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Confusion
Last reviewed: 16.10.2021
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Confusion of consciousness is a form of stupefaction in which separate elements of its various syndromes are combined, first of all, amentia and delirium. The neurological causes of acute confusion often occur in the form of amential disorder. There is confusion (partial or complete) in the place and time of the self, increased distractibility, confusion, and an effect of bewilderment. Attention is fixed with difficulty, perception and reactions are slow, there is inadequate emotionality, the presence of amorphous unstable illusions and hallucinations, fragmentary delusional experiences.
Patients with a state of acute confusion history is often impossible to collect. In this case, a large number of possible diagnoses should be considered. It should also be remembered that symptomatic therapy can change the picture and prevent the establishment of the cause of a state of acute confusion. Moreover, the possible causes should be quickly grouped in order to reduce the number of diagnostic procedures. You can use the following grouping of potential causes of acute confusion: toxic, inflammatory, vascular, exacerbation of degenerative diseases, metabolic, traumatic, and others.
The main causes of confusion:
- Alcohol withdrawal syndrome
- Drug intoxication
- Encephalitis
- Vascular diseases of the brain
- Alzheimer's disease
- Metabolic disorders
- Hidden bleeding (including intestinal)
- Epileptic twilight states
- Post-traumatic psychosis
- Artistic (postresuscitation, after several ECT sessions).
Alcohol withdrawal syndrome
Alcohol intoxication is the most frequent. A state of acute confusion due to the ingestion of large amounts of alcohol is easily recognized. A detailed picture of alcohol withdrawal syndrome (“trembling state”) should not be a serious problem for diagnosis. Such patients are usually anxious and agitated, disoriented in time and place, do not understand the situation in which they find themselves if asked about it. Since the emergence of withdrawal syndrome requires a long period of alcohol intake, an alcoholic tremor of outstretched arms will be detected upon examination. The picture is complemented by icteric sclera and an enlarged liver during palpation. The most significant among laboratory studies are data indicating a violation of hepatic enzymes.
[3], [4], [5], [6], [7], [8], [9]
Drug intoxication
Tranquilizing drugs can also lead to intoxication and, thus, to confusion and disorientation. Such patients are not anxious and not agitated, rather there is a decrease in wakefulness. In these cases, eye symptoms are helpful: many drugs cause nystagmus and pupillary disorders.
Eye symptoms during intoxication
| Eye symptoms | Cause |
| Mio |
Morphine derivatives Rezerpin Meprobamat Acetylcholinesterase inhibitors |
| Midriaz |
Belladonna alkaloids Chlordephenazine Imipramine Botulism Cocaine |
| Nistagm |
Barbituratı Benzodiazepines Barbiphen |
The tremor can come to light, but there is no ikterichnost of scleras, and data of laboratory inspection are unremarkable. Drug intoxication is usually recognizable on EEG: frontal (barbiturates) or generalized (benzodiazepines) beta waves, or dysrhythmic groups of waves appear mainly in the temporal areas. It is useful to do a toxicological analysis of urine, but usually the study is performed long enough to help on the spot. If it is possible to determine the level of antiepileptic drugs in the serum by the enzyme method, then this also applies to barbiturates and benzodiazepines, the most commonly used drugs. There are also determinants for other psychotropic drugs, such as lithium.
[10], [11], [12], [13], [14], [15], [16], [17], [18], [19]
Encephalitis
The next condition in which there is an acute onset of confusion is encephalitis. The presence of any febrile illness before the onset of encephalitis is optional. Unfortunately, the first symptoms of the disease - confusion and EEG changes - are not specific enough. Neurological signs may not appear immediately. Hyperthermia is not always the case. Pleocytosis in the cerebrospinal fluid is not yet defined. Only an increase in protein levels suggests an encephalitis diagnosis. Serological data will be available at the earliest in a week.
Often, the diagnosis of encephalitis is established by eliminating other possible causes. It is useful to pay attention to the acute appearance of fever, headache and impaired consciousness. In the event of a rapid deterioration of the patient’s condition, it is advisable to begin therapy, even when there is still no serological confirmation.
[20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31]
Vascular diseases of the brain
The subgroup of vascular diseases includes a variety of etiologies, which are usually easily differentiated. In ischemic stroke, mental disorders are rarely dominated, while intracerebral hemorrhage can lead to confusion until hemiplegia or brain stem damage syndrome appears. The diagnosis can be assumed if the patient suffered from arterial hypertension for a long time. However, this circumstance should not be the only rationale for performing lumbar puncture. An increase in local plus generalized changes in the EEG can confirm the diagnosis, but only a neuroimaging examination allows the diagnosis to be accurately determined. The onset of subarachnoid hemorrhage is sudden and usually causes a headache in people who have never experienced confusion before. With very few exceptions, there is neck stiffness. Then other meningeal signs appear. Often found oculomotor and pupilomotor symptoms, subfebrile. When lumbar puncture in the cerebrospinal fluid is detected blood, which after centrifugation becomes xanthochromic.
