/m/158412268 Session ID: 158-412-268 Why is it important? • Very common • Encountered in all settings, primary and secondary care • Medical patients • Surgical patients • ICU • Often associated with high morbidity and mortality • Often time-sensitive management Learning Objectives • Clarifying “confusing” terminology • The approach: back to basics – safety, history, examination • Diagnostic testing • Differentials of confusion • Causes of confusion • A few words on management of confusion Join: vevox.app ID: XXX-XXX-XXX POLL OPEN Case1 YouarethemedicalFY1oneveningduty.Anursebleepsyou–sheisconcernedbecausethe74year oldladywhowasadmitted 3daysagowithCAPwasnotinteracting withherappropriately during medicationroundsandseems confused.Whatisyour nextaction? 1. Arrange for blood tests, CXR and CT head scan and review the patient after they are performed 0% 2. Call the patient’s family to ask what her cognitive baseline is 0% 3. Ask for a new set of observations and review the patient in the first instance 0% 4. Review and change the patient’s antibiotics 0% 5. Arrange for the investigations as above, but leave the review to the day team, as they are more familiar with the patient and their cognitive state 0% Join: vevox.app ID: XXX-XXX-XXX POLL OPEN Case2 A67yearoldlefthandedtaxidriverwasadmitted withNSTEMI.Thenursecalls youbecausethepatientappeared confusedearlierwhenhewasaskedwhathewouldlikefordinner.Aboutanhourbeforethat,whenhewasgiven hismedication,heappearednormal.Youarriveandassesshim:Heisfollowing allyourinstructions without problem,howeverwhenyouaskquestions,herespondswith mixed words,orstopshalf-way, seemingly angryand frustrated.Youthinkthatperhapshislefthandgripisweakerthantheright.Hisobservationsshowonly hypertensionandanirregularheartrhythm.Whatisthenextstep? 1. Call his wife to ask if he has previously had similar symptoms 0% 2. Send off blood tests, arrange a CXR 0% 3. Reassure him and the nurse that his symptoms will likely resolve in a few hours 0% 4. Arrange an emergency CT head scan and urgently involve a senior colleague 0% 5. Perform an Addenbrooke’s Cognitive Examination (ACE) 0%Case3 Join: vevox.app ID: XXX-XXX-XXX POLL OPEN A26yearoldwomanwithnopastmedicalhistoryisbrought totheEmergency Department aftera witnessed generalised seizure. Family reportshehasbeenactingoddlyforthepast2weeks. Theywere concerned aboutdruguse, duetoreportedhallucinationsandparanoia.Whatisthemost high-yield testinthispatient’sinvestigation? 1 Toxicology screen 0% 2 Blood tests, including B12, folate, thyroid function 0% 3 EEG 0% 4 MRI scan 0% 5 Lumbar puncture 0%Case4 Join: vevox.app ID: XXX-XXX-XXX POLL OPEN A76yearoldmanpresentswith ageneralised seizureintheEmergencyDepartment.Hiswifementionsthatfor thepast1-2dayshehasnotbeenfeeling verywellandshethoughthehadtheflu andwasincoherent.Heis slightly drowsy,confused.HisobservationsshowBP110/70,HR105,Temp38.4,RR21,Sats93%.Neurological examination islimited,butdemonstratesnoobviousfocalneurology.Bloodsshowhyponatraemia, mild inflammatory markerrise.CXRisclear.Whatisthenextstep? 1 CT Head scan 0% 2 MRI head scan 0% 3 Lumbar puncture 0% 4 Antimicrobials 0% 5 EEG 0%Clarifying “confusing” terminology Confusion Loss of goal-orientated behaviours/actions and cohesive thought processes Consciousness State of alertness and awareness of oneself and their environment Level and content of consciousness: wakefulness and awareness Confusion as a disruption of content of consciousness (contentious)Consciousness matrix Nani A et al (2019) The Neural Correlates of Consciousness and Attention: Two Sister Processes of the Brain. Front. Neurosci. 