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Confusion is a symptom characterized by an altered state of awareness. It may be accompanied by disorientation, memory loss, altered perception, and/or behavioral change. It is a common presenting problem in many older adults and a frequent reason why families and caregivers seek medical attention. As part of normal aging, many adults experience some cognitive changes such as decreases in the speed of processing information, lessened spontaneous recall, and small decreases in executive skills. Confusion, however, is not a normal part of aging. Assessment of the onset and duration of symptoms is important to differentiate causes of confusion.

Confusion may be a feature of other acute or chronic medical illnesses. It is often unrecognized in older adults unless it interferes with their ability to perform their usual activities. Confusion in the acute care setting (often referred to using various terms such as delirium, altered mental status, or encephalopathy) is associated with longer hospital length of stay, increased health care costs, caregiver distress, and worse patient outcomes including higher mortality. Over time, confusion results in impaired functional status and a decreased quality of life.


When a patient presents with confusion, it is critical to perform a detailed history and in-depth physical exam, including a mental status exam, as well as laboratory and diagnostic tests. Interviewing the family and caregiver(s), as well as the patient, is necessary to determine an individual’s baseline state as well as any changes that have occurred.

A. Symptoms & Signs

A thorough history should focus on understanding the specific cognitive, functional, and behavioral changes and how these symptoms have evolved over time. The interviewer must seek to identify any events such as a fall, focal pain, recent medical procedure, medication change, or environmental trigger and consider whether or not it was related to the development of confusion. It is also important to ask about substance use and screen for drug and/or alcohol overuse and potential risk factors for intoxication or withdrawal. Seeking a better understanding of any preexisting medical, neurologic, or psychiatric conditions is also potentially informative and relevant. Table 60–1 details key history domains to assess. The medical evaluation should incorporate data from the psychosocial assessment, a thorough and accurate review of medications (including nonprescription and complementary alternative therapies), and any barriers to taking medications as prescribed such as a misunderstanding about the purpose or dosing of the medication, access problem or cognitive impairment.

Table 60–1.Key history domains when evaluating confusion.

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