Any discussion of confusion requires beginning with a definition, but there are no neat, firm definitions of confusion that separate it from absolutely everything else. No one can say: "This and only this is confusion." So often the meaning is relevant to the situation. Confusional behavior includes a constellation of behaviors that are given the label "confusion" because they baffle the caregiver, as much as anyone. What is confusion in one situation may seem quite right and proper in another. The behaviors usually included in a definition of confusion are:
Loss of memory - first for recent events and later for remoteevents, and easy distractibility, or an inability to concentrate on anything for a sufficient length of lime to be productive. This may be more an inability to organize one's efforts.
Communication that often borders on incoherence so far as logical thinking processes are concerned. This is one of the first really apparent signs, for it interferes with the staff's ability to work with the client in an effective way. Communication problems may not be the first sign, but they may be first that catch and hold the caregiver's attention.
Lack of judgment. This is a subjective evaluation on the part of the caregiver, and is based on the caregiver's expectations and particular sense of values. It is undoubtedly linked to inability to use past judgments. It is another function of memory loss by which the past is denied access to the present.
An inability to put cues together to form a meaningful pattern, e.g., the confused person who sees hot sunshine is unable to associate it with daylight, or summer. Uniformed nurses and hospital wards are not associated with illness or hospitals. There is a difference between not knowing, or not having access to information, and being unable to tap into the storage places of the mind for the process of retrieving the right memory bits and assembling the whole into meaning.
Add to the above an inability to maintain control over one's possessions and routines, and you have a picture of confusion.
Confusion, then, is shorthand for a number of behaviors that render a person unable to use the mind in its usual way. It represents a change in mental status from a state in which the client seemed a relatively whole person in control of life. Baseline information is important, and should be gathered on admission rather than after strange behavior forces the issue. Remember, there are people who have never expressed a coherent thought in their lives. It is their normal, natural state - normal for them. And we all know totally disorganized people who accept disorganization as normal, for they have never known another way of thinking.
Unfortunately, humans are not made of little compartments neatly labeled physiology, mental health, social being, etc. We are a unity. Some of us prefer to see the human being as a physiologic process; others prefer to see the human being as a social interactional process. As humans we are both, and much more. Desmond Cormack1 took the FANAPES model I adapted from June Abbey's work2 and explained · this. Cormack states that, in any physiologic problem, the physiologic needs are primary, that is, the need for adequate air, fluid, nourishment, elimination and pain relief. Secondary to these there is always the need for communication, activity, sexuality, dependency, and psychomotor and interpersonal social skills. And there are secondary nonphysical problems, including trust, hostility, reality orientation and perception, affect, anxiety, selfesteem, cognition, and intellectual processes. In mental health problems, the last named problems become primary. The physical problems are secondary, and communication, dependency, sexuality and social skills remain common secondary problems for both physical or mental health clients. The whole are linked and only in our need to take people apart and compartmentalize them can we unlink. This framework can be used to propose the concept that the individual is a unity, and that any physical problem affects the emotional and intellectual self, and the converse also is true. So confusion is secondary to physiologic problems. This is not news. We have used confusion as a sign or symptom of physiologic problems for many years. Take the neurologic signs of any disorder that involves the brain and the rest of the body; "confusion" is listed early in the signs and symptoms.
Another way of saying this is that confusional states are secondary to brain failure (the word failure is used as in renal failure or cardiac failure - an inability to perform its usual functions). This idea is recent. It was easy to link confusional states to senility when they occurred in the elderly, but more recently the term "organic brain syndrome" has been used to label such confusional states, instead of "senile dementia." More recently the terms "acute (or rapid) onset confusional states" and "reversible" have been used, rather than "chronic," "long-term," or "irreversible." Even more recently the terms "brain failure" or "cognitive decrement" have been used to describe the reversible acuteor rapid-onset types. I prefer to think that there are three kinds of confusional states:
1. Acute onset, reversible types of confusional states;
2. Chronic, long-term, irreversible types of confusional states like Alzheimer's disease - senile dementia (AD-SD type), usually termed organic brain syndrome; and
3. The too-often unrecognized: Acute onset superimposed on the chronic long-term irreversible form.
All three represent forms of brain failure. It is the history and related systemic problems that determine whether the confusion is secondary to brain failure from physiologic problems that affect the whole of the organism.
