Confusion
Perspective
The term confusion connotes an alteration in higher cerebral functions, such as memory, attention, or awareness. In addition, the ability to sustain and focus attention is impaired. Confusion is a symptom, not a diagnosis. The degree of confusion may fluctuate, as may the patient’s level of consciousness. Clinical jargon includes the phrases “altered mental status,” “delta MS” (change in mental status), “altered mentation,” and “change from baseline.” Implicit in the definition is a recent change in behavior. Chronic mental status changes such as dementia typically have a different clinical chronology. Other forms of altered mentation include states of diminished alertness on the coma spectrum; these presentations may result from some of the same pathophysiologic processes causing confusion and are discussed in Chapter 16. Confusion may range in severity from a mild disturbance of short-term memory to a global inability to relate to the environment and process sensory input. This extreme state is termed delirium. Delirium has two subtypes: hyperactive and hypoactive.1 Hyperactive delirium is characterized as an acute confusional state associated with increased alertness, increased psychomotor activity, and disorientation and is often accompanied by hallucinations. In hypoactive delirium (sometimes referred to as quiet delirium), the confusional state is present but the patient has a reduction in alertness and behavior. Hypoactive delirium may be the more common type in emergency department (ED) patients.2 Confusion has many causes, and an orderly approach is necessary to discover the causative diagnosis. The assessment of mental status and cognitive impairment in elderly ED patients has been proposed as a key quality indicator in the care of elderly patients by the Society for Academic Emergency Medicine Geriatric Emergency Medicine Task Force.3
Epidemiology
Physicians underestimate the incidence of confusion in patients.4,5 Often, confusion is accepted as an incidental or secondary component of another condition. A patient with injuries from a motor vehicle crash or with dyspnea may be confused, but the primary condition overshadows the underlying abnormal mental status. When confusion exists as an isolated or unexplained finding, it is more likely to receive full and immediate consideration by the clinician. Confusion is estimated to occur in 2% of ED patients, 10% of all hospitalized patients, and 50% of elderly hospitalized patients.4,6 Delirium in older ED patients was found to be an independent predictor of increased mortality within 6 months in one study.7
Diagnostic Approach
The observation of acute confusion prompts a search for an underlying cause. Four groups of disorders encompass most causes of diffuse cortical dysfunction: (1) systemic diseases secondarily affecting the CNS, (2) primary intracranial disease, (3) exogenous toxins, and (4) drug withdrawal states (Box 17-1).1 Focal cortical dysfunction, such as from tumor or stroke, typically does not cause confusion, although occasionally, receptive or expressive dysphasia may be mistaken for confusion. Likewise, subcortical or brainstem dysfunction most frequently results in a diminished level of alertness and consciousness, not confusion.
Rapid Assessment and Stabilization
In general, in patients with schizophrenia and other psychiatric disorders, results of tests of cognition, orientation, and attention are normal unless the condition is severe. The term psychosis implies a disorder of reality testing and thought organization severe enough to interfere with normal daily functioning. Psychosis is a nonspecific syndrome, and careful evaluation is required to differentiate between psychiatric and organic origins (e.g., drug intoxication or other systemic process) (Box 17-2).
Pivotal Findings
A patient with an altered state of consciousness including confusion is evaluated through a focused history and a pertinent examination, performance of rapid bedside screening investigations, and observation of the response to certain therapies (e.g., dextrose or naloxone). Additional evaluation may include laboratory testing and diagnostic imaging with various modalities. Information that suggests the cause of confusion is found roughly in descending order from the patient’s history, the examination findings including results of rapid bedside testing, and the response to ED therapies; the results of laboratory testing and diagnostic imaging are less often useful.8
