Why it fits
Heavy alcohol use, malnutrition, triad of confusion/ataxia/eye signs may be incomplete
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Heavy alcohol use, malnutrition, triad of confusion/ataxia/eye signs may be incomplete
Inattention plus altered awareness/arousal are the key separators. Usually precipitated by acute illness, surgery, injury, retention, constipation, pain, or medicines.
Separates the Delirium / Acute Confusion / Encephalopathy group. It is not specific to Wernicke encephalopathy.
Applies to the Delirium / Acute Confusion / Encephalopathy group — not specific to Wernicke encephalopathy
Rows marked “Whole group”: Applies to the Delirium / Acute Confusion / Encephalopathy group — not specific to Wernicke encephalopathy
Heavy alcohol use, malnutrition, triad of confusion/ataxia/eye signs may be incomplete
Permanent cognitive injury, Korsakoff syndrome.
Applies to the Delirium / Acute Confusion / Encephalopathy group.
Inattention plus altered awareness/arousal are the key separators. Usually precipitated by acute illness, surgery, injury, retention, constipation, pain, or medicines.
Applies to the Delirium / Acute Confusion / Encephalopathy group.
Do vitals, BGL, sats, attention testing, collateral, and medication/substance review early Use 4AT in most adult settings, and ICU tools where appropriate Quiet hypoactive delirium is commonly missed Treat precipitants and use non-drug care first Reserve antipsychotics for severe distress or immediate risk Do not stop at behavioural labels
Applies to the Delirium / Acute Confusion / Encephalopathy group.
Blood glucose, Vitals and oxygen saturation
Applies to the Delirium / Acute Confusion / Encephalopathy group.
Primary psychosis, dementia, severe depression, catatonia, intoxication, post-ictal state, stroke, medication overdose, stimulant intoxication
Clinical reference — not validated decision support. Review before use.