We do not even need to consider physiologic problems like sleep deprivation, lack of rest, overfatigue, or elimination. These represent interruptions in the normal body rhythms and feedback cycles. Their function is so automatic that we rarely become aware of them until some change forces them into our consciousness. We should consider the three major systemic problems - hypoxia, changes in the glucose content of the blood, and toxicity, e.g., drug toxicity.
Certain confusional states can be predicted - any problem that interferes with oxygenation of the brain cells, or interrupts their constant need for glucose for metabolism, or alters the neural function by chemical means, can precipitate confusional states. Nursing care can be planned around this concept. For too long confusional states have surprised us, as if we could not have predicted them, yet we knew that in certain circumstances they were very common - even inevitable.
Confusional States Secondary to Hypoxia
The first and foremost effect on confusional states is the cell's constant need for oxygen. The brain cell has a minute by minute need for oxygen, and dies without it. Timiras3 reported that in the elderly there is a state of chronic hypoxia of a small degree, which is compensated until demands increase the need for oxygen. If there are no body reserves to supply it, a more apparent state results. Groer and Shekleton4 classified hypoxia according to four categories that will be used for our purposes: (1) anemic hypoxia, or lack of ability to transport oxygen in the blood because of lack of red cells or hemoglobin; (2) hystotoxic hypoxia, or conditions that prevent the cell from metabolizing oxygen, i.e., hypo- or hyperthermia, dehydration or the accompanying electrolyte disturbances like hypokalemia, hyponatremia, hypo- or hypercalcemia, and uremia; (3) hypoxemia or ventilatory problems, which interfere with gas exchange in the lung membrane itself; and (4) ischemic hypoxia, or the obstruction in blood flow to brain. This last may be due to cardiac failure, atherosclerotic patches in the arteries, hypotension, or even to increased intracranial pressure. Some writers estimate that 13% of confusional states are caused by cardiac failure.
Anemic hypoxias are found in clients who do not have enough red cells or hemoglobin. There may be acute blood loss, e.g., from a hemmorrhage, and the rapid onset may contribute to the confusional state itself. But large and sudden losses of blood are dramatic and usually are treated promptly. More insidious is the gradual blood loss from the use of aspirin or other drugs that irritate or ulcerate the lining of the gastrointestinal tract. The elderly tend to use inexpensive and easily available aspirin as medicine. If each dose of aspirin is accompanied by loss of a few drops of blood the cumulative loss can become considerable, especially if there is poor nutrition. Diets of many elderly persons are iron -poor. There is a lack of meat and green vegetables because of low income and lack of dentition, so that nutritional iron is a luxury. Iron-containing supplements often are very unsatisfactory because they irritate the gastrointestinal trac. The nurse who cares for such clients should ask about aspirin or drug ingestion and patterns of food intake. Nursing measures should work toward supplying nutritional iron and educating the elderly about aspirin use.
The pernicious anemia of older people is common; it is particularly a disease found with aging. Confusion often is the first sign preceding even the neurologic signs of sensation loss and motor difficulties. All older people are high risk clients who should have screening blood studies. Pernicious anemia may be treated by vitamin B- 12 injections, which may be necessary during the rest of the client's life. The necessity for continued treatment is part of the teaching, and discharge planning includes assessing the client's lifestyle to determine whether the client can maintain a regime that will become lifelong.
Folic acid deficiency is preventable. It is found in clients whose diets do not contain folate, a substance often found in association with ascorbic acid - in the same foods. Fresh fruits and vegetables are the foods least likely to appear in the elderly client's diet. In alcoholics, who constitute a fair number of the elderly, there is a high risk of folic acid deficiency. The nurse's assessment of lifestyle and nutritional patterns may be a first step toward recognition of folic acid deficiency. At high risk are those whose incomes prevent the luxury of fresh foods, and those who drink. The disorder will recur unless the circumstances that caused it are changed. Nursing intervention includes education toward modifications in food patterns and lifestyle.
