Impact of clinical and various lab parameters on final outcome of acute confusional state patients of different etiologies at tertiary care center

Background: Acute confusional state or delirium is a clinical syndrome characterized by disturbed consciousness, cognitive function, or perception. The delirium usually develops over a short period of time (usually hours to days) and it has a tendency to fluctuate during the course of the day. Materials and methods: This study was undertaken on the patients presenting with acute confusional state to the emergency wing of Acharya Shri Chander College of Medical Sciences and Hospital, Jammu to find out the Outcome, Hospital Stay and Prognosticate of different causes of ACS. Patients of acute confusion state that were admitted in the emergency wing of Postgraduate Department of Medicine Acharya Shri Chander College of medical sciences and hospital were enrolled prospectively in the study. Sixty patients of acute confusional state from November 2015 to October 2016 were enrolled who were selected from various patients admitted in ASCOMS. Results: Most patients were in the age group of 61-70 years i.e. 6th decade. Mean age of males was 63.78 (range, 35 to 92) years and of females was 65.85 (range, 26 to 95) years. Median age of males was 64 years and of females 68 years. Sex wise, patients were equally distributed with 32 (53.33%) males and 28 (46.67%) females with male to female ratio of 1.14:1 Out of 60 patients there were 10 deaths, the mortality being 16.67%, 39 (65%) had good recovery and 11 (16.67%) patients had partial recovery. Overall mortality was 16.67%. The mortality depends on age, etiology of acute confusional state, initial GCS and some lab Parameters (TLC, PH, SO2). Conclusion: The increased hospital stay and the prolonged acute confusional state in patients discharged alive were increased age, etiology of ACS, abnormal CT head, decreased PO2 and SO2, focal neurological deficit.

A study of etiological profile of acute confusional state

Background: ACS (Acute confusional states) are on the rise taking the shape of an epidemic. These states are common among the elderly, but young individuals are also not spared. Prompt diagnosis and management of these states can decrease the associated morbidity and mortality.Methods: In this prospective observational study, etiological profile of ACS was evaluated in a total 100 patients, selected over a period of one year, after they fulfilled the CAM (Confusion Assessment Method) criteria.Results: Among 100 patients of ACS, mean age was 54.77�.50 years, males were 66% and 34% were females. The most common diagnosis provisionally made on the basis of history and clinical examination was metabolic encephalopathy in 37% patients, meningoencephalitis (24%), CVA (Cerebrovascular accident) (18%), seizures (9%), sepsis (6%), poisoning (6%). Whereas the final diagnosis made after subjecting the patients to relevant investigations, was metabolic encephalopathy in 37% of patients, meningoencephalitis (20%), CVA (18%), sepsis (12%), unprovoked seizures (6%), poisoning (6%) and undetermined in 1%. The final diagnosis matched the provisional diagnosis in most of the patients except sepsis as a provisional diagnosis was underdiagnosed. The mean duration of hospital stay was 7.6�67days and the hospital stay was most commonly complicated by aspiration pneumonia and acute kidney injury.Conclusions: This study emphasizes that the ACS is an emergency medical situation, where prompt identification, workup and treatment should be done parallelly and urgently to prevent the morbidity and mortality.

Incidence and risk factors of delirium in patients with acute ischaemic stroke

@#Background & Objectives: The reported incidence of post-stroke delirium varies substantially in current medical literature. The impact of delirium on mortality and morbidity is significant and there is need for sustained research on the topic. We aimed to determine the incidence, risk factors and outcome of delirium in acute ischaemic stroke. Methods: We conducted a cross-sectional observational study on consecutive patients with ischaemic stroke. The Confusion Assessment Method was used to diagnose delirium within seven days of stroke onset. Results: Two hundred and eighty patients were recruited (mean age 63.6 years) and 36 (12.9%) developed delirium. After adjustments for covariates, age >65 years (odds ratio, OR 5.2; 95% confidence interval 1.6-17.5); pre-existing dementia (6.5; 1.1-38.2); TACI (7.2; 1.5-35); and a National Institute of Health Stroke Scale of ≥10 (6.8; 1.7-26.4), were independently associated with a risk of developing delirium. Lacunar infarcts were not associated with delirium (0.07; 0.03-0.16). The majority of patients with delirium were cared for in a dedicated stroke unit but this proportion was not significant compared to those without delirium (69.4% vs 58.2%, p=0.20). Delirious patients had significantly higher in-patient mortality (8.3% vs 0%, p=0.002) and longer length of hospital stay (6.94 vs 3.98 days, p< 0.001). Conclusions: One in 8 patients with ischaemic stroke in our centre developed delirium. Older age, pre-existing dementia and severe stroke were independent predictors of delirium. Patients with lacunar infarcts did not develop delirium as often as those with other stroke types. Delirium significantly increased in-patient mortality and length of hospital stay.

