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ASSESSING CONFUSED PATIENTS
  1. Michael H Johnson
  1. Dr Michael H Johnson, Department of Neurology, St James' University Hospital, Beckett Street, Leeds LS9 7TF, UK michael.johnson{at}leedsth.nhs.uk

https://doi.org/10.1136/jnnp.71.suppl_1.i7

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    The approach to a patient who is confused demands the same principles of assessment that would be applied to other situations in neurology or medicine. The doctor requires knowledge, skill, and most of all experience, but can improve the chances of a correct diagnosis and appropriate management by careful history taking, examination, and observation. This is one area in which expensive investigations are difficult to perform and frequently unhelpful. The challenges are:

    • Is this patient confused and what does that mean?

    • If so, what is the cause?

    • Can the cause be corrected so that the confusion clears?

    TERMS AND DEFINITIONS

    Although“confused” orconfusional state are convenient descriptions to apply to a patient, they do not have a precise medical meaning and are best avoided as diagnostic terms. The termdelirium is much better defined and accepted in the classification of mental disorders. It has been defined as: “an aetiologically non-specific organic cerebral syndrome, characterised by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion and the sleep-wake cycle”.

    An apparently “confused” patient may have an alternative diagnosis such as dysphasia, dementia or psychiatric disorder.

    Delirium, as defined above, includes a range of different behaviours and may be subdivided into hyperactive oragitated delirium, andhypoactive or quiet delirium. The same patient can have both or neither subtype.

    Delirium tremens is a specific term for the confusional state caused by withdrawal of alcohol.

    PREVALENCE AND INCIDENCE

    The prevalence and incidence of delirium depend on the population studied. Prevalence in hospital ranges from 10–20% in medical wards and could become higher as the elderly population in hospital increases. The incidence during hospitalisation ranges from 4–30%, again depending on the population studied. About 25% of people over 70 years old admitted to hospital have delirium.

    CLINICAL FEATURES OF DELIRIUM

    The history and examination should be directed to look at …

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