Confusion and delirium

Tuyển tập các báo cáo nghiên cứu về y học được đăng trên tạp chí y học Critical Care giúp cho các bạn có thêm kiến thức về ngành y học đề tài: A comparison of the CAM-ICU and the NEECHAM Confusion Scale in intensive care delirium assessment: an observational study in non-intubated patients...

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Delirium: Treatment Management of delirium begins with treatment of the underlying inciting factor (e.g., patients with systemic infections should be given appropriate antibiotics and underlying electrolyte disturbances judiciously corrected). These treatments often lead to prompt resolution of delirium. Blindly targeting the symptoms of delirium pharmacologically only serves to prolong the time patients remain in the confused state and may mask important diagnostic information. Relatively simple methods of supportive care can be highly effective in treating patients with delirium.

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A cost-effective approach to the diagnostic evaluation of delirium allows the history and physical examination to guide tests. No established algorithm for workup will fit all delirious patients due to the staggering number of potential etiologies, but one step-wise approach is detailed in Table 26-3. If a clear precipitant is identified early, such as an offending medication, then little further workup is required. If, however, no likely etiology is uncovered with initial evaluation, an aggressive search for an underlying cause should be initiated.

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Abbreviations: LSD, lysergic acid diethylamide; GHB, γ-hydroxybutyrate; PCP, phencyclidine; CNS, central nervous systemPrescribed, over-the-counter, and herbal medications are common precipitants of delirium. Drugs with anticholinergic properties, narcotics, and benzodiazepines are especially frequent offenders, but nearly any compound can lead to cognitive dysfunction in a predisposed patient.

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Physical Examination The general physical examination in a delirious patient should include a careful screening for signs of infection such as fever, tachypnea, pulmonary consolidation, heart murmur, or stiff neck. The patient's fluid status should be assessed; both dehydration and fluid overload with resultant hypoxia have been associated with delirium, and each is usually easily rectified. The appearance of the skin can be helpful, showing jaundice in hepatic encephalopathy, cyanosis in hypoxia, or needle tracks in patients using intravenous drugs.

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Approach to the Patient: Delirium As the diagnosis of delirium is clinical and made at the bedside, a careful history and physical examination is necessary when evaluating patients with possible confusional states. Screening tools can aid physicians and nurses in identifying patients with delirium, including the Confusion Assessment Method (CAM) (Table 26-1); the Organic Brain Syndrome Scale; the Delirium Rating Scale; and, in the ICU, the Delirium Detection Score and the ICU version of the CAM.

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Epidemiology Delirium is a common disease, but its reported incidence has varied widely based on the criteria used to define the disorder. Estimates of delirium in hospitalized patients range from 14 to 56%, with higher rates reported for elderly patients and patients undergoing hip surgery. Older patients in the ICU have especially high rates of delirium ranging from 70 to 87%.

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Harrison's Internal Medicine Chapter 26. Confusion and Delirium Confusion and Delirium: Introduction Confusion, a mental and behavioral state of reduced comprehension, coherence, and capacity to reason, is one of the most common problems encountered in medicine, accounting for a large number of emergency department visits, hospital admissions, and inpatient consultations. Delirium, a term used to describe an acute confusional state, remains a major cause of morbidity and mortality, contributing billions of dollars yearly to health care costs in the United States alone.

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