Management of Acute Confusional State
The initial approach to managing a patient with acute confusional state should prioritize assessment and stabilization of vital functions (ABCs), prompt blood glucose measurement, and rapid identification of underlying causes through targeted evaluation. 1
Initial Assessment and Stabilization
- Immediately assess and secure airway, breathing, and circulation (ABCs) as the first priority 1, 2
- Check blood glucose level promptly to rule out hypoglycemia as a reversible cause 1, 2
- Monitor vital signs including oxygen saturation to identify hypoxemia 1
- Provide supplemental oxygen to hypoxic patients but not to nonhypoxic patients 2
- Identify and treat fever, as elevated temperature can worsen outcomes 2
Rapid Diagnostic Evaluation
- Determine time of onset and progression of confusion (last known well time) to establish a timeline 1, 2
- Perform targeted neurological examination to identify focal deficits that may suggest stroke or other structural lesions 1, 2
- Obtain comprehensive medication history with special attention to recently added medications, opioids, sedatives, and anticholinergics 1
- Screen for common stroke mimics and conditions that present with confusion (see table below) 2
Common Conditions Mimicking or Causing Acute Confusion
- Hypoglycemia: Check in patients with diabetes, decreased consciousness 2
- Infections: Particularly common in elderly patients admitted with confusion 3
- Hypertensive encephalopathy: Look for headache, significant hypertension, cortical blindness 2
- Drug toxicity: Consider medication side effects or withdrawal 1
- Congestive heart failure: Common cause in elderly patients 3
- Stroke: Especially right middle cerebral artery territory infarctions 4
Laboratory and Diagnostic Testing
- Order complete blood count to identify leukocytosis, which is frequently associated with delirium 5
- Check electrolytes, particularly sodium levels, as hyponatremia is a common factor 5
- Consider toxicology screen if drug intoxication is suspected 1
- Perform neuroimaging (CT or MRI) when focal neurological signs are present, history of head trauma exists, or fever without clear source is noted 1
- Consider lumbar puncture to exclude CNS infection when fever is present without clear source, meningeal signs are present, or in immunocompromised patients 1
Treatment Approach
Address the underlying cause as the primary treatment strategy - this significantly improves outcomes 5
Implement non-pharmacological interventions as first-line approach:
Reserve pharmacological interventions for patients with severe agitation that poses safety risks or prevents essential medical care 1
Do not administer haloperidol or risperidone for mild-to-moderate delirium as they have no demonstrable benefit and may worsen symptoms 2
Consider olanzapine, quetiapine, or aripiprazole for symptomatic management of delirium when necessary 2
Avoid benzodiazepines as first-line agents except in alcohol/sedative withdrawal 1, 2
Consider dexmedetomidine in surgical patients as it may reduce delirium incidence 6, 2
Monitoring and Follow-up
- Implement systematic delirium screening at least once per nursing shift using validated tools such as the Confusion Assessment Method (CAM) 2
- Monitor for resolution of confusion as it typically accompanies recovery from the underlying condition 3
- Be aware that approximately 25% of patients who experience acute confusional state may have residual cognitive deficits 6
Common Pitfalls to Avoid
- Overlooking medication side effects as potential causes of confusion 1
- Using physical restraints as first-line management, which can worsen agitation and confusion 1
- Administering sedatives without addressing the underlying cause 1
- Failing to recognize iatrogenic causes, especially in patients who develop confusion after hospitalization 3
- Dismissing acute confusional state as benign or self-limiting, when it actually increases mortality and hospital length of stay 6, 5