Acute Brain Syndrome/Acute Confusion/Delirium

Case: Your next patient in GP practice is an 85-year-old woman who was brought by her daughter because her mother was
acutely confused over the past few days. (one case with DM and one with UTI)

Task
a. History (3 days and patient unable to recognize anyone, wondering around the house and at times became
incontinent, + dark, cloud and smelly urine, on medications for BP and cholesterol)
b. Explain plan of management

Case 2: Your next patient Mrs. Gladys George brought to your surgery by the staff from a Low level nursing facility. Mrs.
George moved to the Nursing home one month ago, after being discharged from an old aged care psychiatry unit. Before
her admission, she had been living independently at home. The precipitant for her admission was a fire in her flat. When the
fire departments arrived Mrs. George was running around the premises of the building claiming she was Messiah and the
blaze was started by demons. She was to taken to the hospital and was treated at an old age psychiatry unit. She had
normal blood tests and MRI brain showed generalized atrophy consistent with age. The nursing staff thinks she had lost
some weight. She had been wandering the halls at night on few occasions. She is agitated and seems confused. On one
occasion she asked the staff are the Russians here yet -. One of the nurses think Mrs. George has been seeing some
things.

Task
a. How will you manage Mrs. George

Case 3 (Feb 4, 2012): An elderly whos confused and has SOB is admitted in the rural hospital where youre working which
is 300km away from the city. ECG and CXR showed right-sided heart failure. In the blood test, no abnormalities were
detected. The daughter wants to talk to you.

Task
a. Talk to the daughter
b. Counsel accordingly
o (LHF SOB sec. backflow of blood into lungs and patient cannot breathe properly)
o Sit upright, start furosemide to remove fluids CPAP if not working
o Start high flow oxygen, explain about heart failure
o Arrange cardiology consultation;
o Investigation: Transthoracic Echocardiography to measure ventricular function
o Advice: Low-salt low fat diet, ideal weight, stop smoking/alcohol, control HTN, DM and lipids; ACEI,
diuretic,
o beta-blockers when stabilized
o no indications to transfer to hospital

Features Delirium Dementia Acute

Psychosis
Onset Rapid Slow insidious Rapid
Duration Hours to weeks Months to years Depends on
response to
treatment
Course over 24 Fluctuates Minimal Minimal
hours worse at night variation variation
LOC Reduced Alert Alert
Perception Misperceptions Misperception May be
common (esp. rare misperception
visual)
Hallucinations Common Uncommon Common,
(visual) usually mainly auditory
or auditory
Attention Distractable Normal to Variable may
impaired be impaired
Speech Variable, may Difficulty finding Variable:
be incoherent correct words normal, rapid or
slow
Organic Illness One or both Often absent Usually absent
or drug toxicity present

Causes:
- Depression/Drugs/alcohol
- Ears/Eyes
- Metabolic (hyponatreamia, diabetes, hypothyroidism)
- Emotion/encephalopathy (loneliness)
- Nutrition (Vitamin B12/diet)
- Trauma/tumor
- Infections
- Arteriovascular disease (CVA, MI)

Investigations:
- LFTs, BSL, TSH, FBE, Blood culture, U&E, CXR, CT scan, urine MCS, ECG

History
- What do you mean confused? Did she have any fever? Lumps or bumps? Any headaches or early morning
vomiting? Did she lose consciousness at any time? Any weakness in any part of the body or any problem with
speech? Any chest pain or shortness of breath? How about her appetite and weight? Has she lost any weight?
Any weather preference? Any swelling all over the body? Any medical illnesses like diabetes or hypertension?
SADMA? Any recent change in medications? Problems with waterworks? Any change in color? Any concerns with
the bowel?
- Whom does she live with at home? How is her mood? What does she do? Recent hospitalization

Management
- I would like to admit your mother to the hospital. I will arrange an ambulance for that. There are a lot of reasons for
acute confusion or delirium.
- From the history, I believe she has a UTI, but because she is also hypertensive, she might also be suffering from a
stroke which is why we need to admit her to do some investigation for hypoxia (pulse oxymetry, saturation, ABG
and CXR), sepsis or infection (FBE, blood culture, urine MCS, ESR/CRP), metabolic (BSL, U&E, arterial pH),
cardiac (ECG, cardiac enzymes), CVA (CT scan). They will also review the medications.