There are hundreds of possible individual causes of confusion. Patients with acute confusion are usually elderly and often present out of hours via a call from an anxious relative or neighbour. The dementias constitute the chronic confusional states, which are not considered here.
COMMON
hypoxia (respiratory and cardiac)
systemic infection
cerebrovascular accident (CVA: stroke and transient ischaemic attack (TIA))
hypoglycaemia
diabetic ketoacidosis (DKA)
OCCASIONAL
alcohol withdrawal or intoxication
cerebral infection
electrolyte imbalance and uraemia
iatrogenic (e.g. digoxin, diuretics, steroids and opiates)
myxoedema
drug abuse
RARE
Wernicke’s encephalopathy
cerebral tumour
hypo- and hyperparathyroidism
Cushing’s disease
postictal state
carbon monoxide poisoning
Acute confusion has so many causes and possible presentations that it is difficult to provide a definitive guide of investigations for the GP. A number of investigations might be considered according to the clinical picture and social circumstances; in the majority of cases, though, the patient will be admitted and necessary tests therefore arranged by the hospital.
LIKELY: urinalysis, blood sugar (usually glucometer), pulse oximetry.
POSSIBLE: FBC, CXR, ECG, cardiac enzymes, TFT.
SMALL PRINT: calcium, digoxin levels, CT scan.
Urinalysis is very helpful if possible: look for glucose and ketones (DKA), specific gravity (dehydration), pus, blood and nitrite in UTI. Ketones alone in starvation and possibly hypoglycaemia.
A blood glucometer reading is more practical than a formal blood glucose in the acute situation to diagnose hypo- and hyperglycaemia.
Pulse oximetry: to detect hypoxia.
FBC: raised WCC in infections. Raised MCV helpful pointer to excess alcohol and myxoedema.
U&E important, especially if any signs of dehydration or on diuretics.
LFT and TFT: alcohol, disseminated malignancy and hypothyroidism should always be considered.
CXR: may reveal a cause of hypoxaemia (e.g. pneumonia, cardiac failure).
ECG, cardiac enzymes: if silent infarct suspected as cause.
Calcium: to detect possible hypo- or hyperparathyroidism.
Digoxin levels: for digoxin toxicity.
CT scan: invariably a hospital-based investigation in acute confusion: may reveal space-occupying lesion, bleed or infarct.
The key to management is establishing that the confusion really is acute rather than a gradual deterioration of cognition. This requires a careful history from someone who knows the patient well.
Don’t forget a drug history: if little information is available on a visit, check the patient’s medication cupboard.
In acute confusional states, it can be difficult to obtain useful clinical pointers from the patient’s history. The examination therefore assumes greater importance than usual.
It is virtually impossible to reach a firm diagnosis and treat safely in the home. Be very sure of yourself if you choose not to admit.
Central cyanosis is an ominous sign. Give oxygen, if possible, and dial 999.
In a diabetic on treatment, always check the blood sugar – remember that hypoglycaemia can produce confusion with neurological signs, mimicking a CVA.
Altered physiological responses in the elderly may result in a normal pulse and temperature even in the presence of significant infection. Don’t be misled by this.
Ask if any other household members have been unwell – carbon monoxide poisoning could affect others too.
This common and vague symptom can mean different things to different people. It is treated here as being a sense of light-headedness without the illusion of movement characteristic of vertigo. This is a useful distinction in practice as the causes of true vertigo are different – see p. 89. Dizziness tends to be a heartsink symptom as it is so common, has so many diagnostic possibilities, is so often linked with anxiety and other symptoms – and very often the exact cause remains obscure.
COMMON
viral illness
anxiety (and hyperventilation)
hypoglycaemia
postural hypotension (e.g. elderly and pregnancy)
vertebrobasilar insufficiency (elderly with cervical osteoarthritis)
OCCASIONAL
acute intoxication: drugs/alcohol
effects of chronic alcohol misuse
iatrogenic: drug therapy (antihypertensives, antidepressants)
cardiac arrhythmia
any severe systemic disease
RARE
aortic stenosis
subclavian steal syndrome
partial seizures
Addison’s disease
carbon monoxide poisoning (blocked flue)
LIKELY: none.
POSSIBLE: urinalysis, FBC, U&E, LFT, glucometer blood glucose.
SMALL PRINT: EEG, ECG/24-hour ECG, echocardiography, CT scan.
Urinalysis for glucose: underlying diabetes may cause dizziness, either through general malaise or because of an autonomic neuropathy.
FBC: underlying anaemia will exacerbate any cause of light-headedness; raised MCV may indicate alcohol abuse.
