How do you assess and manage confusion in a patient?

Assessment and Management of Confusion

Immediate Stabilization Takes Absolute Priority

Assess and secure airway, breathing, and circulation (ABCs) first, then immediately check point-of-care blood glucose to exclude hypoglycemia as a rapidly reversible cause of altered mental status. 1, 2 Monitor vital signs including oxygen saturation, as hypoxemia can contribute to or worsen confusion, and provide supplemental oxygen only if the patient is hypoxic. 1, 2

Assume Delirium Until Proven Otherwise

Given the high mortality risk associated with delirium, you must assume delirium is present in any confused patient until proven otherwise. 1, 3 This is a life-threatening medical emergency requiring urgent evaluation and treatment. 1, 3

Apply the Confusion Assessment Method (CAM)

Use the CAM criteria to screen for delirium, which requires ALL of the following: 1, 2

• (1) Acute onset with fluctuating course
• (2) Inattention
• PLUS either (3) disorganized thinking OR (4) altered level of consciousness

For ICU patients specifically, use the CAM-ICU or Intensive Care Delirium Screening Checklist (ICDSC), as these demonstrate very good psychometric properties and are explicitly designed for both ventilated and non-ventilated ICU patients. 4

Obtain Critical Historical Information

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

Perform Targeted Neurological Examination

Conduct a focused neurological examination specifically looking for: 1, 2

• Focal deficits suggesting stroke, intracranial hemorrhage, or structural lesions
• Meningeal signs (neck stiffness, photophobia) indicating CNS infection
• Signs of increased intracranial pressure

Complete Comprehensive Medication Review

Medication side effects are one of the most common and reversible precipitants of confusion. 1, 2 Obtain detailed medication history with special attention to: 1, 2

• Recently added medications
• Opioids (consider opioid-induced neurotoxicity, particularly with rapidly increasing doses or renal impairment)
• Sedatives and benzodiazepines
• Anticholinergics
• Corticosteroids
• All over-the-counter drugs and herbal supplements

Mandatory Laboratory Testing

Order the following tests in every confused patient: 1, 2

• Complete blood count with differential to evaluate for infection and hematologic abnormalities
• Comprehensive metabolic panel including electrolytes, renal function, liver function, and calcium
• Thyroid function tests to exclude thyroid disorders
• Urinalysis and urine culture given the high frequency of urinary tract infections as precipitants
• Toxicology screen if drug intoxication is suspected

Selective Neuroimaging (Not Routine)

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, 2 Consider CT head or MRI when: 1, 2

• Focal neurological signs are present
• History of head trauma exists
• Patient is on anticoagulation
• New-onset seizures occur
• Signs of increased intracranial pressure are present
• Fever without clear source is present

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, 2 Do not delay lumbar puncture if CNS infection is suspected, as this is time-sensitive. 1

Special Population Considerations

In patients over 50 years old, assess for symptoms of giant cell arteritis including: 1, 2

• Headache
• Scalp tenderness
• Jaw claudication
• Temporal artery tenderness

Order erythrocyte sedimentation rate and C-reactive protein emergently if giant cell arteritis is suspected. 1, 2

Non-Pharmacological Management First

Implement environmental and supportive interventions: 1, 2

• Ensure proper orientation with clocks, calendars, and familiar objects
• Minimize sensory deprivation or overload with appropriate lighting and reduced excessive noise
• Encourage family presence when possible
• Encourage early mobilization when clinically appropriate

Pharmacological Management: Use Sparingly

Reserve pharmacological interventions for patients with severe agitation that poses safety risks or prevents essential medical care. 2

Critical Medication Guidance:

Do not administer haloperidol or risperidone for mild-to-moderate delirium as they have no demonstrable benefit and may worsen symptoms. 2 Haloperidol carries significant risks including tardive dyskinesia (potentially irreversible involuntary movements), neuroleptic malignant syndrome (potentially fatal), falls, and extrapyramidal symptoms. 5

If pharmacological management is absolutely necessary for severe agitation: 2

• Consider olanzapine, quetiapine, or aripiprazole for symptomatic management
• Use the lowest effective dose for the shortest duration
• Avoid benzodiazepines as first-line agents except in alcohol/sedative withdrawal

Common Pitfalls to Avoid

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

Ongoing Monitoring in ICU Settings

Implement systematic delirium screening at least once per nursing shift using validated tools such as the CAM-ICU or ICDSC. 4, 2 ICU patients at moderate to high risk for delirium (those with baseline history of alcoholism, cognitive impairment, hypertension, severe sepsis or shock, on mechanical ventilation, or receiving parenteral sedatives and opioids) should be routinely monitored. 4