CLINIC:
The disorders are fluctuating during the day, worsen in general at night.
■ Alternation of stuporous phases and stirring phases
■ Anxiety, perplexity: the elderly subject appears dazed, awkward, neglected
■ Nycthemeral reversal with frequent sleep disturbances
■ Lack of words, flight of ideas, disorganized and incoherent speech
■ Difficulties with concentration, attention disorders
■ Temporospatial disorientation
■ Disorders of judgment and criticism, false recognition
■ Onirism with visual, auditory and tactile hallucinations, interpretations
■ Interrogation of relatives
It is essential for the etiological approach and must in particular make it possible to collect information on:
– the previous cognitive state (progressive dementia?);
– recent events (bereavement, loss of a pet, moving, entering an institution, etc.);
– initiation of psychotropic treatment or sudden discontinuation, treatment with hypoglycemic, diuretic, anticholinergic;
– the heating system used in the home (CO poisoning).
Physical examination:
It is necessary to calm the patient before examining it. We will try to avoid the noise, speak calmly, explain the clinical examination and the present situation.
It will include a comprehensive somatic examination with, in particular, research:
– dehydration;
– cardiac decompensation;
– an infection (pneumonia +++);
– a sign of neurological focus;
– a faecal (systematic TR);
– a bladder globe;
– a pain syndrome. Confusional syndrome can thus be the only symptom of acute pain in the demented elderly and the only somatic expression of actual organic suffering.
It will be supplemented by a systematic capillary blood glucose.
ADDITIONAL EXAMENS:
Biological examinations:
– NFS: anemia, leukocytosis.
– CRP: Infectious state.
– Blood glucose.
– Serum Ionogram: hyponatremia.
– Calcemia.
– Urea, creatinine: iatrogenic medications, acute renal failure.
– TSH.
Be wary of serotonin reuptake inhibitors, diuretics.
Paraclinical exams:
They will be performed according to the clinical context in search of an infectious, cardiac, neurological cause (chest X-ray, ECG, EEG). In the absence of obvious clinical etiology, in the presence of a fall with facial trauma or sign of focus, the brain CT scan will be systematic (subdural hematoma, intracerebral hemorrhage).
PL should be systematic in case of unexplained febrile syndrome.
TECHNOLOGY:
The search for an organic cause is systematic:
– infectious : pneumopathies, urinary infections, meningitis, meningoencepahlitis (HSV reactivation, VZV);
– iatrogenic: antidepressants, benzodiazepines, diuretics, corticosteroids, anticholinergics, L-Dopa, cimetidine, antiepileptics, digitalis;
– metabolic: hypoxia, hyponatremia, hyper- or hypoglycemia, dehydration, hypercalcemia;
– heart: acute heart failure, myocardial infarction;
– neurological: stroke, epileptic seizure;
– traumatological: falls, fracture of the femoral neck, etc.
TRAITEMENT:
It associates the treatment of the cause and these consequences, in a hospital environment in most cases:
Symptomatic treatment:
– Quiet room, lit and supervised.
– Avoid physical restraint.
– Psychomotor agitation will be treated, only if it does not yield with the etiological treatment and reassurance attitude of the caregivers, by neuroleptics (Tiapridal or risperidone) and short half-life benzodiazepines (Séresta).
– Correction of dehydration and secondary metabolic disorders.
Etiological treatment:
He alone will allow the disappearance of psycho-behavioral symptoms.
Listening and reassurance of loved ones:
The relatives of the confused elderly are totally helpless by the sudden change in behavior of their parent, the hospitalization, essential, usually resulting in a transient worsening of the agitation of this confused old subject. It should therefore be explained that this state is only transient and that it will give way with etiological treatment.