With a bilateral stroke in the pool of the posterior cerebral arteries, vision loss and a state of confusion are often observed. Anosognosia in acute cortical blindness may occur. Such patients do not respond to visual stimuli, sound stimuli attract the eye, but this is not a very accurate fixation. In addition, patients deny the existence of blindness and describe their surroundings if asked to do so by resorting to confabulations that complement the state of confusion. Optokinetic nystagmus is absent.
Multi-infarction dementia can lead to periodic states of confusion. A series of small (sometimes large) strokes leads to a gradual deterioration of various cognitive functions, such as memory, speech, attention, which forms multi-infarct dementia. Often there are episodes of nighttime confusion. Emotionality is flattened, complacency appears, sometimes pathological laughter and crying develop.
In this situation, the next stroke leaves the patient in a state of confusion. Diagnosis is based on a characteristic history and neurological deficit, which corresponds to the lesion in a particular vascular pool. Neuroimaging examination reveals residual effects of previous strokes.
In practice, it is very important to single out “atherosclerotic” patients who do not have a history of multi-infarction dementia, are fully balanced, sensible older people. Only after, for example, surgical intervention under general anesthesia can they wake up in a state of deep confusion, as well as during any acute illness. On MRI, signs of transferred "dumb" heart attacks, usually lacunary, are detected.
Alzheimer's disease
In contrast, in Alzheimer's disease, a neuropsychological deficit is constantly progressing. Possible identification of unstable neurological symptoms (especially when mixed type of dementia). Initially, emotional reactions are maintained, as well as the usual social skills of patients. The occurrence of acute confusion is often associated with changes in the patient's life, such as relocation, loss of expensive family members or hospitalization. Neuroimaging data indicate a global decrease in brain volume. Neuropsychological research confirms the diagnosis.
[32], [33], [34], [35], [36], [37], [38]
Metabolic disorders
The state of acute confusion due to metabolic disorders is almost impossible to diagnose at the clinical level. Of course, it is well known that fluttering tremor, that is, asterixis, is observed in the pathology of the liver and kidneys and other metabolic disorders. However, as a rule, the diagnosis is based on laboratory data. In the presence of a state of acute confusion of unknown etiology, screening of metabolic disorders is necessary.
The list of the main reasons, which, of course, is not complete, includes: diabetes mellitus, Addison's disease, dehydration, hypercalcemia, hyperinsulinism, hyper- and hypoparathyreoidism, porphyria, respiratory acidosis and thiamine deficiency, renal and hepatic insufficiency, chronic lung diseases and others. Metabolic encephalopathy, as a rule, is accompanied by a tendency to slow down the bioelectric activity on the EEG.
[39], [40], [41], [42], [43], [44], [45]
Hidden bleeding
In this regard, it should be noted that latent bleeding, including intestinal, can lead to such a decrease in the number of circulating red blood cells, which will result in global cerebral hypoxia, debuting with a state of confusion without neuropsychological disorders or a decrease in wakefulness. Pallor and, especially, tachycardia in a sitting position are characteristic; with intestinal bleeding - black feces. Most often, hidden internal bleeding leads to fainting.
Epileptic twilight states
Twilight states of epileptic nature can occur not only in patients who are aware of their disease, but also after the first attack. They may follow a large convulsive seizure or a series of seizures. In this case, the patient is disoriented in time, and cannot correctly assess the situation. The patient may have delusional disorders, a vague sense of danger, a misinterpretation of even the neutral movements of the people around them, and aggressiveness.
With a continuous series of complex partial attacks, aggressiveness is not typical. Often patients move slowly, perform inadequate actions, and an impression of incomplete wakefulness. Diagnosis is greatly facilitated if there are oral automatisms, such as chewing, swallowing, and (or) stereotypical movements in the hands, as is often observed with an isolated partial complex attack. The final diagnosis is based on monitoring the patient and the EEG.
[51], [52], [53], [54], [55], [56], [57], [58], [59]
Post-traumatic psychosis
The state of post-traumatic psychosis is often not diagnosed if it occurs when a patient wakes up after a post-traumatic loss of consciousness in the surgical department. Characteristic features are anxiety, anxiety and illusory disturbed interpretation of the environment. Patients tend to leave their bed or even leave the department, despite strict instructions to comply with bed rest. This is often regarded as a violation of the regime, and the pathological nature of the condition is not recognized.
Artistic state of confusion
Sometimes a transient state of confusion with disorientation and inappropriate behavior develops in a post-resuscitated state or after several sessions of electro-pulping therapy.