CONFUSION

Confusion describes a state of mind whereby the patient is at least partially disorientated in time and place and may not seem to be fully in contact with reality. This can be anything from a very brief lapse to something much more severe and enduring. There may be hallucinations (seeing things for example) and the patient may be alert or they may be somewhat drowsy. They may have other obvious symptoms such as a fever. They may have very fixed and wrongheaded ideas (e.g. that somebody means them harm). In confusion the patient's thought processes are usually very disordered and confusing whereas in some other psychiatric conditions what the patient may be saying may be obviously wrong but nevertheless comprehensible. When this is of recent onset it may be due to any of the following:

• Stroke or T I A. This may not necessarily affect the parts of the brain controlling limbs or speech and may instead cause disorientation or confusion. If it is a T I A then you would expect rapid recovery.
• Epilepsy. This is not always associated with a classical fit. Often with minor seizures the patient remains awake but may be confused during and after the fit and sometimes the confusion is the only manifestation of the fit. After full-blown grand mal fits the patient will remain confused and drowsy for an hour or so afterwards.
• Acute illness and fevers. Very high fevers can cause patients to hallucinate and they may be confused. If the symptoms don't resolve rapidly on lowering the temperature then the patient must be seen.
• Drugs. Both legally prescribed and illicit drugs can cause confusion - often this is likely to reflect an excessive dose but it may happen at normal doses in susceptible individuals. Some drugs, such as alcohol can cause confusion in withdrawal.
• Head injury. Both immediately after the injury, in concussion, and after a delay, if there is bleeding inside the skull, head injuries can cause confusion.

In addition to the above the patient may have a pre-existing condition causing longstanding confusion, such as dementia, and this may have become aggravated by a relatively minor condition such as a water infection or constipation or by something more serious.

What to do? In most cases you are going to need advice and probably a visit because the cause is not going to be clear and the effects of the illness are likely to be very distressing. Where there is a physical illness it is likely to need prompt investigation and treatment quite possibly in hospital. If there has been a blow to the head the patient must be checked. Clearly where there is an obvious recurrent cause such as an epileptic fit and the symptoms are following a well established pattern then it is worth waiting for the resolution of symptoms that you would expect. If there is a significant delay in recovery or there is a marked difference from previous episodes you must seek advice.

Although the patient may seem  frightening they are likely to be very frightened themselves and need lots of reassurance. It's best not to directly confront or challenge strange ideas or experiences because they represent current reality to the patient but try to deflect them whilst being as understanding as you can manage.

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