Confusion overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]
Overview
Confusion refers to mental dysfunction in which a lack of attention and disorientation occurs with the inability to think with normal speed or clarity. It is the inability to maintain a coherent stream of thought or action.
Pathophysiology
Confusion results from global impairment of function of brain. Few areas of brain are identified for various presentations of confusion. Drugs, poisons, chemicals interact with the neurotransmitters and cause confusion. Inflammatory agents are involved in conditions like fever.
Causes
Confusion is a common symptom associated with various diseases and metabolic disorders. Common causes of confusion include insults to the central nervous system (CNS), metabolic disorders, and the side effect of medications or illicit drugs.
Differentiating Confusion from other Diseases
Various conditions such as dementia, depression and amnesia involve confusion as part of their presentation. Obtaining a clear history about the onset of symptoms, and the onset of confusion in association with other symptoms, helps in differentiating confusion from other conditions.
Epidemiology and Demographics
Nearly about 30% of older patients admitted for medical conditions are confused at some point of time during their admission.[1] In surgical wards the chances of confusion ranges from 10-50%.[2] Increasing rates are seen in patients admitted to intensive care units and in hospice care. There is no significant difference in the distribution based upon gender or race.
Risk Factors
Increasing age, admission to the hospital, post-surgical status, alcoholism, and underlying brain lesions are a few important risk factors for confusion. Special care is required for elderly patients who are hospitalized.
Natural History, Complications and Prognosis
Confusion is disturbance in mental status which develops rapidly. If untreated it develops into stupor / coma. Confusion caused due to metabolic changes can be rapidly corrected and have good prognosis compared to the one caused by underlying structural abnormalities of brain. Mortality rate for those who developed confusion at hospital is nearly 39% in first year which nearly twice compared to age matched controls.[3]
Diagnosis
History and Symptoms
Confused patients will not be able to provide a coherent history. Confirming the history with patient’s caregiver is the key to get good history about the patient. Determining the patient’s drug history and co morbid conditions is very important. In young patients drug abuse and withdrawal should be evaluated. Few assessment scales are used to identify and diagnose confusion, and they include the Confusion Assessment Method, Mini Mental Status Examination, and The Neelon and Champagne (NEECHAM) Confusion Scale.
Physical Examination
Physical examination in cases of confusion helps in localizing the lesion if the cause is from the brain. It even gives clues to the underlying cause of the disease. Complete neurological examination may not be done due to limitation of patient's condition.
Laboratory Findings
Several laboratory tests are there for evaluating confusion. It is the part of physician to choose the most useful once basing upon the history of the person. like patient presenting with confusion with severe neck stiffness, headache and fever have to be looked for infective foci and tests for the same are to be ordered.
Electrocardiogram
Various heart conditions can cause hypoperfusion of brain. This hypoperfusion can be a cause of confusion. Electrocardiogram helps us identifying any associated heart conduction problems and aids in diagnosis.
Chest X Ray
Lung pathologies usually cause hypoxia and confusion if untreated. Chest x ray is the most important tool to evaluate such conditions. It helps in identifying various lung lesions and infections.
CT
A CT scan of the head is an important diagnostic tool in cases of confusion where a cause couldn't be established. It is the preliminary test to perform, before doing a lumbar puncture, in cases of suspected infections like meningitis.
MRI
MRI scan is more sensitive in identifying intra cranial lesions than CT scan. It can be used in cases of high index suspicion and negative report on CT scan.
Echocardiogram or Ultrasound
Echocardiogram is a valuable tool to asses the cardiac output. It helps in determining the perfusion. Ultrasound is used for determining the cause of confusion in certain abdominal conditions like any liver injuries, bleeds in to abdomen, injury to major vessels in abdomen.
Other Imaging Findings
There are several other imaging studies which are not quite that often used for diagnosis. They are mostly used in cases of unconfirmed diagnosis. Few of them are CT angiography,FLAIR(Fluid attenuated inversion recovery images.
Other Diagnostic Studies
Certain studies like electroencephalography(EEG) are of noticeable importance. These tests are done to exclude other differential diagnosis and aid in diagnosis of certain conditions.
Treatment
Medical Therapy
Complete evaluation of the person in emergency department has to be done and appropriate treatment is administered. Every confused individual should be administered with glucose and thiamine, followed by naloxone and flumazenil. Treatment must be started awaiting results. Early treatment can save the individual from long term effects.
Surgery
Surgical options are limited for confusion. It all depends on the cause of confusion. Few conditions like sub dural hematoma which can be drained are surgically evacuated. In such cases consultation with neurosurgery may be needed. In cases of road traffic accidents , person may be bleeding severely due to fractures and visceral injury. In such cases consult with orthopedics and surgery.
References
- ↑ Francis J (1992). "Delirium in older patients". J Am Geriatr Soc. 40 (8): 829–38. PMID 1634729. Unknown parameter
|month=ignored (help) - ↑ Dyer CB, Ashton CM, Teasdale TA (1995). "Postoperative delirium. A review of 80 primary data-collection studies". Arch. Intern. Med. 155 (5): 461–5. PMID 7864702. Unknown parameter
|month=ignored (help) - ↑ Inouye SK, Charpentier PA (1996). "Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability". JAMA. 275 (11): 852–7. PMID 8596223. Unknown parameter
|month=ignored (help)