U&E and LFT may be worth measuring if systemic disease suspected; in particular, sodium low, and potassium and urea both high in Addison’s disease; LFT may be abnormal in alcohol abuse.
Glucometer blood glucose: blood glucose measurement will provide a diagnosis of hypoglycaemia only if done during an episode.
EEG: if partial epilepsy a possibility (would also then require CT scan) – both arranged by specialist.
ECG/24 h ECG: for possible arrhythmia.
Echocardiography: for suspected aortic stenosis.
The first step in the history is to establish what the patient means by dizziness, and, in particular, to distinguish it from true vertigo.
Dizziness is often multifactorial, especially in the elderly – so do not necessarily expect to find a single underlying pathology.
If no clear diagnosis is obvious from the history, the dizziness is long standing, and the patient presents a list of other vague symptoms yet is objectively quite well (e.g. no weight loss), the likely diagnosis is anxiety.
Don’t forget that commonly prescribed drugs can cause or aggravate postural hypotension – review the patient’s medication.
If the patient has episodic loss of consciousness as well as dizziness, then the chances of significant pathology are much greater: investigate or refer.
In puzzling cases, ask about other family members and type of domestic heating used. Carbon monoxide poisoning is a completely avoidable but regular killer.
If an aortic murmur is heard, refer urgently. Significant aortic stenois can cause sudden death.
Remember denial is very strong in alcoholics. If in doubt, check MCV and LFT.
A hallucination is a sensory perception occurring without any external stimulus. This distinguishes it from an illusion, which is a distortion of a sensory perception. Hallucinations can occur in any sensory modality and may present in isolation or as part of a larger clinical problem (particularly an acute confusional state). A hallucination is often a very frightening experience for the sufferer.
COMMON
drugs (amphetamine, cocaine, LSD, ecstasy, solvents and tricyclic overdose) and drug withdrawal
extreme fatigue
alcoholic hallucinosis (delirium tremens of acute alcohol withdrawal)
febrile delirium
schizophrenia
OCCASIONAL
severe metabolic disturbance of any cause
temporal lobe epilepsy
cerebral space-occupying lesion
psychotic depression
bereavement reaction
hypoxia
RARE
narcolepsy
mania
post-concussional state
iatrogenic: idiosyncratic adverse drug reaction
near-death experience
The GP’s use of investigations will depend on the clinical situation. If hallucinations are part of an acute confusional state, particularly in adults, admission is likely to be required and will result in a battery of tests to check, for example, for sources of fever, hypoxia and metabolic disturbance. The following are investigations the GP might use in patients who do not require admission or who are not presenting acutely.
Urinalysis: very useful in the acute situation, particularly in the elderly. May reveal UTI or hyperglycaemic ketotic state or severe dehydration.
Pulse oximeter: to detect hypoxia.
Glucometer blood glucose: in a known diabetic or if any glycosuria.
FBC and LFT: raised MCV and abnormal LFT suggest chronic alcohol excess.
U&E: may reveal electrolyte disturbance as underlying cause.
EEG: may suggest diagnosis of temporal lobe epilepsy or narcolepsy.
CT scan: the definitive test for a cerebral space-occupying lesion.
Delirium in children with a fever is quite common, especially at night and is not in itself a sinister sign; assess possible causes of the fever in the usual way, and if the cause is not serious, reassure the parents as they may be quite frightened by the child’s hallucinations.
Patients with anxiety, personality disorder and borderline mental illness may sometimes complain of auditory hallucinations, occasionally because experience has told them that this generates action from health professionals. Genuine auditory hallucinations are usually distressing and often in the second person (psychotic depression) or third person (schizophrenia) – and are accompanied by other hard evidence of mental illness.
Minor and transient auditory and visual hallucinations are normal in the recently bereaved – but the patient will need reassurance that he or she isn’t ‘going mad’.
Hallucinations caused by drugs, or by drug and alcohol withdrawal, can be terrifying and dangerous for the patient and carers, so admission is likely to be required.
Auditory hallucinations strongly suggest psychotic illness, particularly schizophrenia and depression; visual hallucinations are almost always organic in nature.
Purely olfactory hallucinations are pathognomic of temporal lobe pathology and require urgent investigation.
Tactile hallucinations are very suggestive of acute alcohol withdrawal and occasionally cocaine abuse.
There are almost as many causes for headache in medicine as there are disorders. This universal symptom presents a challenge to all GPs because it is common, very often non-organic, but seriously pathological just often enough to merit a thorough and usually negative examination. The chance of a sinister hidden problem is always there, but the known vast majority of benign headaches can put the clinician off guard.
