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cult, and at a certain stage these patients no longer notice or respond to much of what is happening around them Questions may be answered with a single word or a short phrase, spoken in a soft tremulous voice or whisper, or the patient may be mute Asterixis is a common accompaniment if a metabolic or toxic encephalopathy is responsible for the confusional state In the most advanced stages of the illness, confusion gives way to stupor and nally to coma (see Chap 17) As these patients improve, they may pass again through the stages of stupor and confusion in the reverse order All this informs us that at least one category of confusion is but a manifestation of the same disease processes that in their severest form cause coma Typical confusional states, in which impairments of alertness and attention dominate, are readily distinguished from delirium; in others, with more than the usual degree of irritability and restlessness and perhaps a eeting hallucination, one cannot fail to notice their resemblance to one another Further, when a delirium is complicated by an illness that superimposes stupor (eg, delirium tremens with pneumonia, meningitis, or hepatic encephalopathy), it may be dif cult to differentiate from other acute confusional states This explains in part why some psychiatrists (Engel and Romano, Lipowski) insist that there is only one disorder, which they call delirium Etiology The many causes of this common type of confusional state are listed in Table 20-1 The most frequent in general practice are drug intoxications and endogenous metabolic encephalopathies, mainly electrolyte and water imbalance (hypo- and hypernatremia, hyperosmolarity), hypercalcemia, etc, disorders of acid-base balance, renal and hepatic failure, hyper- and hypoglycemia, septic states ( septic encepephalopathy discussed further on), and chronic cardiac and pulmonary insuf ciency as well as hypertensive encephalopathy Diffuse or mulifocal disease of the cerebral hemispheres are frequent causes of a transient or persisting confusional state Concussion and seizures, especially petit mal or psychomotor status, and certain focal (eg, right parietal and temporal) cerebral lesions may also be followed by a period of confusion Focal lesions, most often infarctions but also hemorrhages, of the right cerebral hemisphere may evoke an acute confusional state Such states have been described with strokes mainly in the territory of the right middle cerebral artery (Mesulam et al; Caplan et al; Mori and Yamadori); usually the infarcts have involved the posterior parietal lobe or inferior frontostriatal regions, but they have also occurred in the territory of one posterior cerebral artery Of course, there may be elements of confusion with stroke in almost any cerebral territory, but the aforementioned lesions stand apart in that the confusional state has occasionally been unattended by prominent motor and sensory disorders A somewhat more restricted group of focal cerebral diseases may cause delirium, as discussed below A variety of more generalized or multifocal cerebral diseases may be associated with transient or persistent confusional states Among these are meningitis, encephalitis, disseminated intravascular coagulation, tumors, and trauma Pathophysiology of Confusional States All that has been said on this subject in Chap 17, Coma and Related Disorders of Consciousness, is applicable to at least one subgroup of the confusional states In most cases no consistent pathologic change has been found because the abnormalities are metabolic and subcellular As discussed in Chap 2, the electroencephalogram (EEG) is almost invariably abnormal in even mild forms of this syndrome,.

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Table 20-1 Classi cation of delirium and acute confusional states I Acute confusional states associated with psychomotor underactivity A Associated with a medical or surgical disease (no focal or lateralizing neurologic signs; CSF clear) 1 Metabolic disorders (hepatic stupor, uremia, hypo- and hypernatremia, hypercalcemia, hypo- and hyperglycemia, hypoxia, hypercapnia, porphyria, and some endocrinopathies) 2 Infectious illnesses (pneumonia, endocarditis, urosepsis, peritonitis, and other illnesses causing bacteremia and septicemia septic encephalopathy) 3 Congestive heart failure 4 Postoperative and posttraumatic states B Associated with drug intoxication (no focal or lateralizing signs; CSF clear): opiates, anticholinergics, barbiturates and other sedatives, trihexyphenidyl, corticosteroids, anticonvulsants, L-dopa, dopaminergic agonists, serotonergic antidepressants C Associated with diseases of the nervous system (with focal or lateralizing neurologic signs or CSF changes) 1 Cerebrovascular disease, tumor, abscess (especially of the right parietal, left temporal and occipital, and inferofrontal lobes) 2 Subdural hematoma 3 Meningitis 4 Encephalitis 5 Cerebral vasculitis (eg, granulomatous, lupus) 6 Hypertensive encephalopathy 7 Postconvulsive state II Delirium A In a medical or surgical illness (no focal or lateralizing neurologic signs; CSF usually clear) 1 Pneumonia 2 Septicemia and bacteremia (septic encephalopathy) 3 Postoperative and postconcussive states 4 Thyrotoxicosis and corticosteroid excess (exogenous or endogenous) 5 Infectious fevers such as typhoid, malaria B In neurologic disease that causes focal or lateralizing signs or changes in the CSF 1 Vascular, neoplastic, or other diseases, particularly those involving the temporal lobes and upper part of the brainstem 2 Concussion and contusion (traumatic delirium) 3 Meningitis of acute purulent, fungal, tuberculous, and neoplastic types (Chap 32) 4 Encephalitis due to viral (eg, herpes simplex, infectious mononucleosis), bacterial (mycoplasma), and other causes (Chaps 32 and 33) 5 Subarachnoid hemorrhage C Abstinence states, exogenous intoxications, and postconvulsive states (signs of other medical, surgical, and neurologic illnesses absent or coincidental) 1 Withdrawal of alcohol (delirium tremens), barbiturates, and nonbarbiturate sedative drugs, following chronic intoxication (Chaps 42 and 43) 2 Drug intoxications: scopolamine, atropine, amphetamine, cocaine, and other illicit drugs, particularly hallucinogens, phencyclidine, etc 3 Postconvulsive delirium III Confusional states due to focal cerebral lesions (see Chap 22) IV Beclouded dementia, ie, dementing or other brain disease in combination with infective fevers, drug reactions, trauma, heart failure, or other medical or surgical diseases.