Confusion in the Elderly

Online Course #924 V.2 - 4 Contact Hours
Author: Joan Ratchford, RN, BSN, MSN
Editor: Shelda L. Shank, RN, BSN, PHN
© National Center of Continuing Education, Inc.

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Instructional Objectives:

1. Define confusion.
2. Summarize assessment of confusion.
3. State the risk factors for confusion.
4. Identify the common causes of confusion.
5. List nursing interventions for confusion.
6. Name ways to communicate with the confused patient.

Introduction

As nurses, we are taught to make sure we know the meaning of the terms we use. When the term "confusion" is used, do we really know the meaning? According to many authors, the answer to that question is "no". In this course, we will examine the causes of confusion, especially confusion in the elderly, how to accurately assess confusion and what to document, and interventions to be included in the nursing care plan, including how to communicate with the confused patient. These principles will be illustrated and reinforced through presentation of a case study. We will also examine what we, as health care professionals, can learn from our confused patients. By the end of this course, you will have a clearer understanding of the term "confusion" as well as how to intervene with elderly patients who exhibit confusion.

What is Confusion?

What do you do to "prove" your assessment of confusion to family members and friends? How do you feel when your confused patients have periods of lucidity? Can you accurately assess confusion in your patients? As with many medical conditions, confusion is not a diagnosis in itself, but frequently the reason for the presentation of older persons to the emergency room, for admission to a nursing home, and for transferring from independent living to an assisted living environment. The prevalence of acute confusion among elders in long term care has been estimated to be as high as 40%; only a quarter of these residents were recognized as being confused by staff nurses. Acute confusion has been said to occur in 10 to 60% of the older hospital population, and is unrecognized in 33 to 66% of cases. Recent research on confusion reveals that elderly hospitalized persons who experience acute confusion are three to five times more likely to die than those who are not confused. Confusion can mask significant medical diagnoses, and almost always complicates the patient's course of treatment and recovery.
What is confusion? How does it manifest in elderly patients? Most authors agree that confusion can be divided into two categories: acute confusion (also called delirium) and chronic confusion (also called dementia.) There is general agreement that acute confusion, or delirium, is temporary, has an abrupt onset, and may be recognizable by a myriad of inappropriate behaviors. The behaviors associated with delirium may include inattentiveness, sleep disturbances, disjointed speech, hallucinations, and other apparent changes in central nervous system functioning.
Chronic confusion, or dementia, is a long-term, progressive, and possibly degenerative process. Early stages of dementia may resemble delirium, and any confusional state should be considered to be acute and temporary until shown to be otherwise.
Medical dictionaries define confusion as a state of disturbed consciousness, with disruption of thought and decision making capacity. The terminology often is vague, and accurate diagnosis and consistent treatment may be difficult as a result. Studies from Japan have also found inconsistent and contradictory data in the literature, as well as cultural differences in the confusion-related behaviors that caregivers regard as significant. In any setting, it is important for the nurse to perform a careful and thorough assessment before deciding that a patient is indeed confused.

Assessment

Our assessment of a patient begins either the first time we see that patient or when we get the information that the patient is to be admitted to our unit. Some of the time we are so busy that the patient appears before we have had time to prepare for the admission. In any event, the assessment of the confused elderly patient encompasses many elements.
Assessment of the confused patient begins, as does all assessment, with the establishment of a baseline. With a confused patient, it is imperative to talk to the family or other caregiver to determine when the confused behavior began. Some research asserts that the onset of the confusion is more valid than the assessment of orientation when trying to determine whether the condition is acute or chronic. Therefore, if a reliable historian is not available, the nurse may not be able to correctly differentiate between acute and chronic confusion during the first assessment session, and must rely on comparison of the present assessment with future assessments to determine if the confusion is acute or chronic. Medication histories, laboratory tests, and the results of the physical assessment should be combined to make a final determination of the confused state. Even with the additional information, however, accurate assessment may be difficult due to the many combinations of factors that may cause delirium, especially in interaction with normal age-related changes in cognition.
Another problem in accurately assessing the confused patient has to do with our ever-changing health care system. It is becoming increasingly difficult to provide compassionate, consistent care for the patients with whom we come into contact. This is especially true with surgical patients. Many times the surgical patient is received into the hospital the morning of surgery, perhaps into an outpatient or outpatient/inpatient area. The patient is then taken to the surgical suite, then to the recovery room, and is seen by those on the unit where he will continue his recovery only after the surgery has been performed. Since just about everyone awaking from anesthesia is somewhat confused, assessment of the elderly patient who has had surgery becomes more demanding.
Postoperative confusion can have many causes, but in the elderly there are several things to consider when doing an assessment. Mental status at time of admission, gender, age, amount of postoperative mobility, urinary system health, and access to a clock or television are some factors to consider when assessing an elderly postoperative patient. Repeated, accurate assessments can assist the nurse in determining if, and what type of, confusion is present. The presence of risk factors in the patient's history should also be investigated.