COMMON
tension headache (underlying anxiety or depression)
frontal sinusitis
migraine
cervical spondylosis
eye strain
OCCASIONAL
any acute febrile illness (common cause of headache but usually presents with other symptoms)
iatrogenic (e.g. analgesic abuse, calcium antagonists, nitrates)
chronic daily headache
reactive hypoglycaemia
fatigue/sleep deprivation (especially in parents)
trigeminal, sphenopalatine and occipital neuralgias
temporal arteritis
post-concussional syndrome
menstrual migraines (10–14% of women)
RARE
cluster headache
intracranial lesion (e.g. carcinoma, abscess, haematoma, benign intracranial hypertension)
meningitis
intracerebral haemorrhage
carbon monoxide poisoning (blocked boiler flue)
Paget’s disease of skull
severe hypertension
pre-eclampsia
LIKELY: none.
POSSIBLE: FBC, ESR.
SMALL PRINT: U&E, alkaline phosphatase, X-ray of sinuses, cervical spine or skull, CT scan, lumbar puncture.
FBC: WCC raised in abscess and sinusitis. ESR essential if arteritis suspected.
U&E: Na+/K+ derangement in pituitary tumours, alkaline phosphatase raised in Paget’s disease.
X-ray: may see fluid levels in sinusitis (rarely useful in diagnosis). May confirm cervical spondylosis and Paget’s disease.
CT scan: to exclude intracranial lesion.
Lumbar puncture: in suspected meningitis; may also help in diagnosis of benign intracranial hypertension.
Explore the patient’s fears – the majority are worried about serious pathology, such as a brain tumour, and may leave the consultation dissatisfied unless this specific worry is addressed.
Another common concern is hypertension. Patients will expect to have their blood pressure checked, even though this is almost never the cause of the symptom.
Analgesics may paradoxically exacerbate tension headache. It is more constructive to adopt alternative approaches, such as relaxation techniques or antidepressants, as appropriate.
Headache caused by an intracranial lesion usually produces other neurological symptoms or signs.
Suspect subarachnoid haemorrhage given a history of sudden explosive headache. It is frequently described as ‘like a blow to the head’.
If temporal arteritis is suspected, treat immediately. The ESR provides retrospective confirmation only.
Beware of the pregnant woman complaining of headache in the third trimester: check the blood pressure, ankles and urinalysis. Headache, particularly with visual disturbance, may be a symptom of impending eclampsia.
A new and increasing headache present on waking and increased by stooping or straining may be due to raised intracranial pressure. Check for other symptoms and signs and refer urgently if in doubt.
If a headache feels and smells like migraine, then it’s a migraine regardless of age. However, beware of making this the diagnosis in the elderly without systematically ruling out more sinister causes first.
This problem is commoner in women, and commonest in the elderly. Normal sleep requirement varies widely. A few people need only 3–4 hours per night and the average amount of sleep needed declines with age. Self-reporting of time taken to get to sleep and hours slept are said to be inaccurate, but it is the change from the individual’s normal pattern that is significant in practice.
COMMON
anxiety from excess psychological stress (work, relationships, finance)
clinical depression
chronic alcohol excess
poor sleep hygiene: hyperstimulation (e.g. caffeine, nicotine, drugs, exciting television films) and daytime naps
pain of chronic physical illness (e.g. osteoarthritis)
OCCASIONAL
menopausal flushes and sweats
nocturia
external problems (e.g. snoring partner, children who disturb parental sleep)
biorhythm disruption: jet lag and shift work
respiratory problems: asthma, chronic obstructive pulmonary disease (COPD), left ventricular failure (LVF) commonest
benzodiazepine withdrawal
other medical problem, e.g. restless legs syndrome or GORD
RARE
malnutrition and low body weight
post-traumatic stress disorder
parasomnias: nightmares, night terrors and sleepwalking
hyperthyroidism
mania
sleep apnoea (usually presents as ‘tired all the time’ (TATT); only 30% aware of waking)
LIKELY: none.
POSSIBLE: FBC, LFT, TFT.
SMALL PRINT: investigation of primary symptom leading to insomnia (see below).
FBC (MCV), LFT and γGT may show evidence of chronic alcohol misuse.
TSH will differentiate non-organic anxiety state from thyrotoxicosis.
NOTE: pain, nocturia, respiratory problems and sleep apnoea may require investigating in their own right.
Uncover any underlying physical problem such as pain or nocturia and manage as appropriate – it is pointless adopting a ‘sleep hygiene’ approach when the problem is primarily physical.
