Original Article

Acute confusional state/delirium: An etiological

and prognostic evaluation
Dheeraj Rai, Ravindra Kumar Garg, Hardeep Singh Malhotra, Rajesh Verma,
Amita Jain1, Sarvada Chandra Tiwari2, Maneesh Kumar Singh
Departments of Neurology, 1Microbiology, and 2Geriatric Mental Health, King George Medical University, Lucknow, Uttar
Pradesh, India

Abstract

Introduction: Acute confusional state/delirium is a frequent cause of hospital admission, in the elderly. It is characterized by an acute
fluctuating impairment of cognitive functions and inattention. Recognition and prompt treatment is crucial to decrease the morbidity
and mortality associated with it. Materials and Methods: In this retrospective study, we determined the etiology and prognostic factors
of an acute confusional state. A total of 52 patients of acute confusional state were clinically evaluated. All patients were also subjected
to a battery blood biochemical examination, cerebrospinal fluid analysis and neuroimaging. Disability was assessed by using modified
Barthel index (MBI). Patients were followed-up for 3 months. Results: The mean age of our cohort was 65.04 ± 10.6 years. 32 (61.5%)
patients were male. In 33 patients, we were able to identify possible precipitating cause of an acute confusional state. In the rest of the
patients results of all the tests were normal. Leukocytosis and hyponatremia were frequent factors associated with delirium. The mean
duration of the hospital stay was 10.73 ± 3.6 days (range 5-21 days). Patients with an abnormal work-up (possible precipitating cause)
had significantly lower mortality, less duration of hospital stay and less severe disability after 3 months. Age, underlying illness, serum
creatinine, abnormal neuroimaging and MBI were identified as a significant prognostic indicator. 18 (34.6%) of our patients died, of these
in 10 patients we could not find a precipitating cause. Conclusion: Patients, in whom a cause was found out, had better prognosis in
terms of lesser mortality and the duration of hospital stay.

Key Words

Acute confusional state, confusion assessment method, delirium index, modified Barthel index

For correspondence:
Dr. Ravindra Kumar Garg, Department of Neurology, King George Medical University,
Lucknow - 226 003, Uttar Pradesh, India.
E-mail: [email protected]

Ann Indian Acad Neurol 2014;17:30-4

Introduction cause of mortality and morbidity in the older population. It

adds an extra burden to the care givers and family members.
Acute confusional state or delirium is a clinical syndrome
characterized by disturbed consciousness, cognitive function, Delirium may be the result of a variety of systemic or cerebral
or perception. The delirium usually develops over a short disease or to drug intoxication or withdrawal. The key to
period of time (usually hours to days) and it has a tendency the management of cases of an acute confusional state lies in
to fluctuate during the course of the day. It is often associated recognizing a cause or other contributing illness and alleviating
with serious adverse outcomes such as death, dementia, and it.[4] We evaluated the patients of acute confusional state
the need for long-term patient care.[1,2] Incidence of an acute with the objective of identifying the possible causes of acute
confusional state ranges from 6% to 56% in hospitalized patients confusional state along with the evaluation of its prognostic
and nearly 80% in intensive care unit.[3] Delirium is a common importance.

Materials and Methods

Access this article online
Quick Response Code: We conducted this retrospective follow-up study on patients
Website:
www.annalsofian.org with an acute confusional state. These patients were admitted
in the Department of Neurology at King George Medical
University Uttar Pradesh, Lucknow. Study period was from
DOI:
January 2011 to December 2011. approval from the Institutional
10.4103/0972-2327.128541
Research Ethics Committee was obtained. A written informed
consent was taken from the relatives.

