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um, I've been asked you would give this presentation on confusion quite a daunting task to present an approach. The confusion that seems to be a bit like presenting something about how to approach and unwell patient and all the things that you need to see only a bit more complicated. But it is it. It is a topic that's quite dazed me because with quite often as neurology read stress. And there's a lot to learn about the human brain in the human mind when you approach to confuse patient, and it's quite rewarding when you are when you try to treat this. But these patients have have implemented some interactive elements in the talk. So if you take a minute to um used the Debrox up in order to be to participate in these ah, um, questions, yeah, you can either scandic you up code or use the link on the top with using the session idea that's underneath, going to give you a few seconds for that. Okay, they will appear also in the question save you if you're going to be books dot up and then the session, and it will appear when the question spoke up a swell. Why is important as as a presentation? It's a very common one. As I said, you, you will see confused patients in pretty much all of the settings primary and secondary care. Whether you work in medicine, surgery or I see you, you always have to do with the confused patients throughout your career on D and about half half of the elderly patients, for example, they get, admit the hospital. They will have some kind of accused, an acute confusion left side. So it's very important to get get to know what confusion is, how it appears and how to approach it. And it's often very, very much associated with a long, longer term problems that arise from it on the quite often started with high morbidity and mortality, Um, and that requires often very prompt. And, uh, sometimes that time sensitive management, as we will see some some of the pathology is that cause the confusion will require very quick reflex. Almost Ah, um, decision making and treatment commencement. The learning objective from this talk are to clarify if you ah Thames surround confusion and I will give you my, ah, um approach to the um, confusion with a systematic way, including the tools to use a history examination, diagnostic testing and the the differential off the off for confusion. And see, we have some issues with someone not not letting them joy. Ah, um, continuing. Um, we will go into the etiology of confusion and we'll talk a little bit about the, uh, management of confusion as as we push towards the end. So if you if you look into the session I tried to activate the question, it's a bit difficult when we don't do it as ah, right, you should have the first question you should. You should not have it on your mobile. PSAs Well, Europe's s So you are the medical F y on on even beauty of this very common scenario. The nurse blips you because she's consent. As the 74 year old lady who was admitted three days ago with the chest infection, was not interacting with her very appropriately during the medical medication around and seems confused. So have a look at the ways to approach the problem. And all right, sorry to interrupt for jury most. I don't think the question is it showing on the screen. Okay, You might have to reach, uh, if you just want to present as kind of on the full of PowerPoint screen. And she normally words, um, I can wait, asking me questions that's going to make your life easier rather than having to flip between modes said he's quick to present fully on your screen. That may make things easier. Okay. Is that is that Okay? We can see it. We can see it now. Okay. And the Are you able again, then to vote for it? Yeah. Calls open. Yeah. It's just it's showing all the little slides on the side as well. So if you want to present fully, then we can just ask questions in the chart on metal. Okay? I am presenting fully. I don't know for what reason, For whatever reason, it's showing as the okay, that's the anything. Perhaps if we skip the April things with the questions, then I'll go back in to read the mood. Yeah, that's all right. It's just that fills just said it looks like you showed the part with the window, but we can still read it, so Okay. All right. When you should have some kind of the all the questions and the answer is available on the up itself. The Viagra works up, uh, so that would be helpful. It's not very compatible, I guess. But what's we get through the questions, Then I'll go back to reading more than it would be much more visible. All right, So, um, let's have a look at what people think. Good. So, uh, some of you will arrange for some blood tests and review the patient off the in chest X ray and CT have been reviewed the patient after those are performed, so you would, uh, uh, call the basic, come to us with the coughing the baseline and try to get some more information. The majority would ask for a new set of observations, so sort of a basic sort of screen test by the nurse and go to review the patient as soon as possible. None of you would change the patients and budgets blindly. Think that's pretty good on day. You would. Some of you would leave the review for the daytime as they're a bit more familiar, and you would just help them by giving some investigations going. So we'll talk a little bit about the results towards the end, when we when we go through the questions again, um, let's have a look at the second one. So a 67 year old left hand, the taxi driver was admitted with it, and and stemi, the nurse called you because the patient appeared confused earlier when she when he was asked what you would like for dinner, but just about and now, before that, when he was giving his medication, you get completely normal. You arrive in the system and he's falling all your instructions. He understands all distractions, but when you ask him questions, he responds with some mixed words. He stops halfway. He seems angry and frustrated at himself or others on. You think that perhaps his left hand grip is also weaker than the right, which seems to be the dominant hand, His observation show only hypertension and in the regular heart rhythm, what would be your next step? So we have some options. You can call his wife to ask if you had the previous similar symptoms and you send off some blood tests will arrange the test X ray reassurance, uh, arrays In another CT head scam or perform another brooks cognitive examination. This is a cognitive screen testing, which, uh, we'll get to a bit later on during presentation. All right, seconds, Moon, if you were going in. All right. Good. Let's have a look. Good. The majority of you would basically arrange an emergency. The head scan in urgently involve SCN. Your colleague think you're spot on? Uh, I think obviously the concern here is a stroke. Um, that's good. Okay, stream. So 26 year old woman with no past medical history is broke to the emergency department after witness generalized seizure. A family report that she has been acting a bit orderly for the past two weeks. A bit of a strange behavior. They were been concerned about drug used