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To summarize, the entire group of acute confusional and delirious states is characterized principally by an alteration of consciousness and by prominent disorders of attention and perception, which interfere with the speed, clarity, and coherence of thinking, the formation of memories, and the capacity for performance of selfdirected and commanded activities Three major clinical syndromes can be recognized One is an acute confusional state in which there is manifest reduction in alertness and psychomotor activity A second syndrome, already alluded to as a special form of confusion, delirium, is marked by overactivity, sleeplessness, tremulousness, and prominence of vivid hallucinations, with convulsions often preceding or associated with the delirium These two illnesses tend to

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develop acutely, to have multiple causes, and, except for certain cerebral diseases, to remit within a relatively short period of time (days to weeks), leaving the patient without residual damage or with whatever defects were present before their onset The third syndrome is one in which a confusional state occurs in persons with some underlying, more chronic cerebral disease, particularly a dementia The cerebral disease may be focal or diffuse and, in the latter case, may dispose the patient to a superimposed acute confusional state or psychosis, which we have chosen to designate as a beclouded dementia From the neurologic perspective, the generic term psychosis applies to states of confusion in which elements of hallucinations, delusions, and disordered thinking comprise the prominent features An important point to be made here is that a large set of psychoses leaves the sensorium relatively unclouded and allows for normal attentions and high-level performance of many mental tasks These three syndromes and some aspects of psychotic confusion are elaborated below

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Clinical Features Some features of this syndrome have already been described in Chap 17, Coma and Related Disorders of Consciousness In the most typical examples, all mental functions are reduced to some degree; but alertness, attentiveness, orientation, and the ability to concentrate and to grasp all elements of the immediate situation suffer most Characteristically, these abnormalities uctuate in severity, typically being worse at night ( sundowning ) In the mildest form, the patient appears alert and may even pass for normal; only the failure to recollect and accurately reproduce happenings of the past few hours or days reveals the subtle inadequacy of his mental function The more obviously confused patients spend much of their time in idleness, and what they do may be inappropriate and annoying to others Only the more automatic acts and verbal responses are performed properly, but these may permit the examiner to obtain from the patient a number of relevant replies to questions about age, occupation, and residence Even with these mundane questions, answers tend to be slow and indecisive or blatantly incorrect Orientation to the date, day of the week, and place tends to be imprecise, often with the date being off by several days, the year being given as several years or one decade previous, or with the last two numbers transposed, ie, 2005 given as 2050 The techniques that may be used to elicit these aspects of confusion are given on page 364 Such patients may, before answering, repeat every question that is put to them, and their responses tend to be brief and mechanical It is dif cult or impossible for them to sustain a conversation Their attention wanders and they constantly have to be brought back to the subject at hand They may even fall asleep during the interview, and if left alone are observed to sleep more hours each day than is natural or to sleep at irregular intervals Frequently there are perceptual disturbances in which voices, common objects, and the actions of other persons are misinterpreted Frank hallucinations may occur, but often one cannot discern whether these patients hear voices and see things that do not exist, ie, whether they are hallucinating or are merely misinterpreting stimuli in the environment (illusions) Some patients are irritable and others are suspicious; in fact, a paranoid trend may be a pronounced and troublesome feature of the illness There may also be mild degrees of anomia and dysphasia and a labile affect As the confusion deepens, conversation becomes more dif -.

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