eMedicine Specialties > Neurology > Behavioral Neurology and Dementia

Confusional States and Acute Memory Disorders: Follow-up

Author: Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center
Coauthor(s): Daniel H Jacobs, MD, Associate Professor of Neurology, University of Central Florida College of Medicine
Contributor Information and Disclosures

Updated: Jan 11, 2008

Follow-up

Further Inpatient Care

Once a diagnosis is made, the patient requires follow-up until the confusional state resolves or a plateau is reached. In general, good follow-up requires observation and also consideration of the many etiological factors in delirium discussed in this article, including monitoring of medications and laboratory parameters. The specific follow-up tests depend on the diagnosis. Many clinicians underestimate the degree of improvement that is possible in confused patients, even confused elderly patients.

Deterrence/Prevention

Behavioral interventions may help to prevent delirium and even help limit or reverse delirium after it has developed. Inouye and colleagues3  studied a prospective prevention program called the Elder Life Program in hospitalized patients older than 70 years, including such measures as frequent orientation reminders, the use of large clocks and calendars, avoidance of visual or auditory deprivation by use of glasses and hearing aids, use of sitters instead of restraints, mobilization during the day, and promotion of proper sleep-wake cycles by making the environment dark and quiet at night, as well as avoidance of malnutrition and dehydration. Delirium developed in 9.9% of the active group versus 15% of control group (p=0.02). This program was expensive, but simpler measures may be somewhat effective.

Flaherty and colleagues8 reported on a similar program with the development of a “delirium room” in which patients are treated specially, with avoidance of Foley catheters and restraints, use of extra attendants to talk to patients and keep them active. Only 29% of the 69 elderly patients treated in the delirium room required benzodiazepines or atypical antipsychotic drugs. Only 9 patients (13%) lost function, and none died. These authors stated that, with proper care, most delirium is reversible.

Complications

If the patient is not evaluated thoroughly, complications may occur. Usually, if the diagnosis is made, the treatment is obvious.

Prognosis

The prognosis of confusional states is highly variable. Patients frequently become much better than the expected recovery predicted by the admitting physicians. The prognosis may depend on general medical care and attention, rather than specific management of the encephalopathy. Many patients with confusional episodes recover completely. Unfortunately, some patients are left with chronic neurocognitive deficits.

Patient Education

  • Education of the family is a key part of the management of the delirious patient. If the prognosis is not good, the family may or may not reconcile themselves to this. Family meetings and tactful presentations of the patient's condition and prognosis may help. If the physician is unsure about the prognosis, neurologic, neuropsychologic, or other appropriate consultation may be made to assist in family education. If the patient clearly has little chance of returning home or caring for his or her own needs independently, the family should be presented tactfully and compassionately with this information.
  • For excellent patient education resources, visit eMedicine's Dementia Center. Also, see eMedicine's patient education article Dementia Medication Overview.

Miscellaneous

Medicolegal Pitfalls

  • Medicolegal pitfalls occur when important diagnoses are missed or not treated appropriately. In general, a thorough diagnostic evaluation as described in this chapter will help clinicians avoid many pitfalls. The best way to avoid the pitfalls that remain are as follows:
    • Be respectful of family members' and nurses' opinions; their comments may alert you to an important problem, thereby benefiting the patient and avoiding medicolegal risk.
    • Be liberal in obtaining CT scans and spinal taps.
    • Be sure to assess fall risk for inpatients and prescribe restraints at night, when appropriate.
    • Administer thiamine on arrival to the ED.
    • Do not hesitate to call for consultation.
    • Do not leave out any step in the evaluation.
    • Get a blood gas; even if hypoxia is unlikely, its presence is a true emergency and must be addressed at once.
    • Avoid oversedating patients to treat agitation. In this regard, benzodiazepines can cause paradoxical agitation, and antipsychotic drugs, even the atypical ones, have some cardiovascular risk.
 


More on Confusional States and Acute Memory Disorders

Overview: Confusional States and Acute Memory Disorders
Differential Diagnoses & Workup: Confusional States and Acute Memory Disorders
Treatment & Medication: Confusional States and Acute Memory Disorders
Follow-up: Confusional States and Acute Memory Disorders
References
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References

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Further Reading

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Keywords

delirium, encephalopathy, acute confusional state, toxic psychosis, acute organic brain syndrome, acute memory disorders, dementia, psychosis

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Contributor Information and Disclosures

Author

Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center
Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Novartis Consulting fee Review panel membership

Coauthor(s)

Daniel H Jacobs, MD, Associate Professor of Neurology, University of Central Florida College of Medicine
Daniel H Jacobs, MD is a member of the following medical societies: American Academy of Neurology, American Society of Neurorehabilitation, and Society for Neuroscience
Disclosure: Teva Pharmaceutical Grant/research funds Consulting; Biogen Idex Grant/research funds Independent contractor; Serono EMD Royalty Speaking and teaching; Pfizer Royalty Speaking and teaching; Berlex Royalty Speaking and teaching

Medical Editor

Robert A Hauser, MD, Professor, Departments of Neurology, Pharmacology, and Experimental Therapeutics, Director, Parkinson's Disease and Movement Disorders Center, University of South Florida and Tampa General Healthcare
Robert A Hauser, MD is a member of the following medical societies: American Academy of Neurology and Movement Disorders Society
Disclosure: Allergan Sales, LLC Honoraria Speaking and teaching; Bayer Shering Pharma AG Honoraria Consulting; Boehringer Ingelheim France Honoraria Consulting; Centapharm Honoraria Speaking and teaching; Genzyme Corporation Honoraria Consulting; GlaxoSmithKline Honoraria Consulting; IMPAX Laboratories, Inc.  Consulting; Kyowa Pharmaceuticals, Inc. Honoraria Consulting; Novartis Pharmaceuticals Corp. Honoraria Consulting; Prestwick Pharmaceuticals, Inc. Honoraria Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Richard J Caselli, MD, Professor, Department of Neurology, Mayo Medical School, Rochester, MN; Chair, Department of Neurology, Mayo Clinic of Scottsdale
Richard J Caselli, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American Neurological Association, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Howard A Crystal, MD, Professor, Departments of Neurology and Pathology, State University of New York Downstate; Consulting Staff, Department of Neurology, University Hospital and Kings County Hospital Center
Howard A Crystal, MD is a member of the following medical societies: American Academy of Neurology and American Neurological Association
Disclosure: Pfizer Honoraria Speaking and teaching; Myriad Honoraria Consulting

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