El delirium: una actualización para Internistas y Psiquiatras

RESUMEN A lo largo del tiempo, al delirium se lo ha conocido por diversos nombres: falla cerebral aguda, síndrome cerebral orgánico agudo, síndrome confusional o psicosis postquirúrgica. No obstante, el término preferido en la actualidad es delirium (de latín delirare, que significa "arar fuera del surco"). El delirium, como síndrome, es un conjunto de signos y síntomas de inicio agudo caracterizado por deterioro cognitivo fluctuante, con enturbiamiento de la conciencia y capacidad disminuida de mantener y cambiar la atención de un punto a otro. Numerosos estudios han demostrado que los pacientes que desarrollan delirium tienen un riesgo aumentado de resultados adversos tanto durante la hospitalización como tras el alta. Este riesgo es independiente de cualquier comorbilidad existente, de la severidad de la enfermedad, la edad u otras variables asociadas. Asimismo, el delirium está asociado a un incremento en la mortalidad, aumento del tiempo de hospitalización y desarrollo de disfunciones cognitivas posteriores al alta. Este artículo de revisión presenta una actualización acerca de la fisiopatología del delirium, de las herramientas de reconocimiento del cuadro y de su tratamiento. Todas estas informaciones resultan útiles en el manejo diario de este tipo de pacientes, tanto por médicos internistas como por médicos psiquiatras.

ABSTRACT Over time, delirium has been known by several names: acute brain failure, acute organic brain syndrome, confusional syndrome, or post-surgical psychosis. However, the currently preferred term is delirium (from the Latin term delirare, which means "to go out of the furrow"). Delirium, as a syndrome, is a set of signs and symptoms of acute onset characterized by fluctuating cognitive impairment, clouding of consciousness and diminished ability to maintain and shift attention from one point to another. Numerous studies have shown that patients who develop delirium have an increased risk of adverse outcomes both during hospitalization and after discharge. This risk is independent of any existing comorbidity, severity of disease, age or other associated variables. Likewise, delirium is associated with an increase in mortality, increase in hospitalization time and the development of cognitive dysfunctions after discharge. This review article presents an update on the pathophysiology of delirium, the tools for recognizing the condition and its treatment. All this information is useful in the daily management of this type of patients, by both internists and psychiatrists.

Utilidad de la punción lumbar en el paciente con síndrome confusional agudo y fiebre / Usefulness of the lumbar puncture in patients with acute confusional state and fever

Los estados confusionales agudos son motivo de consulta frecuente en pacientes añosos. Se evaluó la utilidad de la punción lumbar en pacientes con fiebre y síndrome confusional agudo (SCA) cuando existe un origen extrameníngeo que explique la fiebre. Criterios de inclusión: pacientes mayores de 50 años, de ambos sexos, con fiebre y SCA admitidos entre junio de 2005 y noviembre de 2006. Se excluyeron pacientes con infección por HIV o que hubieren estado internados en las últimas 72 horas. Se realizó punción lumbar (previa realización de TAC) y se analizó el líquido cefalorraquídeo (LCR). Se incluyeron 30 pacientes. 20 pacientes tuvieron una causa extrameníngea demostrada de la fiebre (66.6%). Se diagnosticaron 6 pacientes con meningitis (20%). El análisis bacteriológico directo del LCR fue positivo en 3 pacientes (10%): en 2 casos se aisló un coco gram positivo y en el restante un bacilo gram negativo. El cultivo de LCR fue positivo en dos casos (6.6%): en un caso se aisló un Streptococcus pneumoniae y en otro Escherichia coli. El hallazgo de una causa clara de fiebre no descarta la posibilidad de meningitis concomitante. Se encontró una asociación entre la presencia de hemocultivos positivos y la de meningitis, tanto en un caso de neumonía por Streptococcus neumoniae como en una infección urinaria por Escherichia coli (p=0.0022, test exacto de Fisher). Conclusión: los pacientes añosos con SCA y fiebre podrían requerir la realización de punción lumbar como parte de la evaluación inicial, independientemente de encontrarse una causa extrameníngea de la fiebre.