to do some reported hallucinations in some paranoid thoughts. Um, we have a few investigations here, but you could do you think it might do all of them. But I was hoping to ask you what you would think the most helpful test would be in this in this case, which will prompt a little bit discussion later on, give you a few seconds down. Some gonna say that the most high yield. I mean, the one that would probably help more than others in terms of helping out with the diagnosis from the accurate diagnosis. Good right, look good. Interesting. Eso. More than half of you would choose the toxicology screen on something which is blood test people. Full eight hour function. E g. And a few of you would choose an MRI scan and 0% would choose a lumbar puncture that that's a very interesting results. I've from my experience, I've rarely seen Texaco's the screen being used. Your expense might be different, but I have them really seen it happen. Um, and the concern here would be in a young patient with paranoid. The hallucinations would be, uh, if there wasn't any drug use, obviously. And it would be for Olympic if I like this. And that's something that we will encounter during the presentation, and we'll see what the most probably test for that is. And the last one For now. Ah, 76 year old man presents with generalized seizure in the emergency department. His wife mentioned that for the past, the cup couple of days he has not been feeling very well and she thought that he had the flu and one was incoherent, confused. It's likely drowsy, and his it still confused with you is observational show, essentially a high temperature and a few others with our bit borderline abnormal. The neurological examination is not very easy to perform, but it doesn't show any clear, obvious Focalin urology, his Bloods show hyponatremia and the slight increase in the inflammatory markers his chest X rays clear would be the next step. What would you do again? Usually one right answer. But equally all of the answers might be correcting the same context. The next step is the question. I'll wait a little bit longer. Okay, Maybe we'll hit 20. There we go. Good. Um, good. So that's that's Ah, that's a healthy sort of answer. People are choosing different things. So, um CT head scan Most lances, MRI, head scan, lumbar puncture out of microbes so easy I don't see the any of them is wrong. Toe started organize. Um, I'll get to the to the question again once we towards the end about this specific one because it's it's important mind. Let me just Okay, I hope this is a little bit better enough. So, um, trying to trying to clarify few confusing so of terminology issues. Confusion is a presentation. It's a symptom. In a way. It's not a condition itself. It's a very it's an umbrella at them that encompasses different behaviors. But essentially it's a loss of the normal goal orientated behavior or actions that we do on a daily life and the cohesive thought processes that underlie left. Um, some people might see confusion as a disruption of the content of consciousness if we think about consciousness as being alert, but also wear off ourselves and the environment, and then confusion would fall towards the awareness and off consciousness and the disruption off those processes that and control that part of consciousness. Um, for the sake of visualizing it, you can see here that this this graph shows in one access the level of consciousness in the other axis, the content of consciousness we are sort of when we're assessing confusion, work towards the upper right corner. Eso the person needs to be alert usually, but they might be drowsy. It's only to show that the consciousness, awareness and confusion they are presentations off, disruption in in urinal networks that are very well connected to each other. So that's why I often we see confused base is becoming very drowsy and sleepy and, um, making presentation towards the end of April with, uh, we'll talk about how to deal with the reduced consciousness levels in patients. The Librium is something different. There's a specific terminology, and on Bs and five in the psychiatric manual, you can read it. But essentially what it is is is a change in cognition, which is usually happens the development over a very short period of time. So it's an acute confusion I pursued. The significant whole month of that is that it fluctuates throughout the day. And, uh, it has to be a new thing and not sort of a progression of the dementia. Um, in all though all this time, the Lyrica confusion, abnormal behavior, sleepiness change in mental status. They're in daily life that used interchangeably by the staff, nurses and other healthcare professionals and as well among doctors. You will see a lot of variability in the use of the time, so whatever time is being used, whenever you hear any of these times, really, your approach will need to be the same. So prompt, careful and systematic way of approaching the problem. So getting onto the approach that I will be suggesting, um, it's it's an idea of going back to the basics and thinking about what our goals are when we're being asked to assess it. Confused patients. So what I always see as the first goal is to recognize the words. The left of the presentation is to recognize the high risk causes of confusion that can be very easily picked up and treated promptly. So I have hypoglycemia as the most common sort of this kind, of course, for confusion, which can be picked up on about doing a simple blood test, and you can correct it very quickly just by giving some glucose. Um, the same can be with hypo hypotheses. For example, if someone smokes is in the 70% obviously, the big confused. So, um, get first the very quickly recognizable and easily treatable causes of confusion and then move on to the second step or the second goal, which is to try to collect as much information as possible to allow an accurate diagnosis. So I will be via a history examination and diagnosis investigations. The set third step would be always to think about the differentials of confusion. There are confusion, mimic. So there are pathologies and presentations that maybe can mimic confusion. And it's important to differentiate. Been separate them because they will have a different treatment, too. Confusion and the different approach them. Ah, then think you will need to obviously identify any reversible causes off confusion and treat them, um, as they know the immediate once but other ones that we will regard a bit of more work up. And we always need to keep the patient comfortable and safe while we do so. Finally, the final goal is to trying to get all of the diagnosis that might be contributing towards confusion and make them as accurate as possible to allow a proper prognostication. Ah, off, um, the part of the underlying pathology out tools, a simple are a B, C D. E R. History, examination and diagnostic tests, and usually it can be with in this order with a B, C. D. Always has to be first time. That's my approach. But then history examination. The diagnostic test can run in parallel. I will not go into the A B c D. Because you know it very well. I think it would