acute confusional state

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Acute confusional state

Synonyms : post operative psychosis, delirium, acute brain failure


Incidence Acute confusional state is a common condition, occurring in 10-20% of all hospital admissions. It is
more likely to occur in elderly patients, particularly in those patients who already have some impairment of
cognitive ability.

Risk factors: Age, pre-existing cognitive impairment, drug therapy, regular alcohol use, co-morbidity and
previous similar problems are all predictive factors for the development of an acute confusional state, and
patients with one or more risk factor should be closely observed for the first indications of confusion and
treatment started at an early stage as delay in treatment may result in a poorer outcome due to falls etc.

Acute confusional state is a common occurrence in both community and hospital settings, it describes a
period of reversible confusion with sudden onset, most often associated with concurrent illness or post
operative state, and often in a setting of unfamiliar surroundings. The symptoms of an acute confusional
state are many and varied, and because of this, may be mistaken for symptoms of other psychiatric
disorders. The condition may be responsible for increased morbidity, and increased hospital stay if not
recognised and treated early and carers and relatives may find the symptoms very alarming and should be
advised as to the likely cause and course of the disorder


Symptoms The symptoms are many and varied, but will commonly fluctuate in severity and may include2:

Sudden onset of impairment in cognition
Problems with orientation in time and/or place and/or person
Impairment of memory
Impairment in ability to plan or organise
Changes in sleep–wake cycle
Altered affect, often with emotional lability
Altered perception of external stimuli
Visual hallucinations-often vivid
Agitation or change in activity levels

Differential Diagnosis Due to the nature of the presenting symptoms, an acute confusional state is commonly
mistaken for:

Psychotic illness
Initial assessment of apparently confused patient

When possible, take a history from the patient and/or any person accompanying them ask about drugs,
alcohol use, illnesses especially diabetes, head injury, previous mental state.

Assess their level of disorientation using either the Confusion Assessment Method (CAM)2,3 or the
Abbreviated Mental Test (AMT).

Date of birth
Time to the nearest hour
Name of institution
Recognition of two people (e.g. can they recognise your job and that of the nurse)
Year of the first world war ( or some other major event for younger people)
Name of the monarch
Count backwards from 20 to 1
A score of less than 6 suggests impaired cognition
Look for any obvious cause e.g. head injury, hypothermia, dehydration, hip fracture, CVA, urinary retention
Assess their general state, if clean and appropriately dresses this may suggest an acute problem
Check temperature, pulse , BP and JVP
Look for sources of infection e.g. chest infection, cellulitis
Dip test urine for blood protein and sugar
Check for hypoglycaemia
FBC looking for raised white cell count and anaemia
U+Es looking for electrolyte imbalance and dehydration
Serum Calcium- hypercalcaemia may result in confusion
+/- CXR even if no clinical signs of pneumonia



Environmental factors are particularly important in the treatment of acute confusional state and the following
factors are helpful in shortening the period of confusion.
Continuity of care personnel i.e. the same nurse/doctor whenever possible
Clear concise communication
Repeated verbal reminders of time, place and person.
Clock, calendar, TV, newspaper, radio readily accessible as a means of orientating in time
Bedside lighting available and left on at night
Simplify the environment, single room when available, reduce noise levels, remove unnecessary equipment
Correct sensory impairment by ensuring the patient is wearing hearing aid/glasses/false teeth etc
Allow maximum periods of uninterrupted sleep
Allow patient to become involved in self care regime, decide level of analgesia etc.
Encourage mobilisation and increase activity levels

Drugs and other therapeutic measures

Oxygen if cause uncertain or secondary to cardiac or respiratory problems
50 mls 50% glucose if hypoglycaemic
Treat the underlying cause e.g. infection
Drug treatment must only be used in conjunction with the environmental measures above, or otherwise may
in some instances worsen the confusion. Early intervention with drugs when required is associated with
lower overall drug use and better eventual outcome.
Discontinue or change any drugs which may by contributing to the confusion as drugs are implicated in 10-
20% of cases. All drugs are capable of producing the state, but some are much more likely to produce
problems e.g. narcotics, opiates, benzodiazepines and drugs with anticholinergic activity.
Identify the reason for prescribing drugs, as benefits from decreased agitation may be associated with risks
of longer periods of confusion or cognitive impairment.
Antipsychotic agents such as chlorpromazine or haloperidol are commonly used in preference to
benzodiazepines, and low doses of haloperidol are preferable to other agents due to a lower side effect
Droperidol may be used if a fast onset of action and increased sedation is required.
Olanzapine and respiridone have been used with some success and early studies suggest they are less
sedating and have fewer side effects, but further controlled studies require to be performed.5
If it is felt that treatment with a benzodiazepine would be beneficial, then lorazepam is the drug of first choice
due to it’s rapid onset of action and low side effect profile.
Complications Acute confusional state can result in increased morbidity and increased length of hospital stay
and use of care facilities on discharge if not recognised and treated early. Common problems occur as a
result of falls, injury during periods of agitation, increase in problems from poor mobility secondary to
sedation e.g. chest infections, pressure sores, pulmonary emboli and therefore early intervention with
environmental factors+/- appropriate drug therapy is important in preventing secondary problems.