Risk Factors

Risk factors associated with confusion in the elderly include normal, age-related changes as well as physical conditions and emotional and social disruptions in lifestyle. Age-related changes include the diminished ability of the brain to adapt to both internal and external changes. For instance, as aging occurs, recent memory may become less reliable than long-term memory. Think of the difficulty all of us can encounter in remembering to take medication four times a day. Have you ever been given a prescription for an antibiotic, for example, ordered to take it four times a day for ten days, and had to make a checklist after the third or fourth day so that you would remember to take it?
Physical conditions that are risk factors for the development of acute confusion, or delirium, include:

• nutrition, including fluid and electrolyte imbalances
• medication reactions or interactions o altered metabolic function, including diabetes mellitus, hypoglycemia or hyperglycemia, and thyroid, parathyroid and pituitary disturbances
• cardiovascular alterations such as decreased cardiac output, cardiac disorders, and vascular disorders
• infections
• urinary alterations
• abnormalities in temperature regulation such as hypothermia, hyperthermia.

Increased interest is being paid to nutritional factors in the development of both acute and chronic confusion. Vitamin B 12 deficiency has long been suspected as a cause for confusion in the elderly, and has been studied for its relationship to the development of Alzheimer's disease. B 12 supplementation may improve aspects of cognitive function, but rarely has been noted to reverse dementia. Thiamine deficiency has been noted in significant numbers of Alzheimer's patients and may affect their cognitive function. Screening for thiamine levels should probably be considered in more cases of confusion, given the propensity for thiamine to be depleted by use of diuretics. Research has also been conducted on the use of plasma chain-breaking anti-oxidants (which include alpha- and beta-carotene as well as Vitamins A, C and E) to improve cognitive function in Alzheimer's disease. Use of Vitamin C and E supplements has been suggested to protect against vascular dementia and to improve cognitive function in general in later life. The beneficial effects may indicate that increased free-radical activity has a common role in the cognitive impairment seen in various dementing conditions, and may suggest an avenue for more aggressive treatment. Unfortunately, rigorous research in this area is lacking.
The elderly are more likely than younger patients to exhibit cognitive impairment from taking medications; these result from age- and disease-associated changes in brain neurochemistry, as well as changes in the body's overall ability to handle various drugs. Delirium is the most commonly seen cognitive disturbance related to drug toxicity, but dementia has also been reported. Drugs have been implicated as the cause of acute confusion in 11 to 30 % of cases among elderly hospitalized patients, and medication toxicity occurs in up to 12% of patients presenting with possible dementia. Central nervous system toxicity may be dose dependent, resulting from interference with neurotransmitter function.
Almost any drug can cause delirium, especially in a vulnerable patient. Anticholinergic medications are important causes of both acute and chronic confusional states, but multiple anticholinergic drugs are still commonly prescribed, especially to nursing home residents. Recent studies have indicated that the total anticholinergic burden may determine the development of confusion rather than any single medication. In evaluating a patient's medication history, the nurse should keep in mind that anticholinergic effects have been identified in many drugs other than those classically thought of as having significant anticholinergic effects.
Psychoactive drugs are important causes of delirium. Acute confusion was a major complication of treatment with the tricyclic antidepressants, but is less often seen with the newer selective serotonin reuptake inhibitors (SSRIs) and atypical agents. Narcotic agents can cause delirium in postoperative patients; and the neuroleptics and long-acting benzodiazepines are known to cause or increase delirium and dementia.
Drug induced confusion with non-psychoactive drugs is most often idiosyncratic in nature, and as a result the diagnosis is easy to miss. Cardiac medications such as digoxin and beta blockers, corticosteroids, histamine H2 receptor antagonists, nonsteroidal anti-inflammatory drugs (NSAIDS), and antibiotics can all cause or exacerbate confusion.
Among other specific causes of confusion that are often seen in the nursing home are dehydration and urinary tract infection, and should be suspected in any resident showing an abrupt change in mental status. In the hospital setting, thyroid dysfunction, vitamin B-12 and other vitamin deficiency, and normal pressure hydrocephalus are among the differential diagnoses to be considered.
Emotional and social disruptions in lifestyle include confinement to a restricted, unfamiliar area; absence of needed prosthetics (hearing aid, glasses, dentures) or items that complete body image (purse, cane, makeup); loss of stable environment and contact with family; enforced bed rest; disrupted patterns of daily living, especially sleep; loss of control over body processes; relocation; and recent loss of significant person or possessions.