be a bit superfluous for this talk. We'll head on and decide with a history taking. The patient obviously will, in most cases will be completely unable to provide it. But you will have to make a few attempts in order to try to see if, if you're dealing with the confusion, mimic. So if the patient can give you information, then we're not really talking about the confusion. Patient will have to think about harder about it if the patient can provide the history. If they're probably confused, then we check the notes would check with the nursing staff, the relatives, other healthcare professionals as much as information as we can get from other people who have seen the patient and what they can describe. And we tried to get it. When you request the information and when you document, try to document exactly what the behavioral changes are that raise the concern. So don't just say that the patient is confused. That will be a bit difficult for other healthcare professionals in temperate. If they have to come back, just write you know, the patient responded this to my question or try to be a bit more descriptive, especially if something it doesn't add up. So if you don't have to write all the details. But if question is unanswered of the patient or behavior is particularly worrisome or strange to you, then it's worth documenting it. And it's always important from the history part of the assessment, to establish the onset of the progression of the confusion and to establish the baseline, the cognitive baseline of the patient. The answer, the progression self explanatory. When was the patient last seen well or normal? Or the use yourself was the change of seconds, minutes, hours, years on? What? How has this progressed over these seconds? Minutes, hours, days over years. This is very important because it hits two different pathology so sometimes only from the history you can say if you're dealing with the dementia progression or with the limbic lives with infections and give her like this on me. But just asking the questions about the answer than the progression. Establishing the cognitive Baylor baseline is very important. When you're trying to talk to relatives, sometimes you can go a bit to the background, not in the immediate sort of assessment of the patient might go to the next day. We're doing a night shift and you can get hold of anyone to give you this information. Um, the way I see it is you can either go with cognitive domains, so ask specific alternative remains and how the person does. And in order to be able to compare with what you have in front of you, or you can ask about the elective, it is that's a lot more practical, and I think easier for a level off y r. One daily activities. They can say a lot about our cognitive baseline. We started with something simple like Is the person the patient working and what's the profession? And if they can do simple stuff like eating, drinking, toileting, dressing themselves all the way to sort of more complex things that require a higher cognitive baseline, such as doing that? Are they doing the personal finances? Do they use computers? Do they have any high end, high skill hobbies or ah, professionals of the chess global? This would be important because, and especially with a poor cognitive baseline who has a little bit of fluctuation on, be a bit of more confused, a little bit more confused than usual is completely different for someone who's sort of cognitively intact, as we say and the is having a a new onset of confusion. But most of the history is really not related to the condition itself for the confusion itself. So you just have to go through your usual structure of history taking, and you have to be deep filled and Thora, you have to check the reason for admission of a patient when you remember when you are assessing an inpatient and how they progress, have there been any complications and infections on any false during their state? This will make a huge difference because you can. You can pick up the diagnosis just by reading a few notes. You always have to check the medical background, alcohol, excess and the illicit drug use, or any previous mental health issues which might hint towards over those is or drug related confusion that travel history and then, well, context. It's part of the usual structural structure of a history taking the current drug history and any medication that have been stopped recently or started recently. And finally, especially for elderly patients, that fluid status, they eating and drinking. Okay, if they have been opening the bowels, all right, and if they have been mobilizing the past few days while they're in hospice will see this quite important. And we'll move on after we're taking all the history, all the information that we can Ah, we move on to the examination of the patient. I usually try to think of it as, uh, the examination of the cognition first, the general neurological examination and a general physical examination. You don't have to do it in a in a particular order, but it's just something that you will just have to have in mind that you need to approach this technical. This is the matter. So the cognitive examination has a few domains. This might seem a little bit daunting, but essentially, it's things that you do and you will be doing as an F one all the time. When you're assessing the first patient, you can ask them, trying to see if they're orientated. You can ask them. This will be during your A B city anyway, when you do the D and letter off the disability. You can ask him about the name Month, Data year. This will take less than 30 seconds to see if the patient's already been time and space. Um, and then from orientation, which I won't go into is very self expanding. We're going to our attention. Attention is the whole Markoff. Acute confusion, Allchin, jizz. So most of the the confusion of acute confusion episodes they are. They definitely have a problem with attention. There's an impairment off attention. Um, you can check it with these tests that I have listed here. You can always go back in the on demand sort of videos and have a look at all the tests that I'm suggesting. But essentially, you can ask them to name the months of the year for words and backwards. Um, you can ask them to, uh, repeat some digits that you give them. Normal people can remember. Um, up to seven days is, um you give them and that's not really memory. It's more attention. Process will see how memory is different from attention. Really, you can ask them to remove seven from 100 keep doing that as they keep doing that one after the other time on see how they get on and try to spell the world the word world forwards and backwards, although that to the last of ones are and beat the related to the education level of the patient as well. So but the first do they're quite good, and they can assess attention very easily. And you can write it down and then you will know if the patient kind of say, the months of the year backwards, If they can save one day and they can save the other day, then that shows a change. Um, then you move on to language examine the language. You have to pay