The confused patient must not be discharged from hospital in the expectation of spontaneous recovery at home without alerting primary care to the situation. If everything does settle down, the patient still needs to be assessed as there may be a degree of dementia.Furthermore, sending a confused person home too early is potentially very dangerous. However, this may not be so, especially if there is a different reason for the admission. The most effective policy is early discharge as stability usually returns in the familiar surroundings.This lowers the level of consciousness and may well add to confusion so caution is needed. If the patient is distressing others, or being inconvenient for staff, there will be a call to give sedation.This is not the time to attempt a mental state assessment for dementia. Exclude organic causes and, if present, treat them.If sedation without analgesia is given, such as an hypnotic benzodiazepine, this can cause acute confusion. Failure to sleep may be due to pain, especially after an operation.However, it can mean that patients in hospital are receiving higher doses than at home and this may reach toxic levels. The reliability of the administration of medication in hospital is often less than perfect but this imperfection is usually substantially better than fluctuations of the self-administered regime at home.
Hospitals are noisy and unfamiliar places at night and night sedation may be offered, which may have adverse effects both at night and into the next day.The role of antibiotics in iatrogenic toxicity should not be underestimated.High doses of steroids can cause psychosis.This applies not simply to psychotropic medication but drugs for conditions like Parkinson's disease may cause confusion.Medications are often changed or started when patients come into hospital and this may be responsible for problems.Whenever there are problems of confusion or aberrant behaviour, an examination of the drug sheet should be one of the first investigations.
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