Don’t forget the role of alcohol; this is often an underlying or contributory cause, paradoxically taken by the patient to relieve the insomnia.
If the diagnosis seems likely to be tension or poor sleep hygiene, establish the patient’s agenda early. Patients who simply want sleeping pills are unlikely to listen to well-intentioned advice until this issue has been discussed and resolved.
Explain to elderly patients that sleep requirements fall with increasing age and that daytime naps are to be discouraged.
Shift workers are significantly at risk of developing clinical depression. Be sure to assess carefully for this pathology in the insomniac shift worker.
Beware of young male temporary residents presenting ‘urgently’ with insomnia. They may well be drug addicts trying to obtain a prescription for benzodiazepines.
Bone or joint pain waking an elderly patient at night is highly significant. In the patient with known arthritis, joint replacement may be indicated; in others, it may indicate serious bony pathology such as secondaries.
Take the problem seriously even if the cause seems trivial or obvious (for example, a patient’s snoring) – insomnia can be extremely debilitating, and by the time patients attend, they may be desperate for help.
Anxiety and severe weight loss with sweating and tachycardia suggests hyperthyroidism. Be sure to check TSH before deciding this is non-organic.
Loss of libido can be a daunting presentation for established GP and registrar alike. This universal problem spans adulthood in both sexes. Conventional medical school teaching seems to fail to prepare the generalist; however, the didactically taught approach of systematic enquiry and examination is the key to successful management.
COMMON
depression
relationship problems
perimenopause
excess alcohol intake (and cirrhosis in men)
ageing
OCCASIONAL
low testosterone in men
hypothyroidism
antihypertensive treatment in men
hyperprolactinaemic drugs in men (e.g. phenothiazines, haloperidol)
anti-androgenic drugs in men (e.g. cimetidine, finasteride)
anti-androgenic drugs in women (e.g. cyproterone)
RARE
hypothalamic/pituitary disease
renal failure
primary testicular disease or damage
adrenal disease (Cushing’s and Addison’s diseases)
feminising tumours in men: testis or adrenal gland
LIKELY: none.
POSSIBLE: FBC, U&E, LFT, TFT.
SMALL PRINT: hormone profile.
FBC: may show evidence of general disease; MCV raised with significant excess alcohol.
U&E: check for renal failure. Na+ and K+ deranged in adrenal disease.
LFT and γGT: should reveal hard evidence of excess alcohol.
TFT: will demonstrate hypothyroidism.
Hormone profile: FSH/LH, prolactin, oestradiol and testosterone may be useful in both sexes. Altered by primary endocrine disease, drugs and alcohol.
This is often a ‘by the way’ or ‘while I’m here’ symptom. It may be tempting to ask the patient to return for a further appointment, but bear in mind that this may mean a lost opportunity to help the patient.
General examination is important to detect rare causes. This also demonstrates that the problem is being taken seriously.
Avoid over-medicalising the situation if it is clearly a relationship problem.
Be prepared to revise or augment your diagnosis – the problem is often multifactorial.
Don’t forget iatrogenic causes and be prepared to undertake a trial without treatment.
Loss of libido may be the tip of the iceberg of significant pathology, such as depression or alcoholism – don’t be distracted into a superficial approach.
Depression and relationship difficulties can cause each other and coexist. A careful history will reveal whether antidepressants and/or psychosexual counselling is appropriate
Investigations don’t often help – but lower your threshold for blood tests if the patient seems generally unwell and isn’t obviously depressed.
Early hypothyroidism closely mimics depressive illness.
Memory loss is a distressing and perilous symptom for both sufferers and caring relatives. It may be due to organic or non-organic causes. Memory is classified into immediate, short-term (or recent) and long-term (or remote) memory. The type of loss varies according to the cause. Memory loss is also a feature of any cause of acute confusion; this problem is covered elsewhere (see Acute confusion, p. 68).
COMMON
anxiety/stress
depressive illness
dementia (multi-infarct, Alzheimer’s disease and dementia with underlying cause, such as tumour, neurosyphilis, hypothyroidism, vitamin B12 and folate deficiency)
trauma: head injury
CVA (infarct in posterior cerebral artery territory)
OCCASIONAL
chronic excess alcohol intake (thiamine deficiency: Korsakoff’s syndrome)
subarachnoid haemorrhage
other thiamine deficiency: malabsorption, carcinoma stomach, hyperemesis gravidarum
transient global amnesia
fugue states and psychogenic amnesia
tumour of third ventricle or hypothalamus
RARE
personality disorder
malingering
intractable epilepsy
carbon monoxide poisoning
herpes simplex encephalitis
LIKELY: (unless obvious depression or anxiety) FBC, TFT, LFT, calcium.