extra consideration here because off aphasia, which is often confused with simple confusion, s So you take the comprehension. You ask him to do things. If they do them properly, then they have good comprehension. Um, how they speak. And if their speech is fluent simply by saying by answering some questions, you will understand if the words are good, I will skip repetition and reading and writing because your big time limited. But one important thing is to do a confrontation naming this is essentially holding a pen to them and saying, What is this? What is this cold or a watch? Or a notebook? Uh, if they're unable to answer that or they can say the right words, but their attention is intact, and that might suggest that they have a language problem in naming problem, which might point towards a phase here memory. You just ask them about the reason for admission you have a discussion about if they understand where they are and why they're they're what has happened, what happened yesterday or day before that. Any recent current events like pandemics, wars, what's happening on the outside world? President Monarchs, they says. More remote memory and you can give the three words to begin with when you assess them and ask them within five minutes to repeat it back to you. So this is in in contrast to the simple seven disease that you will give them, and you ask them to repeat back to you immediately, whereas with memory assessment you will allow them five times to see if their recall is good practice. It might be a little bit above sort of level of an F one, but essentially it's It just shows how the best. In my direct, it might be a bit above the level of who, if want to interpret, really, rather than to do. Because it's fairly easy. You just ask the patient to wave goodbye, blow your case how they brush their teeth by folding a toothbrush or come back here by holding it hair brush. You will see the patients who are a practical, which is usually Ah, an impairment of the frontal lobes. Um, you will. You will see that they will. Instead of holding a toothbrush, they will use their finger as being to trust itself. Or they will come the hair. But just running the fingers through the hair instead of showing how they This is called median motor a practicing and it's good because you can documented and it will. It will make a difference. If further sort of specialists and put this required for me. It will make a huge difference to see that I know that the person has a set, their patient appropriately, Um, you can all of these tests and we talked about the cognitive assessment that cause cognitive examination. You can just use the two like this. So the confusion assessment method that come is very high sensitivity and specificity. It's, um um, it's very useful. You can give you, if you're forget sort of the structure that I suggest that here you consist use the counter method. You can write the score, and that can be easily reproducible, and you'll be able to compare it from day to day. The mini mental test has been found to be the least accurate in studies that have been done, so I would still prefer the come method if you google it. It's very, fairly simple. It's basically what we would have been discussing about, but in a more sort of structured way, and the other books takes time. You don't have to do it. Is this something to know about? It's a more in depth assessment of cognitive domains in a patient. After you examined and cognitively, I would suggest to go into a general neurological examination. It needs to be a top to bottom. I have a cure code here who for whoever's using the mobile, you can check your oh paces, the Solomon Method, um, on YouTube. They're equally there are five minutes euros, euros, examinations. I would urge you to just have a look at them. You can do it in urological screening examination within five minutes, or even less than that. Ah, and get a lot of helpful information, the helpful information and the and the consideration that careful considers you need copies to check for visual and sensory neglect. You move both hands. If the person's not being attention to the left, usually the left side of the world. And even though they were able to see you but the know, paying any attention to it and only so only focusing on one side of the world, then that's visual neglect. It signifies a A structural lesions in the brain, usually a stroke, usually in there in the non dominant. The same spirit check for millions is, um, that's really help important for a confused basis, especially if they have any signs of infection. Um, or high fever check for focal neurological deficits that will signify that. That might be a structural lesion in the brain, which needs scamming and check for asterixis asterixis. You know it. You use your hands, you extend your elbows and you bring your your risk back. And if you have any negative micro nose on both sides, using this signifies in couple Opathy mostly associate with hepatic encephalopathy, but it can be pretty muscle other in people with these, and then you're going to general physical examination. You check the observations you need to check for any acute medical issues. It's often that we in your old is being called to see patients. We often skip it. A swell, But imagine someone has an acute abdomen and we're looking at, you know, limbic. If I like this, it's it's no good. So you will be sort of well equipped to when you're assess a patient who just have no bias and just go there. Assessment physically. Check for any acute medical surgical pathology in the pulmonary edema and acute up the minimum severe conduct disease that's happening. Check for skin changes. Um, Nonblanching rash for meningitis Cellulitis is an infection source, or I think that's that should be enough, um, there and always think about hidden infection. So effective endocarditis. The sky itis and scrotal effectual very often missed. Very often. Missing patients become septic, and we never know what what's going on because within the system, properly and after you do your your examination and throughout the examination and the history. This is the list that I use to think about things that are look like confusion but might not be a confusion. So I always think about I need to rule these out in order to make accurate diagnosis. Does the patient have a face to face? Is an acquired, essentially impairment off language? It might be either problems with understanding, language or producing language. As we explained in the in, in one of the examples, you will hear the patient jumble the words. All the other cognitive domains will be usually normal, so they will be attentive. But they have expressive aphasia production problem that will jump of the words they will say, Uh, I went yesterday, too. Yeah, how's this kind of way? So they will will have problems with producing language, and that's on that that usually will be isolated if there isn't any focal. Other neurology understanding, language problems, the receptive a phase. It might be a bit more difficult to differentiate if you have to have a very high index of suspicion. Thankfully, some most of the