Acute Confusion

For a doctor, the overwhelming feeling one gets when trying to talk to a patient in an acute confusional state is that he or she just is not really with you. The precise manifestations of what is known medically as "clouded consciousness" differ between individuals, sometimes quite widely, but the condition is common, and usually quite easy to identify.

What is Acute Confusion?

By definition, acute confusional state, sometimes known as delirium, is a period of reversible confusion, with sudden onset, often associated with illness or post operative state, often in unfamiliar surroundings, and often affecting the elderly.

How Common is it?

According to the studies, it occurs in between 10-20% of all hospital admissions, and more rarely among old people who get sick at home.

For the patient herself and her loved ones, an episode of acute confusion is horribly disconcerting and quite unlike anything previously or subsequently experienced. But for doctors and nurses working in general medical or surgical wards, the condition is seen as pretty much an everyday occurrence, and its characteristic signs are easy to spot.

What are the Signs and Symptoms?

The confused person may seem somewhat dopey, unable to focus on surrounding events, conversations or instructions. She may be disorientated in time, place or person, unable to recognise friends or family, and to comprehend that she is in a hospital and that medical staff are trying to treat her. She may ramble or have garbled speech, may hallucinate and may misunderstand surrounding events, often believing that those around are trying to harm her.

Some confused patients become agitated and disruptive, and these are the ones who of necessity end up getting lots of attention from medical staff. Others just become uncharacteristically quiet or drowsy, and this can be more dangerous. Unless there are family members around to raise the alarm that something is wrong, a confused patient who merely seems sleepy may just get ignored. If the state of confusion isn't recognised, no measures will be taken to identify and treat the cause, which may be very dangerous.

Confusional state usually worsens in the late afternoon and evening, a phenomenon called "sundowning". No-one knows why this is.

What Causes Acute Confusion?

The causes are many and varied, and lists include virtually any physical disease and any drug.The commonest causes include:

• Urine or chest infections
• Head injury e.g. after a fall
• Metabolic abnormalities- this means that chemicals or hormones in the blood are out of balance e.g. very low or high blood sugar in diabetes or very low or high blood sodium
• Alcohol, drug or medication withdrawal
• Liver or kidney failure
• Low oxygen levels in the blood
• Dehydration

How is it Treated?

Acute confusion is, by definition, reversible, and the way to reverse it is to find and treat the cause. So the first step is a thorough medical check up, including a full history, physical examination, and relevant laboratory or imaging tests to identify the underlying cause. The cause is often something that's easy to treat and the confusion then clears up very quickly, for example after sugar is given to a diabetic with low blood sugar, or antibiotics to someone with a urine infection.

In the meantime, a confused patient will benefit greatly from appropriate nursing conditions. These include a quiet, calm, familiar, well lit room with consistent carers. Of course, in practical terms, a busy hospital may find it hard to provide this. If a confused patient is very agitated and disruptive, sedating medicines in small doses may be useful. They are usually stopped as soon as possible so recovery from confusional state can be assessed.

The best way to prevent acute confusion from developing is to prevent the many possible causes from occurring. Interestingly, one innovative study showed a decrease in the incidence of post-operative confusion amongst elderly patients undergoing hip and knee surgery when they were exposed to music during their time in hospital.

What is it Like to be Acutely Confused?

Many patients who have recovered from an acute confusional state have, at best, hazy recollections of what occurred, but some are able to remember details of events, and describe how they felt in this mental shadowland. They may recount a feeling of being trapped inside incomprehensible experiences, desperately trying to get a grip while encountering a turmoil of the past and the present and the realm of the imagination as if they are all co-existing realities. The mystery that we don't at present come even close to understanding is what's actually happening inside the brain, and why so many totally different and divergent causes should lead to such a similar and characteristic type of mental clouding.

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