Causes

What causes confusion, especially confusion in the elderly? Many authors agree that confusion is the most common complication of hospitalization of the elderly. There is also evidence that elderly patients are sometimes confused following surgical procedures, with anesthesia thought to be a primary causative factor.
The risk factors that can predispose the elderly to confusion can also be considered causes. Age-related changes, physical conditions, and emotional and social disruptions in lifestyle may be implicated. Many of the changes in mental status may be related to the side effects and interactions of the numerous drugs usually prescribed for people in this age group. When hospitalized, the elderly are confronted with the additional stressors of changes in health status as well as separation from family, familiar environment, and familiar routines.
Causes of confusion may be organized into three categories: systemic, mechanical, and psycho-social/environmental. The first category, systemic, includes factors that interrupt normal brain functioning through the alteration of metabolic processes in the brain. As noted above, this category would include blood sugar abnormalities as well as hormone changes. The second category, mechanical, refers to a blockage or other physical restriction of normal brain functioning, such as those associated with stroke or traumatic injury. Finally, psychosocial/environmental factors are non-biological in origin and tend to diminish personal meaning. Loss of loved ones and changes in residential setting and circumstances fall into this third category.

Symptoms

It is difficult to list symptoms for confusion, either acute or chronic, since that list becomes a "laundry" list containing just about every vague symptom known to the medical profession. However, consideration of the most common and well-known symptoms gives a convenient starting point from which to perform the assessment.
Sometimes the confused person can't function intellectually or deal with the environment in the usual way. They may be disoriented to time, place, and/or person, or develop inaccurate perceptions, such as thinking a television image is a person. They may have delusions, use poor judgment, or forget, especially if they are hospitalized. Social interactions may become a problem; when they can't communicate meaningfully and have difficulty maintaining their attention, they may become angry, belligerent, withdrawn, uncooperative, or restless. Health care professionals as well as family may find it impossible to reason with the confused patient. Behavioral changes, which may be out of character, may occur. The patient may become hyperactive and display agitation, excitability, and/or irritability. Conversely, they may become hypoactive and display lethargy, somnolence, apathy, and/or reduced activity. Additionally, a confused patient may periodically exhibit both hyper- and hypoactive behaviors.
Some differentiations may be made between the clinical features of acute and chronic confusion with regard to onset, course, progression, duration, awareness, and alertness. Acute confusion often has an abrupt onset associated with an identifiable risk factor or cause. The course is short with diurnal, or daily, fluctuations in the symptoms; confusion may appear worse at night, in the dark, and on awakening. The associated cognitive and behavioral deficits show no clear pattern of progression, despite their variability throughout the day. Duration may range from hours to less than one month. Awareness of the environment may be reduced, and level of alertness may fluctuate from lethargic to hypervigilant.
Chronic confusion associated with dementia, in contrast, has a slower, more generally insidious onset, again depending on the cause. The course is long with no marked diurnal effects, and symptoms are progressive but relatively stable over time. The progression is slow but fairly even, and the duration is months to years, with no expectation of recovery of function. With chronic confusion, the patient is likely to exhibit adequate awareness of surroundings and a generally normal level of alertness.
To complicate matters even further, an acute confusional state may develop in a patient already suffering from chronic dementia, as a result of factors such as hospitalization, development of an acute illness, or a medication change. Detection of delirium superimposed upon dementia can be particularly challenging for both nurses and physicians. Delirium with dementia can be associated with new onset incontinence, depression, and weight loss; patients with both diagnoses are much more likely to be re-admitted to the hospital within thirty days than patients with delirium alone are. The causes of the "new" delirium must be identified and addressed regardless of the baseline cognitive status of the patient. Even after appropriate treatment, however, the patient may not return entirely to their baseline level of function.
A phenomenon associated with confusion that may be observed in patients with dementia is "sundowning" or "sundown syndrome," a constellation of behaviors associated with increased agitation and confusion that occurs in the late afternoon. Specific etiologic hypotheses that relate to sundowning behaviors include disruptions in regulation of melatonin, disturbances in Rapid Eye Movement (REM) sleep, episodes of sleep apnea, and a deterioration of an area in the hypothalamus. Decreased visual acuity related to waning natural light may lead to misperceptions of the environment, and reduced levels of structured activities associated with mealtime and staff shift changes have also been implicated. Management can include the identification and treatment of any physiologic factors, low doses of specific psychotropic medications, and non-pharmacological interventions, such as restriction of daytime sleep, exposure to bright lights during the day, and moderate but consistent activity schedules.

Nursing Interventions:

