Pellagra as a differential diagnosis in the confused patient on the acute medical unit.

A man in his 80s was admitted via the acute medical take after presenting with increased confusion and features of alcohol withdrawal. He had a several-month history of a worsening pruritic rash surrounding his neck, arms and legs in addition to new, profuse diarrhoea. In view of the background of known chronic alcoholism and the coexisting symptoms of rash, confusion and diarrhoea, pellagra was diagnosed via a multidisciplinary approach. Oral nicotinamide supplementation was commenced and his symptoms responded rapidly. The bias and challenge of reaching a unified diagnosis in the context of a multisystem condition are exemplified in this case report.

[Non-aphasic misnaming: a case report and literature review].

A 71-year-old, right-handed woman was admitted to our hospital due to a sudden difficulty with conversation. On admission, she was alert, but had a euphoric mood, disorientation, and a disturbance of recent memory. Her speech was fluent. Her repetition and auditory word cognition were excellent, but she had a slight difficulty with naming visual objects. She frequently showed word-finding difficulty and irrelevant paraphasia during free conversation and a word fluency task. Her irrelevant paraphasia was observed more frequently when she was asked to explain her outbreak of anger at the hospital, i.e., it was situation-dependent. She also had anosognosia. MRI showed an infarct in the territory of the left tuberothalamic artery. Single-photon emission computed tomography revealed low-uptake lesions in the left thalamus and orbital frontal, medial frontal, and medial temporal lobes. The patient was diagnosed with non-aphasic misnaming. The clinical characteristics of patients with non-aphasic misnaming in the literature were reviewed. All of the patients with non-aphasic misnaming had word-finding difficulty and irrelevant paraphasia. Additionally, they had either emotional disturbance or anosognosia.

Metabolic encephalopathy caused by nitrous oxide ('laughing gas') induced hyperammonaemia.

A 26-year-old man presented at the emergency department with confusion and decreased consciousness after several days of vomiting. In the preceding 6 months, he had used a 2-litre tank of nitrous oxide (N2O) weekly. His metabolic encephalopathy was caused by hyperammonaemia which probably resulted from interference of N2O-induced vitamin B12 deficiency with ammonia degradation. A catabolic state might have contributed to the hyperammonaemia in this case. After treatment with vitamin B12 and lactulose, both his consciousness and hyperammonaemia improved. He reported no residual complaints after 3 months of follow-up. Since N2O is increasingly used as a recreational drug, we recommend considering hyperammonaemia as a cause of metabolic encephalopathy in cases of N2O use and altered mental status.

Psychophysiological assessment and correction of spatial disorientation during simulated Orion spacecraft re-entry.

The National Aeronautics and Space Administration (NASA) has identified a potential risk of spatial disorientation, motion sickness, and degraded performance to astronauts during re-entry and landing of the proposed Orion crew vehicle. The purpose of this study was to determine if a physiological training procedure, Autogenic-Feedback Training Exercise (AFTE), can mitigate these adverse effects. Fourteen men and six women were assigned to two groups (AFTE, no-treatment Control) matched for motion sickness susceptibility and gender. All subjects received a standard rotating chair test to determine motion sickness susceptibility; three training sessions on a manual performance task; and four exposures in the rotating chair (Orion tests) simulating angular accelerations of the crew vehicle during re-entry. AFTE subjects received 2 h of training before Orion tests 2, 3, and 4. Motion sickness symptoms, task performance, and physiological measures were recorded on all subjects. Results showed that the AFTE group had significantly lower symptom scores when compared to Controls on test 2 (p = .05), test 3 (p = .03), and test 4 (p = .02). Although there were no significant group differences on task performance, trends showed that AFTE subjects were less impaired than Controls. Heart rate change scores (20 rpm minus baseline) of AFTE subjects indicated significantly less reactivity on Test 4 compared to Test 1 (10.09 versus 16.59, p = .02), while Controls did not change significantly across tests. Results of this study indicate that AFTE may be an effective countermeasure for mitigating spatial disorientation and motion sickness in astronauts.

PERFECTED enhanced recovery (PERFECT-ER) care versus standard acute care for patients admitted to acute settings with hip fracture identified as experiencing confusion: study protocol for a feasibility cluster randomized controlled trial.

