What is Acute Confusion (delirium)?

When someone is confused, they are disorientated in:

·         Time (e.g. you ask the time and they say 11 am when it is in fact midnight)

·         Place (e.g. they say they are on holiday, when in fact they are in their own bedroom)

·         Person (they cannot recognise people around them, or if extreme cannot even recall their own name).

Confusion can either be:

i). short-term (and usually recovers) - this is called an acute confusional state.

ii). long-term (irreversible) - and this is called dementia.

Acute confusional state is described here. Dementia is summarised in a separate entry.

In sudden-onset short-term confusion there is usually a rapid onset of new (or worsening) confusion. The person may seem "dopey", as if drunk or intoxicated and can't take in conversations or seem to understand instructions. Medically this state is called  "Clouded consciousness". Because the person is so cut-off from what is going on around them, they often misperceive what is happening. They may fail to recognise people they know well - and often believe that others are attacking them or trying to do them harm. They may see hallucinations - where they can see attackers, or animals and often become very scared as a result.

The good news about acute confusion is that it is reversible. Treating the cause results in improvement. Typically acute confusion therefore only lasts a few hours or days at most when treated.

The most common causes of confusion are:

Infection (e.g. water works infection or a chest infection)

Trauma (for example a head injury through a fall, car crash or assault)

Metabolic abnormalities where the balance of blood contents is upset. For example in diabetes confusion may occur when blood sugar becomes either too low ("hypo) or too high.

Withdrawal from alcohol, drugs or some medications which are stopped too rapidly.

Sometimes the confusion is a symptom of another serious illness such as a heart attack, stroke, low blood oxygen (for example after a pulmonary embolism, or heart failure) or very occasionally a brain tumour. In the elderly by far the most common cause is infection and this rapidly improves with treatment by antibiotics.

The Treatment of Acute confusion
If someone develops acute confusion or a sudden worsening of previously milder confusion then a medical check-up is required. This will usually involve a physical examination (e.g. to look for infection, trauma, and to check the persons heart rate and body temperature), blood tests (looking for blood biochemistry abnormalities such as anaemia, low sugar levels, or low sodium levels caused by diuretics/water tablets).

Simple treatments such as good nursing, keeping the person eating and drinking and time can make a huge difference.

The following can help:

·       Keep the room well lit so that the person has good cues as to where they are. This can help keep them calm and oriented.
·       Consistent treatment by one or two people who they can get to know (either a family member at home or a consistent nurse in hospital).
·       Treat the cause (e.g. antibiotics for infection, sugar for low blood sugar etc.).
·       Sedating medication may be needed if they are very upset and agitated. On occasion sedation may be needed if the person is so disturbed that they try to run away and escape. In this situation it is important not to let the person flee from the house as they can be at risk of being knocked over by cars or of hypothermia.

Because of the need for close observation and the possibility of aggression/disturbance most people with acute confusion are offered admission to hospital for a day or so until things improve.

References:
Overcoming Depression: A Five Areas Approach. Williams C, (2001) Hodder Arnold: London ISBN  0-340-76383
Overcoming Anxiety: A Five Areas Approach. Williams C, (2003) Hodder Arnold: London ISBN: 034081005X
I'm not supposed to feel like this: A Christian self-help approach to amxiety and depression. Williams, C. Whitton, I., Richards, P. (2002). Hodder and Stoughton: London.

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