13:1169. doi: 10.3389/fnins.2019.01169Clarifying “confusing” terminology Delirium – specific terminology in DSM-5 awareness.nce in attention (reduced ability to direct, focus, sustain, and shift attention) and ● The disturbance develops over a short period of time (usually hours to days), represents a change from baseline, and tends to fluctuate during the course of the day. ● An additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, or perception). ● The disturbances are not better explained by another preexisting, evolving, or established neurocognitive disorder, and do not occur in the context of a severely reduced level of arousal, such as coma. is caused by a medical condition, substance intoxication or withdrawal, or medication side effect.banceClarifying “confusing” terminology In practice, “delirium”, “confusion”, “abnormal behaviour”, “abnormal drowsiness/sleepiness”, “change in mental status” are used interchangeably Approach always the same: prompt, systematic, carefulThe approach – Back to basics Our Goals Provide as Recognise high accurate as risk causes of possible diagnosis confusion and Rule out to allow treat promptly (eg “confusion appropriate hypoglycaemia) mimics” prognostication Collect as much Treat reversible information as causes of possible to allow confusion and accurate keep patient diagnosis (often comfortable and multifactorial safe confusion)The approach – Back to basics Our tools ABCDE History Examination Diagnostic tests History • Patient will not be able to provide it • Notes, nursing staff, relatives, other healthcare professionals (Occupational Therapists, Physiotherapists etc) • Request and document exact behavioural changes that raised the concern, rather than just “confused” (somnolence, agitated confusion, incoherence, specific behaviours/responses) • Important to establish onset, progression and baseline History Onset and progression o when last seen well/normal o was the change over… seconds/minutes (instant), hours, days, weeks, months/years o what has changed over the past minutes, hours, days, weeks since the symptoms startedHistory Establishing cognitive baseline Think in cognitive Cognitive domains domains or in normal daily activities (simple Daily activities •Sensation (visual, auditory) •Work status and profession •Motor skills (manual work, hobbies) to complex) •Eating, dressing, toileting, washing •Attention (able to hold a conversation) and personal hygiene •Memory (facts, dates, keeping lists, names, faces, locations) •Conversing, memory and language •Visuospatial (getting lost, fail to see •Taking walks, exercising things in front of them) •House chores, visiting shops/markets, •Executive (finances, driving, house cooking, driving chores, use of computers) •Personal finances, use of computers, •Language (fluency, book reading, high-skill hobbies or profession naming items/animals etc) (chess, writing, playing music etc)History Most of the history is not related to the confusion itself! • Detailed information on reason and progress of admission, in-hospital events (eg falls) and complications (eg nosocomial infections etc) • Medical background • Alcohol excess, illicit drug use, medication overdose/previous suicidal attempts • Travel history, unwell contacts • Drug history (extra attention to common culprits) • Fluid status, nutritional status, bowel habit, mobilisation out of bedExamination • Cognitive/Mental Status examination • General Neurological Examination • General Physical ExaminationExamination – Cognitive Orientation -ABCDE (name, month, date, year, day of the week, season, and current location) Attention – hallmark abnormality