Health Articles

Two tasks must be accomplished quickly: protecting the patient from harm and, if possible, treating the cause of the confusion. Nurses should be alerted so that they can assess the need for close observation or continuous sitters. Increased supervision is almost always needed, and both mental status and medical status should be frequently reevaluated. Restraints are almost always unacceptable; human, not mechanical, care is needed. The environment should be stable, with the same caregivers if possible, because frequent changes can exacerbate confusion. The room should be either well lighted or, at night, dark; ambiguous lighting can induce illusions and even hallucinations.
Confused patients need information repeated frequently; patience is important. Many elderly persons have impaired hearing, which makes communication more difficult, but shouting is inappropriate because a hearing impaired person responds to clear enunciation rather than to loud voices. Caregivers should speak slowly, be prepared to repeat their remarks several times, and use the patient’s name, which can be an important point of reference in the midst of confusion.
Dehydration and electrolyte imbalance, which are ever-present threats to ill older persons, may occur rapidly. Fluid intake must be charted meticulously (especially if the patient is febrile), and urinary output must be estimated, even if the patient is incontinent. Blood chemistry reports must be obtained promptly from the laboratory. In the short term, hydration is much more important than nutrition.
Specific treatment depends on the cause of the confusional state (eg, infections require specific drug therapy). Often, the symptoms must be treated. Sedatives may break the vicious circle of confusion, anxiety, and more confusion, but these drugs can also worsen confusion. Occasionally, a patient is so restless that sedation is needed to allow hydration and feeding; however, this is always a difficult course, for heavy sedation may worsen mental status. Treatment should be limited to a small, familiar range of drugs. A regular regimen and close observation is the best approach; drugs should almost never be prescribed on an as-needed basis. Proper dose titration is the responsibility of physicians, not nurses.
All drugs have risks, but phenothiazines (eg, thioridazine 10 to 25 mg tid) or butyrophenones (eg, haloperidol 1 mg tid initially) are useful in most cases of acute confusion. These drugs are all antipsychotics and are indicated for treating acute confusion, hallucinations, delusions, and paranoia; generally they should not be used solely for their sedating effects. (For the caveats in using these drugs in patients with chronic confusion and behavior disorders, see Ch. 10.) Butyrophenones are less sedating but more likely than phenothiazines to cause dystonic reactions. Promazine 25 mg tid is an antipsychotic with mild sedating effects that rarely causes dystonia. All these drugs usually should be given orally; liquid forms are sometimes easier to administer. Occasionally, an 1M injection (eg, haloperidol 2.5 mg) may be required. Benzodiazepines are purely sedative and do not alter confusion.
For sleep, chloral hydrate (eg, as syrup, 500 mg in 10 mL) may be niven alone or combined with a phenothiazine in low doses. Occasionally, a short-acting oral benzodiazepine hypnotic (eg, oxazepam 10 to Is! ing, temazepam 7.5 to 15 mg, lorazepam 0.5 to 1 mg, or lormeta-f.cpuni [not available in the USA] 0.5 to 1 mg) may be needed.
I’ 11 L-C I i vc treatment of a confusional state may leave other disabilities oi care needs unresolved. Proper management includes attending to all of the patient’s needs and making appropriate arrangements for continuing care.
When medical or drug-related causes are treated successfully, most patients will recover to their baseline mental status. However, not all patients recover fully, particularly when the confusion was caused by hypotension or hypoxia. Yet, even when the cause is something less obviously toxic to the central nervous system, recovery may not be complete. The extent of recovery cannot be predicted. However, a slow recovery is not necessarily cause for despair because many elderly patients require several weeks to return to their baseline status.
Failure of a confusional state to resolve after successful treatment of an underlying cause calls for a thorough review. Several causes may be involved, only one of which was treated, or a new cause may have developed.

Has the patient been confused before? If so, what caused the confusion? What treatment did it respond to? Has the patient been depressed before? Lifestyle: Does the patient use alcohol or prescribed or illicit drugs? A thorough drug review is essential. What is the patient’s nutritional status? Has the patient been exposed to infection? Are the patient’s living conditions, including heating, adequate?
Laboratory findings: The EEG is the only regularly abnormal test in acute confusion, but it is rarely necessary because it usually provides no more information than can be determined clinically. The value of other laboratory tests depends on the clinical findings. The tests most often ordered are CBC, blood chemistry profile, urinalysis, and chest x-ray. Specific tests may be required for certain conditions (see TABLE 9-1) or for diagnosing other suspected disorders (eg, thyroid function tests, vitamin Bμ measurements, toxicology screening, or lumbar puncture). Brain imaging by CT, MRI, or single photon emission computed tomography may be indicated after discussion with the radiologist.

Because a confused patient rarely gives a useful history, another information source is essential. Potential sources may be difficult to find, especially after the patient has been admitted to the hospital. Whenever possible the initial examination and history should be taken when such sources are most likely to be available (ideally in the patient’s home). Persons who may have accompanied the patient to the hospital (relatives, friends, police, or neighbors) should be interviewed before they leave; their names, addresses, and telephone numbers should be noted in case further information is needed.
The principles of history taking are routine, but certain factors must be considered. Onset: Was the onset sudden or insidious? Was it associated with any possibly related events (eg, trauma, illness, development of specific symptoms such as cough, urinary tract infection, changes in medication)? Duration: When did the changes first become apparent? Has the duration of confusion been very short? Brief duration strongly suggests a specific precipitating cause. Course: Has the patient’s condition been constant or variable? Is there a diurnal pattern? Are relatively lucid periods associated with any specific factors? What makes the patient worse?

