🩺 Acute Confusion

Acute confusion, often clinically termed delirium, is a syndrome characterized by disturbed consciousness, cognitive function, or perception, which has an acute onset and fluctuating course. It is extremely common in the hospital setting, particularly among the elderly and those with pre-existing dementia. Delirium is a medical emergency associated with increased mortality, longer hospital stays, and increased risk of dementia. Management is primarily focused on identifying and treating the underlying cause(s) while providing a supportive, reorienting environment.

The hallmark of acute confusion (delirium) is an acute onset (hours to days) and a fluctuating course. Collateral history is essential to establish the patient's baseline cognitive function and the timeline of change. Ask about symptoms of infection (cough, dysuria), pain, and last bowel movement. Review all medications, paying close attention to anticholinergics, benzodiazepines, and opioids. Enquire about alcohol intake and the timing of the last drink (withdrawal). A history of sensory impairment (hearing/vision) is a significant risk factor for delirium in the elderly.

Start with a GCS or AVPU assessment. Conduct a full physical examination to find a source of infection (lungs, abdomen, skin, UTI). Assess for signs of dehydration (reduced skin turgor, dry mucous membranes) and nutritional status. Perform a neurological exam to check for focal deficits or signs of raised ICP. Check the bladder for distension (urinary retention) and the abdomen for faecal impaction. Review the 'drug chart' as a primary part of the physical exam—look for recent additions or withdrawals. Mental state examination should focus on fluctuations and level of consciousness.

Delirium (due to infection, drugs, etc.), Dementia (chronic progression, but can have 'delirium on dementia'), Sepsis, Hypoglycaemia, Electrolyte imbalance (Hyponatraemia/Hypercalcaemia), Wernicke’s Encephalopathy, Alcohol Withdrawal (Delirium Tremens), Hypoxia/Hypercapnia, Post-ictal state.

Reduced GCS/low level of consciousness, Signs of sepsis or shock, New focal neurological deficits, Signs of Wernicke’s Encephalopathy (ataxia, ophthalmoplegia), Severe agitation posing a risk to self or others, Sudden onset in a young person (consider toxicology or encephalitis).

Basic 'delirium screen' includes: FBC, U&Es, LFTs, CRP, Calcium, Glucose, and Thyroid function. Urinalysis should be performed but interpreted cautiously in the elderly (asymptomatic bacteriuria is common). A Chest X-ray and ECG are standard to rule out pneumonia or silent MI. If focal neurology or head injury is present, a CT Head is indicated. If there is fever and neck stiffness, consider a Lumbar Puncture. Monitor oxygen saturations to rule out hypoxia. Measuring bladder volume (bladder scan) can rule out retention-induced confusion.

Always look for 'the PINCH ME' acronym to identify common causes of delirium: Pain, Infection, Nutrition/Constipation, Hydration/Hypoxia, Medication, Environment. Use the 4AT tool (Alertness, AMT4, Attention, Acute change) as a validated, rapid screening method for delirium in the UK. Avoid prescribing antipsychotics if possible, as they can worsen outcomes and are particularly dangerous in Lewy Body Dementia or Parkinson's. If medication is absolutely necessary for safety, use the lowest dose for the shortest time. Delirium is often 'hypoactive' (lethargy/withdrawal), which is frequently missed compared to 'hyperactive' (agitation) delirium.

Covers 'Geriatric Medicine', 'Psychiatry', and 'Emergency Medicine'. Understanding the 4AT tool and the legal aspects of treating confused patients (Mental Capacity Act) is essential for UK practice. Differentiate between Delirium, Dementia, and Depression (The 3 Ds).