Acute Confusional State: A Common Clinical Condition with Versatile Variability-A Prospective Study

Acute confusional state account for a substantial proportion of admissions to emergency wards. As the etiology of acute confusional state are numerous and presentation also variable, so many time create confusion regarding the actual diagnosis and thus delay the prompt management which may result in fatal outcome. The objectives of this study was to explore the etiology and age & sex distribution of acute confusional state among hospitalized patients. In this prospective hospital based study, 345 adult patients presenting with acute confusional state were collected from medicine unit Dhaka Medical College Hospital during the period of July’08 to October’08. Patients known to have previous history of stroke, chronic dementing neurological disease were excluded from the study. This study revealed that, patients with acute confusional state constitute about 21% of total hospital admission in medicine wards. Peak incidence of acute confusional state was found to be in two age groups: one in 2nd to 3rd decades and another in 5th to 6th decades. The first peak was due to acute poisoning, CNS infection and hepatic encephalopathy; and the second peak was due to stroke, electrolyte imbalance, systemic infection and disturbance of glucose metabolism. This study also showed male preponderance over female and metabolic causes higher than the structural causes. Stroke comprised the highest percentage (25%) of cases in this series. Keyword: acute confusional state, versatile variability 1. Consultant, Medicine.Shaheed khalek-Ibrahim general hospital, National Healthcare Network, Wari 2. MS Student (Urology) NIKDU 3. MO Endocrine wing, Medicine Department BSMMU 4. Professor of Medicine Correspondence: Dr. Homayra Tahseen Hossain, FCPS (Medicine), MRCP (UK),Consultant, Medicine. Shaheed Khalek-Ibrahim General Hospital, National Healthcare Network, Bangladesh Diabetic Society, Wari, Dhaka. E-mail:homayra.tahseen@gmail.com regarding the actual diagnosis and thus delay the prompt management which may result in fatal outcome. Acute confusional state is thus associated with high rate of mortality and morbidity, specially if undiagnosed. Therefore an awareness regarding the common causes of acute confusional state is essential for all level of medical practitioner for its early diagnosis, proper treatment and prevention as well. The aim of the study is to explore the etiology and age & sex distribution of acute confusional state among hospitalized patients. Methodology: A prospective study was conducted at DMCH over the period of four months from July 08 to October 08. A total number of 345 out of 1649 cases with age ranging from 16 to 93 years were purposefully collected for conducting the study. Patients were assessed on the basis of the definition of acute confusional state given by the Diagnostic and Statistical J MEDICINE 2012; 13 : 46-50

regarding the actual diagnosis and thus delay the prompt management which may result in fatal outcome.Acute confusional state is thus associated with high rate of mortality and morbidity, specially if undiagnosed.
Therefore an awareness regarding the common causes of acute confusional state is essential for all level of medical practitioner for its early diagnosis, proper treatment and prevention as well.
The aim of the study is to explore the etiology and age & sex distribution of acute confusional state among hospitalized patients.

Methodology:
A prospective study was conducted at DMCH over the period of four months from July 08 to October 08.A total number of 345 out of 1649 cases with age ranging from 16 to 93 years were purposefully collected for conducting the study.
Patients were assessed on the basis of the definition of acute confusional state given by the Diagnostic and Statistical J MEDICINE 2012; 13 : 46-50 .Manual, 4th Edition (DSM-IV) of American Psychiatric Association (APA) and level of consciousness was assessed according to Glasgow Coma Scale.Detailed neurological and systemic examination was done.All the relevant investigations like complete blood count, random blood sugar, blood urea, serum creatinine, serum electrolytes, prothrombin time, urine RE, chest X-Ray were done immediately as per clinical context.Other important investigations like lumbar puncture, CT scan head, MRI, Toxicologic screening etc were done where indicated.Patients admitted with some of the following features of acute confusional state in medicine unit in Dhaka Medical college hospital were included in the study - Regarding gender distribution it was found that among total 345 patients with acute confusional state, number of male patients was 239, which constitute 69.27% and number of female patient was 106, constituting 31% (Fig- 4).This finding is similar to a study of Higashi et al, which showed the percentage of male was 68.18% and female was 31.82%. 3his finding reflects that male sex is an independent risk factor for acute confusional state.However, as in our hospital, total number of bed allocated for male patient is more than female patient, so such a high percentage of male patient in comparison to female counterpart may not be the true reflection of the scenario.
In this study,53%of patients with acute confusional state was due to metabolic causes and 38% was due to organic causes (Table-V, Fig- 5).Unknown cause and multiple cause constitute the remainder 9%.This finding is consistent with a studu by Plum & Posner, who showed 65.2% cases due to metabolic and 34.8% due to organic causes.Another study by Faheemur Rehman Khan et al showed that neurological lesions and metabolic encephalopathies accounted for about 70% of the cases, followed by infections(10%) and drugs/ toxins (8%). 5 this study, the most frequent cause of acute confusional state is found to be stroke, comprising 25% of total study population (Table-I).This is similar with an international study. 2,3In the study by Levy et al 36.2% of non traumatic acute confusional patients were due to stroke.Present study is almost similar with that study. 7xt to stroke the second most common cause of acute confusional state was found to be acute poisoning, comprising 22% of total cases (Table-II) and 42% of metabolic cases.Plum and Posner showed 29.8% altered consciousness were due to drug poisoning and 37.5% of altered consciousness of metabolic causes was due to acute poisoning. 4The poisonous substances used for poisoning were mostly unknown (47.36%), followed by insecticides (39.47%) and sedatives/hypnotics (13.15%).The patients of unknown poisoning are mainly travelers.They are victims of street poisoning, which are usually strong hypnotics or mixture of two or more drug that can induce deep sedation.
No case of alcohol intoxication was found in this study which may be due to limited number of study case or majority of study population belonging to poor socio-economic status.However alcoholism is not very uncommon in our country now-a-days.Limitations of the study are: the study population is small and total time span is also limited.

Conclusion:
The study was designed to work out the important aetiology and epidemiology of acute confusional state in our population, so as to help in pointing out important and common causes with age and sex distribution of acute confusional state in our set up, thus helping to keep in mind different diseases while we are confronted with a patient of acute confusional state.This prospective hospital based study with a limited number of study population may not reflect the exact situation of the condition in the community, but its nearness to the reality cannot be underestimated.
Age The study also highlighted that the aetiology of a significant number of cases of acute confusional state remained unknown.So in conclusion, it needs to be mentioned that, our clinical and investigation facilities must be improved a lot to solve the unresolved factors of the present study, which would improve the morbidity and mortality from acute confusional state.
is an important predictor of the aetiology of acute confusional state.In older age group acute confusional state is mostly due to stroke, electrolytic imbalance, systemic infection or disturbance of glucose metabolism.In younger age group, acute poisoning, CNS infection or hepatic encephalopathy are the common aetiology of acute confusional state.It is important to note that, many causes of altered consciousness are completely reversible with prompt diagnosis and proper management, like-infections & metabolic abnormalities.This finding emphasize the great importance of early accurate diagnosis of acute confusional state, as correct diagnosis can lead to judicious management and save many valuable lives.