BACKGROUND: Health and social care provision for an ageing population is a global priority. Provision for those with dementia and hip fracture has specific and growing importance. Older people who break their hip are recognised as exceptionally vulnerable to experiencing confusion (including but not exclusively, dementia and/or delirium and/or cognitive impairment(s)) before, during or after acute admissions. Older people experiencing hip fracture and confusion risk serious complications, linked to delayed recovery and higher mortality post-operatively. Specific care pathways acknowledging the differences in patient presentation and care needs are proposed to improve clinical and process outcomes. METHODS: This protocol describes a multi-centre, feasibility, cluster-randomised, controlled trial (CRCT) to be undertaken across ten National Health Service hospital trusts in the UK. The trial will explore the feasibility of undertaking a CRCT comparing the multicomponent PERFECTED enhanced recovery intervention (PERFECT-ER), which acknowledges the differences in care needs of confused older patients experiencing hip fracture, with standard care. The trial will also have an integrated process evaluation to explore how PERFECT-ER is implemented and interacts with the local context. The study will recruit 400 hip fracture patients identified as experiencing confusion and will also recruit "suitable informants" (individuals in regular contact with participants who will complete proxy measures). We will also recruit NHS professionals for the process evaluation. This mixed methods design will produce data to inform a definitive evaluation of the intervention via a large-scale pragmatic randomised controlled trial (RCT). DISCUSSION: The trial will provide a preliminary estimate of potential efficacy of PERFECT-ER versus standard care; assess service delivery variation, inform primary and secondary outcome selection, generate estimates of recruitment and retention rates, data collection difficulties, and completeness of outcome data and provide an indication of potential economic benefits. The process evaluation will enhance knowledge of implementation delivery and receipt. TRIAL REGISTRATION: ISRCTN, 99336264 . Registered on 5 September 2016.

Assessing Mental Imagery to Evaluate Topographical Disorientation: Group Study and Preliminary Normative Data.

There is currently no specific neuropsychological test assessing spatial orientation abilities, despite the fact that navigational deficits are heavily incapacitating in daily life. This lack of a specific test is probably due to theoretical vagueness of concepts in this field and important interindividual differences in spatial cognition. Here we propose a new standardized test assessing a fundamental component of spatial orientation-namely, mental imagery: Adequate mental visualization of the environment is indeed a necessary step in finding one's way. Two conditions of mental imagery were proposed to a group of 58 patients with a right cerebral lesion and to a control group (N = 117). The 1st condition assessed global, categorical imagery; the 2nd evaluated precise, metric imagery. We evaluated performance of the 2 groups in the 2 conditions and the impact of sociodemographic variables (age, gender, education). Results show that the right-lesioned patients presented difficulties in mental imagery, especially in the metric condition. Moreover, the data indicate a global impact of age and a milder effect of education on mental imagery abilities. Although sample sizes are sometimes small, preliminary normative data are given; already in the present form, they are usable and informative in assessing mental imagery, and more generally, spatial orientation, in a clinical practice.

Assessment of Topographical Disorientation: First Application of New Tests and Case Report.

A right posterior cerebral lesion can lead to an inability to orient and can consequently interfere with daily-life autonomy. Despite the wide literature about navigation abilities, it is still difficult to assess topographical disorientation (TD) because of the interindividual specificity of spatial knowledge and the diversity of symptoms. We describe here a set of new tests evaluating spatial cognition in a patient with TD presenting difficulties in navigating inside the hospital and in his hometown more than 3 years after his diffuse ischemic right Sylvian stroke. These tests assess mental imagery (global and specifically spatial imagery), perspective change, and the ability to recall spatial relations in familiar environments. The evaluation revealed difficulties with all the tests (but not in global mental imagery) in this patient when compared with matched controls. Hence, these new tests seem specific and affected by a right hemispheric lesion. The observed deficits can explain, at least partially, the spatial orientation difficulties experienced by this patient in the hospital and familiar environments. In conclusion, these tests could be appropriate tools for the assessment of visuospatial and spatial processes.

Where Am I? A new case of developmental topographical disorientation.

Recently, developmental topographical disorientation (DTD) was described (Bianchini et al., 2010, J Clin Exp Neuropsychol, 20, 807-27; Iaria & Barton, 2010, Exp Brain Res, 206, 189-96; Iaria, Bogod, Fox, & Barton, 2009, Neuropsychologia, 47, 30-40) as a navigational deficit in the absence of neurological or psychiatric disorders. Here, we reported the case of a healthy subject who presented this disorder. Dr. WAI was a 29-year-old right-handed man with normal development and no clinical history of neurological or psychiatric diseases who was affected by a very pervasive topographical orientation and navigational disorder. A neuroradiological exam confirmed the absence of structural and anatomical alterations of the brain. Dr. WAI was submitted to an extensive neuropsychological examination and to a battery of tests specifically developed to assess developmental topographical disorder. Using this battery, we analysed Dr. WAI's acquisition of navigational information and re-orientation processes. He showed severe DTD accompanied by deficits of different cognitive processes directly or indirectly involved in navigational skills. Dr. WAI showed a deficit in developing cognitive maps, already found in previous cases, plus difficulties in evaluating distances and computing metric environmental features. He represents a further confirmation of the existence of DTD suggesting dissociations within the disorder related to the level of development of the ability to build cognitive maps and the association of different imagery deficits. Dr. WAI can help in shedding some light on the mechanisms underlying lack of development of navigational skills.