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 Rai, et al.: Acute confusional state 31

Inclusion criteria Inc, 444 N. Michigan Avenue, Chicago, IL, USA) and Microsoft
We included patients with acute confusional state/delirium of Excel. The difference between two values was considered to be
less than 7 days duration. The enrolled patients fulfilled the significant only if P value was found to be <0.05. Two sample
diagnostic criteria of an acute confusional state, according to t-test was used to see the difference between the mean of two
the confusion assessment method. The confusion assessment delirium groups. If data was not normally distributed, a non-
method diagnostic algorithm included the following criteria: parametric equivalent of two sample t-test, two sample Wilcoxon
(1) An acute onset and fluctuating course; (2)  inattention; rank-sum (Mann-Whitney) test was used. Chi-square or fisher
(3) disorganized thinking; and (4) altered level of consciousness. extract test was used for qualitative data. A multivariate analysis
The diagnosis of delirium by confusion assessment method was subsequently carried out using a logistic regression model.
needed the presence of features 1 and 2 and either 3 or 4.[5] Patients
with preexisting illnesses, such as dementia, cerebrovascular Results
accidents, a known psychiatric illnesses and recurrent seizures,
were excluded. During the study period, 84 patients of acute confusional state
were screened. 32 patients did not meet the inclusion criteria
Evaluation [Figure 1]. Our study cohort, thus, comprised of 52 patients.
All patients were subjected to a detailed history, neurological The mean age of patients was 65.04 ± 10.6 years. 32 (61.5%)
and systemic examinations. Information about the drug patients were male. 25 (48.1%) patients had a presence of a
and alcohol intake was recorded. Cognitive evaluation was co-morbid medical condition. Hypertension was the most
performed using the Mini-Mental State Examination (MMSE). common (n = 14, 26.92%) associated condition. Four patients,
All the patients were subjected to routine biochemistry with cerebrovascular accidents, had multiple infarcts. In this
(serum sodium, potassium levels and blood sugar), complete study, 33 (66.5%) patients had a possible precipitating factor
hemogram, liver, renal and thyroid functions, arterial blood gas and in remaining patients a precipitating cause of acute
analysis, chest X-ray, ultrasound abdomen, cranial computed confusional state was not established [Figure 2]. The mean
tomography and cerebrospinal fluid (CSF) analysis. Patients duration of hospital stay was 10.73 ± 3.6 days (range 5-21 days).
were categorized into two groups. One group included 18 (34.6%) of our patients died, of these in 10 patients we could
those patients in whom we were able to establish a possible not find a precipitating cause.
precipitating cause for an acute confusional state and other
group included those patients in whom we could not identify Details of other precipitating factors, observed in our study, have
the possible precipitating cause. Clinical, biochemical and been mentioned in the Table 1. Leukocytosis and hyponatremia
neuroimaging parameters of two groups were compared. were frequent contributing factor for delirium. In our study,
the cause for acute confusional state could be identified
Severity of confusion was assessed by delirium index (DI). DI is a more frequently in male patients (P = 0.02). The frequency
clinical instrument to measure the severity of delirium symptoms. of hyperactive and mixed type of delirium was significantly
I this scoring system, inattention, disorganized thinking, altered higher in the group with an identified precipitating condition
level of consciousness, disorientation to time and place, memory for acute confusional state [Figure 3].
impairment, perceptual disturbances and psychomotor agitation
or retardation were taken into account and scored 0-3 points We observed that the mortality rate was higher (P = 0.03)
each, according to the severity.[6] All the patients were classified and hospital stay was prolonged (P = 0.002) among patients,
into one of the 3 types of delirium (hypo-active, hyperactive in whom the cause for delirium could not be ascertained
and mixed). Hyperactive delirium was diagnosed if patient [Figure 4]. We found a significant correlation between age,
was hyperactive, combative and uncooperative. Hypoactive
delirium was diagnosed if patient appeared sluggish, lethargic
and stuporosed. Patients with mixed-type delirium fluctuated
between hyperactive and hypoactive types.