Communication
As you remember from nursing school, the way the nurse communicates can set the tone for the patient's experience with the medical professions in general, and influence the outcome of medical interventions. When the elderly person is admitted to the hospital, the nurse must recognize the changes that this has caused in that person's life. The nurse should also recognize what the age difference may mean in terms of acceptance of care. Our parents' and grandparents' generations have seen tremendous advances in every aspect of life; things that we take for granted. For instance, the telephone was invented in 1876, 125 years ago. Anyone born before 1960 (just 40 years ago) will probably remember the black desk-type telephone or even separate hand and mouth sets. The automobile was first mass-produced in this country less than 100 years ago, and air travel did not become commonplace until well after World War II. The television did not become a common household item until the 1950's, and our children are amazed that television shows were not in color when we were growing up. The advances in medical technology are too numerous to list; however, before 1950, most physicians were general practitioners, antibiotics were just being utilized routinely, and CT scans and MRIs had not even been dreamed of. Should we then be surprised at the fear and helplessness an elderly person may feel when admitted to the hospital? In today's world of medicine, even the hospital room can be scary to the uninformed.
Let's look at a hospital room through the eyes of a patient, starting with the call system. These will vary among hospitals and areas of the country, but most are all inclusive with the call button, the television control, and the bed control all on the same panel. Perhaps the call system is on a hand-held control or on the bed rail. Next time you are in a patient room, try to look at that control as if you'd never seen one and think about what you see. Of all the additional equipment that may be used, the most frightening for the elderly patient may be the intravenous set-up, especially if a pump of some kind is used. Most of the pumps have blinking lights as well as warning "beeps". With the constant changes and upgrading of systems, they have been hard enough for nursing professionals to learn. How intimidating they must be to the uninitiated!
Of course, there are always those elderly patients that break all the rules when it comes to knowledge of medical facts and facilities. In fact, there are many elderly adults (in their 80s and 90s) that can run circles around the most energetic nurses! The point is to assess the patient's level of knowledge and then communicate on their level. This can alleviate much of the confusion they feel in relation to their surroundings. Confusion can also cause some bizarre behaviors on the part of the elderly patient. Crying out, banging on the side rail, and trying to get out of bed are some of the behaviors that assist us in making the diagnosis of confusion. However, contact with another human being may be all that is needed to bring them back to the present.
Confusion is increased if the nurse communicates alarm by tone of voice and actions. The patient may become agitated and unmanageable and may agitate the nurse.
A relaxed approach to this kind of situation is difficult, yet may be the only one that is workable. The nurse should speak in a soft, low voice, telling the patient who is there, and make simple, reassuring statements. Holding the patient's hand to further the feeling of safety and permit some organization of thoughts is appropriate if the nurse is comfortable with this intervention. It is important that the actions of the nurse reflect true feelings so that the patient is reassured and not even more confused.
When the patient does not fully comprehend what is happening, the nurse's facial expression, touch, and tone of voice can create a more comfortable atmosphere. Frequently, all that the confused elderly patient needs is extra time and patience or, truly, some "tender loving care."
Consider the example of the nursing student. Students, especially during the first clinical rotation, have more time to spend with the patient. Once personal hygiene is completed and the patient is comfortable in a chair, the student can, many times, sit with the patient and talk. Report at the end of the shift may, then, go something like this, "I don't know why the nurses think this patient is confused. He didn't seem at all confused to me and I spent the entire morning with him."
Family members are often embarrassed and distressed by confusion in their elderly relative, especially if that person was not previously confused. The family may need some type of comfort, a touch or word of support, so that they can interact with their loved one in a satisfactory way. They need to know their mother or father is experiencing a state that is common and almost predictable in the elderly hospitalized patient. Methods of communicating that have worked with the patient, such as touching and reassuring, will be beneficial to the family.
Since information is still being gathered during this intervention phase, care must be exercised. Many patients appear to give accurate data, but they may confabulate to cover up a loss of memory. In cases of doubt, it is best if the information can be confirmed by a family member.
An additional problem that may appear as confusion is that words and actions have different meanings to people of different ages and cultures. The nurse must determine what the patient means, and what the patient understands. A client 40, 50, or 60 years older than the nurse is probably viewing the world from an entirely different perspective. A 90-year-old man who remembers when medicine was primitive and a physician was called only as a last resort when someone was dying, may view the efforts of modern scientific medicine with suspicion and may not follow the necessary medical regimen. The patient may appear confused but in actuality is only acting on his earlier belief that medicine and physicians are really unable to help. He may not be able to accept the opinions of a young physician who has long hair or a beard or who is of a different race. Some older patients react negatively to a nurse who is a man, because they have always perceived nursing as a profession for women. In all these instances, no matter what the nurse feels or thinks, professionalism in handing the situation is necessary.

