Confusion in older adults: assessment and differential diagnosis

Confusion has long been considered a normal consequence of aging. The growing incidence and cost of this untreated symptom has unfairly condemned many elders to live out their lives at a low level of functioning and has placed unnecessary hardships on their families. This article offers a complete protocol to assess and differentiate arrestible and reversible causes of confusion from irreversible presenile dementia. The history is the most important aspect of the examination of the confused elder. Onset of symptoms, corresponding illness, medication use and time of day that the confusion occurs should be included. Objective data include mental-status exams, but only as a screening tool and stepping stone for other exams. Judgment and abstraction are examined by assessing the client's ability to interpret proverbs and plot a sensible course of action. Special cortical function is assessed by asking the client to draw a house, a clock and a person. A functional pattern assessment specific to the confused elder is included. The general assessment centers on ruling out systemic or mechanical problems in the brain. Possible pathological causes with corresponding lab results, symptoms and clinical data are presented. Confusion is a symptom of many different and often unrelated disease entities. Many of these diseases are preventable, curable or arrestible. A diagnosis of irreversible presenile dementia should never be made without thorough evaluation. The health care provider should refer clients suspected of having irreversible presenile dementia to neurological specialists for confirmation of clinical findings.