Acute Confusional State

Today's Pearls:

1. Confusion & Cognitive Impairment Framework
2. Acute Confusional State: DDX & Work Up

3. Transient Global Amnesia

----------------------------------------------------------------

Drs. Schmidt & Evoh presented a patient who was otherwise in normal health when he had abrupt onset memory loss & related confusion.

----------------------------------------------------------------

Confusion & Cognitive Impairment -  A Framework:

Borrowed from: Symptom to Diagnosis, An Evidence Based Guide. Chapter 11: 11: Delirium and Dementia - https://accessmedicine.mhmedical.com/content.aspx?bookid=1088&sectionid=61697830

----------------------------------------------------------------

Acute Confusional State:

DDX 

Delirium
Seizure, Non-Convulsive Status
TIA/Stroke
Transient Global Amnesia
Dissociative Disorder
Migraine
Subdural Hematoma
Anton Syndrome: When a patient with complete loss of vision confabulates due to anosognosia (pt is unaware of the deficit) 
Wernicke's Aphasia: deficit of language comprehension

The patient:

The patient had a non-focal exam. His confusion consisted of persistent difficulties with memory and recall. Other cognitive functions & ADLs were preserved.

Work up:

Neurologic examination
Cognitive evaluation
Depression screen
Medication review
Screen for sleep, & alcohol use disorders

Labs: CBC, CMP, vitamin D level, UDS, Vitamin B12 & TSH, RPR (if risk factors)

EEG

Imaging: MRI or CT WO

Borrowed from: https://cdn.reachmd.com/cache/d0/05/d005f466f86be2e91eceae8c4e0b509d.jpg

He eventually received the diagnosis of transient global amnesia. 

----------------------------------------------------------------

Transient Global Amnesia: 

Characterized by anterograde & retrograde amnesia which is sudden onset & self limiting (<24 H in duration). Patients typically retain other cognitive functions & do not have behavioral disturbances. 

• Anterograde amnesia = inability to make new memories
• Retrograde amnesia = inability to remember personal facts or general information

Patients should receive empiric treatment for Wernicke Encephalopathy with high dose thiamine.

----------------------------------------------------------------

After this case....

Dr. Schmidt asked the question whether one episode of transient global amnesia is linked to an increased incidence of cognitive impairment in the future: 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682935/

"In this case cohort, population-based study, we examined the risk of cerebrovascular events, seizures, and cognitive impairment after a single episode or multiple episodes of TGA. Our results demonstrate that patients are not at a higher risk of having a cerebrovascular event, seizures, or developing cognitive impairment over the long-term after an episode of TGA." - Arena et al.

Borrowed from: http://betterzits.blogspot.com/2009/02/memory-lapse.html

----------------------------------------------------------------

Thanks for reading, Emma