times you will find also Focalin urology on examination. Focal Neurological deficit because of a stroke, him in a collect would talked about transit. Global amnesia. This is something that is, um, is a benign condition most of the times, and it comes. It's usually we say it's monophasic. So it comes once in your life doesn't come again. We don't quite know what's the cause of it, but the whole markovich is the constant repetitive questioning off. Where am I? What happened that people cannot register any new memories. Usually comes states for a few hours and then goes away, and the person may or may not have memory of what happened. Usually they don't. Psychosis is another differential. You usually have mental health background there. If you don't have that, then you should have a high suspicion for organic pathology. As the psychiatrist say. So no, that's psychiatric condition. Charles Bonnet syndrome is a problem with vision. People might appear confused because they don't see and they have hallucinations. But a brief conversation with them will show you that they actually know that they have hallucinations and the may or may not be affected by it, but they are not confused. They know where they are. They just see things that do not exist. That, and that's because they're eyes in their brain. Miscommunicated, sensually defer The efferent see a shin of the occipital of the visual cortex. Anthem syndrome is, ah, a syndrome off bilateral. Um, it's cortical blindness in school, so you have bilateral occipital lobe. In fact's the visual cortex goes completely, but still the person thinks that they can see, but they cannot really see so they're blind with the cannot see. It's a bit daunting. It's a bit difficult if you see someone who take things that they see something from them, or they sort of confirm you're late and speak about things that are not really there in front of them might be a bit difficult. You might think that they might hallucinate, but you can always involved seniors, and you can always ask. Especially simple. Is that something to have in mind? Sun Downing is the diagnosis of exclusion. It's related with dementia patients. In the evenings, they get a little bit more drowsy or they might get a little bit more confused. We don't really know what the mechanism of that is, but we can only arrived to that conclusion after we have ruled out all the other investigation. Or at least with history examination or the diagnostic test, we'll rule out other causes. Diagnostic testing usually will include all these tests. Well, some of them obviously blood this chest X ray, a CT and other imaging off the effect of limps or areas in the body. A noncontrast CT head scan and where I had EKG lumbar puncture. As you see, we move. Usually I suggest moving from the least invasive and, ah, least resource may resource demanding so easier to get. Ah, towards the more invasive and more demanding on resource is obviously this might very depending on what the clinical suspicion is. But if you move from with the left and towards the right, and here in this presentation, if you have, if you just need the systematic approach, you're gonna get most things in appropriate manner. These this is a list of the blood tests that you would need to think about. Um, I would, um I would add you to have a look at the assessment off the confused patient or the demented. The suspicion of dementia. Ah, nice CKs the pathways because they suggest all these tests essentially for everyone who presents with confusion before we named that before we suggest that they have dementia. So a full blood count to see if they have infection or anemia. CRP for infection, urine and electrolytes if they have uremia or having electrolyte abnormalities that its hype on a pre me usually or hypocalcemia the glucose levels. If they have hypo or hyper glycemia, they can be confused. Liver function tests for hepatic encephalopathy, Ammonia as well, if you are suspective, hepatic encephalopathy is very helpful. Vitamin B 12 and folate. Very easy to get in this good screening test. Um, ABG to check for High Proxy A or hypercarbia hired function tests again very easy to get very often confused. I have had cases and my colleagues have cases have had cases where they presented with strange neurological signs of the made this thing that they might have something in the brain like a primary intracranial problem. And they ended up with this having hot them Ah, dysfunction of the thyroid. And with this treatment, appropriate treatment, they just that just results simply, it's simple tests. Easy to do your analysis. Don't do it. The patient is asymptomatic, but do do it if the patient has symptoms, and confusion usually is one of the symptoms they might not. Especially elderly. Might not complain of urinary problems. HIV and syphilis, if suspected, We do use it for screening, but not as a first line. Screening is something to keep in mind. Toxicology screen Begin. As I said, I don't see it very often. Um, paracetamol. Submissively, then ethanol levels. Yes, the others bit difficult to get, get to get and for them to be accurately. I don't know what the availability in the lab tests is in the UK either, and blood coaches again. Easy to do. If you required, I will know explain. The other ones will move on to ideological um, the ideological diagnostics off confusion. So the seven categories to remember We'll see how the diagnostic test feeding and also in the next life that I have prepared. So, um, I usually think of seven big categories and then try to work out. If if it's either of these categories, what kind? In the category there is huge list. I'm afraid, Um, I don't think that there's any and sort of benefit in going into detail with all of them. But essentially, you can have toxic metabolic encephalopathy. Is there the most common cause of confusion, especially in admitted patients? Um, simple infections on per Xia, especially in the elderly, will lead to confusion. Treat the you focus on treatment off the non CNS infection. Your email electrolyte imbalance, as I mentioned, because embolus, blood gases, invalid thyroid and vitamin B 12 deficiency other vitamin deficiencies as well as well see next with the ethanol related, the in careful opuses can are possible. There are Myriads of toxins that can cause confusion. I would say you keep in mind the common prescribed medication that can cause confusion, opioids, benzodiazepine, sleeping aids and anticonvulsants. Antidepressants as well might do that. Especially the opiates are very often used for perioperative. For all of those surgical. If wants perioperative situations, they can. They can always cause confusion. Keep that in mind. Um, drugs of abuse. The common ones are ecstasy. Kept him in cocaine, heroin and house emergence. Um, but I have a small sort of region in your brain. Yeah, just for cut carbon monoxide poisoning. I have never seen it, but it might happen and you don't want to miss it because it's It's often deadly, but also really treatable. Usually ah, in the elderly. Always think about things that we do in our daily lives and how, if they get disrupted in