What is the initial approach to managing acute confusion in an adult patient?

Initial Management of Acute Confusion in Adults

Immediately assess and stabilize airway, breathing, and circulation (ABCs), then check blood glucose at the bedside to rule out hypoglycemia—the most critical reversible cause that requires immediate correction. 1

Immediate Stabilization and Vital Assessment

• Check fingerstick glucose immediately upon patient contact, as hypoglycemia is rapidly reversible and can cause profound confusion 1, 2
• Assess and secure airway patency, breathing adequacy, and circulatory status as the absolute first priority 1
• Measure oxygen saturation and provide supplemental oxygen only if hypoxic (SpO2 <90-92%), as hypoxemia directly worsens confusion 1, 3
• Obtain complete vital signs including temperature, as fever suggests infection and hypothermia can precipitate delirium 1, 2

Rapid Timeline and Focused History

• Establish the exact time of onset and last known well time to distinguish acute delirium (hours to days) from chronic dementia (months to years) 1, 2
• Obtain collateral history from family or caregivers regarding baseline cognitive function, as this is foundational to diagnosis 1
• Review all medications with specific attention to recent additions, opioids, sedatives, benzodiazepines, and anticholinergics 1, 2
• Screen for alcohol or sedative use history, as withdrawal requires different management 4, 1

Targeted Physical and Neurological Examination

• Perform a focused neurological exam specifically looking for focal deficits (weakness, visual field cuts, aphasia, neglect) that suggest stroke or structural lesion 1
• Assess for meningeal signs (neck stiffness, photophobia) that indicate CNS infection 1
• In patients over 50 years, palpate temporal arteries for tenderness and ask about jaw claudication to screen for giant cell arteritis 1
• Examine for signs of trauma, particularly in anticoagulated patients where subdural hematoma may occur without obvious injury 2

Essential Laboratory Testing

• Order immediately: complete blood count, comprehensive metabolic panel (electrolytes, renal function, liver function, calcium), urinalysis with culture 1, 5
• Thyroid function tests should be obtained, as thyroid disorders are common reversible causes in elderly patients 4, 1, 2
• Toxicology screen if substance intoxication or withdrawal is suspected based on history or examination 1, 5
• Blood cultures if fever is present without obvious source 1

Selective Neuroimaging

• Order CT head when: focal neurological deficits present, history of recent head trauma, patient on anticoagulation, signs of increased intracranial pressure, or unexplained fever without source 1, 5, 2
• The yield of neuroimaging in undifferentiated acute confusion without these features is only 5-11%, so selective use is appropriate 1, 2
• MRI brain is preferred over CT when available and patient can cooperate, particularly if stroke remains suspected despite normal CT 2

Lumbar Puncture Indications

• Perform lumbar puncture when: fever without clear source, meningeal signs present, immunocompromised status, or unexplained confusion despite initial workup 1, 5
• This is essential to exclude CNS infection, which carries high mortality if missed 1

Non-Pharmacological Management (First-Line)

• Reorient patients frequently using clocks, calendars, and familiar objects 4, 1, 5
• Encourage family presence when possible, as familiar faces reduce agitation 1
• Ensure patients have eyeglasses and hearing aids if normally used 4
• Maintain appropriate lighting (avoid darkness but minimize excessive stimulation) and reduce noise 4, 1
• Promote early mobilization when medically appropriate, as immobility worsens delirium 4, 1
• Avoid physical restraints as first-line management, as they paradoxically worsen agitation and increase complications 4, 1

Pharmacological Management (Reserved for Severe Agitation)

• Reserve antipsychotics only for severe agitation that poses safety risks or prevents essential medical care 1, 5
• Do not use haloperidol or risperidone for mild-to-moderate delirium, as they have no demonstrable benefit and may worsen symptoms 1
• If pharmacological intervention is necessary for severe agitation, consider low-dose olanzapine, quetiapine, or aripiprazole 1
• Avoid benzodiazepines except in alcohol or sedative withdrawal, as they worsen delirium in other contexts 4, 1

Special Consideration for Dehydration

• In patients with advanced illness or end-of-life scenarios, consider a short and limited trial of parenteral hydration to rule out dehydration as a precipitating cause 4, 1

Systematic Delirium Monitoring

• Use validated screening tools (CAM-ICU or ICDSC) at least once per nursing shift to detect and monitor delirium 4, 1
• The CAM-ICU and ICDSC have the strongest psychometric properties for delirium detection in both ventilated and non-ventilated patients 4

Critical Pitfalls to Avoid

• Do not attribute confusion to dementia without investigating acute causes, as this leads to missed treatable conditions 5, 6
• Do not overlook hypoactive delirium, which is commonly missed because patients appear calm rather than agitated 4, 5
• Do not administer sedatives without first addressing the underlying cause 1
• Mortality doubles when delirium is missed, making prompt recognition a medical emergency 2
• Do not assume syncope or other diagnoses without proper delirium evaluation 2