05.01 Acute Confusion

The first thing we need to do is define what acute confusion is. Acute confusion, also known as delirium, is an acute, potentially reversible change in a person's level of consciousness. It can manifest with changes in cognition, perception and attention. It comes on suddenly and progresses quickly.

When we try to determine causes (and we are going to get into this more), it can be due to a general medical condition, the use of a substance (prescription, or maybe not-so-much...you know...recreational), or it can be a combination of factors...think of the intoxicated patient who has fallen and hit their head… is their confusion due to the intoxication or a bleed in the brain?

And really quick here, i want to make a point to differentiate between delirium and dementia. This becomes truly important in dealing with the elderly. Delirium is acute and can last hours to days. Dementia is slow and can last months to years. Consciousness in delirium is often fluctuating and reduces while with dementia, it's often clear. Attention in delirium is impaired (a hallmark symptom) while in dementia its usually normal. Orientation is both is often impaired which is where some confusion and misdiagnosis can occur. We have to do a thorough history to determine what we are dealing with. 

One tool we can use to assess for acute confusion, or delirium, is the Confusion Assessment Method:

We can determine that delirium is present if they have BOTH a change in their mental status from the baseline. This is easy if they have someone with them, not as easy if they come in alone. And they have a level of inattention. An easy way to test their attention is by asking them to spell the word “world” backwards. Now i know you all just did that and realised you had to spell it forwards a few times...come on, you know you did.

So they have to have both of those symptoms and at least some disorganized thinking or an altered level of consciousness. Anything other than alert and oriented to time, place, person, and situation is considered an alteration. 

So we want to assess the cause. A really good mnemonic to use is AEIOU-TIPS. Lets go through it. 

Alcohol - are they intoxicated or going through withdrawal?

Epilepsy or any other seizure or seizure disorder.

Insulin - have they taken too much or too little?

Oxygen - an underdose is easy to spot, but they can also be overdosed on oxygen.

Uremia or other metabolic issues. One of the most common causes of acute confusion in the elderly is a UTI. 

Trauma, toxicity or thermoregulation. Is something broken, did they take something ot were they given something, and are they overly cold or hot. 

Infection or ischemia, both or which can cause a decrease in blood flow and oxygen to the brain.

Psychiatric or poisoning

and Stroke or syncope. The fact is that most cases of acute confusion are going to start with a stroke protocol as that is the one that is most time sensitive for diagnosis and treatment. 

Now once we think we know what caused the confusion, how do we treat it in the emergency department?

Alcohol - if they are intoxicated, its time for detox. If they are withdrawing, prevent any withdrawal complications. 

Epilepsy, stop the seizure and wait for them to return to their baseline

Insulin - treat the hypoglycemia or give them more, depending on what their level is. With acute confusion, one of the easiest spot diagnostic tests is your finger stick. 

Oxygen - This is pretty simple, put it on or take it off

Uremia or other metabolic issues. Get up the antibiotics and fluids and treat the underlying infection

Trauma, toxicity or thermoregulation. treat the appropriate “T”. Trauma, well, check our other lessons on trauma here on NRSNG.com. Toxicity, its supportive measures until you can determine the toxin. And with thermoregulation, get them warm or cool them off depending on what they need. 

Infection or ischemia - Treat the infection or clear the blockage

Psychiatric or poisoning - for either of these, we want to call in the experts. A psych consult if we think its not metabolic, or a quick call to poison control if we know they have been poisoned. 

and Stroke or syncope. Syncope allows for a little less urgent actions. Blood work, EKGs, basic cardiac workup most of the time. A suspected stroke however, is usually a CODE STROKE and requires some very fast interventions and diagnostics. Check with your facility on their stroke policies and follow them accordingly. 

Some quick concepts to think about:

We have to use our clinical judgement here guys. If an elderly person with no significant medical history comes in with acute confusion… we think stroke. But don't forget to get that finger stick and urine sample. The first 5-10 minutes of patient care can help to determine their entire treatment. 

Cognition - determine the level of confusion. You can use the confusion assessment method, or anything your facility likes to use to assess for confusion. 

Lab values - they go along way in helping us to identify metabolic causes for our symptoms 

Some key points to remember

Use the confusion assessment method or whichever method your facility likes to determine if your patient is truly acutely confused.

Remember the differences between delirium and dementia as it can determine whether you have a true emergency or not.

Use the mnemonic AEIOU-TIPS to help you come up with your differential diagnosis and the possible cause for your patients symptoms.

You want to be quick but efficient. Everything in the ED moves fast, don't forget the finger stick, urine sample, labs, all the things that are done in the first few minutes of a patient's arrival

And of course, don't get tunnel vision. You are focusing on your patients minor head trauma but forget to assess the non-healing gangrenous ulcer on his foot which is the true cause of his confusion. 

Ok guys, that's it for today. Don't forget, to get more in-depth info on some of our emergency topics, just check our other lessons on NRSNG.com but for now…

HAPPY NURSING!