[Delirium caused by nonconvulsive status epilepticus]. / Nonkonvulsiver Status epilepticus als Ursache eines Delirs.

We report about a patient (66 years) who was referred to our psychiatric hospital because of a progressive confusional state with acute onset. The colleagues of the referring psychiatric hospital considered a first manic episode as the cause of the symptoms and under therapy with haloperidol the confusional state had shown a progression.The clinical examination's findings were a mild central facial paresis on the right side and a mild hemiparesis on the right side with elevated reflex levels.The patient was disoriented, he had cognitive and mnestic deficits. His reasoning was slowed, incoherent and perseverating. The patient had a slight euphoria.An EEG recording showed a continuous regional EEG-seizure pattern. In combination with the clinical symptoms we diagnosed a nonconvulsive status epilepticus. Under anticonvulsive treatment with Lorazepam and Valproic acid the status epilepticus sustended but a control EEG recording showed signs of a Valproate-encephalopathy. Under treatment with Topiramate symptoms ameliorated but due to a vascular dementia the patient still showed fluctuating symptoms of cognitive and mnestic disturbances.

Colonic irrigation-induced hyponatremia.

A 42-year-old Chinese woman presented with transient confusional state and memory loss due to acute water intoxicational hyponatremia complicating colonic irrigation (enemas) used as an alternative medicine to promote health. Although there is no evidence that such "antiautointoxication" technique conveys true benefit in any condition, this form of "quackery" may actually cause harm, such as water intoxication as in this case.

The effect of music listening on acute confusion and delirium in elders undergoing elective hip and knee surgery.

This study was undertaken to determine the effect of music on elders undergoing elective hip and knee surgery who experience acute confusion and delirium postoperatively. Postoperative confusion and delirium in elders often cause complications that negatively effect recovery. Music listening was introduced as an intervention to an experimental group. Nurses documented episodes of acute confusion and delirium experienced by elders postsurgically. Scores from a readiness-to-ambulate profile to determine if patients were cognitively ready for postoperative therapy were evaluated. There was a significant decrease in the number of episodes of postoperative confusion among those in the experimental group compared with those in the non-listening control group. In addition, the experimental group had significantly higher scores on the readiness-to-ambulate profile than the control group. These findings indicate that music listening is an effective nursing intervention that can be used to decrease acute postoperative confusion and delirium in elders undergoing elective hip and knee surgery.

Psycho-affective disorder in intensive care units: a review.

This paper reviews the literature related to the Intensive Care Unit (ICU) Syndrome. The intention of the paper is to explore the range of psychotic and affective phenomena that may be observed in practice, together with the management of contributory stressors. Patients experience a range of psycho-affective disturbances that may be triggered by drugs, the environment, dehumanizing practices and sleep deprivation. Symptoms do not always disappear following discharge and further research is required to determine the long-term psychological effects of an ICU. Comprehensive assessment of the patient's psychological state, using an appropriate tool, is necessary and should form an integral part of ongoing care. Interventions identified include eradication of dehumanizing behaviour, modification of environmental stimuli, effective communication and therapeutic touch. Where possible, communication needs should be addressed prior to admission, and patients and their families prepared for the unfamiliar world of the ICU.

Alterations in selected measures of mood with a single bout of dynamic Taekwondo exercise in college-age students.

This study was designed to investigate and to compare the acute alterations in selected measures of mood profile in novice Taekwondo practitioners while evaluating whether dynamic Taekwondo practice was an appropriate exercise modality for enhancing six psychological state dimensions: Vigor, Anxiety, Depression, Anger, Fatigue, and Confusion. 20 male and female college-age students enrolled in Taekwondo activity class and an additional 20 students enrolled in the lecture-con trol class (ages 18 to 21 years) completed the Profile of Mood States (POMS) inven tory prior to and immediately following one 75-min. session of dynamic Taekwondo or lecture. To examine the exercise effect, a series of 2 x 2 analysis of covariance were performed on mean posttest scores, using pretest scores as the covariate. Analysis indicated that Taekwondo participants reported a significant improvement (p<.007) with respect to the control group in scores on Tension, Depression, Anger, Fatigue, Confusion, and Vigor. Also, Total Mood Disturbance significantly improved after the dynamic Taekwondo session. The selected affective benefits of an acute Taekwondo exercise in this study were independent of sex. Unlike the exercising subjects. the control subjects reported no such benefits and, indeed, increased their scores for negative mood states. These results suggest that a dynamic version of Taekwondo achieves the necessary activity parameters that begin to induce positive mood state changes and that extensive Taekwondo skill is not necessary to elicit some beneficial change in affect. This study also supports the findings of several earlier studies indicating that acute exercise may elicit positive changes in affective states and that prolonged exercise is not necessary to produce immediate beneficial alterations of mood.

