Acute confusion – Patient assessment and diagnosis of cause Mr Rob Simpson ED Consultant UHCW

Acute confusion Definition Abreviated mental test (AMT) Causes – interactive Patient assessment (a practical approach) – Interactive Summary & close

Acute confusion - definition There are several medical definitions of delirium (including those in the DSM-IV and ICD-10). However, all include some core features. DSM-IVICD-10 The core features are: Disturbance of consciousness (that is, reduced clarity of awareness of the environment, with reduced ability to focus, sustain, or shift attention) – Change in cognition (e.g., problem-solving impairment or memory impairment) or a perceptual disturbance – Onset of hours to days, and tendency to fluctuate. – Common features also tend to include: Intrusive abnormalities of awareness and affect, such as hallucinations or inappropriate emotional statesaffecthallucinations

Abbreviated mental test (AMT) Abbreviated mental test score 1. Age ? 2. Time? (to nearest hour) 3. Address for recall at end of test (this should be repeated by the patient to ensure it has been heard correctly): "42 West Street“ 4. Year? 5. Name of this place? 6. Identification of two persons (doctor, nurse etc.)? 7. Date of birth? 8. Year of First World War? 9. Name of present Monarch? 10. Count backwards 20 to 1 Address recall correct?

Abreviated mental test score = /10 Should score 7 or more out of 10 Score of 6 or less suggests delirium or dementia

About / problems Developed by geriatricians in 1972 Not validated for primary care or screening tool Some cultural validity issues Sensitivity: 70-80% Specificity: 71-90% (at 7-8 cut-off)

Causes of acute confusion DIBBS pnemonic – Drugs – Infection – Biochemical – Bladder – Surroundings – For each consider common and less common causes

Approach to the confused patient Rapid tranquilisation ? Capacity / best interests ? Assessment – History ? – Examination – Bloods – Notes and drug chart – Other investigations

Summary & Close Acute confusion is VERY common Need a robust and practiced approach to secure the underlying cause (DIBBS) Common things are common Having diagnosed the cause – remove it or treat it!