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Physicians are all too familiar with the situation of an elderly patient who enters the hospital with a medical or surgical illness or begins a prescribed course of medication and displays a newly acquired mental confusion Presumably the liability to this state is determined by pre-existing brain disease, most often Alzheimer disease but sometimes Parkinson disease or another dementing process, which may or may not have been obvious to the family before the onset of the complicating illness Or, the effects of preexisting cerebral diseases (vascular, neoplastic, demyelinative) may have been too subtle to be appreciated by the patient or the family but nonetheless emerges as disorientation and confusion when precipitated by acute illness All the clinical features that one observes in the acute confusional states may be present, but their severity varies greatly The confusion may be re ected only in the patient s inability to relate the history of the illness sequentially, or it may be so severe that the patient is virtually non compos mentis Although almost any complicating illness may bring out a confusional state in an elderly person, the most common are febrile infectious diseases, especially cases that resist the effects of antibiotics; trauma, notably concussive brain injuries; surgical operations, and particularly general anesthesia and pre- and postoperative medication; even small amounts of pain or sedative medications used for any cause; and congestive heart failure, chronic respiratory disease, and severe anemia, especially pernicious anemia With regard to medications, those with atropinic effects have the highest tendency to cause confusion, but others, even seemingly innocuous ones, in particular circumstances may do the same (eg, histamine blockers used to reduce gastric acid, anticonvulsants, corticoste-

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ever, the acute medical illness marks the beginning of a persistent decline in mental clarity that over time can be identi ed as a dementing illness

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A small proportion of psychoses of schizophrenic or manic-depressive type rst become manifest during an acute medical illness or following an operation or parturition and need to be distinguished from an acute confusional state Rarely, a catatonic state will make its rst appearance in these circumstances A causal relationship between the psychosis and medical illness is sought but cannot be established The psychosis may have preceded the medical illness but was not recognized, or it may have emerged during the convalescent period The diagnostic study of the psychiatric illness must proceed along the lines suggested in Chaps 57 and 58 Close observation will usually disclose a clear sensorium and relatively intact memory, features that permit differentiation from an acute confusional or delirious state or dementia

TABLE 6-12

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The syndromes themselves and their main clinical causes are the only satisfactory basis for classi cation until such time as their actual causes and pathophysiology are discovered (Table 20-1) The former practice of classifying the syndromes according to their most prominent symptom or degree of severity eg, picking delirium, acute delirious mania, has no fundamental value The rst step in diagnosis is to recognize that the patient is confused This is obvious in most cases, but, as pointed out above, the mildest forms, particularly when some other alteration of personality is prominent, may be overlooked In these mild forms, a careful analysis of the patient s thought processes, as details of the history of the illness and the patient s personal life are obtained, will usually reveal incoherence A subtle disorder of orientation may be betrayed by an incorrect response regarding dates (off by more than one day of the month or day of the week) or in misnaming the hospital Digit span forward (normally 7) and backward (normally 5), spelling a word such as world or earth forward and then backward, reciting the months of the year in their reverse order, and serial subtraction of 3s from 30 or 7s from 100 are useful bedside tests of the patient s capacity for attentiveness and sustained mental activity Another is the ef ciency in performing dual tasks such as tapping alternately with each hand while reading aloud Memory of recent events is one of the most delicate tests of adequate mental function and is readily accomplished by having the patient relate the details of entry to the hospital; ancillary examinations; naming the president, vice president, and mayor; and summarizing major current events, etc, as outlined in Chap 21 Once it is established that the patient is confused, the differential diagnosis must be made between an acute confusional state associated with psychomotor underactivity, delirium, a beclouded dementia, and a confusional state that complicates focal cerebral disease This is done by taking into account the degree of the patient s alertness, wakefulness, psychomotor and hallucinatory activity, and disturbances of memory and impulse as well as the presence or absence of asterixis or myoclonus or signs of overactivity.