[Etiology of initially unexplained confusion of excitability in deadly nightshade poisoning with suicidal intent. Symptoms, differential diagnosis, toxicology and physostigmine therapy of anticholinergic syndrome]. / Atiologisch zunächst unklare Verwirrtheit und Exzitation im Verlauf einer Tollkirschenvergiftung mit suizidaler Absicht. Symptomatik, Differentialdiagnose, Toxikologie und Physostigmin-Therapie des anticholinergen Syndroms.

HISTORY AND ADMISSION FINDINGS: After a walk in a wood a 55-year-old teacher was admitted to the emergency unit of a university hospital because of somnolence and excitability. Her rectal temperature was 37.8 degrees C, she had sinus tachycardia (rate of 130/min) but no other significant findings. INVESTIGATIONS: With the exception of C-reactive protein (10 mg/dl), MCV (101 fl), MCH (34 pg) and arterial blood gases (pH 7.483, pCO2 35.5 mmHg, base excess 5.1 mmp/l) laboratory tests were within normal limits. Qualitative screening of serum for benzodiazepines, barbiturates and antidepressives was negative. Neurological examination, including lumbar puncture and cranial computed tomography were noncontributory. TREATMENT AND COURSE: 10 hours after admission the patient developed signs of an anticholinergic syndrome with mydriasis, dry mouth, tachycardia, hot skin and an atonic bladder. Physostigmine 2 mg completely reversed the neurological and mental symptoms. After gas chromatography, mass-spectrometry of a urine sample showed an atropine molecular fragment with a molecular weight of 271. At intervals of 3 to 5 hours the recurrence of confusion and excitability required 4 further i.v. injection of physostigmine. The patient subsequently became accessible to psychiatric examination and reported that during the walk she had swallowed 8-10 berries of deadly nightshade with suicidal intent. CONCLUSION: In case of excitability and confusion as well as somnolence or coma of uncertain aetiology an anticholinergic syndrome caused by ingestion of atropine-containing plants or psychoactive drugs (phenothiazines, butyrophenones, tri- or tetracyclic antidepressants) should be included in the differential diagnosis. If there are suggestive clinical findings (tachycardia, somnolence, coma or threatened respiratory arrest, physostigmine should be given if there are no contraindications.

Treatment of agitation in dementia.

Behavioral and psychological signs and symptoms associated with dementia are common and often confusing because they do not meet criteria for typical discrete psychiatric disorders. Although the symptoms tend to occur in clusters, the clusters often vary with time and between patients. Recognizing the behavioral pathology associated with dementia is important because it can be distressing to the patient, lead to dangerous interactions with others or the environment, and result in the use of inappropriate psychotropic medications. A practical, general approach to the evaluation and management of agitation in dementia for psychiatric consultants confronted with such problems is proposed.

[Confusion syndromes in hospitalized aged patients: polymorphism of symptoms and course. Prospective study of 183 patients]. / Les syndromes confusionnels du sujet âgé hospitalisé: polymorphisme sémiologique et évolutif. Etude prospective de 183 patients.

Using explicit criteria contained in the DSM III R, we collected in a prospective cohort study clinical features, outcome and risk factors from two cohorts of delirium in hospitalized elderly patients: 138 hospitalized in geriatric department and 45 patients admitted to an acute and comprehensive care hospital. The clinical features were assessed using a quantitative scale (developed by Derouesné). Delirium was unrecognized or misdiagnosed by physicians in 34% of the cases. The onset was known only two thirds of cases. The incidence of hyperactive type, prolonged hospital stay, poor outcomes (persistent delirium leading up to dementia) were highest in subjects admitted in comprehensive hospital. The etiology of delirium is complex and multifactorial. An underlying cause was identified in 80% of patients. The length or the worsening of delirium was significantly higher in patients with psychiatric or dementia comorbidity (OR: 0.2; IC 95%: 0.1-0.5). The prognosis was better in patients without psychoactive medications (OR: 0.2; IC 95%: 0.1-0.4) or with metabolic abnormalities or acute diseases and disorders (OR: 3.3; IC 95%: 1.5-7.6). The predisposing factors to the development of dementia were prior use of psychoactive medications and signs of prior cognitive impairment. This article suggests delirium in elderly patients is associated with several outcomes. The prognosis should be improved at admission by specific scale and an evaluation of predisposing and precipitating factors.