Raiyyan Tahsan

Raiyyan Tahsan
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Case of clinical clue no.1 Acute Confusional State

জাহেদা ৭২ বছর বয়স, গত ৫-৭ দিন থেকে সে Agitated and Aggressive হয়ে আছে, এর আগে ভালো ছিলো, ১৫ দিন আগে তার UTI + Urinary retention + constipation হয়ে সে হসপিটাল এডমিট ছিলো,. ওখান থেকে আসার পর এখন তার মাঝে একটা confusion কাজ করে, সকালে কি দিয়ে খেয়েছে তা মনে থাকেনা ( short term memory loss), রুমে কেউ নাই, তাও উনি সেখানে কাউকে দেখতে পান, শব্দ শুনতে পান,

ঘুমানোর চেষ্টা করেও ঘুমাতে পারেন না, অনেকটাই sleep disturbance… হাত পা এইদিক সেইদিক আছাড় মারে, Restlessness and Aggressive behaviour.. তা ছাড়া ওনার সন্তান ওনাকে ডাক্তারের কাছে আনতে চাচ্ছেন, ওনার মনে হচ্ছে ওনাকে মেরে ফেলা হবে, আবার তিনি কিছুক্ষণ নিজ সন্তান কে চিনেন না, রাত নাকি দিন, বলতে পারেন না, ডাক্তারের চেম্বারে নাকি দোকানে তা বলতে পারেন না..

ওনার Dx and Rx কি হবে?

পুরো সিনারিও থেকে আমরা যা দেখতে পাই-

ওনার মুল সমস্যা-

short term memory loss

Disorientation of time and place and person..

Unusual thought..

Aggressive and agitation and restlessness.

Visual and auditory hallucination.

> ৬৫ বছর বয়স, সাথে যদি রিসেন্ট কোনো UTI, urinary retention and Constipation or any drug withdrawal এর হিস্ট্রি থাকে, অথবা Pulmonary or cardiac complain থাকে, এর পরে পেশেন্ট যদি হঠাৎ করে এমন সিনারিও নিয়ে আসে, তাহলে তাকে সিজোফ্রেনিয়া ভাবার কোনো কারণ নাই–

এখানে Diagnosis হবে Delirium. বা acute confusional state.

ASUN jene nei delirium ki?

What is delirium?

Delirium is a fast-developing type of confusion that affects your ability to focus your attention and awareness. It happens when there’s widespread disruption in brain activity, usually because of a combination of factors. Delirium is more common in medical settings, such as during long hospital stays or in long-term care facilities.

People with delirium often act very differently than they do under ordinary circumstances. A common statement or feeling among people who see a loved one with delirium is, “That’s not the person I know.”

In years past, experts thought delirium was a relatively harmless and minor concern. Today, they know it’s a serious problem that should be recognized and prevented whenever possible.

Symptoms and Causes:-
What are the symptoms of delirium?

Delirium indicates a widespread disruption in brain activity. That means there are many possible symptoms of delirium. It’s also important to remember the symptoms may look different from one person to the next. It can also fluctuate. Delirium can often get better during the day and worse as nighttime approaches, which is why this condition sometimes gets the incorrect name of “sundowning.”

The main symptom of delirium is confusion. That means you have trouble with:

  • Focusing or shifting your attention when necessary.
  • Thinking and concentrating.
  • Remembering facts, events, people, etc.
  • Staying aware of your surroundings.
  • Answering correctly when asked what time it is, the date and where you are.
  • Trouble speaking clearly, answering questions or understanding what others are saying.
  • Trouble processing what you see, including identifying objects or where you are.
  • Feeling more emotional, scared or angry.

Symptom patterns of delirium tend to fall into one of three categories:

  • Hyperactive.
  • Hypoactive.
  • Mixed.

Hyperactive delirium

This type of delirium involves higher activity levels. It can include:

  • Agitation.
  • Aggression, combativeness or refusal to cooperate.
  • Mood swings.
  • Poor sleep during nighttime hours.

Psychosis symptoms, including delusions and hallucinations .

  • Loss of “filter,” such as using profanity in a way that’s not typical of you or saying things you wouldn’t ordinarily say.

Hypoactive delirium

This type of delirium involves lower activity levels. Hypoactive delirium is harder to diagnose because healthcare providers may mistake it for fatigue or depression. Symptoms include:

  • Reduced facial expressions and speaking.
  • Reduced responsiveness to changes in your environment.
  • Apathy and a lack of interest in what’s happening around you.
  • Sluggishness, slowed movements or lethargy.
  • Diminished interest or participation in your care.

