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If the studies are within normal limits, much has been done to rule out an acute medical condition. But let’s say you have all the time and all the money in the world. You say, “Look, we’ve done all this acute stuff, we said they are not going to die in the next hour, what do we do now?” I’m the only neurologist in town, there is no psychiatrist, I’ve got to pretty much do everything myself, what do I do? Consider an MRI to detect a CNS lesion. Consider a EEG. Sometimes subtle forms of seizures, as you know, can present with confusion. These second tier of laboratory studies, things they probably wouldn’t do in an ER but might do on a psychiatric unit; iron, magnesium, B12, folate, thyroid panel and VDRL. Then if you want to rule out everything in the world - say you’ve got a 20-year-old. He comes in, he’s confused. You’ve done all this stuff and you are probably thinking at this point, what? You’ve done all these studies and everything is negative and this kid is still confused, what do you think it probably is? Probably schizophrenia. You’ve probably got a kid who has got an underlying psychiatric condition. But what you want to do in a 20-year-old is you want to spend every last dollar before you say, oh this is schizophrenia and let’s treat it like schizophrenia. Because every psychiatrist’s worst nightmare is treating some kid for schizophrenia for five years and then seeing one day a Kayser-Fleischer ring. Oops. The kid had Wilson’s disease all along. So the “every-last-dollar-workup” is you want to get a serum ceruloplasmin and there are some other things with the Wilson’s workup. ESR, ANA and heavy metal screening.
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Treatment of confusion. Number one treat the underlying cause, then treat agitation if present.

The confused alcoholic. Keep the patient in the hospital if withdrawal is suspected. If there is a question of what to do with this alcoholic and he seems confused, his blood alcohol level has returned to normal, so it’s not just drunkenness and he doesn’t seem drunk. Confusion isn’t the same as drunkenness. They don’t know where they are, they don’t know what year it is, they are confused. Don’t send that alcoholic home because you are risking DTs, seizures and DTs. Once you see confusion, unfortunately, you may be heading into the DTs and once you head into the DTs there’s no going back. So if you keep them in the hospital, even if they are just drunk and not confused, you’ve got to prophylax for the DTs. So let’s say you keep the person in the hospital because you think they are confused, you think they might be a DT risk, put them on seizure precaution. Because they might seize, of course. Give them thiamin. A reasonable order is 100 mg IM times three, then 100 mg PO per day for the rest of the hospitalization. Give one multivitamin per day and PO folic acid. That’s a common order. Give benzodiazepine, typically chlordiazepoxide or lorazepam.
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When the psychiatrist is called to the emergency room because the patient is confused; somebody who is not acting their normal self the treatment should quickly rule out the potentially lethal and continue or refer their workup as appropriate for their subacute or sublethal condition. The patient can’t tell you what’s going on. They are having confusion, so you need somebody else to tell you, to give you part of the history. Elderly people are more apt to become confused with less of a medical insult. People, when they get older, don’t have the reserve that young people do and as a result a small medical insult will cause major mental status changes. What if you or I have a urinary tract infection? An elderly person with a urinary tract infection, their presenting complaint might be hiding themselves in their bedroom and closing the shades because they think the police are going to come and get them. So they can have mental status changes as the chief complaint in a mild pneumonia or a mild urinary tract infection.
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Another question: any psychiatric or substance abuse history? I think that’s pretty much self-explanatory. Quick review of systems. Any problem with head trauma, seizures or HIV risk? Then this is important; has there been a loss of alertness recently? Is this a new delirium or a chronic dementia? And we’ll talk about delirium versus dementia later in the day. Emergency rule-outs, kind of the quick things you want to go through. Wernicke’s encephalopathy. What do we see with Wernicke’s? Ataxia, sixth nerve palsy and confusion. That’s kind of the classic triad. Alcohol/sedative withdrawal. Hypertensive encephalopathy. What do we see with that? Papilledema, increased CSF pressure. But remember, hypertensive encephalopathy sometimes can be kind of chronic and you see this sort of mild personality stuff develop over time. Hypoglycemia. Is their blood sugar real low? Do they have a tremor? Are they dizzy? Hypoperfusion kind of goes along with hypoxemia. They are not perfusing well enough and that’s why they are confused. CNS bleed, meningitis or encephalitis. What do we see with meningitis? Stiff neck, photophobia, headache. And then acute and toxic metabolic causes and that list can be endless in and of itself.
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Initial workup of the confused patient: first, you assume there is a serious medical condition. You say, okay, there is something medically wrong with this person that needs to be reversed. Then when you have done that, you say, okay, it’s a functional problem. Call the psychiatrist. Functional is the word we use to describe not due to a medical condition. Although you may not find the cause of the confusion, and often you don’t, you want to at least rule out the potentially lethal conditions listed above. The physical exam is going to have a neurological focus, which is good because you are all neurologists. Initial diagnostic studies: chemistry profile, including electrolyte, CBC, U/A, EKG, also consider blood gas and pulse oximetry. Sometimes you want drug screening, depending on the circumstances. Obviously if they are older and in a nursing home you are probably not going to need that, but if they are a young person coming into the ER you definitely are going to need it. You want levels of commonly toxic medications like digoxin, anticonvulsants, such as Dilantin, lithium. Depending on the circumstances, you are going to want a CT scan. Sometimes a spinal tap, depending. Particularly if you are thinking something like meningitis.
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