Acute confusional state

Introduction

Acute confusional state, also known as delirium or confusional syndrome, is an acute and fluctuating disorder of consciousness and attention, associated with cognitive impairment (memory, orientation, language) or perceptual changes (hallucinations, delusions). It develops within a few hours to a few days, against an underlying pathological background. It affects up to 30% of hospitalized elderly patients and is always a medical emergency, as it often reveals a serious underlying cause (infection, dehydration, stroke, medication, withdrawal).

If a loved one exhibits a sudden change in behavior, alertness, or orientation, first contact your primary care physician. If they are unavailable, Docadom offers an emergency medical consultation by a doctor at home: call 021 845 45 45 or use our application available on the App Store and Google Play.

Who is at risk?

Confusional state primarily affects elderly people (especially after age 65, and even more so after 80), patients suffering from dementia or Alzheimer’s disease, hospitalized patients (particularly in intensive care or post-operatively), patients on polypharmacy, and patients at the end of life or in palliative care. Sensory deficits (vision, hearing), malnutrition, bed rest, isolation, and sleep deprivation are significant predisposing factors.

Symptoms of acute confusional state

The diagnosis is clinical and relies on the observation of characteristic signs. The presentation can be hyperactive (agitation, hallucinations), hypoactive (drowsiness, withdrawal — the most common and most frequently missed) or mixed.

Main symptoms

• Attentional deficit: difficulty focusing, following a conversation, distractibility.

• Disorientation in time, space, or person.

• Behavioral disorders: agitation, aggressiveness, wandering, or on the contrary, apathy and drowsiness.

• Fluctuations throughout the day: episodes of lucidity alternating with moments of confusion.

• Hallucinations, often visual, and delusional ideas.

• Reversal of the sleep-wake cycle: nighttime agitation, daytime drowsiness.

• Recent memory impairment, incoherent speech.

• Anxiety, fear, sometimes depressive symptoms.

When to seek urgent medical attention?

An acute confusional state is always a medical emergency:

• Sudden or rapid onset of confusion, disorientation, or change in behavior.

• Confusion associated with a fever, or neurological signs (paralysis, speech impairment, stiff neck) — call 144.

• Confusion in a patient with diabetes (hypoglycemia), or heart, respiratory, or renal failure.

• Confusion after a fall, head injury, or recent medication intake.

• Confusion with withdrawal signs (alcohol, benzodiazepines, opiates).

• Uncontrollable agitation, dangerous behavior for the patient or those around them.

What to do before calling Docadom? First, contact the primary care physician of the person concerned, as they are familiar with their medical history and treatments. If they cannot be reached, call Docadom on 021 845 45 45 or make your request directly from our smartphone app (App Store and Google Play). In case of severe signs (fever, neurological deficit, head injury, serious impairment of consciousness), call 144 without delay.

Causes of acute confusional state

Acute confusional state is not a disease in itself but the symptom of an underlying, most often multifactorial cause. The mnemonic device "DELIRIUM" summarizes the main causes.

Infectious causes

Urinary tract infections and pneumonias are the most common causes in elderly individuals, followed by meningitis and encephalitis, septicemia, and COVID-19.

Metabolic and organic causes

Hypoglycemia, hyperglycemia with ketoacidosis, dehydration, electrolyte imbalances (sodium, calcium), kidney failure, liver failure, hypothyroidism or hyperthyroidism, hypoxia, hypercapnia.

Neurological causes

Stroke, subdural hematoma (after a fall, even a minor one), brain tumor, epileptic seizure, head trauma.

Medication-induced and toxic causes

Nearly 40% of confusional states in the elderly are linked to medications. Common culprits: benzodiazpines, opiates, anticholinergics (tricyclic antidepressants, antihistamines), corticosteroids, antibiotics, anti-parkinsonian drugs. Withdrawal from alcohol (delirium tremens), benzodiazepines, or intoxications (alcohol, CO).

Cardiovascular and other causes

Myocardial infarction, heart failure, pulmonary embolism, arrhythmias, uncontrolled pain, urinary retention, fecal impaction, change of environment, sensory deprivation (forgotten glasses or hearing aids).