elderly person, that could make them confused. I have very often seen people be very confused this because they were elderly people, people with fragile brain's just because they were dehydrated or constipated, even if they're in in pain. So you you manage your mind. Is there these simple things? They get better? Ethanol hepatic encephalopathy is also metabolic encephalopathy is just it's it's a bit more. Ah, it's it's important. That's why I mentioned it separately. The little room Cremins happens after Ah, Southern cessation of alcohol you might be might be assisted with seizures and autonomic dysfunction. You just treat it symptomatically. The might need I see you even on that might need antibiotic medication for the seizures. Then it isn't careful opathy be one deficiency. Whoever has even a slightest sort of history of alcohol excess and the company actually confused. I will always think about proper next that there's no harm in giving them proper next. I have never seen anything any adverse effect of it, and you don't want to leave people with. Then it isn't a pill opathy and created because it can be devastating on they can develop Korsakov's etcetera hepatic encephalopathy. Bit more complex, you will have a lot of liver disease evidence in your hand. Um, treatment is usually you look much better than me, but freedom's usually laxatives in order to get the excess ammonia out of the body. Spinal fluid by players, of course, is this is another big category. This will include all the infections, meningitis, these enkephalin incapability this and all the different kinds of, um, microbes that cause that new plastic meningitis is, well, autoimmune. Limbic it for like, this, uh, is a new Um, yeah, it's not. It's not very new, but it's a recent sort of discovery off people who develop psychosis, abnormal behavior, seizures, confusions on day. Often they get treated as, ah, new onsets psychiatric disorders, but they're usually due to the usual doing reflux or e process in the brain, you concede with an MRI scan. Um, see if you. If you love the infection, then you treat them with the steroids and the immuno suppressants. Most of the times well, not all most advanced, but many times they're associated with the new blood. And so as a paraneoplastic syndrome that sometimes they can be on their own autoimmune conditions. Truck inducement. Inside this, there are three trucks that you should sort of remember nonsteroidal anti inflammatories. You can get the drug induced meningitis, Kakkar amoxicillin and immunoglobulins IV edgy. Um, just to keep in mind, all of these conditions will require a sense in one way or the other will require a lumbar puncture that you have an infectious meningitis. You will see someone with fevers, seizures, confusion, anyone who comes in with confusion and a fever or a seizure. And the fever more so. Seizure if we were always think about. If exercising careful like this, Um, and it's particularly important treating with that cycle of their early on because it's devastating it. The motel is very high, you don't treat them, and then you can always very quickly arranged for a brain scan and a lumbar puncture and rule that out. No convulsive status epilepticus so That's an entity that we often see. Um, not that often, but more often than other specialties. I guess it's very difficult to descend from a metabolic encephalopathy is, um you need to have a high index of suspicion if someone comes in with known epilepsy, have a seizure. Is prolonged difficulty coming around from the seizure talking about our hours half a day rather than a few? Just a couple of I was Or slightly more than that, then, um, or there's an unexplained confusion that you have investigate. Otherwise, you can find the cause. Think about Nonconvulsive status. Epilepticus. Essentially, it's ongoing seizure activity that doesn't manifest. That's more trouble seizures or other sort of clinically obvious seizures and congest me, causing the patient confusion so they're just not able to have normal thought processes. That's because of the abnormal ah, brain function, but they will not manifest differently. You do any GI you can see there's no convulsive status epilepticus structure, brain lesions that's a bit self explanatory. You see focal neurological deficits, very high index of suspicion to do your imaging humus, abscesses, bleeds, strokes. Strokes are a bit uncommon because confusion, but there are a situation where you might have isolated confusion. Um, usually when there is some background of cognitive impairment anyway. Ah, practically most patient with the new onset confusion will have eventually a noncontrast CT has got, unless you have a very clear other cause, causing the confusion. Uh, and it's a simple scan to get nowadays. Very simple. You just get it done. Get it out of the way. You don't you don't miss subdural hematomas, which my present with confusion. We don't make mistakes like that. Then you roll it out with a simple scan, and the MRI scans are much better for low grade glioma. Still, um, IC in facts and for something else, which is called press. This is a course of confusion, which you might not be very familiar with. Um, it might be a little bit unnecessary to learn that now, but essentially the it's it's a syndrome of vaginal Dema. It's really it's related to very high BP. Sometimes it's in the in the spectrum, off hypertensive encephalopathy and a. This is what usually causes seizures. Also in a clumsy and women with the clumsy um, MRI scan is required for that. If you have a right to the point where you have someone with confusion on seizures. For example, CT scan doesn't SHOW ANYTHING. All the other tests don't show anything. You will eventually need an MRI scan, so that's my advice. So you will eat better imaging of the brain if you think that there is something ongoing in the brain causing the confusion. If the CT scan does insure it, go for a new MRI. Scan your electric malignant syndrome. It's something that happens in people who the whole microbio is rigidity and hypothermia and autonomic problems, but also people get confused. It's people who get started on the psychotics. If you have taken appropriate drug history, even if it doesn't come to your mind now, it will, because it's in your systemic approach. If you have taken a proper history while working in this chain off investigations off for for your patient, you will have offered someone else the idea off neuroleptic malignant syndrome being a possibility. But you will see this place and they're very rated. The neurological exam is completely abnormal. You most likely will immediately asked for senior input so you can see that we started from a lot of very basic things to quite advanced things. Ah, some reporter things to remember is that obviously not every confused patient will need an MRI, EEG and LP. I don't mean that with the systemic approach, so use the cost effective approach. This is also the the approach of least harm to the patient. Help, ease, don't come without their problems. Um, and even a prolonged staying hospital, because of and not good approach through the investigations, will