Mixed

As the name suggests, the mixed type of delirium combines features of the hyperactive and hypoactive types. It tends to have one of the following appearances:

  • Typical activity level: You’re still confused and not fully aware of your surroundings, but your activity level is similar to what’s usual for you.
  • Shifting activity level: You shift back and forth between the hyperactive and hypoactive delirium types. Sometimes you may show hyperactive symptoms but then change to hypoactive symptoms. This can also involve hypoactive symptoms and sleeping during the day, and hyperactive symptoms like agitation or aggression at night.

Types of delirium:-

Experts have identified three types:

  • Hyperactive delirium. This may be the easiest type to recognize. People with this type may be restless and pace the room. They also may be anxious, have rapid mood swings or see things that aren’t there. People with this type often resist care.
  • Hypoactive delirium. People with this type may be inactive or have reduced activity. They tend to be sluggish or drowsy. They might seem to be in a daze. They don’t interact with family or others.
  • Mixed delirium. Symptoms involve both types of delirium. The person may quickly switch back and forth from being restless and sluggish.
Causes of Delirium:-

Delirium occurs when signals in the brain aren’t sent and received properly.

The disorder may have a single cause or more than one cause. For example, a medical condition combined with the side effects of a medicine could cause delirium. Sometimes no cause can be found. Possible causes include:

  • Certain medicines or medicine side effects
  • Alcohol or drug use or withdrawal
  • A medical condition such as a stroke, heart attack, worsening lung or liver disease, or an injury from a fall
  • An imbalance in the body, such as low sodium or low calcium
  • Severe, long-lasting illness or an illness that will lead to death
  • Fever and a new infection, particularly in children
  • Urinary tract infection, pneumonia, the flu or COVID-19, especially in older adults
  • Exposure to a toxin, such as carbon monoxide, cyanide or other poisons
  • Poor nutrition or a loss of too much body fluid
  • Lack of sleep or severe emotional distress
  • Pain
  • Surgery or another medical procedure that requires being put in a sleep-like state

Some medicines taken alone or taken in combination can trigger delirium. These include medicines that treat:

  • Pain
  • Sleep problems
  • Mood disorders, such as anxiety and depression
  • Allergies
  • Asthma
  • Swelling
  • Parkinson’s disease
  • Spasms or convulsions

এই ক্ষেত্রে আপনি যা করবেন-

Drug history নেন,

কতদিন থেকে এমন, তার খোজ নিন

নিম্নের পরিক্ষা গুলি করেন

1.. CBC, CRP (exclude infection)

2.. Chest X-Ray

3. Urine RE

4.. Serum electrolyte

5.. Serum creatinine

6.. ECG.

Definitive test: CAM (confusional assessment Method)

এইসব পরীক্ষায় কোনো abnormality থাকলে তা চিকিৎসা করুন।

পেশেন্ট পার্টি কে Reassurance করুন।

তার সাথে কথা বলুন, তাকে খোলা পরিবেশে নিন, ঘুরে আসুন,

যদি বেশি পরিমান aggressiveness থাকে, তাহলে Tablet- Haloperidol 0.5 mg once daily for 7 days.

Tablet:-Halopid 5mg( AS A Haloperidol AS A Butyrophenone drugs, Drugs used in tremor, tics & related disorder).

Indications of Halopid drug:-

In low doses- Will be applied if pt. condition below

  • nervousness, anxiety states and associated psychic disorders as irritability gressiveness, psychic lability and insomnia
  • functional disorders caused by anxiety states such as trembling, thorax oppression, gastrointestinal hypermotility and digestive disorders
  • tics and stuttering
  • nausea and vomiting

In higher doses- Will be applied if pt. condition below

  • psychomotor agitation in mania, dementia, acute and chronic schizophrenia, alcoholism
  • delusions and hallucinations in acute and chronic schizophrenia, acute confusion
  • choreatic movements
  • behavior and character disorders in children
  • tics and stuttering
  • vomiting
Side Effects:-

Haloperidol is a safe neuroleptic. Headache, vertigo, insomnia are the more common side effects encountered. Drowsiness, lethargy, stupor, confusion, restlessness, agitation, anxiety, euphoria and exacerbation of psychotic symptoms including hallucinations also may occur. Dry mouth, blurred vision, urinary retention, heartburn, nausea, vomiting, anorexia, diarrhea and hypersalivation have also been reported.

পেশেন্ট এর মধ্যে ভালো হয়ে যাবে।

এইসব পেশেন্ট দের ক্ষেত্রে একজন নিউরোলজিস্ট এর কাছে রেফার করবেন।

Raiyyan Tahsan ❤️date:29-10-24 Tuesday time 10.20pm

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