Acute Confusional State (ACS) is a frequent cause for seeking professional help among elderly patients. We evaluated the usefulness of lumbar puncture in patients with acute confusional state and fever, when an evident extrameningeal cause of fever is present. All patients over 50 years of age, from both sexes, with fever and ACS, who were admitted to hospital in a period between June 2005 and November 2006, were included. Patients with a history of HIV infection and patients who had been hospitalized within the previous 72 hours were excluded. Lumbar puncture was performed, and the cerebrospinal fluid (CSF) was analyzed. Thirty patients were included. Twenty of the included patients (66.6%) had a demonstrable extrameningeal fever cause. Six patients (20%) with meningitis were detected. The CSF bacteriologic smear was positive in 3 patients (10%); in two cases a gram positive coccus was identified and in one case a gram negative bacillus. The CSF culture was positive in two patients (6.6%) for Escherichia coli (o and Streptococcus pneumoniae. The finding of a clear cause for fever does not rule out the possibility of meningitis. We found an association between the positive blood cultures and the presence of meningitis, both in a case of pneumococcal pneumonia and in a case of urinary tract infection due to Escherichia coli (p=0.0022, Fisher’s Exact test). We conclude that all elderly patients with ACS and fever may require performing a lumbar puncture as part of the initial assessment, regardless of the finding of a extrameníngeal cause of fever.

Effectiveness of Lumbar Puncture in the Diagnosis of Central Nervous System Infection for the Elderly Patients Presenting with Acute Confusional State.

Objective: To evaluate the effectiveness of lumbar puncture (LP) as a diagnostic procedure for central nervous system infection in cases of acute confusional states in elderly patients. Patients and Methods: This is an observational prospective study as a short research article that enrolled 50 elderly patients with acute confusional state to assess lumbar puncture results as a diagnostic procedure for central nervous system infections in Al-Fallujah Teaching Hospital in Al-Anbar, Iraq, between January 2011 and January 2013. All of the patients have been subjected to lumbar puncture (LP), as well as laboratory investigations. Results: This study reveals slight female predominance (54%) in cases of acute confusional state. The mean age was 68 years. Acute confusional state in 92% of our cases was due to systemic disease, and central nervous system infection (meningitis and encephalitis) represented only 8% of cases. Most LPs were negative (normal). Fifty per cent of CNS infections were in pre-LP cases presenting systemic diseases. Central nervous system infections were mostly bacterial meningitis. Conclusions: This study reveals that positive LP results were low in elderly patients presenting with acute confusional state. This gives an idea about the LP effectiveness that should be suspected. Since the causes of such presentation are life threatening diseases, so LP remain the best useful procedure in spite of its low positive results.

Factores asociados a síndrome confusional agudo en adultos mayores internados en emergencia de un hospital terciario / Acute confusional state-associated factors in older adults admitted to a tertiary hospital emergency unit

Introducción: El síndrome confusional agudo es un problema frecuente en el adulto mayor, incrementado por patologías agudas. Objetivos: Determinar la frecuencia del síndrome confusional agudo en adultos mayores no críticos hospitalizados en un servicio de emergencia e identificar factores asociados. Diseño: Estudio transversal. Lugar: Servicio de Emergencia del Hospital Nacional Edgardo Rebagliati Martins, Lima, Perú. Participantes: Pacientes de 60 años o más. Intervenciones: Siguiendo normas de buenas prácticas clínicas, se entrevistó entre mayo y agosto 2010 a paciente/cuidador de 172 pacientes de 60 años o más, hospitalizados en salas de emergencia; se revisó la historia clínica. Principales medidas de resultados: Detectar síndrome confusional agudo mediante el Confussion Assessment Method. Resultados: La frecuencia de síndrome confusional agudo fue 34,9%, según categoría de adulto mayor: enfermo 6%, frágil 28%, complejo 58% (p<0,001). Se encontró antecedente de demencia en 30% de pacientes con síndrome confusional, deterioro cognitivo previo en 45%, síndrome confusional previo en 40,2%, dependencia funcional parcial 46% y total 39%, deterioro cognitivo moderado 27% y severo 40%. El 41,7% de pacientes con síndrome confusional presentó deshidratación moderada-severa (p=0,001) y 20% sepsis, como diagnósticos de ingreso (p=0,003). Las patologías de ingreso más frecuentes fueron infecciosas, cardiovasculares y metabólicas. No se encontró diferencia significativa en sexo, grado de instrucción, estado civil, pluripatología, hospitalización previa, polifarmacia, estado nutricional, presencia de sonda urinaria o nasogástrica, destino al egreso de emergencia ni estancia hospitalaria. Conclusiones: Existe alta frecuencia de síndrome confusional agudo en adultos mayores hospitalizados en servicios de emergencia, siendo factores asociados la demencia, deterioro cognitivo previo, confusión previa, dependencia funcional, categoría geriátrico complejo, deshidratación moderada-severa y sepsis.