Specific Interventions
Nursing interventions should focus on priority patient care issues. Safety, privacy, reduction of stimuli, frequent monitoring of confusion status, and reality orientation are all important areas when planning the nursing care of the confused elderly patient.
Safety is one of the most important foundations of good patient care. How to keep a confused elderly patient safe may be the biggest job the nurse has, especially if the confusion leads to significant agitation. There have been three traditional ways to maintain safety: drug therapy, restraints, and use of a sitter or family member to stay with the patient at all times.
Acute treatment of agitated patients has traditionally relied on antipsychotic medication, primarily haloperidol (Haldol), alone or in combination with benzodiazepines, usually administered IM. The recommended adult dose of Haldol 2 to 5mg IM is likely to be poorly tolerated in the elderly confused patient, and a more prudent approach would be 0.5 mg of Haldol combined with a like amount of benzodiazepine; higher doses only result in increased adverse extrapyramidal effects.
Benzodiazepines alone are also effective in controlling acute agitation also, and are better tolerated than the typical antipsychotics. IM lorazepam (Ativan) acts as quickly and as effectively as IM haloperidol in most instances, and oral lorazepam acts much more quickly than oral haloperidol. Recent studies have shown that lorazepam with risperidone (Risperdal) is generally equivalent to lorazepam with IM haloperidol in controlling acute agitation; given the greater tolerability of risperidone, this combination may eventually become the treatment of choice. Several medications in addition to the ones listed above have been used for longer-term treatment of agitation in the chronically confused patient. Propranolol (Inderal) has been used to control impulsivity and agitation, but use must be monitored carefully for potentially dangerous effects on cardiovascular function. Both carbamazepine (Tegretol) and divalproex (Depakote) have been used effectively, with divalproex often chosen due to its relatively benign side effect profile.
Restraints have become a controversial intervention with much research devoted to the topic. According to a recent study on confused elderly patients, restraints are used about 40% of the time, with the vest (Posey) restraint being the most commonly used. The probability of being mechanically restrained increases if the elderly patient is new on the unit, presents a risk for falls or other injuries, or requires more extensive nursing care.
If restraints are chosen as a nursing intervention, patients should be observed for restlessness, since agitation has been noted to increase when the elderly patient is restrained. Use of restraints requires a physician's order, and documentation requirements are significant. Careful and frequent monitoring of the patient is imperative. See Figure 1 for guidelines on using restraints properly.

FIGURE 1

How to Use Restraints Properly

Under federal guidelines, health care institutions should have a policy on the use of restraints. Such a policy should describe:

1. alternatives to attempt before resorting to restraints
2. indications that restraints are necessary
3. how long (time frame) the client should be restrained
4. how and when the restrained client should be assessed

You must have a physician's order now that restraints are considered "prescription devices". (Some states authorize other licensed health care professionals to prescribe restraints) The caregiver should consult the institution policy and find out what procedures to follow in an emergency.
The federal government is also requiring the manufacturers of restraints to develop better labeling and to modify their equipment so that it meets new regulations. Look for labels that say "prescription only" and provide graphic instructions on how to apply the restraints.
What can you do to make restraints safer? Always follow the Food and Drug Administration's (FDA's) guidelines as listed below.

In recent years, there has been a movement on the part of both long term care facilities and acute hospitals to limit as much as possible the use of both chemical (medication) and physical restraints, or to eliminate their use entirely. It is certainly true that delirious and demented persons are unable to think clearly and, as a result, exhibit unsafe behaviors. For many of the most problematic behaviors, however, experienced nurses have suggested alternative approaches to the routine use of restraints.
Agitation is often seen in this group of patients and, more often than not, is a response of fear of the unknown or an expression of physical or emotional pain and discomfort. Basic nursing care requires that the patient is kept warm, dry, and comfortable, and some creativity may be required to assess the source of discomfort. If the patient is able to verbalize his needs, listen and validate, then correct the problem as soon as possible. For many patients the source of agitation may be the presence of a tube somewhere on or in his body; and removal of the offending device may not be an acceptable option. If the patient pulls at an IV, the nurse can wrap the site and arm with an elastic compression bandage, and consider use of a capped IV line. One of the most aggravating devices seems to be the urinary catheter; for everyone's sake, they should be removed as soon as possible. In the meantime, the tubing may be hidden by placing the tube between the legs and the bag at the foot of the bed, or by use of an activity apron or lap board for the wheel chair. Leg bags can also be used if appropriate.
Tolerance of a nasal tube can be improved by keeping the oxygen humidified and the patient's nares lubricated. Consider a nasal tube stabilizer or taping the cannulae to the patient's cheeks. For an abdominal tube, one can use a tube stabilizer, an abdominal binder, or both.
Potential for injury from a fall is another major safety concern for the confused patient. Many falls occur when the patient tries to get to the bathroom, so a regular toileting schedule can help (e.g., every two hours; or in the morning, after meals, and at bedtime.) A physical therapy consult can be obtained to address strength and balance issues, and the need for assistive devices. The patient may be positioned where staff can observe him easily, or family members can be asked to sit with him. Whatever approach is used should be frequently evaluated for effectiveness and/or adverse reactions.
Privacy is another essential aspect of nursing interventions. All have heard, at one time or another, jokes regarding hospital gowns. However funny they may be, they are an invasion of privacy even if the patients don't intend for them to be. Try to maintain the patient's privacy as much as possible and avoid embarrassment. Think again about the age range of most of your elderly patients. Not all will be embarrassed easily, but we should treat everyone as if they would be.
Reduction of stimuli may be a more difficult intervention to ensure. Although a nursing home does not have the traffic flow of a hospital, it is still noisier than living with only one or two other people. If equipment is added to the scenario, noise is also added. The number of visitors permitted at a time should be determined based on the reaction of the patient, unless your facility has strict rules regarding visitors. It may also be necessary to monitor the reaction of the patient to a specific visitor. If a person seems to upset or agitate the confused patient, there is a chance the confusion may worsen when that person is present.
Frequent monitoring of the confusion status will add to the assessment that was begun at admission. This may be the only way to determine if the confusion is acute or chronic. Family members can be very helpful in this area especially if they are with the patient the majority of the time. This also offers time to assess for alterations in the patient's condition including nutritional status, adverse drug reactions, sudden acute confusion, or other physical or mental parameters.
Perhaps the most frequently taught intervention and one that most nurses do without too much conscious thought is orientation, sometimes termed reality orientation. Over the years there have been changes in the furnishing of hospital and nursing home rooms with orientation in mind. The large wall clocks and calendars in the intensive care units are one example of the attention orientation has been given. Orientation techniques have also undergone some changes over the years.
The nurse should remember, however, that many elderly patients have difficulty remembering details such as the specific date and the specific time. Time and date orientation is better evaluated on the time of day (daytime or nighttime) and the month or season of the year. Almost all patients should be able to tell you their name, although you may need to separate the truly confused from those who think the question is silly and will give you some ridiculous answer.
Most patients should also be able to tell you where they are, perhaps not precisely, but enough to say either hospital or nursing home (or similar response).
If the patient offers incorrect information, the nurse must use good judgment in determining how much correction to give. Some confused patients will react with agitation to attempts to correct their misperceptions, causing disruptions in relationships and difficulty with care. A good rule of thumb is for the nurse to push the issue of reorientation only if doing so is critical to the health and well being of the patient.
Another way to implement orientation is to introduce yourself when you enter the room, and include orientation information in the course of conversation with the patient. You can then use the evaluation tool of asking the patient what your name is to assess his present level of orientation and memory. Other interventions that are useful to the nurse when caring for an elderly confused patient are:

