What is the initial approach to evaluating a confused patient?

Initial Approach to Evaluating a Confused Patient

Immediately assess and secure airway, breathing, and circulation, then check point-of-care glucose to exclude hypoglycemia, while simultaneously applying the Confusion Assessment Method (CAM) to screen for delirium—assume delirium is present until proven otherwise given its life-threatening nature. 1

Immediate Stabilization (First 5 Minutes)

• Secure ABCs as the absolute first priority in any confused patient 1
• Check fingerstick glucose immediately using point-of-care testing, as hypoglycemia is rapidly reversible 1
• Monitor vital signs including oxygen saturation, temperature, blood pressure, and heart rate 1
• Provide supplemental oxygen only if hypoxic (not routinely to nonhypoxic patients) 1
• Treat fever promptly if present, as elevated temperature worsens outcomes 1

Establish Timeline and Baseline Function

• Determine last known well time to distinguish acute change from chronic process 1
• Obtain collateral history from a knowledgeable informant (family, caregiver, or facility staff) to establish baseline cognitive function and characterize acute changes 2, 1
• Document the patient's baseline cognitive status, functional abilities, and any pre-existing dementia 2, 1
• Ask specifically: "What is the main reason you are here and what would you like to accomplish from this visit?" 2
• Interview patient and informant separately if needed, as diminished insight is common and perspectives may diverge 2

Apply Delirium Screening (CAM Criteria)

Use the Confusion Assessment Method which requires ALL of the following: 1

1. Acute onset with fluctuating course (symptoms vary throughout the day)
2. Inattention (difficulty focusing or maintaining attention)
3. EITHER disorganized thinking OR altered level of consciousness

• Recognize that delirium represents a life-threatening medical emergency with significant mortality risk if untreated 1
• Assume delirium is present until proven otherwise in any confused patient 1

Focused Neurological Examination

• Assess for focal neurological deficits (weakness, sensory loss, visual field cuts, aphasia) that suggest stroke, intracranial hemorrhage, or structural lesions 1
• Evaluate for meningeal signs including neck stiffness, photophobia, and Kernig's/Brudzinski's signs 1
• Check for signs of increased intracranial pressure (papilledema, Cushing's triad) 1
• Examine coordination and gait for cerebellar or extrapyramidal signs 2
• Assess for involuntary movements or abnormalities of motor tone 2

Comprehensive Medication Review

This is one of the most common and reversible causes—do not overlook it. 1

• Review ALL medications including prescription drugs, over-the-counter medications, and herbal supplements 1
• Pay special attention to recently added medications within the past 2 weeks 1
• Specifically identify: opioids, sedatives, anticholinergics (diphenhydramine, hydroxyzine), benzodiazepines, corticosteroids, and any psychoactive drugs 1, 3
• Consider opioid-induced neurotoxicity if patient is on opioid therapy, particularly with rapidly increasing doses or renal impairment 1

Mandatory Laboratory Testing

Order the following tests in ALL confused patients: 1

• Complete blood count with differential to evaluate for infection and hematologic abnormalities 1
• Comprehensive metabolic panel including sodium, potassium, calcium, glucose, BUN, creatinine, and liver function tests 1
• Thyroid-stimulating hormone (TSH) to exclude thyroid disorders 1
• Urinalysis and urine culture given high frequency of urinary tract infections as precipitants 1
• Toxicology screen if drug intoxication or withdrawal is suspected 1

Selective Neuroimaging (Not Routine)

Neuroimaging yields only 11% in undifferentiated confusion—use selective criteria: 1

Order CT head or MRI when ANY of the following are present: 1

• Focal neurological signs or deficits
• Recent head trauma (within 3 months)
• Anticoagulation use (warfarin, DOACs, antiplatelets)
• New-onset seizures
• Signs of increased intracranial pressure
• Fever without clear source
• Immunocompromised state

Lumbar Puncture Indications

Perform lumbar puncture when: 1

• Fever is present without clear source
• Meningeal signs are present
• Patient is immunocompromised
• Do not delay if CNS infection is suspected—this is time-sensitive 1

Special Population Considerations

In patients over 50 years old with confusion and headache: 1

• Screen for giant cell arteritis by assessing for scalp tenderness, jaw claudication, and temporal artery tenderness 1
• Order ESR and CRP emergently if giant cell arteritis is suspected 1

Systematically screen for infection sources: 1

• Urinary tract (most common)
• Respiratory system (pneumonia)
• Skin and soft tissue (cellulitis, pressure ulcers)
• Central nervous system (meningitis, encephalitis)

Critical Pitfalls to Avoid

• Do not use physical restraints as first-line management—they worsen agitation and confusion 1
• Do not administer sedatives without addressing the underlying cause—this masks the problem without treating it 1
• Do not assume a "normal" cognitive screening score excludes impairment, as subtle deficits may be missed 1
• Do not perform formal cognitive testing during active delirium—evaluations are unreliable due to fluctuations; wait 2-4 weeks after complete resolution 1
• Do not overlook medication side effects—this is one of the most common and reversible precipitants 1

Environmental and Non-Pharmacological Interventions

Implement immediately while working up the cause: 2, 1

• Provide orientation aids: visible clocks (24-hour clock in ICU), calendars, and familiar objects 2, 1
• Optimize lighting: appropriate lighting to reduce disorientation, avoid excessive darkness or brightness 2
• Minimize sensory extremes: reduce excessive noise while avoiding sensory deprivation 1
• Encourage family presence when possible 1
• Promote early mobilization when clinically appropriate 1
• Ensure continuity of care: avoid moving patients between rooms or wards unless absolutely necessary 2

Cognitive Symptom Characterization

When the patient or informant reports "memory loss" or "confusion," obtain specific examples: 2

• Distinguish episodic memory loss (difficulty learning and recalling new information and recent events) from word-finding difficulty, inattention, geographic disorientation, or inability to perform step-by-step tasks 2
• Document the profile: characteristics, intensity, temporal course (acute vs. gradual), and functional impact 2
• Assess impact on daily function, interpersonal relationships, and comportment 2

Mental Status Documentation

Document the following elements: 2

• General appearance and nutritional status 2
• Speech fluency and articulation 2
• Mood and level of anxiety 2
• Thought content and process 2
• Perception and cognition 2
• If suicidal ideas are present: assess intended course of action, access to methods (especially firearms), motivations, and reasons for living 2
• If aggressive ideas are present: assess history of violent behaviors and legal consequences 2