Confusional Arousals
Episodes of confusion and disorientation during partial awakening from deep sleep, typically without complex behaviors or leaving the bed.
What is Confusional Arousals?
Confusional arousals are a parasomnia characterized by mental confusion, disorientation, and inappropriate behavior during or following arousal from deep non-REM sleep. During episodes, individuals may appear awake but are mentally foggy, speak slowly or incoherently, respond inappropriately to questions, and have impaired memory and judgment. Unlike sleepwalking, individuals typically remain in bed. Episodes usually last 5-15 minutes but can persist longer. Confusional arousals are very common in children and often occur along with sleepwalking and night terrors as part of the 'disorders of arousal.'
Prevalence
Confusional arousals are very common in children, affecting approximately 17% of children ages 3-13. They typically decrease with age but persist in about 4% of adults. The disorder is more common in individuals with other NREM parasomnias (sleepwalking, night terrors) and those with sleep disorders that cause frequent arousals. There is a strong genetic component.
Causes
Confusional arousals occur when the brain becomes partially aroused from deep sleep but fails to fully awaken. The same factors that trigger sleepwalking and night terrors apply: genetics, sleep deprivation, irregular sleep schedules, stress, fever, certain medications (sedatives, hypnotics), alcohol, forced awakenings from deep sleep, and conditions causing sleep fragmentation (sleep apnea, restless legs, noise). Adults may be more susceptible if they had childhood parasomnias or have hypersomnia disorders.
Symptoms
Confusion and disorientation
The primary symptom is mental confusion during or after arousal from sleep. The person may not know where they are, what time it is, or recognize people.
Slowed speech and thought
Speech is slow, slurred, or nonsensical. Responses to questions are inappropriate or delayed.
Inappropriate behavior
May include answering a phone that isn't ringing, looking for objects that aren't there, or performing strange actions.
Remaining in or near bed
Unlike sleepwalking, individuals with confusional arousals typically stay in bed or only sit up, though some may leave the bed briefly.
Agitation if disturbed
Attempts to fully awaken the person may meet resistance or cause aggression and irritability.
Amnesia for the event
Little or no memory of the episode or the confused behaviors upon full awakening.
Timing in first third of night
Most confusional arousals occur in the first hours of sleep when deep slow-wave sleep predominates.
Diagnosis
Self-Assessment Questions
If you answer yes to any of these questions, consider consulting a sleep specialist:
- 1Do you or your child show confusion and inappropriate behavior when awakened from sleep?
- 2During these episodes, is there slowed, slurred, or nonsensical speech?
- 3Does the person typically stay in or near the bed rather than walking around?
- 4Is there resistance to being awakened or irritability during episodes?
- 5Is there little or no memory of the episode the next day?
- 6Do episodes occur in the first few hours after falling asleep?
Diagnosis is clinical based on the characteristic features of confusional behavior during arousal from deep sleep. Polysomnography is rarely needed unless other disorders are suspected or episodes are concerning for seizures.
Clinical History
Detailed description from observers of the confusion, behavior, timing, and duration of episodes.
Sleep Diary
Tracking episodes and sleep patterns can identify triggers and patterns.
Polysomnography with Video
May be performed if episodes are frequent, if seizures need to be ruled out, or if there are unusual features.
Treatment
Most children outgrow confusional arousals without treatment. Management focuses on avoiding triggers and ensuring safety. Medication is rarely needed.
Address Triggers
Ensuring adequate sleep, maintaining consistent sleep schedules, treating sleep disorders (sleep apnea), and avoiding forced awakenings can reduce episodes.
Reassurance and Education
Parents should be reassured that confusional arousals are common and typically resolve with age.
Safety During Episodes
Gently guiding the person back to sleep without forcing awakening. Don't restrain them, which may increase agitation.
Scheduled Awakenings
For children with predictable timing, briefly waking them 15-30 minutes before usual episode time may prevent arousals.
Medication
Rarely needed, but benzodiazepines (clonazepam) at bedtime may help in severe or frequent cases.
Lifestyle Adjustments
- •Ensure adequate sleep for age
- •Keep very consistent sleep and wake times
- •Avoid forced awakenings from deep sleep when possible
- •Treat any underlying sleep disorders
- •Reduce stress and anxiety
- •Avoid alcohol and sedating medications
- •Create a calming bedtime routine
- •Don't try to fully awaken someone during an episode
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