Diseases » Delirium

Confusion

Confusion: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses

An umbrella term for puzzling or inappropriate behavior or responses, confusion is the inability to think quickly and coherently. Depending on its cause, confusion may arise suddenly or gradually and may be temporary or irreversible. Aggravated by stress and sensory deprivation, confusion commonly occurs in hospitalized patients — especially in elderly patients, in whom it may be mistaken for senility.

When severe confusion arises suddenly and the patient also has hallucinations and psychomotor hyperactivity, his condition is classified as delirium. Long-term, progressive confusion with deterioration of all cognitive functions is classified as dementia.

Confusion can result from fluid and electrolyte imbalance or hypoxemia due to pulmonary disorders. It can also have a metabolic, neurologic, cardiovascular, cerebrovascular, or nutritional origin, or can result from a severe systemic infection or the effects of toxins, drugs, or alcohol. Confusion may signal worsening of an underlying and perhaps irreversible disease.

History

When you take his history, ask the patient to describe what’s bothering him. He may not report confusion as his chief complaint but may complain of memory loss, persistent apprehension, or the inability to concentrate. He may be unable to respond logically to direct questions. Check with a family member or friend about onset and frequency. Find out, too, if the patient has a history of head trauma or a cardiopulmonary, metabolic, cerebrovascular, or neurologic disorder. Find out which medications he’s taking, if any. Ask about any changes in eating or sleeping habits and in drug or alcohol use.

Physical assessment

Perform an assessment to determine the presence of systemic disorders. Check vital signs, and assess the patient for changes in blood pressure, temperature, and pulse. Next, perform a neurologic assessment to establish the patient’s level of consciousness.

Medical causes

Brain tumor

In the early stages of a brain tumor, confusion is usually mild and difficult to detect. As the tumor impinges on cerebral structures, however, confusion worsens and the patient may exhibit personality changes, bizarre behavior, sensory and motor deficits, visual field deficits, and aphasia.

Decreased cerebral perfusion

Mild confusion is an early symptom of decreased cerebral perfusion. Confusion may be insidious and fleeting, as in a transient ischemic attack, or acute and permanent, as in stroke. Associated findings usually include hypotension, tachycardia or bradycardia, irregular pulse, ventricular gallop, edema, and cyanosis.

Fluid and electrolyte imbalance

A fluid and electrolyte imbalance can cause confusion. The extent of imbalance determines the severity of the patient’s confusion. Typically, he’ll show signs of dehydration, such as lassitude, poor skin turgor, dry skin and mucous membranes, and oliguria. He may also develop hypotension and a low-grade fever.

Head trauma

Such head trauma as concussions, contusions, and brain hemorrhages may produce confusion at the time of injury, shortly afterward, or months or even years afterward. The patient may be delirious, with periodic loss of consciousness. Vomiting, severe headache, pupillary changes, and sensory and motor deficits are also common.

Heatstroke

Heatstroke causes pronounced confusion that gradually worsens as body temperature rises. Initially, the patient may be irritable and dizzy; later, he may become delirious, have seizures, and lose consciousness.

Heavy metal poisoning

Chronic ingestion or inhalation of heavy metals (such as lead, arsenic, mercury, and manganese) eventually produces confusion and, typically, weakness and drowsiness. The patient may also experience headache, vomiting, seizures, tremors, gait disturbances, and mental deterioration.

Hypothermia

Confusion may be an early sign of hypothermia. Typically, the patient displays slurred speech, cold and pale skin, hyperactive deep tendon reflexes, rapid pulse, and decreased blood pressure and respirations. As his body temperature continues to drop, his confusion progresses to stupor and coma, his muscles develop rigidity, and his respiratory rate decreases.

Hypoxemia

Acute pulmonary disorders that result in hypoxemia produce confusion that can range from mild disorientation to delirium. In advanced stages, chronic pulmonary disorders produce persistent confusion as well as severe dyspnea, disability, cor pulmonale, and severe respiratory failure.

Infection

Severe generalized infection, such as sepsis, commonly produces delirium. Central nervous system (CNS) infections such as meningitis cause varying degrees of confusion along with headache and nuchal rigidity.

Metabolic encephalopathy

Both hyperglycemia and hypoglycemia can produce sudden confusion. A patient with hypoglycemia may also experience transient delirium and seizures. Uremic and hepatic encephalopathies produce gradual confusion that may progress to seizures and coma. Usually, the patient also experiences tremors and restlessness.

Nutritional deficiencies

Inadequate dietary intake of thiamine, niacin, or vitamin B_12, which causes nutritional deficiencies, produces insidious, progressive confusion and possible mental deterioration. Associated CNS abnormalities may become severe enough to induce hallucinations and paranoia.

Seizure disorders

Mild to moderate confusion may immediately follow any type of seizure. The confusion usually disappears within several hours. The patient may have difficulty talking and may fall into deep sleep after the seizures.

Thyroid hormone disorders

Hyperthyroidism produces mild to moderate confusion along with nervousness, inability to concentrate, weight loss, flushed skin, and tachycardia. Hypothyroidism produces mild, insidious confusion and memory loss; weight gain; bradycardia; and fatigue.

Other causes

Alcohol

Intoxication causes confusion and stupor, and alcohol withdrawal may cause delirium and seizures.

Drugs

Large doses of CNS depressants produce confusion that can persist for several days after the drug is discontinued. Opioid and barbiturate withdrawal also causes acute confusion, possibly with delirium. Other drugs that commonly cause confusion include lidocaine, digoxin, indomethacin, cycloserine, chloroquine, atropine, and cimetidine.

Special considerations

Never leave a confused patient unattended, to prevent injury to himself and others. Take measures to ensure patient safety. Keep the patient calm and quiet, and plan uninterrupted rest periods. Implement interventions to correct the underlying cause of confusion, such as giving supplemental oxygen to the patient with hypoxemia or withholding the offending drug.

Pediatric pointers

Confusion can’t be determined in infants and very young children. However, older children with acute febrile illnesses commonly experience transient delirium or acute confusion.

Patient counseling

To help the patient stay oriented, keep a large calendar and a clock visible, and make a list of his activities with specific dates and times. Always reintroduce yourself to the patient each time you enter his room.

Pictures

Book Source Details

• Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1

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