Prognosis The prognosis will depend on the co-morbidities and the development of complications, but the
majority of patients who develop an acute confusional state will in time, with good management, return to
their pre-morbid state.

Prevention In high risk patients, providing a consistent environment with readily available points of reference
will help to avoid/lessen the degree of confusion.
References Used

Trzepacz PT; Delirium. Advances in diagnosis, pathophysiology, and treatment.;Psychiatr Clin North Am
1996 Sep;19(3):429-448.

Inouye SK; The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation
of delirium in hospitalized elderly medical patients.;Am J Med 1994 Sep;97(3):278-88.

Schuurmans MJ, Deschamps PI, Markham SW, et al; The measurement of delirium: review of scales.;Res
Theory Nurs Pract 2003 Fall;17(3):207-24.

Hassan E, Fontaine DK, Nearman HS; Therapeutic considerations in the management of agitated or
delirious critically ill patients.;Pharmacotherapy 1998 Jan-Feb;18(1):113-29.

Meagher DJ; Delirium: optimising management.;BMJ 2001 Jan 20;322(7279):144-9.


Psychosis is a loss of contact with reality, typically including delusions (false ideas about what is taking place
or who one is) and hallucinations (seeing or hearing things which aren't there).

Alternative Names

Causes, incidence, and risk factors

Psychosis is a severe mental condition characterized by a loss of contact with reality. There are numerous
potential causes:

Alcohol and certain drugs can induce psychosis
Bipolar disorder (manic depression)
Brain tumors
Psychotic depression
Dementia (Alzheimer's and other degenerative brain disorders)


Loss of touch with reality
Seeing, hearing, feeling, or otherwise perceiving things that are not there (hallucinations)
Disorganized thought and/or speech
Emotion is exhibited in an abnormal manner
Extreme excitement (mania)
Depression and sometimes suicidal thoughts
Unfounded fear/suspicion
Mistaken perceptions (illusions)
False beliefs (delusions)

Signs and tests

Psychological evaluation and testing are used to diagnosis the cause of the psychosis.

Laboratory or radiological testing may not be essential, but sometimes can help pinpoint the exact diagnosis.
Tests may include:

MRI of the brain
Tests for syphilis
Drug screens


Treatment varies depending on the cause of the psychosis. Care in a hospital is often needed to ensure the
patient's safety. Drugs that diminish auditory hallucinations ("hearing voices") and delusions, and stabilize
thinking and behavior (antipsychotic drugs) are helpful. Group or individual therapy can also be useful.

Expectations (prognosis)

The expectations for the outcome vary with the specific disorder. Many of the symptoms can be controlled
with long-term treatment.


Psychosis can prevent a person from functioning normally. During psychotic states, there can be an inability
to care for oneself. If the condition is left untreated, there is a possibility of self-harm or harm to others.
Calling your health care provider

Call your health care provider or mental health professional if a member of your family exhibits behavior
indicating a loss of contact with reality. If there is any concern about safety, as described above, immediately
take the person to the nearest emergency room for evaluation.


Prevention depends on the cause. For example, preventing alcohol abuse prevents alcohol-induced

Substance-induced psychotic disorder


Prominent psychotic symptoms (i.e., hallucinationsand/or delusions) determined to be caused by the effects
of a psychoactive substance is the primary feature of a substance-induced psychotic disorder. A substance
may induce psychotic symptoms during intoxication (while the individual is under the influence of the drug) or
during withdrawal (after an individual stops using the drug).


A substance-induced psychotic disorder is subtyped or categorized based on whether the prominent feature
is delusions or hallucinations. Delusions are fixed, false beliefs. Hallucinations are seeing, hearing, feeling,
tasting, or smelling things that are not there. In addition, the disorder is subtyped based on whether it began
during intoxication on a substance or during withdrawal from a substance. A substance-induced psychotic
disorder that begins during substance use can last as long as the drug is used. A substance-induced
psychotic disorder that begins during withdrawal may first manifest up to four weeks after an individual stops
using the substance.


A substance-induced psychotic disorder, by definition, is directly caused by the effects of drugs including
alcohol, medications, and toxins. Psychotic symptoms can result from intoxication on alcohol, amphetamines
(and related substances), cannabis (marijuana), cocaine, hallucinogens, inhalants, opioids, phencyclidine
(PCP) and related substances, sedatives, hypnotics, anxiolytics, and other or unknown substances.
Psychotic symptoms can also result from withdrawal from alcohol, sedatives, hypnotics, anxiolytics, and
other or unknown substances.