1. Doing one thing at a time; have the patient complete the task at hand before performing another. For example, complete brushing the teeth before beginning to comb the hair.
2. Keep all instructions simple, check for comprehension, and allow time for repetition.
3. Tell the patient everything that will happen before it happens, even if he does not seem alert enough to understand.
4. Avoid startling the confused patient. For example, speak gently and pleasantly as you approach the bedside. If possible, be sure the patient can see you, and establish eye contact.
5. Pay attention to complaints of hunger and thirst even if the patient has just eaten. Offer a drink of juice or milk and a cracker if possible. To tell the patient "you can't be hungry" or "you just finished lunch" is to imply that he does not know what he is talking about. The same thing applies if the patient complains of being tired or in pain.
6. Distract the patient who is showing signs of agitation. For example, say, "I like that new plant. Do you have plants at home?" or, "Do you like music?"
7. Stop what you are doing whenever the patient is resisting all your efforts to provide care. Anything else is futile. Maybe it's time for more "TLC". If the patient speaks in a loud voice, wait for an opportunity to speak and then do so in a soft voice. The nurse should help identify and correct causes of confusion and act to protect the patient from injury and other problems. When the patient is confused, the dilemma for the nurse is not necessarily the confusion, but the agitation and lack of cooperation that go with it.

Thorough basic nursing care helps alleviate agitation by eliminating a number of potential causes of increased confusion. For example, deep breathing and moving the extremities increase circulation and blood supply to the brain.

Documentation

A section on interventions would be incomplete without touching briefly on the importance of documentation. Much is taught in nursing school about documentation, yet our follow-through is often inadequate at best.
Especially with a confused patient, complete, accurate documentation is essential. Recent research on documentation of confusion in an acute care setting has found documentation of confusion in 78% of the nurses' notes, but in only 42% of the nursing care plans. Further, "none of the interventions used with confused patients was related to recent documentation in the nurses' notes or nursing care plans". I despise paper work as much as the next nurse, but as any nurse who has given a deposition will tell you, you sink or swim by your documentation.
Don't let inconsistency in your documentation make your plan for the care of the confused patient useless.

Discharge Planning

With an acute episode of confusion, a discharge plan must include the cause of the confusion and ways to avoid it in the future. This may include patient education and/or home health care follow-up. If the patient is diagnosed with chronic confusion, the caregiver must be taught how to care for the patient. If going home, a home health care follow-up is the best way to ascertain if the discharge instructions are being followed. Sometimes the environment must be modified so that the caregiver can follow the discharge instructions.