The treatment of an acute confusional state and delirium was

directed toward identifying and correcting precipitating medical
conditions. Low-dose antipsychotics were used to decrease
psychomotor agitation if indicated. They were followed-up for
3 months. Disability was assessed by using modified Barthel
index (MBI), which includes the degree of dependence for bowel
and bladder, grooming, toilet use, transfer, mobility, dressing,
feeding, use of stairs and bathing. For each activity, a score of 0
indicates a complete dependence and a score of 2 or 3 indicates
that the patient can do that particular activity independently.
A score of <12 indicates poor functional status and a score of
≥12 indicates good functional status.[7]

Statistical analysis
Data were analyzed using the statistical software package,
statistical package for the social sciences (Version 16.0, SPSS Figure 1: Flow diagram of the study

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32 Rai, et al.: Acute confusional state

Table 1: Base line characteristics of patients

Characteristics Cause ascertained (n = 33, Cause could not be P value
63.5%) ascertained (n = 19, 36.5%)
Age (in years) 64.42 (±11.8) 66.11 (±8.5) 0.68
Sex
Male 24 (72.7) 8 (42.1) 0.02
Female 9 (37.3) 11 (57.9)
Underlying illness (DM, HTN, CVA,CAD, CKD, COPD and TB)
None 15 (45.5) 12 (63.2) 0.11
Single 11 (33.3) 6 (31.6)
Multiple 7 (21.2) 1 (5.1)
GCS 13.18 (±1.3) 12.79 (±1.0) 0.06
Meningeal signs 4 (12.1) 0 0.11
Hemoglobin (g/dl) 11.36 (±1.6) 11.31 (±1.4) 0.68
≥11 22 (66.7) 14 (73.7) 0.58
<11 11 (33.3) 5 (26.3)
Total leukocyte count (/µl) 9200.3 (±3884.2) 8067.8 (±1418.9) 0.96
>11000 7 (31.2) 0 0.03
≤11000 26 (78.8) 19 (100)
RBS (mg/dl) 102.06 (±26.2) 114.63 (±38.9) 0.23
≥55 32 (96.7) 19 (100) 0.44
<55 1 (3.3) 0
Serum sodium (meq/L) 134.24 (±9.5) 140.37 (±6.2) 0.02
≥135 24 (72.7) 19 (100) 0.01
<135 9 (37.3) 0
Serum potassium (meq/L) 3.96 (±0.4) 4.20 (±0.2) 0.06
Blood urea (mg/dl) 41.24 (±16.1) 36.97 (±18.0) 0.28
≤40 22 (66.7) 14 (73.7) 0.59
>40 11 (33.3) 5 (36.3)
Serum creatinine (mg/dl) 1.09 (±0.5) 0.87 (±0.3) 0.24
≤1.5 5 (15.2) 1(5.3) 0.28
>1.5 28 (84.8) 18 (94.7)
Liver function test
Normal 31 (93.9) 19 (100) 0.27
Abnormal 2 (6.1) 0
Thyroid function test
Normal 31 (93.9) 19 (100) 0.27
Abnormal 2 (6.1) 0
Chest X-ray
Normal 25 (75.8) 18 (94.7) 0.08
Abnormal 8 (24.2) 1 (5.3)
CNS imaging
Normal 12 (36.4) 6 (31.6) 0.727
Abnormal 21 (63.6) 13 (68.4)
CSF analysis
Normal 20 (60.6) 18 (94.7) 0.15
Abnormal 5 (39.4) 1 (5.3)
MBI at admission 5.39 (±4.4) 4.74 (±1.9) 0.88
MBI at 3rd month 15.80 (±5.3) 15.44 (±4.4) 0.10
DI at admission 14.61 (±2.9) 16.05 (±2.0) 0.05
DI at 3rd month 3.28 (±3.4) 3.44 (±1.3) 0.22
Type of delirium
Hypoactive 15 (45.5) 15 (78.9) 0.03
Hyperactive 13 (39.4) 4 (21.1)
Mixed 5 (15.2) 0
Hospital stay (in days) 9.61(±3.1) 12.68 (±3.6) 0.002
Outcome
Expired 8 (24.4) 10 (52.6) 0.03
Alive 25 (75.8) 9 (47.4)
Disabled (MBI<12) 9 (27.3) 5 (26.3) 0.57
Improved (MBI≥12) 14 (42.4) 6 (31.6)
DM = Diabetes mellitus, HTN = Hypertension, CVA = Cerebrovascular accident, CAD = Coronary artery disease, CKD = Chronic kidney disease, COPD = Chronic
obstructive pulmonary disease, TB = Tuberculosis, CNS = Central nervous system, DI = Delirium index, MBI = Modified Barthel index, GCS = Glasgow coma
scale, CSF = Cerebrospinal fluid, RBS = Random blood sugar

