What is the inpatient treatment for acute confusion?

Inpatient Treatment for Acute Confusion

The primary treatment for acute confusion (delirium) in the inpatient setting involves a multimodal approach focusing on identifying and treating underlying causes, providing supportive care, and using short-term hydration to rule out dehydration as a precipitating factor. 1

Initial Assessment and Management

Identify and Treat Underlying Causes

• Evaluate for common precipitating factors:
  • Infections (urinary tract, respiratory)
  • Metabolic disturbances
  • Medication effects
  • Pain
  • Hypoxia
  • Dehydration
  • Silent myocardial ischemia

Immediate Interventions

• Hydration:

  • Implement short and limited hydration to rule out dehydration as a precipitating cause 1
  • Encourage early oral fluid intake when possible 1
  • Monitor fluid balance carefully

• Oxygenation:

  • Administer supplemental oxygen for at least 24 hours postoperatively 1
  • Maintain adequate oxygenation (PaO2 60-100 mmHg) 2

Pharmacological Management

First-Line Approach

• Avoid unnecessary medications that may worsen confusion
• Treat pain adequately:
  • Use acetaminophen (1g every 8 hours) as first-line 1
  • Avoid combination acetaminophen preparations with opioids 1

Antipsychotics for Severe Symptoms

For patients with delirium manifesting severe agitation or psychotic symptoms:

• Neuroleptics/antipsychotics:
  • Levomepromazine: Starting dose 12.5-25 mg; can be administered orally or parenterally 1
  • Chlorpromazine: 12.5 mg every 4-12 hours IV/IM 1
  • Note: Use only for short-term symptom control

Sedatives

• Benzodiazepines:

  • Midazolam: 0.5-1 mg/h starting dose for severe cases 1
  • Caution: Can worsen confusion in elderly; use only when necessary

• Alpha-2 agonists:

  • Dexmedetomidine: Consider for reducing delirium incidence and providing sedation with minimal respiratory depression 1

Non-Pharmacological Interventions

Environmental Modifications

• Ensure appropriate lighting (bright during day, dim at night)
• Reduce unnecessary noise
• Place familiar objects and orientation cues in patient's room
• Maintain consistent nursing staff when possible

Reorientation Strategies

• Frequently orient patient to time, place, and situation
• Use clocks and calendars in patient's room
• Encourage family visits and involvement

Mobility and Function

• Implement early mobilization 1
• Remove unnecessary catheters and restraints
• Avoid physical restraints which may worsen confusion 3

Sleep Improvement

• Promote normal sleep-wake cycles
• Minimize nighttime disruptions
• Schedule medications to avoid sleep interruption

Monitoring and Follow-up

Systematic Delirium Screening

• Use validated screening tools at least once per nursing shift 1:
  • Confusion Assessment Method (CAM)
  • Confusion Assessment Method for ICU (CAM-ICU)
  • Intensive Care Unit Delirium Screening Checklist

Nutritional Support

• Assess nutritional status and provide appropriate support 1
• Consider nutritional supplementation for malnourished patients

Special Considerations

Postoperative Patients

• Monitor for pain as a potential cause of confusion 1
• Remove urinary catheters as soon as possible to reduce infection risk 1
• Provide supplemental oxygen for at least 24 hours 1

Terminal Illness

• Focus on comfort measures 1
• Consider limited hydration only to rule out dehydration as a cause of confusion 1
• Avoid unnecessary interventions that do not contribute to patient comfort 1

Common Pitfalls to Avoid

• Failing to identify and treat underlying causes
• Overuse of sedatives or antipsychotics as first-line treatment
• Neglecting non-pharmacological interventions
• Inadequate pain management
• Overlooking dehydration as a potential cause
• Using physical restraints which may worsen confusion
• Delaying treatment of precipitating medical conditions

By systematically addressing the underlying causes and implementing appropriate supportive measures, acute confusion can be effectively managed in the inpatient setting, leading to improved outcomes and reduced complications.