Evaluation of Outcome and Prognosis

How do you know if the nursing interventions you offered were successful? With acute confusion the prognosis is usually good and the confusion is generally reversible. If the precipitating factors have been dealt with, the delirium should have resolved, and the patient resumed functioning at close to baseline level. However, the caregiver must realize that acute episodes of confusion are not normal and any additional episodes should be reported to the physician.
The prognosis for chronic confusion, however, is poor since dementia is often progressive and generally irreversible. Interventions are geared toward keeping the patient at as functional a level as possible. In some cases, evaluation of outcome is done from the perspective of comfort measures. When a patient is in the late stages of dementia, nurses can only take their cues from outward appearances. If the patient does not display facial grimaces, does not cry out in pain, and does not display integumentary compromises such as swelling and skin breakdown, the nurse can presume comfort.
As we come to the end of the course, let me reiterate the main points. When looking for a definition for confusion, remember that the definition(s) you find may be vague and inconsistent. Acute confusion has an abrupt onset and is characterized by inappropriate behaviors. Chronic confusion is a long-term, progressive, and degenerative process. Presentation of both may be similar, so acute confusion should be assumed until proven otherwise. Remember that confusion is a symptom and not a disease process, and requires comprehensive evaluation to determine the underlying cause.
The assessment of confusion is usually an ongoing process that may take several sessions with the patient. Assessment may be more difficult if the patient has acute confusion since there are usually more periods of lucidity than with the chronically confused patient. Use every tool available including family members, medical history, medication history, as well as the patient. Look for risk factors that may have contributed to the confusion, and then search for symptoms that will validate that assessment.
Planning of nursing interventions is very important, but must be a flexible area. Due to the changes in the acutely confused patient, interventions that worked yesterday may not work today. The same is true for the chronically confused patient, but for different reasons. If the chronically confused patient has progressed to another level of confusion, interventions must be adjusted to handle those changes.
Communication is vital and the nurse must use all her skills, both verbal and non-verbal. While communication with any confused patient can be very time-consuming and frustrating, it is one of the best ways to evaluate the level of confusion.
Specific interventions should be tailored to the needs of the patient. Safety, privacy, reduction of stimuli, frequent monitoring of confusion status, and reality orientation are all important areas and should be reevaluated as the need arises.
So much more could be said about the area of documentation. It is the only way to effectively communicate among all the health professionals caring for the confused patient. Everyone using the same approach can provide not only better evaluation of the patient's confusion, but may make the duration of acute confusion shorter by cutting down on the patient's frustration.
Discharge planning begins the moment the patient is admitted. If the patient is chronically confused and will be discharged to a nursing home, discharge planning should center around the best and easiest transition to that facility. If the patient is to be discharged to home, discharge planning should center on making sure the caregiver is properly prepared if the patient is still confused upon discharge.
As was said earlier, prognosis is usually good with acute confusion and the confusion is generally reversible. The prognosis for chronic confusion, however, is poor since the condition is progressive and generally irreversible.

A Case History

Now let's consider the case of Mr. Jones, whose story includes many of the elements we have discussed regarding confusion in the elderly. Think of the principles presented as we go along, and we'll pause from time to time to review.

Mr. Jones was born in 1913. He was a retired railroad worker who had lived alone since his wife's sudden death from a pulmonary embolus fourteen years earlier. He lived in a tri-level retirement community (with apartments, assisted living, and nursing home facilities) in his own one-bedroom apartment. His three children were scattered across the United States, but his surviving brother lived within an hour's drive. His children kept in touch by letters and occasional visits. Regular phone calls had gradually ceased over the last six months as Mr. Jones became unable to hear. Mr. Jones was also visited by friends from the community. Mr. Jones' health was excellent; his only medical problem was glaucoma, which was diagnosed in the 1950s. He used eye drops to control the pressure and had had laser surgery at least once. He also took a digitalis preparation due to age related changes in his cardiovascular system, but had no diagnosed heart condition. At the time of his wife's death, Mr. Jones had become severely depressed. He was hospitalized and received a series of electroconvulsive shock treatments. There had been no apparent recurrence of the depression.

What risk factors for the development of confusion can we identify from Mr. Jones' history? At age 85, normal age-related changes should be present. Based on the information available, there is no clear indication of specific physical conditions that would contribute to his confusion. Since he was living alone, however, he may not have been eating adequately or complying with his medications and physician's recommendations. Mr. Jones' history suggested that he had in the past reacted to stress with depression, but there were no new significant stressors noted, and no apparent recurrence of the depression. He had little direct contact with family, and there had been a decline in regular telephone contact due to his hearing problems. He did appear to have a network of friends as well as facility staff to provide emotional support.

In July of 1998, the son received a call from a family friend who had recently visited Mr. Jones. She said she found him somewhat confused and wanted his family to know. The letters Mr. Jones had written in the last months had shown a minimal amount of confusion, but nothing that would signal a problem.
A call to the facility social worker confirmed that he was confused but able to carry on a normal conversation. She also reported that a long time friend of his was staying with him. The son made arrangements to visit his father the next week.
Upon arrival he found him in his apartment with the friend. He had visibly aged since the son's last visit and was a little confused, but still recognized his family. Consultation with facility staff indicated the confusion had had a sudden onset. The nurse had seen him weekly for blood pressure checks, with the exception of the last several weeks, and had not really noticed a difference in him.

How sudden was the onset of Mr. Jones' confusion? Casual contact with medical personnel such as the nurse who did blood pressure checks, with conversation limited to social pleasantries, may not reveal deterioration in cognitive abilities. Mr. Jones' family and friends had sporadic contact with him and did not have the opportunity to observe his day-to-day level of function. In Mr. Jones' case, there was no one who could give an accurate picture of the onset or progression of his confusion. However, it would be entirely appropriate for medical personnel to assume that the confusion was acute and temporary in nature in the absence of evidence to the contrary, and to evaluate him aggressively.