Language Memory Praxis Examination - Cognitive Attention •Months of the year – forwards and backwards •Digit span – normal and reverse •Serial sevens •Spelling “WORLD” forwards and backwards Examination - Cognitive Language – extra consideration! • Comprehension • Production and fluency of speech • (Repetition) • Confrontation naming • (Reading and writing)Examination - Cognitive Memory • Recent/current events, eg reason for admission, any events whilst an inpatient • Recent/current events, eg pandemic, wars • Presidents, monarchs etc • 4-word list (repeat 3 times before allowing 5 minutes)Examination - Cognitive Praxis • Wave goodbye • Blow a kiss • Brush teeth • Hammer nail into a board • Comb hair Examination – Cognitive – Clinical Instruments Confusion Assessment Method - CAM / CAM-ICU (5 minutes) ◦sensitivity 94-100%, specificity 90-95% for delirium diagnosis MMSE - least accurate Addenbrooke’s Cognitive Examination (ACE) instruments. JAMA. 2010 Aug 18;304(7):779-86. doi: 10.1001/jama.2010.1182. PMID: 20716741.bedside Examination – General Neurological • A top to bottom general neurological examination (CN, limbs, cerebellum, gait) • Careful considerations • Visual and sensory neglect • Meningism • Focal neurological deficits • AsterixisExamination – General physical Careful considerations ◦Unstable observations, pyrexia, clinical fluid status assessment ◦Acute severe medical/surgical pathology (pulmonary oedema, acute abdomen, severe pulmonary disease) ◦Skin changes (rash –petechial post-trauma, non-blanching, cellulitis) ◦“Hidden” infections (IE, discitis, scrotal infections)Differential Diagnosis Often “confused with confusion” •Aphasia •Hemineglect (right hemispheric syndrome) •Transient Global Amnesia •Psychosis •Charles Bonnet Syndrome •Anton syndrome •Sundowning (diagnosis of exclusion)Diagnostic T esting CXR, ECG Non- Blood and contrast MRI EEG Lumbar tests other CT head head punctureDiagnostic T esting •Full Blood Count •CRP •Glucose levelsrolytes Blood •Liver function tests, ammonia •ABGamin B12 and folate •TFTs tests •HIV and syphilis if suspected •(Blood Cultures) •(Toxicology screen) – at least paracetamol, salicylate and ethanol levelsAetiology – 7 categories toremember Toxic and metabolic encephalopathies Neuroleptic Ethanol and malignant hepatic syndrome encephalopathy Posterior reversible Spinal Fluid encephalopathy pleocytosis syndrome Structural brain Non-convulsive lesions status epilepticusToxic and metabolic encephalopathies Metabolic encephalopathies ◦ Pyrexia and non-CNS infections (UTI, pneumonia, GI, skin, soft tissues) ◦ Uraemia and electrolyte imbalance (esp. Sodium, Magnesium, Phosphate and Calcium) ◦ Glucose imbalance (hypoglycaemia, hyperglycaemia) ◦ Blood gases imbalance (hypoxia, hypercarbia) ◦ Thyroid disorders (hypothyroidism, hyperthyroidism) and Addison’s ◦ Vitamin B12 deficiency, possibly folate and niacin deficienciesToxic and metabolic encephalopathies Toxic encephalopathies ◦ Myriads of toxins ◦ Common prescribed medication: opioids, benzodiazepines (plus withdrawal), sleeping aids, anticonvulsants ◦ Common drugs of abuse: ecstasy, cocaine, ketamine, heroin, hallucinogens ◦ Keep in mind carbon monoxide poisoning The more fragile the brain networks (think cognitive baseline) the easier it decompensates with metabolic disturbancesToxic and metabolic encephalopathies Considerations in the elderly/people with fragile brain neural networks ◦ Dehydration ◦ Post-operative stress ◦ Hypothermia, hyperthermia ◦ Constipation, urinary retention ◦ PainEthanol and hepatic encephalopathy Delirium tremens Wernicke’s encephalopathy ◦ Pabrinex Hepatic