The hemolytic anemias can be acute, e.g., transfusion of noncompatible blood, or of slower onset when caused by drugs. Treatment is usually within an acute care setting.
Hystotoxic anemia is often found with dehydration. All emergency admissions of the elderly to the medical wards of a Canadian hospital were studied for signs of confusion and dehydration.5 The standard MSQ was used to measure confusion, and the hematocrit, blood urea nitrogen (BUN) and other blood tests were used to confirm clinical signs of dehydration. In 66% of the cases confusion cleared, usually within a week, when rehydration was accomplished. How do the elderly become dehydrated? Many older people do not note their thirst, and many do not drink water but depend on cups of hot beverages that, while satisfactory from a quality viewpoint, may be in insufficient in quantity to maintain hydration. Many (often as many as 20%) are taking diuretics. The high-risk person is one who is taking diuretics, cannot be mobile enough to get fluids, or who just simply does not drink fliiids. The nursing care indicated is vigilance in assessment of the person and lifestyle. Treatment is rehydration, and discharge planning should include education about fluids.
Good nutrition should take care of electrolyte needs, but diuretics may wash out potassium. Lack of calcium is very common in the elderly who have a lack of tolerance for lactose. Milk is expensive for those on low incomes, and heavy to carry. The first easy answer is milk, which for 50-60% of the elderly is intolerable, and the second easy answer is calcium tablets, which are large, difficult to swallow and often not assimilated. The real answer can be the nutritional calcium found in leafy vegetables and beans.
Hypercalcemia may be found in the elderly who treat their hiatal hernia discomforts with milk and alkali. In fact some live on a milk and alkali diet, which leads to alkalosis and formation of kidney stones. If adequate fluids are not taken, hyperosmolarity can result in dehydration. The problem also is found in metastatic carcinoma with loss of calcium from the bone. The problem with nutritional hypercalcemia is in encouraging the client to return to a more compatible diet, with adequate fluid intake. Each older person has hisown perspective on the health problems that confront him, affecting his own regime, which may be used with the physician's treatment plan or instead of it. The whole person, his life style, his physical assessment, and his version of what is happening to him are important in determining what can be changed to return him to normal electrolyte balance.
The aged person has a thermodynamic regulatory system that does not correspond with the norms set for younger people. No one has studied the normal temperature for the inactive older person (or the active), but we now know that hyperthermia may begin at a much lower reading than found in children and young adults. A temperature of 100 F (37.7 C) in an elderly person can cause hallucinations and confusional behavior. Even more important is the fact that older people have a reduced number of sweat glands that decrease heat loss by evaporation. During the period of extreme heat during the summer of 1980, many older people died from hyperthermia. Their refusal to go to cooler centers often was a sign of their confusional state, which interfered with problem-solving and judgment.
Nurses have been acculturated to think about hyperthermia, but hypothermia is one of the grave problems of the elderly. The older apathetic nonresponsive person who easily can be labeled confused often is hypothermic, with a core temperature of 97 F or lower. This problem can be caused by energy shortage and increased cost of utilities, but it is also a problem in our well-run acute care settings. Ozuma and Foster6 studied preoperative patients and found that temperatures dropped a degree before surgery. During preparation, surgery and later, more body heat was lost, while little was generating. Vaughn7 found that elderly people on admission to recoven· rooms had core temperatures that ranged from 97 F to as low as 90 F. The elderly warmed to normal temperatures much more slowlv than their younger counterparts. While in the recovery room they exhibited restlessness, which was often related to pain but could have been the sign of hypoxia from hypothermia. The administration of pain-relieving drugs may depress the respiratory center, resulting in still more distress; this can be handled with oxygen inhalation instead.