Diagnosing an acute confusional state may be difficult. Although acute confusion is usually identifiable in its florid form, physicians and nurses may be unaware that it exists if the patient is withdrawn and quiet.
Since virtually any medical or psychologic condition could cause acute confusion, a meticulous history taking and physical examination are essential. The causes of acute confusion are myriad, and confusional states are often accompanied by other major, nonspecific presentations of disease in the elderly (eg, incontinence or instability and falls). The patient may be smelly and unprepossessing, inspiring little therapeutic optimism. Such patients must be viewed with an open mind, since the results of thorough appraisal may mean the difference between life and death. The initial evaluation usually focuses on drug toxicity, cardiovascular changes, infection, and metabolic abnormalities.

The acute confusional state is characterized by clouding of consciousness, a diminished level of awareness that fluctuates between the extremes of alertness and coma. Alertness, awareness, and ability to pay attention are generally diminished; drowsiness is common. One or more of the following other key features are likely to occur (but rarely do they all occur): a relatively acute onset, clouded sensorium, disorientation, agitation, impaired memory, anxiety, and suspicion (see TABLE 9-2). Frank hallucinations and disrupted or delusional thinking may occur, and speech abnormalities are common. However, many acutely confused elderly persons are not hyperactive and may even become withdrawn and quietly paranoid. Symptoms such as dyspnea and chest pain may provide clues to the cause of the acute confusion. Impaired cardiopulmonary performance or neurologic findings may also provide clues.
Early in its course, acute confusion is characterized by changes in attentiveness. An acutely confused patient will not be able to pay attention to an interviewer, register names, or remember objects even long enough to repeat them. The patient may appear to be following conversations or visual cues that are not part of the interview, as if he were somewhere else. Changes in attentiveness may be subtle and measurable only on thorough testing, or they may be obvious, accompanied by clouded consciousness and obvious hallucinations.
Typically, the acute confusional state has a waxing and waning course. At one moment a patient may appear nearly normal, and just a few minutes later he may appear completely and obviously confused. Thus, conducting more than one evaluation is important before determining that mental status is normal. Confusion often becomes worse at dusk, a phenomenon known as sundowning.

An acute confusional state presumably reflects a disturbance in cerebral metabolism, probably mediated through disturbed arousal systems or structural damage to brain cells. The brain of an aging (particularly very elderly) person, like the immature brain, tends to respond to such disturbances by demonstrating confusion at a lower threshold.
Almost any physical derangement, and even a sudden environmental change, may precipitate acute confusion (see TABLE 9-1). Some psychologic disturbances, most notably depression, can provoke a confusional state in the brain of a very elderly person. Bereavements, actual or symbolic, are among the life events that most commonly precipitate depression. Patients with depression may present with subacute confusion (possibly through arousal disorders). Some cases of depressive pseudodementia, in which depression mimics dementia, would be Ixtu-i labeled depressive confusion, because the depression actually worsens t he underlying (often unrecognized) dementia, precipitating an acute confusional state.
Drugs, prescription or over the counter, are among the most common vausvs of confusional states. Anticholinergic agents are involved particularly often; because many psychoactive (psychotropic) drugs are anticholinergic, these drugs should always be suspected as potential causes of the acute confusion. In addition, many patients have problems complying with standard drug regimens and cannot be assumed to lie taking their drugs as prescribed. Self-medication with over-the-counter or shared drugs must not be overlooked.
Sometimes drugs used in treating the early stages of a confusional slate actually exacerbate or perpetuate it. Antipsychotic and sedative-hypnotic drugs may be potent precipitants of confusion. Drug metabolism in the elderly is often altered, even without disease, leading to high blood levels in patients taking normal or low doses of drugs. Because polypharmacy is common, the elderly are at increased risk for drug interactions that potentiate confusion. Confusional states often are dramatically reversed or alleviated by changing or eliminating drug therapy. Eliminating nonessential drugs should be one of the first steps in determining the cause of and treating a confusional state.

An alteration of mental status characterized by an inability to appreciate and respond normally to the environment, often with altered awareness, disorientation, inability to process visual and auditory stimuli, and other signs of cognitive dysfunction.
Terms such as confusion, delirium, and acute brain syndrome are often used without being clearly defined. Sometimes they are used synonymously, but often the user has very specific (and often subtle) distinctions in mind. In fact, all of these terms refer to aberrations in cognitive mental processes, the ways by which we perceive, think, and remember. The emphasis in this chapter is on acute dysfunction of these mental processes.
Confusion is not a disease or even a single syndrome; rather it is a sign of a whole spectrum of diseases and syndromes. Confusion is often the presenting or most prominent sign in cognitive failure syndromes, all of which are characterized by impaired cerebral function (see also Ch. 90). When acute, confusion is usually caused by medical illness or drugs and can be reversed in most cases.