How to assess confusion in an elderly patient?

Assessment of Confusion in the Elderly Patient

The most effective approach to assess confusion in elderly patients is to use validated tools like the Confusion Assessment Method (CAM) to distinguish between delirium, dementia, and other causes, while obtaining a comprehensive history from both patient and informant about the onset, course, and characteristics of cognitive changes. 1

Initial Assessment Framework

Step 1: Distinguish Between Delirium and Dementia

Delirium and dementia present differently and require different management approaches:

Feature	Delirium	Dementia
Onset	Acute (hours to days)	Insidious (months to years)
Course	Fluctuating	Constant
Attention	Disordered	Generally preserved*
Consciousness	Disordered	Generally preserved*
Hallucinations	Often present	Generally absent*
*Variable in advanced dementia [1]

Step 2: Use Validated Assessment Tools

• Confusion Assessment Method (CAM): Highly specific tool for delirium identification 1
• Mini-Cog: Quick screening with 76% sensitivity, 89% specificity 2
• Montreal Cognitive Assessment (MoCA): More comprehensive with 85% sensitivity, 80% specificity 2

Comprehensive History Taking

When assessing confusion, obtain information from both the patient and a reliable informant (family member or caregiver) about:

1. Onset and progression: Acute (hours/days) versus gradual (months/years) 1
2. Fluctuation patterns: Time of day when symptoms worsen (sundowning) 1
3. Specific examples of memory or cognitive issues (not just vague terms like "confusion") 1
4. Impact on daily functioning: Changes in ability to perform routine tasks 1
5. Medical history: Recent illnesses, hospitalizations, surgeries 1
6. Medication review: Focus on high-risk medications:
   • Anticholinergics
   • Benzodiazepines
   • Opioids
   • Corticosteroids
   • Recent medication changes 2

Physical and Neurological Examination

• Vital signs: Temperature, blood pressure (including orthostatic), heart rate, respiratory rate, oxygen saturation
• Neurological assessment: Focal deficits, signs of increased intracranial pressure
• Hydration status: Skin turgor, mucous membranes
• Sensory assessment: Vision and hearing deficits that may contribute to confusion 2

Laboratory and Diagnostic Evaluation

For acute confusion (delirium), obtain:

• Complete blood count
• Comprehensive metabolic panel
• Urinalysis
• Chest X-ray (if respiratory symptoms)
• ECG
• Oxygen saturation
• Consider blood cultures if infection suspected 1

For gradual cognitive decline (possible dementia), consider:

• Thyroid function tests
• Vitamin B12 and folate levels
• Syphilis serology (if risk factors)
• HIV testing (if risk factors)
• Brain imaging (CT or MRI) 1

Special Considerations

Assessing Communication Abilities

• Evaluate language comprehension and expression
• Assess ability to follow commands
• Note word-finding difficulties 1

Functional Assessment

• Activities of daily living (ADLs)
• Instrumental activities of daily living (IADLs)
• Safety concerns (falls, wandering, medication management) 1

Behavioral and Psychological Symptoms

• Agitation, aggression
• Hallucinations, delusions
• Sleep disturbances
• Mood changes 1

Common Pitfalls to Avoid

1. Assuming confusion is normal aging: Confusion is never normal and always indicates an underlying issue 3
2. Missing delirium in patients with dementia: Delirium superimposed on dementia is common and associated with worse outcomes 1
3. Inadequate history: Failing to interview both patient and informant separately can miss critical information 1
4. Medication oversight: Not reviewing all medications, including over-the-counter and supplements 2
5. Sensory neglect: Not accounting for hearing or vision impairments that may mimic confusion 2
6. Premature diagnosis: Labeling a patient with irreversible dementia before ruling out reversible causes 3

By following this structured approach, clinicians can effectively assess confusion in elderly patients, distinguish between delirium and dementia, identify potentially reversible causes, and develop appropriate management plans.