Prevention? I am sure that we all are making mental notes to notice ambient temperatures to insure that they are warm enough for the elderly, who seem to maintain body temperature better in higher room temperatures. On the other hand, during the heat waves of summer release systems should be used to keep air moving and cooled to a safe level. The inactive or sedated elderly person is at high risk for hypothermia. This describes the elderly client who falls on the floor at night and cannot arise - whether from hypotension, fractured hip, stroke, or other reasons. The client may lie there the coolest part of the room where air currents are swirling, losing body heat by convection.
Treatment for hypothermia is an art and science we have to learn from the British, who have recognized this as a problem for some time. Body heat must be restored slowly, not faster than one degree per hour, and the vasomotor reaction must be monitored constantly because of danger of collapse. The elderly person can go into shock easily unless warmed slowly. External heat is not used, but higher ambient temperature and covering of the body are employed to preserve heat that the body generates spontaneously. Moving the patient, intubation, and excessive handling may trigger arrhythmias. The patient is acutely ill, yet can be brought back safely to normal body heat with good nursing care.
It has been known for a long time that elevated BlTN levels and confusional states are related. Azotemia may be one more cause of hypoxia in brain cells, interfering with function. Who is at risk? A person who is 65 years old in 1981 was born in 1916, almost 25 years before the first sulfa drugs were used to treat streptococcal infection. And that client was more than 30 years of age when the first penicillin was available for civilian use. This group of peopTe - those over the age of 50 now - were subject to scarlet fever and streptococcal throats as part of growing up. The sequelae are damaged kidneys and hearts that, after the wear and tear of years of living and insults of health problems, have little or no reserve. While the threat of streptococcal infection is decreased now, our elderly population bear the scars, and many will have uremia.
Hypoxemic hypoxia or ventilatory failure has been the sequela of our industrial pollution, cigarette smoking, infections, and dust. Black lung, brown lung, and emphysema are taking their toll among our elderly. We know that confusional states are secondary to the hypoxia found in these people. Smith8 found altered breathing patterns in sleeping persons, with periods of apnea or hypopnea. These were accompanied by hypoxia, and resulted in lighter sleep. It is possible that the hypoxia of older clients may contribute to their light sleep and their sleeplessness and confusion during the night.
The aging chest itself contributes to ventilatory problems. There is a rigidity in the chest wall, decreased excursion of the diaphragm, and decreased expansion of the lung with dead space at the base, which can lead to accumulation of fluid with immobilization. The trunk shortening from compression of the vertebrae from fractures or worn cartilage can push the viscera against the diaphragm. The result is a kyphotic elderly person with a protuberant abdomen and thin legs and arms. Prevention is pulmonary hygiene - effective coughing, deep breathing, and belly laughs. Every elderly person should have the opportunity to laugh at some hilarious humor at least once a day. In one nursing home, when the confused patients were being used to demonstrate examination of the chest for students, three out of seven were found to have previously unsuspected pneumonia.
Ischemic hypoxia or poor brain perfusion can cause confusional states secondary to congestive heart failure. Heart failure - brain failure. Do not expect the cardiac patient to be sharp and alert. Hypotension can result from vasomotor problems or postural hypotension, or it can result from phenothiazines and other drugs, and it can result from cardiac failure. The result is a confused patient who is unable to follow a thought through to its natural conclusion. We have named high risk patients, but prevention is the key here, for treatment requires much skillful management during acute stages. After the initial acute episode the discharge plan should include prevention - these problems are rarely one-time events. There must be an understanding of how lifestyle and treatment can prevent further instances.
Increased intracranial pressure is a cause of ischemic hypoxia. Particularly important are tumors, either primary or metastatic. A common cause is subdural hematoma, which often is recognized at the onset of a confusional state that leads to further investigation. Falls, not necessarily those in which there is a blow to the head, cause a shearing of the tine blood vessels of the brain leading to the skull. The decreased brain volume leaves space in which the blood vessels are under tension. The shearing jolt leads to a slow bleeding, with development of a hematoma over several weeks' time. The treatment is surgical. A second form of lesion that can lead to increased intracranial pressure is normal pressure hydrocephalus (NPN). The cerebrospinal fluid does not drain from the ventricles, resulting in enlargement at the expense of the cerebral cortex. The symptoms are confusion, gait changes, and incontinence. Treatment is surgical, with shunts. There are still some less than satisfactory results. Prevention is unknown. Nursing intervention is supportive during surgery and rehabilitation, or supportive through the gradual deterioration leading to death.