Introduction: Acute confusional state is a frequent problem in the elderly and is increased by acute pathologies. Objectives: To determine the frequency of acute confusional state in non-critical elderly emergency service inpatients and to identify associated factors. Design: Cross sectional study. Setting: Emergency Unit, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru. Participants: Sixty-year-old or older patients hospitalized in an emergency unit. Interventions: Between May and August 2010 and according to procedures of good clinical practices, 172 60-year-old or older patients hospitalized in an emergency unit or their caregivers were interviewed and clinical records were reviewed. Main outcome measures: Acute confusional state detection with the Confusion Assessment Method. Results: The frequency of acute confusional state according to category of elderly was 34.9%: ill 6%, fragile 28% and complex 58% (p <0,001). There was history of dementia in 30% of patients with acute confusional state, cognitive previous deterioration in 45%, previous acute confusional state in 40.2%, functional partial dependence in 46% and total dependence in 39%, cognitive moderate deterioration in 27% and severe in 40%; 41.7% of patients with acute confusional state presented moderate -severe dehydration (p=0.001) and 20% sepsis at admission (p=0.003). The most frequent pathologies at admission were infectious, cardiovascular and metabolic. There was no significant difference in sex, instruction degree, marital status, pluripathology, previous hospitalization, polymedication, nutritional condition, use of urinary or nasogastric tubes, destiny at discharge, or hospital stay. Conclusions: High frequency of acute confusional state existed in elderly patients, being associated factors dementia, previous cognitive deterioration, previous confusional state, functional dependence, complex geriatric category, moderate - severe dehydration and sepsis.

Delirium postoperatorio: una ventana hacia una mejoría de la calidad y seguridad en la atención de pacientes quirúrgicos / Postoperative delirium: a window to quality improvement and safety in the care of surgical patients

Postoperative delirium or acute confusional state is a common complication among older subjects. Many factors influence its appearance, such as preexistent problems of the patient, medication use, pain, the perioperative anesthetic management and the intensity of the inflammatory reaction to surgical trauma. Its consequences are a longer hospital stay, higher risk of complications and a long term derangement of functional status and cognitive performance. The management of delirium is multifactorial, including the avoidance of precipitating factors, the maintenance of an adequate environment and the conscious use of neuroleptics. The prevention of delirium should be a priority that will improve health care standards.

El delirium postoperatorio constituye una complicación frecuente y relevante de los pacientes quirúrgicos, en particular en los adultos mayores Su génesis es multifactorial participando características preexistentes del paciente, y gatillantes como medicamentos, dolor, el enfrentamiento anestésico peri operatorio y la intensidad de la respuesta inflamatoria asociada al trauma quirúrgico, entre otros. La aparición de delirium postoperatorio se asocia a desenlaces adversos, como una mayor estadía hospitalaria, mayor riesgo de complicaciones, y a una reducción en la funcionalidad y el estado cognitivo en la evolución alejada. Estrategias de prevención no farmacológicas multimodales, han documentado una reducción significativa en la incidencia de delirium. La terapia del delirium, debe enfocarse en la búsqueda y manejo de factores precipitantes, en favorecer un adecuado entorno no farmacológico, y en el uso apropiado de neurolépticos. El adecuado reconocimiento de esta entidad, y la implementación de estrategias de prevención no farmacológicas constituyen actualmente un estándar que promueve una atención de calidad y segura a los pacientes quirúrgicos.

