Acute confusional state

Acute confusional state is also known as delirium or acute organic brain syndrome. It affects up to 30% of elderly patients admitted to hospital.

Predisposing factors include:

age > 65 years
background of dementia
significant injury e.g. hip fracture
frailty or multimorbidity
polypharmacy

The precipitating events are often multifactorial and may include:

infection: particularly urinary tract infections
metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
change of environment
any significant cardiovascular, respiratory, neurological or endocrine condition
severe pain
alcohol withdrawal
constipation

Features - a wide variety of presentations

memory disturbances (loss of short term > long term)
may be very agitated or withdrawn
disorientation
mood change
visual hallucinations
disturbed sleep cycle
poor attention

Management

identify and treat underlying causes; review potentially contributing medication
provide reassurance, reorientation and a calm environment; involve family/carers, ensure glasses/hearing aids are available and support hydration, mobilisation and sleep
NICE CG103: consider short-term haloperidol only if the patient is distressed or poses a risk to themselves/others and de-escalation is ineffective or inappropriate
- use the lowest appropriate dose, e.g. 0.5 mg orally in older patients; review daily and stop promptly, usually within 1 week
- MHRA safety advice: obtain a baseline ECG, correct electrolyte disturbances and check QT-prolonging interactions; monitor for cardiac and extrapyramidal adverse effects
- haloperidol is contraindicated in Parkinson’s disease and dementia with Lewy bodies
if haloperidol is contraindicated, seek specialist advice; low-dose lorazepam may be considered for urgent sedation, but can worsen delirium and cause respiratory depression
in Parkinson’s disease, seek specialist advice: low-dose oral quetiapine may be considered if medication is necessary
- lorazepam may be considered cautiously for urgent sedation, but can worsen delirium and cause respiratory depression
benzodiazepines are otherwise generally avoided, except for alcohol/benzodiazepine withdrawal

+PassMedicine Notes

Acute confusional state is also known as delirium or acute organic brain syndrome. It affects up to 30% of elderly patients admitted to hospital.

Predisposing factors include:

age > 65 years
background of dementia
significant injury e.g. hip fracture
frailty or multimorbidity
polypharmacy

The precipitating events are often multifactorial and may include:

infection: particularly urinary tract infections
metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
change of environment
any significant cardiovascular, respiratory, neurological or endocrine condition
severe pain
alcohol withdrawal
constipation

Features - a wide variety of presentations

memory disturbances (loss of short term > long term)
may be very agitated or withdrawn
disorientation
mood change
visual hallucinations
disturbed sleep cycle
poor attention

Management

identify and treat underlying causes; review potentially contributing medication
provide reassurance, reorientation and a calm environment; involve family/carers, ensure glasses/hearing aids are available and support hydration, mobilisation and sleep
NICE CG103: consider short-term haloperidol only if the patient is distressed or poses a risk to themselves/others and de-escalation is ineffective or inappropriate

use the lowest appropriate dose, e.g. 0.5 mg orally in older patients; review daily and stop promptly, usually within 1 week
MHRA safety advice: obtain a baseline ECG, correct electrolyte disturbances and check QT-prolonging interactions; monitor for cardiac and extrapyramidal adverse effects
haloperidol is contraindicated in Parkinson’s disease and dementia with Lewy bodies

if haloperidol is contraindicated, seek specialist advice; low-dose lorazepam may be considered for urgent sedation, but can worsen delirium and cause respiratory depression
in Parkinson’s disease, seek specialist advice: low-dose oral quetiapine may be considered if medication is necessary