Confusion Cheat Sheet

Author: Daniel Carlat M.D.
Last Updated: 4/1/20

I. Document the degree of impairment. Be specific about disorientation, ability to repeat 3 objects immediately and after a task, ability to recite months backward. Document findings that can objectively be compared with later exams.

II. Is it dementia vs. delirium vs. psychosis?

Dementia: History of gradually declining memory, get family to confirm.

Delirium: More sudden onset, usually related to a medical illness or side effect of a drug. Symptoms usually fluctuate over the course of a day. Visual hallucinations are common, as is behavior in response to visual hallucinations such as picking at the air. Unexplained agitation is common as well.

Psychosis: Thought blocking? Continuous hallucinations? Delusions causing patient to believe they shouldn’t respond to you? Catatonia?

III. Medication related?

–A medication you started?

• Pregabalin (Lyrica)
• Sedating antipsychotics, Quetiapine, Olanzapine, Chlorpromazine
• Opiates
• Diphenhydramine, (Benadryl)
• Hydroxyzine (Vistaril, Atarax)
• Dicyclomine (Bentyl)

–A medication (or substance) that was stopped? (withdrawal)

• Benzodiazepines
• Alcohol
• Neurontin

–An accumulation of medications?

IV. Due to a medical illness?

• Infection. Fever, elevated WBC, abnormal UA.
• Stroke or other brain issue, such as subdural hematoma. Is there a focal impairment? Check head CT.
• Hypoglycemia. Acute lightheadedness, tachycardia, sweating. Fingerstick glucose low. Give candy.
• Dehydration. High Na, BUN/Cr. Encourage 1 L intake per day, check Is and Os to confirm, then recheck labs.

V. Rare causes

• Post-ictal. Usually obvious because it follows a witnessed seizure.
• Hypothyroidism
• Electrolyte imbalance
• Hepatic encephalopathy. In patients with significant liver disease.
• Hypoxia or hypercapnea. Possible in patients with COPD.
• Thiamine deficiency, wernicke’s encephalitis.

Published on 4/13/2020. Copyright 2020 Inpatient Psychiatry Today.