Volume 6 Issue 4 April 2016
We all come across the presentation of ‘altered sensorium’ in our day to day clinical practice. Typically, the patient presents with an acute/abrupt onset alteration in his cognitive functions such as decreased attention and concentration, disorientation to time, place and person in varying combination, altered level of arousal manifested by decreased or increased motoric activity accompanied by irrelevant speech, perceptual abnormalities and the classical fluctuation in clinical presentation i.e. evening worsening of symptoms. We call it ‘delirium’ or ‘acute confusional state’.
Typically patient is an elderly with a host of medical co morbidities like chronic diseases diabetes mellitus, hypertension, coronary and/or cerebrovascular disease, on a host of medications who has a worsening of physical illness, superimposed infection, medication side effects, dehydration and/or fall/hidden injury. These patients generally have age related or more than age related cognitive decline, sensory deprivation, malnutrition and general neglect that predisposes them for such acute or at times insidious alteration in sensorium. Persons using or abusing various substances in their intoxication and/or withdrawal phase, post-operative patients, persons with CNS infections, sepsis, head injury or those in intensive care for any reason also constitute the common ones presenting with altered sensorium.
Important here is the issues of non-identification of this even in specialized settings leave alone the primary care setting. This presentation is an indicator of the severity of underlying condition, increased hospital stay, mortality and cost of care. Aging population is increasing and so is the number of persons surviving with chronic diseases and road traffic accidents (RTA) as well as substance use. So, this is an important clinical presentation across all strata of health care and more so as first encounter with GPs.
So, its early and timely recognition is the most important first step paving the way for identification of predisposing, precipitating and perpetuating factors. Predisposing factors have already been discussed. In management, it is the precipitating factors which generally clinicians look for immediate respite. Only in very lucky ones a definite cause can be found out otherwise a multi-factorial etiology generally explains the disturbance of which a combination of metabolic, infectious and organ dysfunction is the commonest finding.
Treatment of the underlying causes generally clears the sensorium but it is important to be aware of the fact that there is a lag period of varying duration between correction of etiology and achievement of clear sensorium which again depends upon a varying combination of factors discussed above. Family members must be explained the reason for altered sensorium and behavior and must be told that patient is not having a major mental disorder rather it’s the bra manifestation of underlying physical abnormalities and will get better as these are treated.
Use of benzodiazepines is considered in substance related phenomenon, otherwise low dose antipsychotics are preferred in general scenario to manage behavioral disturbances especially agitation. But the behavioral management is helpful in every case which includes orientation cues, minimizing overstimulation and under stimulation both, ensuring safety of patient, proper exposure to light at various times of day and minimal change of immediate environmental settings.
Dr. Akhilesh Sharma, MD Assistant Professor, Department of Psychiatry PGIMER, Chandigarh Email: drakhileshsharma@gmail.com
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