What is the initial approach to evaluating a patient with confusion?

Initial Approach to Evaluating a Patient with Confusion

Begin by immediately stabilizing the patient's vital functions (airway, breathing, circulation) and checking blood glucose to rule out hypoglycemia as a reversible cause, then use the Confusion Assessment Method (CAM) to determine if delirium is present, as this represents a medical emergency requiring urgent evaluation of precipitating factors. 1, 2

Immediate Stabilization and Vital Assessment

• Assess and secure airway, breathing, and circulation (ABCs) as the absolute first priority in any patient presenting with confusion 1
• Check blood glucose immediately using point-of-care testing to exclude hypoglycemia, which is a rapidly reversible cause of altered mental status 1
• Monitor vital signs including oxygen saturation, as hypoxemia can contribute to or worsen confusion 1
• Provide supplemental oxygen only if the patient is hypoxic, not routinely to nonhypoxic patients 1
• Identify and treat fever promptly, as elevated temperature worsens outcomes 1

Establish Timeline and Obtain Collateral History

• Determine the time of onset and progression of confusion (last known well time) to establish whether this represents an acute change versus chronic process 1
• Obtain collateral history from a knowledgeable informant (family member, caregiver, or facility staff) to determine baseline cognitive function and characterize the acute changes, as this is foundational to distinguishing delirium from dementia 1, 2
• Document the patient's baseline cognitive status, functional abilities, and any pre-existing dementia 2

Apply Delirium Screening Criteria

• Use the Confusion Assessment Method (CAM) to screen for delirium, which requires: (1) acute onset with fluctuating course, (2) inattention, and either (3) disorganized thinking or (4) altered level of consciousness 3, 1, 2
• Recognize that delirium represents a life-threatening medical emergency with significant mortality risk if left untreated 2
• Assume delirium is present until proven otherwise in any confused patient, given its high mortality risk 2
• Identify the delirium subtype (hyperactive, hypoactive, or mixed), as each has distinct clinical features and mortality risks 2

Perform Targeted Neurological Examination

• Conduct a focused neurological examination to identify focal deficits that may suggest stroke, intracranial hemorrhage, or other structural lesions 1
• Assess for meningeal signs (neck stiffness, photophobia) that would indicate CNS infection 1
• Evaluate for signs of increased intracranial pressure 1

Complete Comprehensive Medication Review

• Obtain a detailed medication history with special attention to recently added medications, opioids, sedatives, anticholinergics, benzodiazepines, and corticosteroids, as these are common precipitants of delirium 1, 2
• Review all prescription medications, over-the-counter drugs, and herbal supplements 2
• Consider opioid-induced neurotoxicity if the patient is on opioid therapy, particularly with rapidly increasing doses or renal impairment 3

Mandatory Laboratory Testing

• Order complete blood count with differential to evaluate for infection and hematologic abnormalities 1
• Obtain comprehensive metabolic panel including electrolytes, renal function, liver function, and calcium 1
• Check thyroid function tests to exclude thyroid disorders 1
• Perform urinalysis and urine culture given the high frequency of urinary tract infections as precipitants 1
• Order toxicology screen if drug intoxication is suspected 1

Selective Neuroimaging

• Consider CT head or MRI when focal neurological signs are present, history of head trauma exists, or fever without clear source is present 1
• Recognize that the yield of neuroimaging in undifferentiated acute confusional state is only 11%, so use selective criteria based on clinical indicators rather than routine ordering 1
• Neuroimaging is indicated for: focal deficits, recent head trauma, anticoagulation use, new-onset seizures, or signs of increased intracranial pressure 1

Lumbar Puncture Indications

• Perform lumbar puncture when fever is present without clear source, meningeal signs are present, or the patient is immunocompromised to exclude CNS infection 1
• Do not delay lumbar puncture if CNS infection is suspected, as this is time-sensitive 1

Special Considerations for Specific Populations

• In patients over 50 years old, assess for symptoms of giant cell arteritis including headache, scalp tenderness, jaw claudication, and temporal artery tenderness 1
• Order erythrocyte sedimentation rate and C-reactive protein emergently if giant cell arteritis is suspected 1
• Screen for infection sources systematically: urinary tract, respiratory system, skin/soft tissue, and CNS 1

Common Pitfalls to Avoid

• Do not overlook medication side effects as potential causes of confusion, as this is one of the most common and reversible precipitants 1
• Do not use physical restraints as first-line management, as they can worsen agitation and confusion 1
• Do not administer sedatives without addressing the underlying cause, as this masks the problem without treating it 1
• Do not assume a "normal" score on a cognitive screening tool excludes subtle impairment or substantial functional problems 3
• Do not perform cognitive testing during active delirium, as evaluations are unreliable due to fluctuations in mental status; wait at least 2-4 weeks after complete resolution 4

Environmental and Non-Pharmacological Interventions

• Ensure proper orientation by providing clocks, calendars, and familiar objects in the patient's environment 1
• Minimize sensory deprivation or overload with appropriate lighting and reduced excessive noise 1
• Encourage family presence when possible 1
• Encourage early mobilization when clinically appropriate 1

Pharmacological Management Principles

• 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 1
• For severe agitation requiring medication, use low-dose antipsychotics (consider olanzapine, quetiapine, or aripiprazole) 3, 1
• Avoid benzodiazepines as first-line agents except in alcohol or sedative withdrawal 3, 1

Ongoing Monitoring

• Implement systematic delirium screening at least once per nursing shift using validated tools such as CAM 1
• Monitor for fluctuations in mental status throughout the day, as delirium characteristically waxes and wanes 2
• Reassess vital signs and clinical status frequently 1