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of the autonomic nervous system and of generalized or focal cerebral disease At times, a left hemispheral lesion causing a mild Wernicke aphasia resembles a confusional state in that the stream of thought, as judged by verbal output, is incoherent The prominence of paraphasias and neologisms in spontaneous speech, dif culties in auditory comprehension, and normal nonverbal behavior mark the disorder as aphasic in nature The distinction between an acute confusional state and dementia may be dif cult at times, particularly if the mode of onset and the course of the mental decline are not known The patient with an acute confusional state is said to have a clouded sensorium (a somewhat ambiguous term referring to a symptom complex of inattention, disorientation, perhaps drowsiness, and an inclination to inaccurate perceptions and sometimes to hallucinations and delusions), whereas the patient with dementia usually has a clear sensorium In the demented patient, there are usually a number of frontal release signs such as grasping, groping, sucking, and paratonic rigidity of the limbs However, some demented patients are as beclouded and bewildered as those with confusional psychosis, and the two conditions are distinguishable only by differences in their mode of onset and clinical course This suggests that the affected parts of the nervous system may be the same in both conditions As indicated earlier, schizophrenia and manicdepressive psychosis can usually be separated from the confusional states by the presence of a clear sensorium and relatively intact memory function Once a case has been appropriately classi ed, it is important to determine its clinical associations (Table 20-1) A thorough medical and neurologic examination, computed tomography or magnetic resonance imaging, and in cases with fever or with no other apparent cause lumbar puncture should be performed The medical, neurologic, and laboratory ndings (including measurements of Na, Ca, CO2, BUN, NH3, calcium, glucose, PAO2, PCO2, toxic screen, etc) determine the underlying disease and its treatment, and they also give information concerning prognosis An approach to the laboratory tests that are useful in revealing the common conditions that give rise to the confusional state when the cause is not self-evident from the history and physical examination is given in Table 20-2; but as always, the choice of tests is governed by the Table 20-2 An initial approach to the laboratory evaluation of the acutely confused patient I Afebrile, no meningismus, and no focal neurologic signs A Endogenous metabolic disorders: glucose, sodium, calcium, BUN, PAO2, PCO2, NH3, T4, and special tests in particular circumstances (for porphyria, Hashimoto thyroid disease, etc) B Exogenous toxic state: toxicologic screening of blood and urine II Febrile or signs of meningeal irritation A Systemic infection: CBC, chest x-ray, urine analysis and culture, blood cultures, erythrocyte sedimentation rate B Meningitis and encephalitis: lumbar puncture III Focal neurologic signs or seizures A CT or MRI scan B EEG.

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clinical circumstances In the neurologic examination particular attention should be given to the presence or absence of focal neurologic signs and to asterixis, myoclonus, and seizures

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Care of the delirious and confused patient is of the utmost importance It has been estimated that 20 to 25 percent of medically ill hospital inpatients will experience some degree of confusion; moreover, elderly patients who are delirious have a signi cant level of mortality, variously estimated at 22 to 76 percent (Weber) Optimal care begins with the identi cation of individuals at risk for delirium, including those who have an underlying dementia, pre-existing medical illnesses, or a history of alcohol abuse or depression Further, delirium is more common in males and, not surprisingly, is more likely when sensory function is already impaired (loss of vision and hearing) (Burns, Weber) The primary therapeutic effort is directed to the control of the underlying medical disease and discontinuing offending drugs or toxic agents Other important objectives are to quiet the agitated patient and protect him from injury A nurse, attendant, or member of the family should be with such a patient at all times if this can be arranged A room with adequate natural lighting will aid in creating a diurnal rhythm of activity and reduce sundowning It is often better to let an agitated patient walk about the room than to tie him in bed, which may increase his fright or excitement and cause him to struggle to the point of exhaustion and collapse The less active patient can be kept in bed by side rails, wrist restraints, or a restraining sheet or vest The fully awake but confused patient should be permitted to sit up or walk about the room part of the day unless this is contraindicated by the primary disease All drugs that could possibly be responsible for the acute confusional state or delirium should be discontinued if this can be done safely These include sedating, antianxiety, narcotic, anticholinergic, antispasticity, and corticosteroid medications, L-dopa, metoclopramide (Reglan), and cimetidine (Tagamet) as well as antidepressants, antiarrhythmics, anticonvulsants, and antibiotics Despite the need to be sparing with medications in these circumstances, haloperidol, quetiapine, and risperidone are helpful in calming the agitated and hallucinating patient, but they too should.

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