Hypo- or Hyperglycemia The older person with adultonset diabetes often is treated with an oral antidiabetic agent like tolbutamide. This type of diabetes lacks drama for the health caregiver and often for the patient. There are no daily insulin injections. Dietary control means changing eating customs, habits, and likes of a lifetime, and is unrewarding. But the disease can be quite treacherous. If the older diabetic client does not maintain food intake, as when ill or depressed, and continues to take the oral hyopoglycemic, hypoglycemia can result. It does not have the epinephrine-like symptoms of the insulin-reaction type of hypoglycemia, but the blood glucose level is decreased to the point that the brain does not receive enough glucose to let the nerve cells conduct electrical impulses. The result is an apathy, or confusional state secondary to hypoglycemia, which does not alert the family or the client to action. The high-risk clients are those who conscientiously take their pills whether they eat or not; those who are unable to eat because of physical, social or psychologic reasons; and those who have nausea and vomiting. The early signs are neurologic, and confusion may be the first sign. With recognition that this is occurring, treatment can be immediate and effective. Urine testing tells only that the results are negative. It is not quantitative - there is no indication whether the negative reaction is within safe limits or dangerously low. Urine testing does differentiate from the hyperosmolar reaction of hyperglycemia.
The prevention of hypo- or hyperglycemia is the involvement of the client or the caregiver in selfcare, which must be done on the basis of information. If the client cannot understand the relationship between food intake and oral hypoglycemics, then a caregiver must take responsibility for monitoring and be fully aware of sudden or subtle changes in mental status. The treatment for confusional states secondary to either hypo- or hyperglycemia is to restore the normal blood sugar.
Drugs and Confusional States
Unfortunately all drugs exert chemical reactions in the body that are not limited to the targeted scene of action. A surprising number attack the entire body. One example is digitalis, which affects not only the cardiac muscle and conduction system but the gastrointestinal tract and the nervous system as well. The central nervous system effect is indicated by confusional states, loss of equilibrium, and often complaints of "yellow" vision. In one large geriatric unit with maintenance as its goal, a geriatric nurse practitioner assumed responsibility for primary care of the patients. She asked why certain patients were given digitalis. The answer was hidden deep in the voluminous records - actually lost in history. The digitalis dosage had been continued without question for years. She ordered serum digitalis levels, which were found to be above normal. When the digitalis was discontinued, the men became alert and responsive, and no longer deserved the label "confused. "Their equilibrium improved and mobility was increased. They became part of the "real world" again. Neither confusion nor loss of equilibrium is listed as a major side effect of digitalis therapy. The patients' digitalis was still discontinued at the end of a year without any resumption of cardiac symptoms.
All drugs should be suspect, but the phenothiazines and tranquilizers of all kinds are especially prone to cause as well as relieve confusional states. Ii is important to have a good baseline assessment of the client's mental status. Urinary antiseptics, antibiotics, and drugs of all categories can be culprits, while those given at night to induce sleep are usually involved in nocturnal or early morning confusional states. The first question, when behaviors denoting confusional states are observed, is: "What drugs is this person taking?" The answer should include over-the-counter drugs as well as drug interaction with foods or, as in the case of the oral hypoglycemics, lack of food. The possible interaction of alcohol must be considered as important.
This discussion has attempted to show that confusion should be considered not only in the field of geropsychiatry, but also in the field of physiology. Every client with confusion, whether with sudden or long-term onset, should undergo a complete physical assessment9 and a review of lifestyle and life history for physiologic implications. In one study, five out of 40 clients with longstanding "senile dementia" referred for intensive workup by neurologists were found to have hypothyroidism and normal pressure hydrocephalus. The patients with treated hypothyroidism responded and returned to normal activities. One who had a blood disease improved. The normal pressure hydrocephalus was less easily treated after long-term disease.10 The treatment required diagnosis of the physiologic problem rather than approaching the confusional states through psychiatric intervention. The patient with pernicious anemia may profit from group therapy, but not until after treatment with vitamin B-12.