Some medications that may induce psychotic symptoms include anesthetics and analgesics, anticholinergic
agents, anticonvulsants, antihistamines, antihypertensive and cardiovascular medications, antimicrobial
medications, antiparkinsonian medications, chemotherapeutic agents, corticosteroids, gastrointestinal
medications, muscle relaxants, nonsteroidal anti-inflammatory medications, other over-the-counter
medications, antidepressant medications, and disulfiram. Toxins that may induce psychotic symptoms
include anticholinesterase, organophosphate insecticides, nerve gases, carbon monoxide, carbon dioxide,
and volatile substances (such as fuel or paint).

The speed of onset of psychotic symptoms varies depending on the type of substance. For example, using a
lot of cocaine can produce psychotic symptoms within minutes. On the other hand, psychotic symptoms may
result from alcohol use only after days or weeks of intensive use.

The type of psychotic symptoms also tends to vary according to the type of substance. For instance, auditory
hallucinations (specifically, hearing voices), visual hallucinations, and tactile hallucinations are most common
in an alcohol-induced psychotic disorder, whereas persecutory delusions and tactile hallucinations
(especially formication) are commonly seen in a cocaine- or amphetamine-induced psychotic disorder.


The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) notes that a diagnosisis made only
when the psychotic symptoms are above and beyond what would be expected during intoxication or
withdrawal and when the psychotic symptoms are severe. Following are criteria necessary for diagnosis of a
substance-induced psychotic disorder as listed in the DSMIV-TR:

Presence of prominent hallucinations or delusions.

Hallucinations and/or delusions develop during, or within one month of, intoxication or withdrawal from a
substance or medication known to cause psychotic symptoms.

Psychotic symptoms are not actually part of another psychotic disorder (such as schizophrenia,
schizophreniform disorder, schizoaffective disorder) that is not substance induced. For instance, if the
psychotic symptoms began prior to substance or medication use, then another psychotic disorder is likely.
Psychotic symptoms do not only occur during delirium.


Little is known regarding the demographics of substance-induced psychosis. However, it is clear that
substance-induced psychotic disorders occur more commonly in individuals who abuse alcohol or other


Diagnosis of a substance-induced psychotic disorder must be differentiated from a psychotic disorder due to
a general medical condition. Some medical conditions (such as temporal lobe epilepsy or Huntington's
chorea) can produce psychotic symptoms, and, since individuals are likely to be taking medications for these
conditions, it can be difficult to determine the cause of the psychotic symptoms. If the symptoms are
determined to be due to the medical condition, then a diagnosis of a psychotic disorder due to a general
medical condition is warranted.

Substance-induced psychotic disorder also needs to be distinguished from delirium, dementia, primary
psychotic disorders, and substance intoxication and withdrawal. While there are no absolute means of
determining substance use as a cause, a good patient history that includes careful assessment of onset and
course of symptoms, along with that of substance use, is imperative. Often, the patient's testimony is
unreliable, necessitating the gathering of information from family, friends, coworkers, employment records,
medical records, and the like. Differentiating between substance-induced disorder and a psychiatric disorder
may be aided by the following:

Time of onset: If symptoms began prior to substance use, it is most likely a psychiatric disorder.
Substance use patterns: If symptoms persist for three months or longer after substance is discontinued, a
psychiatric disorder is probable.
Consistency of symptoms: Symptoms more exaggerated than one would expect with a particular substance
type and dose most likely amounts to a psychiatric disorder.
Family history: A family history of mental illness may indicate a psychiatric disorder.
Response to substance abuse treatment: Clients with both psychiatric and substance use disorders often
have serious difficulty with traditional substance abuse treatment programs and relapse during or shortly
after treatment cessation.
Client's stated reason for substance use: Those with a primary psychiatric diagnosis and secondary
substance use disorder will often indicate they "medicate symptoms," for example, drink to dispel auditory
hallucinations, use stimulants to combat depression, use depressants to reduce anxiety or soothe a manic
phase. While such substance use most often exacerbates the psychotic condition, it does not necessarily
mean it is a substance-induced psychotic disorder.

Unfortunately, psychological tests are not always helpful in determining if a psychotic disorder is caused by
substance use or is being exacerbated by it. However, evaluations, such as the MMPI-2 MAC-R scale or the
Wechsler Memory ScaleRevised, can be useful in making a differential diagnosis.


Treatment is determined by the underlying cause and severity of psychotic symptoms. However, treatment of
a substance-induced psychotic disorder is often similar to treatment for a primary psychotic disorder such as
schizophrenia. Appropriate treatments may include psychiatric hospitalizationand antipsychotic medication.


Psychotic symptoms induced by substance intoxication usually subside once the substance is eliminated.
Symptoms persist depending on the half-life of the substances (i.e., how long it takes the before the
substance is no longer present in an individual's system). Symptoms, therefore, can persist for hours, days,
or weeks after a substance is last used.


There is very little documented regarding prevention of substance-induced psychotic disorder. However,
abstaining from drugs and alcohol or using these substances only in moderation would clearly reduce the
risk of developing this disorder. In addition, taking medication under the supervision of an appropriately
trained physician should reduce the likelihood of a medication induced psychotic disorder. Finally, reducing
one's exposure to toxins would reduce the risk of toxin-induced psychotic disorder.