Time of delirium onset and prognosis amongst Southern Brazilian hospitalized elderly patients / Momento de início do delirium e prognóstico em pacientes idosos hospitalizados no sul do Brasil

Abstract: The prognostic significance of delirium in hospitalized elderly has not yet been fully clarified. Objectives: The present study was designed to evaluate the relationship between prevalent delirium (PrD), incident delirium (InD) and final outcome. Methods: A historical cohort of 261 patients was selected. delirium was diagnosed using the Confusion Assessment Method. Results: The total frequency of delirium detected was 42.5%-31.4% PrD and 16.2% InD. Among patients with InD, the average length of hospital stay was 9.1 days longer than for patients without delirium (p=0.002), and the hospital mortality associated with InD was 48% versus 2.7% for those without delirium (p<0.001). However, no difference was observed between patients with PrD and those without delirium. Conclusions: These results suggest that, when investigating delirium and prognosis amongst hospitalized elderly, it is fundamental to differentiate in terms of time of onset. Furthermore, the absence of delirium seems to be an important protective factor.

Resumo: O significado do prognóstico de delirium em idosos hospitalizados ainda não está completamente elucidado. Objetivos: O presente estudo foi designado para avaliar a relação entre delirium prevalente (DeP), delirium incidente (DeI) e o desfecho final. Métodos: Uma coorte histórica de 261 pacientes foi selecionada. delirium foi diagnosticado pelo Confusion Assessment Method. Resultados: A freqüência total de delirium foi de 42.5%, DeP 31.4%, e DeI 16.2%. Para pacientes com DeI, a média de duração de hospitalização foi 9.1 dias maior do que aqueles sem delirium (p=0.002), e a mortalidade hospitalar associada a DeI foi de 48.3% contra 2.7% dos livres de delirium (p<0.001). Contudo, não houve diferença entre pacientes com DeP e sem delirium. Conclusões: Os resultados sugerem que, ao estudar delirium e prognóstico entre idosos hospitalizados, é fundamental diferenciar o problema quanto ao seu momento de início. Além disso, não apresentar delirium parece constituir-se num fator protetor importante.

Estado confusional agudo como manifestação de status epilepticus não-convulsivo em criança previamente hígida: relato de caso / Acute confusional state in a child with non-convulsive status epilepticus: case report

INTRODUÇÃO: O estado confusional em crianças pode ter várias causas. Entre elas está o estado de mal não-convulsivo. OBJETIVO: Relatamos o caso de um paciente que se apresentou ao serviço de emergência com confusão mental. Após investigação preliminar, o EEG mostrou tratar-se de estado de mal de ausência. RESULTADO: A administração de Diazepam endovenoso seguiu-se normalização do traçado eletroencefalográfico e melhora clínica do paciente. CONCLUSÃO: O EEG é fundamental para se diagnosticar e tratar quadros de estado de mal epiléptico não-convulsivo.

INTRODUCTION: There are many causes to acute confusional state in children. Non-convulsive status epilepticus is one of them. OBJECTIVE: We report the case of a patient who came to our emergency service with confusion. After preliminary investigation the EEG revealed abnormalities consistent with absence status. RESULTS: After treatment with diazepam intravenously occurred normalization of the EEG and, clinically, the patient was better. CONCLUSION: The EEG is crucial in the evaluation of patients with non-convulsive status epilepticus.

Incidence and cause of acute confusion in elderly patients.

Acute confusion is a clinical syndrome in the elderly whose diagnosis is made by acute onset of disturbance of consciousness, impairment of cognition and fluctuating perception and has an underlying medical cause associated with usually serious medical illness. Acute confusion has a high morbidity and mortality, and patient need to stay longer in the hospital, have a higher risk for institutionalization and immobilization. The aim of this study is to recognize the incidence and most of medical illness, which cause acute confusion in elderly patients, a retrospective study based on medical record of elderly patients who were hospitalized in Dr Kariadi hospital since 1998 to 1999. 5407 elderly patients were hospitalized, but only 5191 were analyzed and included in this study. 35% (992 men and 846 women) elderly patients had acute confusion on first arrival and 7% ( 197 men and 176 women) acute confusion appears in the ward. Total acute confusion was 40.89%. The mortality rate was 29% (263 women and 381 men). Three most frequent cause of death were sepsis (10.04%); hemorrhagic stroke (5.11%); multifactor (4.16%). Top ten diseases, which cause acute confusion, were hepatic encephalopathy, hemorrhagic stroke, sepsis, moderate dehydration due to gastoenteritis, hyponatremia, acute myocardial infarction, pneumonia, urinary tract infection, congestive heart failure, and arrhythmia cordis.