New confusion
In a workup for new confusion, gather and document onset and fluctuation, baseline cognition from a collateral history, recent medication changes, vital signs, and the possible precipitants.
Older adults: In these presentations, a collateral history and the medication list matter as much as the examination.
Key takeaways
- Get a collateral history to establish the patient's baseline.
- Record whether the confusion came on suddenly and fluctuates.
- List recent medication changes from every source.
What this presentation is
New confusion in an older adult is often delirium, which comes on over hours or days and fluctuates. It can sit on top of dementia, so baseline cognition matters.
Delirium usually has one or more precipitants, such as infection, medication, dehydration, pain or constipation. The workup looks for each.
Gather these sources first
- A collateral history from a relative or caregiver
- Previous letters describing baseline cognition and function
- The medication list, with recent changes
- Complete blood count, renal function, sodium, calcium and glucose
- Inflammatory markers and liver function
- Any brain imaging reports
Document these history questions
- Onset, and whether the confusion fluctuates
- Baseline cognition and daily function
- Recent medication changes
- Symptoms of infection, pain, constipation or urinary retention
- Alcohol use
- Falls or head injury
- Sleep and hallucinations
Record these findings
- Temperature, pulse, blood pressure and oxygen saturation
- Fingerstick glucose
- Attention and cognition, such as a 4AT score
- Neurological examination
- Hydration and signs of infection
Ask about these red flags
Record each one as present or absent. Your local pathway decides what happens when one is present.
- Reduced level of consciousness
- New focal neurological signs
- Head injury, especially on an anticoagulant
- Signs of sepsis
- Low oxygen saturation or low glucose
- A seizure
Put these in the assessment draft
- Whether this is delirium, dementia or both
- The likely precipitants, ranked
- Medicines that may contribute
- The red flags asked about and the answers
- A plan with investigations, review and safety-netting advice for caregivers
How Workup Desk helps
Add the collateral history, previous letters, results and medication list to the workspace. Ask what the letters say about the patient's baseline.
Draft the assessment or a ward handover and edit it. The chat names the letter behind each statement about baseline function.
Frequently asked questions
Why is a collateral history so important here?
A confused patient often cannot describe their usual state. A relative or caregiver can say whether this is new, how fast it came on and what changed.
General guidance on what to gather and document, not advice about any individual patient. Local guidelines and your clinical judgment govern.