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 Rai, et al.: Acute confusional state 33

Figure 2: Bar diagram showing the various causes of acute confusional state found during the study

Figure 3: Bar diagram showing the frequency of type of delirium

underlying illness, serum creatinine, abnormal neuroimaging

and MBI with a disability of the patients [Table 2]. However, Figure 4: Bar diagram showing mortality, duration of hospital
baseline characteristic such as age, sex, underlying illnesses, stay and disability differences between patients with established
precipitating factor and the group without established etiology
Glasgow coma scale, leukocyte count, serum sodium, blood
urea, serum creatinine, abnormal CSF analysis, liver function,
thyroid function, baseline DI and MBI did not significantly outcome in patients with acute confusional state. Both number of
influence the mortality and duration of hospital stay. deaths and duration of hospital stay were longer, if, a precipitating
factor was not identified. Occurrence of delirium, in fact, reflects
Discussion an underlying brain dysfunction, which almost invariably results
following a systemic or brain disorder or to drug intoxication or
We observed that identifying the precipitating factor is important drug withdrawal. Delirium often has an adverse prognostic impact
because treatment of precipitating factors influenced the overall on functional and cognitive outcome, as well as on morbidity

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34 Rai, et al.: Acute confusional state

Table 2: Significant predictors of disability at the end compared with those who did not have delirium and were more
of follow-up likely to be discharged to nursing homes or other institutions.[13]
Though, we had excluded patients of pre-existing stroke;
Variable Disability (P value)
however, four patients had multiple infarcts on neuroimaging.
Age 0.049
Underlying illness 0.005
Several studies have suggested that delirium is associated
Serum creatinine 0.011
with risk of dementia and also acceleration of decline in
Abnormal CNS imaging 0.002 existing dementia. Davis et al., recently, noted that delirium
MBI 0.008 was associated with general cognitive decline, with an 8-fold
CNS = Central nervous system, MBI = Modified Barthel index increase in incident dementia and accelerated decline in MMSE
scores.[14] Early recognition and prompt treatment are essential
and mortality.[8,9] Kiely et al. examined the association between to prevent future cognitive decline in these patients.
persistent delirium and 1-year mortality in 412 newly admitted
patients. Approximately, one-third of subjects remained delirious Conclusion
at 6 months. Cumulative 1-year mortality was 39%. Patients with
persistent delirium were 2.9 times as likely to die during the 1-year Patients, in whom a cause was found out, had better prognosis
follow-up, in comparison to whose delirium resolved. In addition, in terms of lesser mortality and lesser duration of hospital stay.
when delirium resolved, the risk of death diminished thereafter.[10]
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Stroke patients with the development of delirium have

unfavorable outcomes, particularly higher mortality, longer How to cite this article: Rai D, Garg RK, Malhotra HS, Verma
hospitalizations and a greater degree of dependence after R, Jain A, Tiwari SC, et al. Acute confusional state/delirium: An
etiological and prognostic evaluation. Ann Indian Acad Neurol
discharge. In a meta-analysis, it was observed that stroke
2014;17:30-4.
patients with delirium had higher inpatient mortality and Received: 11-04-13, Revised: 11-7-13, Accepted: 02-10-13
mortality at 12 months compared with non-delirious patients.
Source of Support: Nil, Conflict of Interest: Nil
Patients with delirium also tended to stay longer in hospital

Annals of Indian Academy of Neurology, January-March 2014, Vol 17, Issue 1