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with drugs prescribed by physicians is among the most common causes in practice Among the most distinctive syndromes are those from drugs that have direct or indirect anticholinergics properties The delirium asociated with these agents is centrally mediated but may be accompanied by peripheral anticholinergic manifestations This point is critical in the differential assessment of agitated confusional states because other compounds, particularly including serotoninergic agents, also can produce delirium Thus, in addition to confusion, toxic levels of anticholinergic compounds typically cause dry skin, dry mouth, diminished bowel motility, and urinary hesitancy if not frank retention (The clinical maxim that has been used to describe this state is red as a beet, dry as a bone, blind as a bat, hot as a hare and mad as a hatter The last part of this mnemonic has been also attached to the dementia of merecury intoxication) (Mintzer) By contrast, in the toxic serotoninergic syndrome associated with excessive doses of the newer antidepressant drugs, salivation is normal, sweating is increased, and the gut is hyperactive; diarrhea is common Moreover, the deep tendon re exes may be exaggerated and there may be myoclonus (Birmes) Another entity that arises in this context is the neuroleptic malignant syndrome (NMS; see page 1025) This state is associated with an agitated confusion followed by stupor However, the characteristic features in NMS are progressive muscle rigidity and evidence of myonecrosis, as indicated by elevations of the serum creatine kinase; usually there is some elevation of body temperature The clinical examination therefore aids greatly in determining which category of drug is implicated

roids, and L-dopa in certain diseases of the basal ganglia, as described in Chap 39) Very often it is dif cult to determine which of several possible factors is responsible for the patient s confusion, and there may be more than one In a cardiac patient, for example, there may be fever, hypoxia or hypercarbia, intoxication with one or more drugs, and electrolyte imbalance

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Septic Encephalopathy In the instance of fever and confusion, particularly in the elderly person, the problem of septic encephalopathy is offered as an explanation, but it may simply be a rephrasing of the well-known problem of infection leading to a global confusion or delirium Young and colleagues have called attention to the high frequency of this disorder in critically ill patients 70 percent of their bacteremic patients and its accompaniment by a polyneuropathy in a similar proportion of cases Paratonic rigidity is an almost universal accompaniment according to these authors, and focal cerebral or cranial nerve signs are not encountered They have emphasized that all other potential causes of a confusional state must be excluded before attributing the state to an underlying infection The EEG is slowed in proportion to the level of consciousness, but it shows mild changes even in the bacteremic patient who is fully alert The spinal uid is normal or has a slightly elevated protein concentration The widespread MRI changes reported in a single case by Finelli and Uphoff are not characteristic of the cases we have seen, in which imaging studies have been normal While there is no doubt that young and healthy patients may become confused when affected with high fever and overwhelming infections such as pneumonia, most cases of septic encephalopathy are of the beclouded dementia type The point made by Young and colleagues is that subtle degrees of confusion are ubiquitous with serious infections of many varieties The chapter by Young can be consulted for an exposition of the various theories of pathogenesis of this state High fever itself (above 105 F) is probably an adequate explanation for confusion in some cases A similar global confusional state occurs in patients with severe burns (burn encephalopathy, page 971) Postoperative Confusion All that has been stated above may be true of a patient in a postoperative confusional state, in which a number of factors such as fever, infection, dehydration, and drug effects may be incriminated In a study of 1218 postoperative patients by Moller and colleagues, older age was by far the most important association with confusion that persisted for weeks and months after an operation; but a number of other factors including the duration of anesthesia, need for a second operation soon after the rst, postoperative infection, and respiratory complications were each predictive of mental dif culty in the days after the procedure Alcoholism and withdrawal effects may further complicate the problem A more extensive review of this subject can be found in the material by Kaplan and Ropper (see also page 710) When such patients recover from the medical or surgical illness, they usually return to their premorbid state, though their shortcomings, now drawn to the attention of the family and physician, may be more obvious than before In this case, families will date the onset of a dementia to the time of the medical illness and minimize the previous decline in cognition In other cases, how-.