Clients at high risk for developing confusional states should be identified, i/ we can predict confusional states, then we can prevent them. This is particularly important in acute care settings, in which the patient has been admitted with a primary diagnosis, e.g., cholecystitis or hip fracture. Unfortunately, in the elderly there is rarely only one diagnosis. There may be many secondary diagnoses as the result of sudden change. Nursing staff should be aware that the person exists as a whole.
Prevention can be achieved by maintaining the physiology of the patient in a normal state. This may mean rehydrating a patient who is dehydrated. It certainly means being aware of iatrogenic dehydrations that occur with preparations for laboratory and radiologic tests or preparation for surgery. Malnutrition in the hospital is recognized more and more as the result of treatment when a disorder is treated at the expense of the total person. It is here that nurses can take a firm position. All persons need oxygen, regardless of any other fact, which means emphasis on pulmonary hygiene and limitation of respiratory depressants. Fluid must be present in normal quantities for the cell to function and if the patient is NPO, then other means of maintaining fluid balance must be sought. Prevention means maintaining the patient's physiologic status within the normal ranges that humans require.
Treatment and prevention often are nursing actions and responsibilities: supplying adequate fluid and nutrition, activity, relief of pain, elimination and above all else, vigilance with drug administration. The confusional states will not recede until the body's normal physiologic status is restored. To sum: back to the fundamentals of nursing, but with a new insight, that confusional states are often a sign of physiologic imbalance. Vital signs and mental status observations are part of the same package.
To bring the patient back to a state of equilibrium requires recognition of deviance from normal and being honest about reality. Whose reality? We always work from our own version. Often validation is sought by the client. Our concern is to ask whether feelings are making the client uncomfortable- dreams or thoughts that do not seem right. When asked in an understanding manner and without judgment, we can discern the patient's own view of divergence from reality. Often it is related to some factor in the environment that can be explained. The best example is the woman who worried about being watched by TV, an obvious paranoid reaction until it was noted that the TV repairman parked his cart with TVs outside her door while checking at the nurses' station for problems. Drug-related dreaming is mixed with reality, and explanation can provide immense comfort to the patient. First and foremost, though, we must see confusional states for what they often are - a symptom of a physiologic problem like hypoxia, glucose metabolic problems or drug toxicity that interferes with brain function. The physiologic state must be changed to improve the mental status.
- 1. Cormack D. The nursing process: An application of the SOAPE model. Nursing Times, 1980; 76(9):37-40.
- 2. Abbey J. Lecture Notes, University of California, San Francisco. 1968-70.
- 3. Timiras PS. Developmental Physiology and Aging. New York, Macmillan, 1972.
- 4. Groer ME, Shekleton ME. Basic Pathophysiology, a Conceptual Approach. St. Louis, CV Mosby, 1979.
- 5. Seymour C et al. Confusional states in the elderly. Paper read at the International Congress of Gerontology. Tokyo, August 24, 1978.
- 6. Ozuma JM, Foster C. Hypothermia and the Surgical patient. Am J Nurs 1979; 79(4):646-8.
- 7. Vaughan S. Nursing Treatment of Hypothermia in Adult Recovery Room Postsurgical Patients. Doctoral Dissertation, College of Nursing, University of Arizona, 1980.
- 8. Smyth ML. Alterations in respiratory patterns in sleeping subjects with C.O.E.D. Paper read at the 8th Annual Research Conference. College of Nursing, University of Arizona, Tucson, September 19, 1980.
- 9. Anderson D. Confusion in the elderly, a protocol to determine acute brain syndrome versus chronic organic brain syndrome. (For the Geriatric Nurse Practitioner). In: Wolanin MO, Phillips L. Confusion Prevention and Care. St. Louis, CV Mosby, 1980:376-396.
- 10. Fox JH et al. Dementia in the elderly - search for treatable disease. J Gerontol 1975; 30(5):557-64.