eventually prove harmful for the patient that we keep them in. Have all the test that they're not necessary, be always wearing off multiple causes of confusion. So a patient with the seizure may have aspirated have, ah, development pneumonia. Someone with a low B 12 doesn't necessarily have confusion because of a low B 12. Always having open mind. If you're not convinced that the cause that you have found initially is the main cause of the computers or all the cause of the confusion, then keep investigating. So we went as we said, I think we hit all our goals with the ABC the we recognize the high risk one. So we fix them. We collected a lot of information we ruled out the confusion mimics the treated. The reversible causes always because a lot of these conditions are bit complex. Always get senior input as to what the appropriate treatment is. Um, and we provoked. We tried with all this, provided accurate diagnosis. Now, these are all the differential is that I have mentioned. So these are quite don't think quite quite a lot. But I just wanted with a few quick slides to show you that how we moved from with a systemic a bruise it with have suggested we can move from all these different pills to basically zero differential. So we're clearing out all the all the and it causes for confusion one by one or if you buy a few. So by doing our ABC, remove the glucose differential and the blood gases, the hyper same hyper same and the pain would have already recognized. We treated It goes off the differential list with a bit of history. We additionally removed transcend global amnesia. The medication related and toxin related poisoning, constipation, urinary retention. If we asked about this question, we'll have the answers. Ethanol, ethanol and hepatic encephalopathy. If the patient doesn't drink. It's off the list. Drunken use meningitis. You will see what kind of medication patient is. We take the cognitive assessment, do the cognitive assessment. We'll remove aphasia. We'll move psychosis, Charles Bonnet syndrome. We'll do a general neurological examination. We also remove him in neglect. We remove Anton's syndrome, your electric malignant syndrome, and we also away. The other one said that I have marked in yellow. We get a very good sort of idea whether it's one of those. We cannot essentially completely clear them, but we can clinically say whether they're not or whether it possible probable or no. Similarly, with a general physical examination, we removed the hydration A Z well, and we investigate for that. Iraq's is. We do a simple tests, and we checked. We find an infection. Remove it from the list with check for your e me a fire dysfunction Vitamin B 12 deficiency. With the simple test that we've done, we remove those from the equation. We do a CT head, and we know if the patient has a humor, abscesses or bleeds. Remove that from the equation. If they don't with memories, head scan additional. We know if they have press. We know if they have ischemic stroke with a lot more sensitive than the CT head scan, and then we do any idea. We know they have known provocative statements. And finally, with a lumbar puncture we confined confirm if they have an infectious new plastic or two immune limited couple, it's This is obviously simplified. There's obviously a lot of gray areas, but we don't need to go into that. You have a lot of differentials here if you follow this sort of systemic stomachic approach and you're careful, you are over the patient and you listen to them. You you keep your eyes open and, uh, you you you stay on that with the open mind and the systemic, a systematic approach, then you will probably being a much better place than someone who this does. If you run them investigations. As we said, these things can run in parallel. Beware. Beware off over investigation. Do any of the lumber bunch of before a complete that a patient has some damage? You don't really need that. If they don't have any clinical suggestion that they require the lumbar puncture, you don't necessarily do it. You always though, be aware of the under investigation. As we said, a lot of things can run together, so patient with was confused with hyponatremia that might be confused because of the type of treatment. But perhaps you need to think about whether they have, as you know, communicate colitis. There will be other things in the history of the examination that will him towards it. Don't worry treatment. Is this a simple slide? Treat the cause. You will create the confusion. Always keep the patient's safe and comfortable while you do so you don't want the patient's confused. Running on the words and falling and hitting that helps get care is two on one toe. One. Get family and vote. Not nowadays with cover it, but usually yes, better lightning have them visible with with the nurses. Usually there are pathways in each trust that allows for that, and you can also try from a little logical sedation if need be. Always, you know, don't do that first, essentially. So I think we're running a bit, um, sort of, uh, out of time. But essentially, I will just comment on that, um, common on these questions. The first question most of you, I remember asked for a set of observation, reviewed the patient the first day. It says that was the case where you were just asked to see someone because they were confused. I think that's a probably the right thing to do. As we saw in the if you have a systematic approach, this is the mother couple of dictates that you really need to find out what the patient has. And often, you know, it might make a huge difference of you assess them first thing in the night rather than next thing in the morning by the team. Because it might be even saving their life if they have an acute stroke. And you have diagnosed it there and then because someone thought it was confusion. But you thought it was a phase it and someone and they get thrombolysis and you will have, you know, you have saved the language. Really, it's a it's a huge thing. The second case Ah was with the and stemi, I think here you You smashed it? Yes. And, um, it's a CT scan. It was the general who had a crazy Essentially, this scenario letter said, um, this one. I mean, you were all right. As I said, I'm just a bit skeptical about toxicology screen. You know, they might itsn't looking at, like, something in a haystack. Maybe in America is different. They all the American textbooks keep saying toxicology screen I've never really seen in this case. I was bit more worried about what, um, you know, keep the lights. An MRI scan will most likely give us the solution. Every thea answer to that. And if we need to, we do a lumbar puncture, and we sent for autoimmune antibodies. And we investigate further to ask you what kind of limbic live their list. But that's that's for some For the neurologist on the last case. That's a very interesting one. So essentially, this gentleman has fever, seizures, confusion. So my concern here is that this man has infections and careful like this. Okay, you always need to have that in mind. They might have another infection, but if they are a bit if they had a bit of the