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ACUTE

WASIS UDAYA CONFUSIO


Geriatric Sub-Divison
Department of Internal Medicine NAL STATE
Medical Faculty Hasanuddin University
INTRODUCTION
Acute & fluctuative
Acute cognitive changes
Confusional Decreased concentration
State
Decreased awareness
Speech impairment
Sleep disturbance
Hallucination and
delusion
INTRODUCTION

Acute Confusional Hipocrates 2000


State years ago

Geriatric Giant
Fig 1. Hipocrates
INTRODUCTION

Acute Confusional State

1-2% of general population


14% in age > 85 years old
32-67% undiagnosed
23% of Cipto Mangunkusumo Hospital
acute care (2004)
17% of Cipto Mangunkusumo Hospital
inpatients (2004)
ETIOLOGY
Toxin Prescribed medicine
Drugs abused
Toxins
Metabolic Electrolyte imbalance
Hypothermia and hyperthermia
Lungs failure
Renal failure
Liver failure
Heart failure
Vit. Deficiency
Anemia
Dehydration and malnutrition
ETIOLOGY (contd)
Infection Systemic
Central nervous system
Hormonal Hypothyroid and hyperthyroid
Hyperparathyroid
Adrenal insufficiency
Cerebrovascular General hypoperfusion
impairment
Hypertensive encephalopathy
Ischemic and hemorrhagic
stroke
Autoimmune CNS vasculitis
Lupus cerebral
ETIOLOGY (contd)
Malignancy Brain metastasis

Cerebral glimatosis

Meningitis carcinomatous

Hospital inpatient care


PATHOGENESIS

ACS
Pathophysiology Unclear

Acetylcholine
deficiency

Brain oxidative
metabolic impairment
ACS
Increased brain cytokine
on acute illness
Fig 2. Pathogenesis of ACS
Table 1.
CLINICAL SYMPTOMS

Memory impairment
Global Cognitive
Perception disturbance
Impairment
Mind process disturbance
Psychomotor activities
impairment

Irrelevant
Early communication
Symptoms
Autoanamnesis
difficult to understand
CLINICAL SYMPTOMS: Subtype
phenomenon by Liptzin & Leukoff

Hyperactive subtype

Hypoactive subtype

Mixed subtype
CLINICAL SYMPTOMS
Incoherent thoughts

Labile emotions

Lingual disturbance

Illusion/delusion/hallucination

Sleep-awake cycles

Lack of concentration
Disoriented

Lack of memory
DIAGNOSIS

Acute
confusional
state

70% were
difficult to
diagnose
DIAGNOSIS

Armstrong et al

46% elderly patients with delirium were


undiagnosed by referral doctors

Margolis et al

37% patients whom referred to psychiatry


with depression turns out to be delirium
Diagnosis according to DSM IV

Conscious disturbance

Cognitive changes

Short term memory impairment

Evidence from anamnesis, physical


examination and laboratory that support
impairment by medical condition,
intoxication, or drugs adverse reaction
The Delirium Symptom Interview by
Albert et al

Orientation
Sleep disturbance
Perception disturbance
Speech impairment
Consciousness impairment
Psychomotor activities
Observation
TREATMENT

Treat the underlying disease


Supportive treatment
Peaceful environment
Educate family members
Psychotropic
Haloperidol
Benzodiazepine (lorazepam)
Phyzostigmine
PROGNOSIS

Average treatment
& mortality after 6
months were 36%
& 26%

Only 4% of patients
with delirium had
complete recovery
PROGNOSIS
Delirium is a death
independent predictor and
admission for >6 months is
Wesley
similar with patients with
et al coma, using mechanical
ventilator and given
sedatives and analgesics

Delirium inpatients had


increased mortality risk and
Douglas
average life by 62% and 13%,
et al respectively, compared to
non-delirium inpatients
RESUME
ACS is an acute conscious
impairment which is one of the
Geriatric Giant

70% of ACS were missed


diagnose or given wrong
treatment
RESUME
ACS is caused by toxins, metabolic
disease, hormonal, cerebrovascular
impairment, autoimmune, seizures and
malignancy
ACS treatment includes treating
underlying disease, supportive,
education and medicine
Mortality rates for ACS is as high as sepsis
or myocardial infarction