Carlos Ballario and Ma. Eugenia Ferri
Acute confusional state is a syndrome characterized by a transitory disorder of the intellect and attention, accompanied by alterations in the sleep-wake cycle and psychomotor behavior. Most confusional states are seen in the elderly. According to different series, its prevalence in patients over 65 years of age reaches 14 to 56%. The terms delirium and toxic psychosis are synonymous.
Attention disorders : characteristically the patient constantly disperses his attention. The time of fixation of attention on each object, situation or person is very short, which causes an impression of "acceleration". During the interrogation the sentences are incomplete with a notable fragmentation of the speech.
Perception disorders : the patient may have a distorted vision of objects (Illusions) or observe non-existent people and objects (Hallucinations). These pictures increase with darkness, which is why nocturnal exacerbation is very common.
Psychomotor activity disorders : restlessness characterizes these patients. They are permanently restless, being very difficult to contain themselves in bed, wandering aimlessly or manipulating their clothes with the intention of undressing. Handling is not straightforward as the restriction can further ease confusion.
Hourly fluctuation of symptoms : it is such a constant fact that its absence puts the diagnosis in doubt. We have already commented on the nocturnal exacerbation, but there are also daytime fluctuations. This is how the patient goes from restlessness to calm and from hallucinations to a partially coherent dialogue. The state of consciousness can vary from complete wakefulness to coma in the most severe cases.
Systemic infections : especially respiratory and urinary infections
Hydroelectrolyte Disorders : dehydration, hypokalaemia, hypocalcaemia, acidosis, hyponatraemia
Systemic diseases : respiratory, kidney, liver and / or heart failure. Decompensated diabetes, hypoglycemia, acute abdomen, prolonged constipation, severe trauma with fractures, anemia, neoplastic impregnation syndrome
Neurological causes : vascular lesions both ischemic and hemorrhagic, acute subdural hematomas, are the most frequent causes. In younger patients, meningitis or meningoencephalitis of any origin, but especially viral, can manifest in this way.
Toxic Causes : alcohol, medications (anticholinergics, antidepressants, neuroleptics, antihistamines, hypnotics, digitalis, ASA, oral hypoglycemic agents, diuretics), carbon monoxide.
It is necessary to carry out a complete clinical and neurological physical examination, placing special interest in the evaluation of the temporospatial orientation and the detection of neurological signs that may orient towards the cause. Especially collect data on drug consumption and alcohol intake.
The laboratory should include: blood count, kidney and liver function, ionogram (Na, Ca, Mg), acid-base status, glycemia, thyroid function and vitamin B12 levels.
In those patients in whom the neurological examination reveals focal signs, a head CT or MRI should be performed.
If the patient has a fever and no infectious focus is detected, a lumbar puncture is required to rule out meningitis.
The EEG shows diffuse slowing, although a normal EEG does not rule out a confusional picture.
It basically consists of correcting the triggering cause, whether it be treating an infection, hydrating, replenishing electrolytes, etc. If the excitement is very important, major tranquilizers such as halopidol can be used or, if it were alcohol withdrawal, benzodiazepines.