flu, this they have a seizure. Um, state of a person who had stopped up on the navigation? Yep. We'll go to the questions. I'm just finishing up here. These are the take home messages for you. Sorry. This one before I go to your questions. Um, so the in this case, if we have Ah, General with this, I would probably just give them antimicrobials first. Then get in urgency to his scan within an hour. Um, depending on examination fundings and then do a lumbar puncture on Try to do it as quickly as I can in order to know, um, have the results being, um yeah, influenced by the by the end of microbial that I'm giving so the take home messages for you Confusions the presentation. Know the condition. As we said, you have a systematic, prompt in detail inquiry. You increase the chances of better survival for your patient. Ah, diagnosis isn't not an instant. You would most likely be part of the diagnostic changing my take days with to reach the diagnosis. So do you do your best to be the strongest link in the chain and be aware of the risk of over and under investigation? While you always investigate which will take, Maybe take this, always give in mind that we need to keep the patient's safe um well, you investigate for the cause is so thank you very much for your attention. I'll just give you the QR code for the feedback and certificate link. Also, if you scroll up the questions, that chap, you will be able to find the feedback and at the feet. But link and get your certificate, and I will try to answer questions I would like to know a little. So Mukata Marina is the first question I would like to know a little bit about about neuro state off a person who stopped dopamine agonist abruptly. Yeah, so Ah, this was in the new reluctant malignant syndrome. Ah, essentially a person who takes dopamine agonists. If you stop them abruptly, it's kind of like the same as giving them dopamine. Ah, antagonist. So a lot of the anti seconds have dopamine antagonism, so if you do that, then it's very so. It's a little bit of feedback on the very on my voice, but the sense if you do that, then there's a high tension of developing neuroleptics malignant syndrome, where you get this sort of pneumonia, you get changed in you get the impairment of your autonomic nervous system, you might get fluctuations in your BP flushing you get the hypothermia will become very hot. Uh, and you get confusion of end rigidity, so they become very rigid. These people with neuroleptics malignant syndrome, you need to move many times you need to involve. I see you. You need to keep them safe in terms of the autonomic dysfunction. And you might need to give them some medication. Usually it's done truly Ah, which is, uh, um, something to, ah, like a muscle relaxant. And you give him from Krypton, which is in a bonus, if this if they were on antagonist and on the story on dopamine agonists and they stopped abruptly, obviously you just give them the dopamine agonists, and usually that might reverse the problem. I hope that answers the question. Um, is there any tips on performing in your exam on the computer? Basically, yes, that was very good. And I really want to talk a little bit more about that. So the important things you will see a lot of overlap with the presidential. I'll do ah, on the Commodores patient. Essentially, I would say so, trying to do it talk to bottom examination, you may not being able to get them to, ah, do visual fields. So instead of visual fields with moving your hands up and down, you can do blink to threat. So you try to move your hand in front of their eyes and you see if they blink. So that's your visual fields. I movements. You might get them to just seems if they contract your your face. Usually, people stare up staring your eyes, even if they're confused, so they might not be able to follow your finger. So you might just want to move around and you will see if they track your your eyes or your face as you move around. And I will give you an idea of how they're eyes. Move. Um, you can see the if they're grimacing. And if there's any a symmetry to that. If as a response to pain, for example, if they're grimacing and this symmetry in both sides, then that gives you a bit of a facial expression, um, weak weakness wise. Power wise, it's a bit difficult to assess, but a sense of what you try to do is, for example, if the patients had stated, you will try to, ah, get them to push you away Know, trying to put them in harm. But see if they have the strength in both sides to push your way. If they if they get an added, it obviously don't, you know, stay clear of any punches or slaps. But, um, other things you might want to do is, ah, how they respond to, um ah, pain stimuli. So if you if you do pain stimulator on one side and they retract completely, But on the other side, they just they just have no response. That mining indicate a difference between left and right, which might indicate a problem. For example, a stroke which might have affected the pathways off sensation and motor responses. There are other things that you see in patients who, again as they become more common things. But I think more on that when we assess that you can always do the reflexes, uh, that, you know, they that's quite easy to do, and you can always do a plant. The response, you know, deceive there's any difference or an upgoing plant. The babinski with sort of signs of weakness might suggest that there is, for example, a stroke or a a structural lesion that's causing a problem within the corticospinal tracks. Um, I think that comes to mind very easily. You can see that. You know, if they drink the water in the don't cough. Um, the the swallow is okay. For example, it's just trying to get as much information as you can really, Just by being over them and always documents. I mean, I find it very important that you document, um, you know, patient move their arm or, you know, just in simple words, knowing that would be very helpful for me to just read that rather than, you know, difficult to assess. And if any other questions, uh, shoveling together, The linguists said any other questions? Anyone have any other question? I'm sorry. Because there there's a lot of differentials in the in this scope. Wrote present a shin, but then I couldn't help it. Um Thanks. Alex. Yeah. Who do you find a helpful? Uh huh. All right. It looks like it was the end of the questions. Yeah, we call it in. Yeah. Thank you so much for doing that was really, really helpful. Sadly, yes, we're been about? Yeah, a few minutes, so hopefully wasn't too long. Have you known care of the elderly for four months? The differential is normally sort of set in stone, Really? But it's definitely helping make a wider Yeah. Um, yeah. I mean, as we said, you know, metabolic talk, metabolic encephalopathy, Zar. You know, usually the case It's going to like I've seen I've seen a lot of elderly with the infection syncopal it it is. Which is good to have that in mind. Yeah. All right. Well, thank you very much. We don't know several questions, so we will call it that. Dinner here is controlled the broadcasting. But if we stop Uh huh. No. Should hopefully get off.