encephalopathySpinal Fluid pleocytosis Infectious meningitis and encephalitis ◦ Be wary of immunocompromisedpatients ◦ Bacterial ◦ Viral ◦ Lyme ◦ Tuberculous ◦ Fungal (coccioides and cryptococcus) Neoplastic meningitis Autoimmune/Limbic encephalitis Drug induced meningitisNon-convulsive status epilepticus Often difficult to discern from metabolic encephalopathies, high index of suspicion needed EEG required for diagnosis history or risk factors for seizures) or prolonged post-ictal confusionStructural brain lesions Tumours, abscesses, bleeds (mostly subdural haematomas) and ischaemic strokes (uncommon) Examination will almost always hint at an intracranial lesion Practically, most patients with new onset confusion will have a non-contrast CT head scan MRI for low grade gliomas, thalamic infarctsPosterior Reversible Encephalopathy Syndrome (PRES) Risk factors ◦ Significant hypertension ◦ Immunosuppressants (eg tacrolimus, cyclosporine) ◦ Eclampsia MRI required for diagnosis most times Conservative management May need ICU Blood pressure control, stop responsible drugs, baby delivery Antiepileptics for seizuresNeuroleptic Malignant Syndrome Antipsychotics (usually classic, but also atypical) and other dopamine antagonists (eg metoclopramide) People who remove dopamine agonists abruptly (think Parkinson’s Disease patients) measurest will include dantrolene, bromocriptine among otherThe approach – from basics to advanced Cost-effective approach; gather information and Be wary of multiple Not every confused eliminate differentials, causes of confusion (a patient will need MRI, screen with simple patient with a seizure EEG and LP tests, move to less may have aspirated and available/more invasive developed a tests pneumonia)The approach – Back to basics Our Goals Provide as Recognise easy, accurate as high risk causes possible diagnosis of confusion and Rule out to allow treat promptly (eg “confusion appropriate hypoglycaemia) mimics” prognostication Collect as much Treat reversible information as causes of possible to allow confusion and accurate keep patient diagnosis (often comfortable and multifactorial safe confusion)Differentials • Aphasia • Common prescribed medication: opioids, benzodiazepines, sleeping aids, anticonvulsants • Hemineglect (right hemispheric syndrome) • Common drugs of abuse: ecstasy, cocaine, ketamine, heroin, • Transient Global Amnesia hallucinogens • Psychosis • Carbon monoxide poisoning • Charles Bonnet Syndrome • Anton syndrome • Dehydration • Hypothermia, hyperthermia • Sundowning (diagnosis of exclusion) • Constipation, urinary retention • Pyrexia and non-CNS infections (UTI, pneumonia, GI, skin, soft tissues) • Pain • Uraemia and electrolyte imbalance (esp. Sodium, Magnesium, • Ethanol and hepatic encephalopathy Phosphate and Calcium) • Infectious meningitis and encephalitis • Glucose imbalance (hypoglycaemia, hyperglycaemia) • Blood gases imbalance (hypoxia, hypercarbia) • Neoplastic meningitis • Thyroid disorders (hypothyroidism, hyperthyroidism) and • Autoimmune/Limbic encephalitis Addison’s • Drug induced meningitis • Vitamin B12 deficiency, possibly folate and niacin deficienci• Non-convulsive status epilepticus • PRES • Tumours, abscesses, bleeds • Neuroleptic Malignant Syndrome • Ischaemic strokeDifferentials - ABCDE • Aphasia • Common prescribed medication: opioids, benzodiazepines, sleeping aids, anticonvulsants • Hemineglect (right hemispheric syndrome) • Common drugs of abuse: ecstasy, cocaine, ketamine, heroin, • Transient Global Amnesia hallucinogens • Psychosis • Carbon monoxide poisoning • Charles Bonnet Syndrome • Anton syndrome • Dehydration • Hypothermia, hyperthermia • Sundowning (diagnosis of exclusion) • Constipation, urinary retention • Pyrexia and non-CNS infections (UTI, pneumonia, GI, skin, soft tissues) • Pain • Uraemia and electrolyte imbalance (esp. Sodium, Magnesium, • Ethanol and hepatic encephalopathy Phosphate and Calcium) • Infectious meningitis and encephalitis • Glucose imbalance (hypoglycaemia, hyperglycaemia) • Blood gases imbalance (hypoxia, hypercarbia) • Neoplastic meningitis • Thyroid disorders (hypothyroidism, hyperthyroidism) and • Autoimmune/Limbic encephalitis Addison’s • Drug induced meningitis • Vitamin B12 deficiency, possibly folate and niacin deficienc• Non-convulsive status epilepticus • PRES • Tumours, abscesses, bleeds • Neuroleptic Malignant Syndrome • Ischaemic strokeDifferentials - History • Aphasia • Common prescribed medication: opioids, benzodiazepines, sleeping aids, anticonvulsants • Hemineglect (right hemispheric syndrome) • Common drugs of abuse: ecstasy, cocaine, ketamine, heroin, • Transient Global Amnesia hallucinogens • Psychosis • Carbon monoxide poisoning • Charles Bonnet Syndrome • Anton syndrome • Dehydration • Hypothermia, hyperthermia • Sundowning (diagnosis of exclusion) • Constipation, urinary retention • Pyrexia and non-CNS infections (UTI, pneumonia, GI, skin, soft tissues) • Pain • Uraemia and electrolyte imbalance (esp. Sodium, Magnesium, • Ethanol and hepatic encephalopathy Phosphate and Calcium) • Infectious meningitis and encephalitis • Glucose imbalance (hypoglycaemia, hyperglycaemia) • Blood gases imbalance (hypoxia, hypercarbia) • Neoplastic meningitis • Thyroid disorders (hypothyroidism, hyperthyroidism) and • Autoimmune/Limbic encephalitis Addison’s • Drug induced meningitis • Vitamin B12 deficiency, possibly folate and niacin deficienci• Non-convulsive status epilepticus • PRES • Tumours, abscesses, bleeds • Neuroleptic Malignant Syndrome • Ischaemic strokeDifferentials – Cognitive • Aphasia • Common prescribed medication: opioids, benzodiazepines, sleeping aids, anticonvulsants • Hemineglect (right hemispheric syndrome) • Common drugs of abuse: ecstasy, cocaine, ketamine, heroin, • Transient Global Amnesia hallucinogens • Psychosis • Carbon monoxide poisoning • Charles Bonnet Syndrome • Anton syndrome • Dehydration • Hypothermia, hyperthermia • Sundowning (diagnosis of exclusion) • Constipation, urinary retention • Pyrexia and non-CNS infections (UTI, pneumonia, GI, skin, soft tissues) • Pain • Uraemia and electrolyte imbalance (esp. Sodium, Magnesium, • Ethanol and hepatic encephalopathy Phosphate and Calcium) • Infectious meningitis and encephalitis • Glucose imbalance (hypoglycaemia, hyperglycaemia) • Blood gases imbalance (hypoxia, hypercarbia) • Neoplastic meningitis • Thyroid disorders (hypothyroidism, hyperthyroidism) and • Autoimmune/Limbic encephalitis Addison’s • Drug induced meningitis • Vitamin B12 deficiency, possibly folate and niacin deficienci• Non-convulsive status epilepticus • PRES • Tumours, abscesses, bleeds • Neuroleptic Malignant Syndrome • Ischaemic strokeDifferentials – General Neurological • Aphasia • Common prescribed medication: opioids, benzodiazepines, sleeping aids, anticonvulsants • Hemineglect (right hemispheric syndrome) • Common drugs of abuse: ecstasy, cocaine, ketamine, heroin, • Transient Global Amnesia hallucinogens • Psychosis • Carbon monoxide poisoning • Charles Bonnet Syndrome • Anton syndrome • Dehydration • Hypothermia, hyperthermia • Sundowning (diagnosis of exclusion) • Constipation, urinary retention • Pyrexia and non-CNS infections (UTI, pneumonia, GI, skin, soft tissues) • Pain • Uraemia and