POSSIBLE: syphilis serology, B12 and folate levels, CT/MRI scan.
SMALL PRINT: none.
FBC may show raised MCV, suggesting either alcohol abuse or B12/folate deficiency. Check B12 and folate levels if MCV raised.
TFT: hypothyroidism is an important remediable cause of dementia.
LFT and γGT will give useful clues to alcohol intake (history likely to be unreliable).
Calcium level: may show hypo- or hypercalcaemia.
Syphilis serology: for possible neurosyphilis as underlying cause of dementia.
CT scan/MRI: will detect space-occupying lesions, cerebrovascular disease, atrophy and subarachnoid haemorrhage.
Patients with dementia are often unaware of, or deny, their memory loss; the problem is more often brought to the GP’s attention by a concerned friend or relative.
Patients who present themselves to the GP complaining of memory loss are most likely to be suffering from anxiety or depression.
Even if a diagnosis of anxiety or depression seems obvious, patients are likely to be concerned about the possibility of dementia, which will exacerbate the situation; explaining that the problem is more to do with poor concentration than failing memory will help reassure them.
Establishing the onset gives valuable clues to the problem: a dementia pattern progressing slowly over a year or two is likely to be Alzheimer’s or multi-infarct dementia; with a shorter history, an underlying cause is possible; and sudden onset of memory loss is likely to be caused by a vascular event or trauma.
It can be very difficult to distinguish between depression and dementia – and the two may coexist. Consider a trial of antidepressants.
Rapid onset of apparent dementia over 3–6 months or less suggests a possible underlying cause.
True memory loss after a head injury suggests significant trauma.
Depression in the elderly may mimic dementia (pseudodementia) with behavioural changes like hoarding and bad temper. Do not miss this treatable condition.
Vertigo is an illusion of movement of either the patient or his or her environment. This is both visual and positional. Associated nausea or vomiting are common and, in its acute form, it is a severe and completely disabling symptom. It must be distinguished from ‘light-headedness’ (see p. 71).
COMMON
benign positional vertigo
vestibular migraine
Ménière’s disease
vestibular neuritis
Eustachian tube (ET) dysfunction (causes mild vertigo)
OCCASIONAL
chronic otitis media
drugs: salicylates, quinine, aminoglycosides
acute alcohol intoxication (common, but unlikely to present to the GP)
neurological conditions (e.g. CVA, multiple sclerosis (MS), vertebrobasilar insufficiency, syringobulbia, cerebellar tumours)
epilepsy
RARE
earwax (common problem but rare cause of vertigo)
syphilis
acoustic neuroma
nasopharyngeal carcinoma
post-traumatic
There are no investigations likely to be performed in primary care. Referral might lead to a number of secondary care tests, such as audiometry for cochlear function; electronystagmography, calorimetry and brainstem-evoked responses to assess vestibular function; CT or MRI scan for possible neurological conditions; EEG for suspected epilepsy; lumbar puncture in possible MS; and syphilis serology if syphilis is suspected.
Take a careful history: the patient may use the term ‘vertigo’ inaccurately, or describe true ‘vertigo’ as light-headedness. The diagnostic possibilities for vague dizziness and true vertigo are quite different.
The vast majority of cases seen in primary care are benign positional vertigo, vestibular migraine, Ménière’s disease or viral neuritis.
Ménière’s disease tends to be over-diagnosed. It comprises violent paroxysms of vertigo lasting for several hours, associated with deafness and tinnitus, often necessitating urgent attention because of prostration and vomiting.
Benign positional vertigo is usually easily diagnosed by the history: the patient experiences vertigo lasting only for a few seconds, classically on turning over in bed.
Vestibular migraine is under-diagnosed. Consider it in any case of recurrent vertigo – enquire about headache before, during or after the vertigo.
The patient who has chronic otitis media and then develops vertigo probably has significant disease – especially if the fistula sign is positive (putting pressure on the external ear canal by forcibly occluding the external auditory meatus with a finger causes vertigo). Refer urgently.
Young or middle-aged patients with atypical, episodic vertigo who have other, diffuse and transient neurological symptoms may have MS.
Loss of consciousness with vertigo suggests epilepsy.
An acoustic neuroma can cause quite mild vertigo. Consider this possibility if the patient also has a unilateral sensorineural deafness and tinnitus.
A neurological cause such as a stroke is suggested by any CNS symptoms or signs; a new type of headache, especially occipital; acute deafness (otherwise unexplained); or vertical nystagmus.