Diagnosis of acute confusional state

The diagnosis is clinical. Further examinations aim to identify the underlying cause.

Diagnostic methods

• Anamnesis with loved ones: history of cognitive issues, medications, medical history, context of onset.

• Diagnostic scales: Confusion Assessment Method (CAM), 4AT, which help distinguish confusion from dementia.

• Full physical examination: search for neurological signs, infectious signs, hydration status, urinary retention, fecal impaction.

• Laboratory tests: CBC, CRP, electrolytes, blood glucose, kidney function, calcium, liver function, TSH, arterial blood gas.

• Urinalysis and urine culture.

• Chest X-ray to screen for pneumonia.

• ECG to detect an arrhythmia or a myocardial infarction.

• Brain CT scan or MRI in case of neurological signs, head trauma, or diagnostic doubt.

• Lumbar puncture if meningitis or encephalitis is suspected.

Alternative diagnoses

• Dementia: a progressive and permanent disorder, without fluctuations or impairment of alertness.

• Depression with psychomotor retardation.

• Acute psychiatric disorder (manic or psychotic episode).

• Aphasia as part of a stroke.

Management and treatment

Treatment is primarily etiological: it targets the underlying cause. Symptomatic treatment helps protect the patient and limit complications.

Treatment of the cause

Antibiotic therapy for infections, correction of metabolic and fluid-electrolyte imbalances, stopping or adjusting the responsible medications, treating uncontrolled pain, relieving urinary retention, managing withdrawal, and treatment of a stroke or subdural hematoma.

Non-pharmacological measures

• Reorientation: visual cues (clock, calendar), repeated and calm explanations.

• Familiar presence, soft voice, adapted communication.

• Restoring sensory aids: glasses, hearing aids.

• Maintaining the sleep-wake cycle: light during the day, darkness at night.

• Early mobilization, combating malnutrition and dehydration.

• Avoiding physical restraint unless there is immediate danger.

Pharmacological treatment

Reserved for highly agitated or dangerous behaviors. Low-dose haloperidol or risperidone for psychotic symptoms. Benzodiazepines only in cases of alcohol or benzodiazepine withdrawal. To be avoided in the elderly outside of these specific indications.

Prevention of acute confusional state

• Regular prescription reviews, especially for elderly individuals: avoid high-risk medications, simplify treatment plans.

• Maintaining good hydration and balanced nutrition.

• Cognitive stimulation: interaction, reading, television, outings.

• Quality sleep, daylight, and dark nights.

• Sensory aids worn daily.

• Screening and early treatment of infections (urinary, pulmonary).

• Anticipating high-risk situations: preparation for hospitalization, postoperative support.

Possible complications

Acute confusional state significantly increases mortality, prolongs the hospital stay, promotes falls, fractures, postoperative complications, institutionalization, and loss of independence. It can also leave long-lasting cognitive issues and promote or worsen dementia. Early detection and management reduce these complications.

When to contact a doctor for a confusional state

Any newly onset confusion, even modest, is a medical emergency:

• First call: contact the patient's primary care physician, who knows their medical history, treatments, and usual cognitive state.

• If the primary care physician is unavailable (evenings, weekends, holidays), Docadom offers an emergency consultation with a home doctor. Call 021 845 45 45 or submit your request through our mobile app, available free of charge on the App Store and Google Play.

• In case of severity signs (high fever, neurological deficit, head trauma, impaired alertness, dangerous agitation), call 144 immediately.

Conclusion: a frequently overlooked emergency

Acute confusional state is a medical emergency that, in most cases, reveals a serious underlying cause in elderly patients. It is characterized by a sudden and fluctuating attention disorder, disorientation, behavioral issues, and hallucinations, which can lead to complications such as falls, loss of independence, institutionalization, and increased mortality. Systematically identifying the cause (infection, medication, dehydration, stroke) is the key to treatment.

At the slightest sudden change in behavior in a loved one, first consult their primary care physician. If they are not available, Docadom provides an emergency doctor at home 7 days a week: call 021 845 45 45 or use our mobile app (App Store, Google Play) to request an emergency consultation.