Altered level of Conciousness

Overview

Definition

Delirium: Cognitive impairment typically caused by acute illness or drug toxicity (sometimes life threatening) and is often reversible. Delirium mainly affects attention.
Confusion: disturbed orientation in regard to time, place, or person, sometimes accompanied by disordered
Dementia: Cognitive impairment typically caused by anatomic changes in the brain, has slower onset, and is generally irreversible. Dementia mainly affects memory.

Differential diagnosis of altered level of Consciousness – AEIOUTIPS)

Alcohol
Electrolyte imbalance, Endocrine problems
Insulin (Hypoglycemia)
Opiates or Overdose
Uremia or Underdose
Trauma (Closed Head Injury), Temperature (Hypothermia, hyperthermia), or Toxemia, Brain Tumor
Infections (Sepsis, Meningitis, Encephalitis)
Psychogenic, Poisoning (Toxin Ingestion)
Space occupying lesions, Stroke (including Intracranial Pressure), Shock, Seizure

Remember Confusion is not specific to delirium; it may be found in other psychiatric disorders, such as dementia or depression.

Difference between Dementia and Delirium
	Dementia	Delirium
Onset	Sub-acute	Acute
Conscious level	Normal	Fluctuates
Hallucinations	Late event	Common
Agitation/agression	Uncommon until late	Common
Thought form	Poverty of thought late	Flight of ideas
Memory	Slow decline	Poor

Approach

History
Examination
Investigation
- Blood sugar level
- FBC
- EUC
- Paracetamol level
- Alcohol level
- Urinalysis
- Urine drug screen if available
- +/- Head CT/MRI

Altered level of consciousness turning agitated and violent

Steps to take

Assess
Reassurance
Verbal de-escalation
- Empathy
- I want to help
- Positive
Physical restraint
- Indications
  - Preventing harm to the patient
  - Preventing harm to other patients
  - Preventing harm to staff
  - Preventing serious disruption or damage to the environment
  - To assist in assessing and management off the patient
- Mental Health Act Victoria 2014
Chemical restraints
- Indications as above