As the visit progressed, it became evident that Mr. Jones was periodically very confused. Upon recommendation of the facility, arrangements were made for an aide to visit daily to make sure he got a bath, dressed, and ate breakfast. Mr. Jones appeared to understand the arrangements and be in agreement. The day after the son arrived home, the facility called to say that the sitter had found Mr. Jones on the floor where he had apparently fallen. He was not injured, but had been moved to the assisted living area of the facility.
After extensive family consultations, it was decided to put Mr. Jones in the hospital and do some diagnostic tests to try to determine if the sudden onset of confusion had a medical basis. By this time, his room was noted to smell of urine and his clothing and bedding had been soiled.

The presence of urine and soiled linens may indicate a deterioration in Mr. Jones' level of function. If immediate causes such as a urinary tract infection are ruled out, it could be a sign of progressive dementia. Events such as a fall or a move to a new environment often precipitate such a progression.

The nurse that admitted Mr. Jones was a young, fairly new graduate. She asked all the right questions, but his response was to chuckle at most or just not answer. It was very difficult to determine what he understood and what he thought was silly. To assist in the confusion assessment, the nurse tried to explain to him why he was being asked these questions. He then answered some of them accurately, but to others he just chuckled. She was never sure just what he understood.

Despite the nurse's best efforts, she was unable to determine Mr. Jones' level of confusion. This underscores the need to assess for changes over time with repeated evaluations, and the importance of the observations of family and friends when they are available.

The diagnostic tests showed nothing and the decision was made by both family and physician to do nothing more and see what developed over time. He was kept in the assisted living facility with the aide coming every morning. His apartment was held until such time as the final decision was made to keep him in the assisted living area.
Ongoing assessments in every area were done: by the nurse at the home health agency, the physician, the nurses in the assisted living area, a physical therapist, and an occupational therapist. Finally a psychological evaluation was ordered. The physician wanted to make sure that every area was covered since the confusion seemed to have such an abrupt onset.
Physical therapy was begun three times a week in an attempt to conserve the muscle mass and mobility he still had. Occupational therapy was begun, but discontinued due to his ability to do some of his care, even though it took him a long time. All the other assessments showed nothing else except a progressive confusion.

Even though there were no clear risk factors related to physical condition, the assessments would look for such things as evidence of nutritional problems, metabolic abnormalities, thyroid imbalance, cardiovascular disease, changes in the structure or function of the brain, and infections. At this point, Mr. Jones had been presented with psychosocial and environmental disruptions due to hospitalization and return to the assisted living center (and the need to conform his daily schedule to those of the institutions), decreased mobility and control of bodily functions, and loss of relationships with familiar staff and neighbors due to his move. Again, sometimes the best assessment is to watch for changes over time.

Over the next year, Mr. Jones' confusion progressed to a clear dementia. He had periods of relative lucidity, but even during those times he tended to get things confused. He continued to get physical therapy until his balance became so bad that he had difficulty standing. When he tried to rise from the wheelchair, he kept his body in a "V" shape and almost toppled over on his head. When he tried to sit in the wheelchair, he bent over and then just "plopped" into the chair. At that time, the physical therapist recommended doing only exercises that he could do in his bed, mostly those which would keep his muscles from atrophying. It was soon after that when physical therapy, now mostly range of motion, was turned over to the workers on his unit. He was also moved to the dementia wing of the nursing home facility since his condition required more individual attention. The long time friend who had stayed with Mr. Jones earlier continued to visit him on a regular basis. She insisted, against all other evidence, that he was getting better and was always lucid when she visited. She wanted to take him out on rides and out to dinner. Based on the recommendations of the nurses and the physical therapist, along with their own concerns about his balance and her ability to handle him by herself, the family denied her request.
That summer, Mr. Jones' children gave him a birthday party. He smiled and seemed to enjoy the cake and ice cream that were fed to him. How much he understood no one knew. He didn't verbally communicate except with an occasional "no". Also during this visit, the children met with Mr. Jones' physician to discuss care and prognosis. The medical prognosis was poor. The diagnosis was dementia which, at this point according to the physician, was consistent with the presentation of Alzheimer's disease. Since there was no cure, and since Mr. Jones had made a living will that was explicit in his wishes, the decision was made to honor his request that no unnecessary medications be given or procedures done to prolong his life. It was a very hard decision to make, but one about which his children thought he had been very clear.
In June 2000, the family received a call from the nursing home that Mr. Jones had "just stopped breathing" and died peacefully. His old friend had continued to visit until just prior to his death, insisting that he always knew her and responded to her appropriately.

The rapid progression of Mr. Jones' dementia from initial diagnosis is quite unusual, especially in the absence of other major medical problems; life span after diagnosis averages eight to twelve years. However, the course described is fairly typical.
Why might the old friend's assessment of Mr. Jones be so different from those of others?

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