CONFUSION
PATHOPHYSIOLOGY
Various theories are postulated for the development of confusion.
Delirium is a type of confusional state which develops suddenly and causes rapid changes in brain function.
Lesions involving the ascending reticular activating system causes disturbances in arousal.
Lesions involving non-dominant frontal and parietal lobes causes disturbances in attention.
Lesions of the cortex will cause disturbances in the insight and judgement capacity of the individual.
Disturbances in the global function of the brain leads to delirium.
Certain diseases and strokes cause confusion. There is evidence to support a sub cortical mechanism for confusion.
Certain drugs have anticholinergic properties which can impair brain function in elderly people and when used in high doses.
In certain conditions, post surgical recovery states can induce cytokine activation, which may be the cause for confusion.
Certain metabolic states like hypoglycemia, electrolyte abnormalities, and hypoxia cause global brain dysfunction leading to confusion.
MEDICATION
Delirium - may be hyperactive, hypoactive or mixed state (Benzodiazepines alone do not improve cognition in delirium, and may worsen it)
Acute on chronic confusion example in dementia, cerebrovascular disease
Emergency sedation of an acutely agitated /disturbed patient
sedate with haloperidol 2.5-5mg IM +/- benzodiazepine Example: midazolam 2.5mg IM or diazepam (rectal solution) 5-10mg, PR
repeat after 30 –60 minutes if needed
maintenance treatment may be needed based on stat doses used (Patients who are larger and physically fit may need higher doses)
use haloperidol:- stat+ PRN; 1.25-5mg, SC or 0.5-5mg, oral maintenance ; 2.5-10mg/ 24hrs, SC via a syringe driver or 0.5-3mg b.d, oral
delirium haloperidol as above
chronic confusion risperidone 0.25-1mg nocte, increasing gradually to 1mg bd, oral
insomnia trazodone 50-100mg nocte. (should be withdrawn gradually)
IMPORTANT ASSESSMENTS (INCLUDING ONGOING ASSESSMENTS)
Assess for fluctuating levels of consciousness, which is key in delirium.
Interview family or other caregivers.
Assess for past confusion states.
Identify other disturbances in medical status such as dyspnea, edema, presence of jaundice.
Identify electroencephalogram (EEG), neuroimaging, or laboratory abnormalities in the patient's record.
Assess vital signs, level of consciousness, and neurological signs.
Ask the patient if lucid or family what they think could be responsible for the delirium such as medications, withdrawal of substance, other medical condition.
Assess the potential for injury, is the patient safe from falls, wandering.
Assess the need for comfort measures pain, cold, positioning
Are immediate medical interventions available to help prevent irreversible brain damage
NURSING INTERVENTIONS
When patients are confused and frightened and are having a difficult time interpreting reality, they might be prone to accidents. Therefore, safety is a high priority.
Delirium is transitory when interventions are instituted and if delirium does not last a prolonged period of time. Therefore, immediate intervention for the underlying cause of the delirium is needed to prevent irreversible damage to the brain. Medical interventions are the first priority.
Delirium is a terrifying experience for many patients. When some individuals recover to their premorbid cognitive function, they are left with frightening memories and images. Preventive counseling and education after recovery from acute delirium is helpful.
Avoid the use of restraints. Encourage one or two significant others to stay with the patient to provide orientation and comfort.
PATIENT EDUCATION
Orient patient to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking and defensive reactions may result.
Encourage family to participate in reorientation as well as providing ongoing input such as current news and family happenings.
Tell patient to decrease caffeine intake.
Teach or assist the family and significant others in developing coping strategies that are helpful to the patient
Teach family to recognize signs of early confusion and seek medical help.
BEHAVIORAL INTERVENTIONS
Modulate sensory exposure. Provide a calm environment; eliminate extraneous noise and stimuli.
Avoid challenging illogical thinking.
Provide for safety needs such as supervision, siderails, seizure precautions, placing call bell within reach, positioning needed items within reach/clearing traffic paths, ambulating with devices.
Avoid or limit the use of restraints.
Communicate patient’s status, cognition, and behavioral manifestations to all necessary providers.
Manipulate the situation to make it as close to the patient as possible. Use a large clock and calendar. Encourage visits by family and friends. Place familiar objects in sight.
Offer reassurance to the patient and use therapeutic communication at frequent intervals.