electrolyte imbalance (esp. Sodium, Magnesium, • Ethanol and hepatic encephalopathy Phosphate and Calcium) • Infectious meningitis and encephalitis • Glucose imbalance (hypoglycaemia, hyperglycaemia) • Blood gases imbalance (hypoxia, hypercarbia) • Neoplastic meningitis • Thyroid disorders (hypothyroidism, hyperthyroidism) and • Autoimmune/Limbic encephalitis Addison’s • Drug induced meningitis • Vitamin B12 deficiency, possibly folate and niacin deficienci• Non-convulsive status epilepticus • PRES • Tumours, abscesses, bleeds • Neuroleptic Malignant Syndrome • Ischaemic strokeDifferentials – General physical • Aphasia • Common prescribed medication: opioids, benzodiazepines, sleeping aids, anticonvulsants • Hemineglect (right hemispheric syndrome) • Common drugs of abuse: ecstasy, cocaine, ketamine, heroin, • Transient Global Amnesia hallucinogens • Psychosis • Carbon monoxide poisoning • Charles Bonnet Syndrome • Anton syndrome • Dehydration • Hypothermia, hyperthermia • Sundowning (diagnosis of exclusion) • Constipation, urinary retention • Pyrexia and non-CNS infections (UTI, pneumonia, GI, skin, soft tissues) • Pain • Uraemia and electrolyte imbalance (esp. Sodium, Magnesium, • Ethanol and hepatic encephalopathy Phosphate and Calcium) • Infectious meningitis and encephalitis • Glucose imbalance (hypoglycaemia, hyperglycaemia) • Blood gases imbalance (hypoxia, hypercarbia) • Neoplastic meningitis • Thyroid disorders (hypothyroidism, hyperthyroidism) and • Autoimmune/Limbic encephalitis Addison’s • Drug induced meningitis • Vitamin B12 deficiency, possibly folate and niacin deficienci• Non-convulsive status epilepticus • PRES • Tumours, abscesses, bleeds • Neuroleptic Malignant Syndrome • Ischaemic strokeDifferentials – Bloods,CXR, ECG, Urinalysis • Aphasia • Common prescribed medication: opioids, benzodiazepines, sleeping aids, anticonvulsants • Hemineglect (right hemispheric syndrome) • Common drugs of abuse: ecstasy, cocaine, ketamine, heroin, • Transient Global Amnesia hallucinogens • Psychosis • Carbon monoxide poisoning • Charles Bonnet Syndrome • Anton syndrome • Dehydration • Hypothermia, hyperthermia • Sundowning (diagnosis of exclusion) • Constipation, urinary retention • Pyrexia and non-CNS infections (UTI, pneumonia, GI, skin, soft tissues) • Pain • Uraemia and electrolyte imbalance (esp. Sodium, Magnesium, • Ethanol and hepatic encephalopathy Phosphate and Calcium) • Infectious meningitis and encephalitis • Glucose imbalance (hypoglycaemia, hyperglycaemia) • Blood gases imbalance (hypoxia, hypercarbia) • Neoplastic meningitis • Thyroid disorders (hypothyroidism, hyperthyroidism) and • Autoimmune/Limbic encephalitis Addison’s • Drug induced meningitis • Vitamin B12 deficiency, possibly folate and niacin deficienci• Non-convulsive status epilepticus • PRES • Tumours, abscesses, bleeds • Neuroleptic Malignant Syndrome • Ischaemic strokeDifferentials – CT Head • Aphasia • Common prescribed medication: opioids, benzodiazepines, sleeping aids, anticonvulsants • Hemineglect (right hemispheric syndrome) • Common drugs of abuse: ecstasy, cocaine, ketamine, heroin, • Transient Global Amnesia hallucinogens • Psychosis • Carbon monoxide poisoning • Charles Bonnet Syndrome • Anton syndrome • Dehydration • Hypothermia, hyperthermia • Sundowning (diagnosis of exclusion) • Constipation, urinary retention • Pyrexia and non-CNS infections (UTI, pneumonia, GI, skin, soft tissues) • Pain • Uraemia and electrolyte imbalance (esp. Sodium, Magnesium, • Ethanol and hepatic encephalopathy Phosphate and Calcium) • Infectious meningitis and encephalitis • Glucose imbalance (hypoglycaemia, hyperglycaemia) • Blood gases imbalance (hypoxia, hypercarbia) • Neoplastic meningitis • Thyroid disorders (hypothyroidism, hyperthyroidism) and • Autoimmune/Limbic encephalitis Addison’s • Drug induced meningitis • Vitamin B12 deficiency, possibly folate and niacin deficienc• Non-convulsive status epilepticus • PRES • Tumours, abscesses, bleeds • Neuroleptic Malignant Syndrome • Ischaemic strokeDifferentials – MRIHead • Aphasia • Common prescribed medication: opioids, benzodiazepines, sleeping aids, anticonvulsants • Hemineglect (right hemispheric syndrome) • Common drugs of abuse: ecstasy, cocaine, ketamine, heroin, • Transient Global Amnesia hallucinogens • Psychosis • Carbon monoxide poisoning • Charles Bonnet Syndrome • Anton syndrome • Dehydration • Hypothermia, hyperthermia • Sundowning (diagnosis of exclusion) • Constipation, urinary retention • Pyrexia and non-CNS infections (UTI, pneumonia, GI, skin, soft tissues) • Pain • Uraemia and electrolyte imbalance (esp. Sodium, Magnesium, • Ethanol and hepatic encephalopathy Phosphate and Calcium) • Infectious meningitis and encephalitis • Glucose imbalance (hypoglycaemia, hyperglycaemia) • Blood gases imbalance (hypoxia, hypercarbia) • Neoplastic meningitis • Thyroid disorders (hypothyroidism, hyperthyroidism) and • Autoimmune/Limbic encephalitis Addison’s • Drug induced meningitis • Vitamin B12 deficiency, possibly folate and niacin deficienc• Non-convulsive status epilepticus • PRES • Tumours, abscesses, bleeds • Neuroleptic Malignant Syndrome • Ischaemic strokeDifferentials – EEG • Aphasia • Common prescribed medication: opioids, benzodiazepines, sleeping aids, anticonvulsants • Hemineglect (right hemispheric syndrome) • Common drugs of abuse: ecstasy, cocaine, ketamine, heroin, • Transient Global Amnesia hallucinogens • Psychosis • Carbon monoxide poisoning • Charles Bonnet Syndrome • Anton syndrome • Dehydration • Hypothermia, hyperthermia • Sundowning (diagnosis of exclusion) • Constipation, urinary retention • Pyrexia and non-CNS infections (UTI, pneumonia, GI, skin, soft tissues) • Pain • Uraemia and electrolyte imbalance (esp. Sodium, Magnesium, • Ethanol and hepatic encephalopathy Phosphate and Calcium) • Infectious meningitis and encephalitis • Glucose imbalance (hypoglycaemia, hyperglycaemia) • Blood gases imbalance (hypoxia, hypercarbia) • Neoplastic meningitis • Thyroid disorders (hypothyroidism, hyperthyroidism) and • Autoimmune/Limbic encephalitis Addison’s • Drug induced meningitis • Vitamin B12 deficiency, possibly folate and niacin deficienci• Non-convulsive status epilepticus • PRES • Tumours, abscesses, bleeds • Neuroleptic Malignant Syndrome • Ischaemic strokeDifferentials – Lumbar puncture • Aphasia • Common prescribed medication: opioids, benzodiazepines, sleeping aids, anticonvulsants • Hemineglect (right hemispheric syndrome) • Common drugs of abuse: ecstasy, cocaine, ketamine, heroin, • Transient Global Amnesia hallucinogens • Psychosis • Carbon monoxide poisoning • Charles Bonnet Syndrome • Anton syndrome • Dehydration • Hypothermia, hyperthermia • Sundowning (diagnosis of exclusion) • Constipation, urinary retention • Pyrexia and non-CNS infections (UTI, pneumonia, GI, skin, soft tissues) • Pain • Uraemia and electrolyte imbalance (esp. Sodium, Magnesium, • Ethanol and hepatic encephalopathy Phosphate and Calcium) • Infectious meningitis and encephalitis • Glucose imbalance (hypoglycaemia, hyperglycaemia) • Blood gases imbalance (hypoxia, hypercarbia) • Neoplastic meningitis • Thyroid disorders (hypothyroidism, hyperthyroidism) and • Autoimmune/Limbic encephalitis Addison’s • Drug induced meningitis • Vitamin B12 deficiency, possibly folate and niacin deficienc• Non-convulsive status epilepticus • PRES • Tumours, abscesses, bleeds • Neuroleptic Malignant Syndrome • Ischaemic strokeApproach considerations History, examination and investigations will work most times in parallel and will feed back to each other Beware of over-investigation (do I need a lumbar puncture before I conclude a patient has sun-downing?) hyponatraemia have LGI-1 autoimmune encephalitis?)patient withA few words on treatment Keep the patient Pharmacological Treat the cause! safe and sedation comfortable Join: vevox.app ID: XXX-XXX-XXX POLL OPEN Case1 YouarethemedicalFY1oneveningduty.Anursebleepsyou–sheisconcernedbecausethe74yearold ladywhowasadmitted3daysagowithCAPwasnotinteractingwithherappropriatelyduring medicationroundsandseemsconfused.Whatisyournextaction? 1. Arrange for blood tests, CXR and CT head scan and review the patient after they are performed 0% 2. Call the patient’s family to ask what her cognitive baseline is 0% 3. Ask for a new set of observations and review the patient in the first instance 0% 4. Review and change the patient’s antibiotics 0% 5. Arrange for the investigations as above, but leave the review to the day team, as they are more familiar with the patient and their cognitive state 0% Join: vevox.app ID: XXX-XXX-XXX POLL OPEN Case2 A67yearoldlefthandedtaxidriverwasadmitted withNSTEMI.Thenursecalls youbecausethepatientappeared confusedearlierwhenhewasaskedwhathewouldlikefordinner.Aboutanhourbeforethat,whenhewasgiven hismedication,heappearednormal.Youarriveandassesshim:Heisfollowing allyourinstructions without problem,howeverwhenyouaskquestions,herespondswith mixed words,orstopshalf-way, seemingly angryand frustrated.Youthinkthatperhapshislefthandgripisweakerthantheright.Hisobservationsshowonly hypertensionandanirregularheartrhythm.Whatisthenextstep? 1. Call his wife to ask if he has previously had similar symptoms 0% 2. Send off blood tests, arrange a CXR 0% 3. Reassure him and the nurse that his symptoms will likely resolve in a few hours 0% 4. Arrange an emergency CT head scan and urgently involve a senior colleague 0% 5. Perform an Addenbrooke’s Cognitive Examination (ACE) 0%Case3 Join: vevox.app ID: XXX-XXX-XXX POLL OPEN A26yearoldwomanwithnopastmedicalhistoryisbrought totheEmergency Department aftera witnessed generalised seizure. Family reportshehasbeenactingoddlyforthepast2weeks. Theywere concerned aboutdruguse, duetoreportedhallucinationsandparanoia.Whatisthemost high-yield testinthispatient’sinvestigation? 1 Toxicology screen 0% 2 Blood tests, including B12, folate, thyroid function 0% 3 EEG 0% 4 MRI scan 0% 5 Lumbar puncture 0%Case4 Join: vevox.app ID: XXX-XXX-XXX POLL OPEN A76yearoldmanpresentswith ageneralised seizureintheEmergencyDepartment.Hiswifementionsthatfor thepast1-2dayshehasnotbeenfeeling verywellandshethoughthehadtheflu andwasincoherent.Heis slightly drowsy,confused.HisobservationsshowBP110/70,HR105,Temp38.4,RR21,Sats93%.Neurological examination islimited,butdemonstratesnoobviousfocalneurology.Bloodsshowhyponatraemia, mild inflammatory markerrise.CXRisclear.Whatisthenextstep? 1 CT Head scan 0% 2 MRI head scan 0% 3 Lumbar puncture 0% 4 Antimicrobials 0% 5 EEG 0%T ake home messages Confusion is a presentation, not a condition treatmenttic, prompt, detailed inquiry will increase chances of accurate diagnosis and More often than not, diagnosis is not instant, you are part of a diagnostic chain Be aware of risks of over- and under-investigation. Keep the patient safe while you investigate and treat causes of confusionAny Questions?Feedback and certificate link