Confusion in elderly nursing home nursing residents is a significant problem for health care professionals. The proportion of elderly in institutions who suffer some form of cognitive or affective impairment is estimated to be as high as 50-70%.1,2 According to the National Nursing Home Survey of 1977, the third and fourth most common diagnoses for persons admitted to nursing homes are "senility" and "chronic brain syndrome."3 No statistics are available for the numbers of elderly who become confused when they are removed from the familiar environment of their home to the nursing home. How many residents are confused because of hypoglycemia, anemia, or hypotension? What percentage are forced into a mold of senile behavior because of labeling by staff?
There are many reversible sources of confusion. Butler recognizes over 100 forms of treatable dementia.1 In the nursing home it is the investigator's observation that little distinction is made between those elderly with reversible forms of confusion, and those with irreversible brain disease.
There are several reasons for this. First, there is no standard definition of confusion. The term is used indiscriminately to refer to a variety of behaviors and conditions. Wolanin finds that the label "confused" was attached to nursing home residents based largely on subjective impressions of caregivers.4 Patients who exhibit socially undesirable behavior, are unattractive, or are problematic for nurses are likely to be called "senile", according to a study by Phillips, reported in Wolanin and Phillips.4
Secondly, the literature provides little assistance in the definition of management of confusion. Few studies exist that describe confused behavior, or discuss management based on the reversibility or irreversibility of the confusional state.
This study was designed to assess the level of knowledge and opinions of nursing staff about reversible and irreversible forms of confusion. It was assumed that the type of nursing care the person received depended on staff beliefs about the source of the person's confusion.
Nursing assistants are the primary caregivers in most nursing homes and the subjects of the study included nonlicensed personnel (defined as nursing assistants) and licensed personnel (defined as registered nurses and licensed practical nurses). When staff believe the confusion to be reversible, they frequently take action to prevent further deterioration and complications. However, when staff believe the confusion to be irreversible, the person may be labeled a "senile old person," thus perpetuating his confused behavior.
Acute organic brain syndrome (reversible brain disease) was defined by Raskind and Storne as "a clinical picture of diverse organic etiology whose most prominent feature is disorder of attention, rapid onset of fluctuating disturbance of affect, memory, and orientation."5 Innumerable causes were listed for this condition. These ranged from neurological and metabolic disorders to drugs, surgery, and cancer.5 While many authors favored physiologic factors in the origin of acute brain syndrome, a few proposed a combination of physical, psychological, and social variables.
Chronic organic brain syndrome (irreversible brain disease), as defined by Cape, was characterized by a "progressive long-standing decline of intellect and personality, which reflects disturbances of memory, orientation, capacity for intellectual thought and often of affect. "6 The majority of persons with this syndrome were identified as having Alzheimer's disease or multiinfarct dementia. As the etiology of these conditions, particularly the former, is unknown, they are considered permanent and untreatable.
In the nursing literature, most authors subscribed to the medical categorization mentioned previously. Few research studies were found that addressed the syndrome of "confusion." One, by Williams, et al was conducted on post-hip-fracture patients in the acute care setting.7 The authors found the best predictors of post-operative confusion to be confusion on admission, presence of post-operative urinary problems, limited mobility, and absence of clocks and calendars.
The major work in the area of confusion was done by Wolanin and Phillips in their book, Confusion: Prevention and Care. This book represented a synthesis of the current knowledge and research on confusion. Based on adaptation theory, confusion was described as a failure to adapt to changes in the external and internal environment.
Within their framework, Wolanin and Phillips delineated five categories which they believed were the primary sources of confusion. We used these categories for the development of the study instrument: 1) compromised brain support; 2) sensoriperceptual problems; 3) disruption in pattern and meaning; 4) alterations in normal physiologic states; and 5) the true dementias. Examples of conditions that might cause acute confusion in the comprised brain support category are congestive heart failure, anemia, pneumonia, fluid and electrolyte imbalance, hypotension, hypoglycemia and toxic drug reactions.4 Wolanin and Phillips cited more than thirty different conditions as possible sources of acute confusional states.
The second category of sources of confusion was sensoriperceptual problems. Sensory aging changes, such as diminished vision and hearing, could lead to sensory deprivation, sensory overload, or sensory distortion. Studies of environmental effects on mental status have shown cognitive decline in elderly as a function of decreased vision and hearing, lack of environmental cues, constructed territory, social isolation, and relocation.8"13
Confusion secondary to disruption in pattern and meaning was the third category. Disruption may occur when the elderly person is unable to cope with chronic stress-producing situations.
In an institution, Phillips explained, elderly learn to withdraw when faced with punishing behavior from the caregiver.4 As the resident becomes increasingly socially inaccessible through apathy, wandering and incoherent speech, the caregiver rewards this behavior with increased attention or decreased punishing behavior.6
As the fourth category of sources of confusion, Wolanin and Phillips identified alterations in normal physiologic states. Some of the states they implicated were problems with sleep, eating, elimination, and pain, all of which interrupt normal body rhythms and feedback mechanisms. Confusion was thought to arise as the elderly person became preoccupied with the stress of impaired function. Other authors have found relationships between confusion and incontinence, eating and sleeplessness.6,14,6
The final category proposed by Wolanin and Phillips for the etiology of confused behavior was the true dementias. This category encompassed those irreversible organic conditions described earlier as chronic organic brain syndrome. The diseases of multiinfarct dementia, Alzheimer's disease, and a variety of other neurological conditions were included.
The sample for the study consisted of 110 volunteers from the licensed and nonlicensed nursing personnel of two large (over 100 beds) philanthropic nursing homes in a midwestern suburban area. The subjects included 35 licensed and 75 nonlicensed nursing personnel. Subjects completed an investigator - designed instrument consisting of three parts.
Part I was composed of five demographic characteristics; age, education, position, years of nursing experience, and years of experience in a nursing home. A knowledge questionnaire with 20 true-false items was Part II, based on the five categories previously discussed. Part III contained 20 opinion items based on the same five categories.*
The subjects were between the ages of 21 and 60 years of age, with approximately one-third being 51 years or older (36%). The majority of nonlicensed personnel were high school graduates (67%), while the licensed nurses were largely licensed practical nurses (31%). Some of the registered nurses had bachelor's degrees (20%) and some were diploma graduates (22.9%). About half of the staff (48%) had ten years of nursing experience. Sixty-eight percent had worked in a nursing home less than ten years.
Study question one was: What is the extent of licensed and non-licensed nursing staff's knowledge about sources of confusion? Answers to this question were based on the number of correct answers on Part JJ, the Knowledge Questionnaire. Licensed subjects had a higher mean score than nonlicensed staff. The range of scores was approximately the same for both subsamples. Answers for the individual true-false questions were studied to determine specific adequacies and gaps in subjects' knowledge.
The item most often answered correctly was "Scolding a person when he does something wrong will help lessen his confusion" (False). Most frequently answered incorrectly was the item: "Confusion can result from having to be fed all the time." (True).
Study question two was: How do knowledge scores on a questionnaire regarding sources of confusion vary according to demographic characteristics of study subjects? The highest mean knowledge scores were attained by the licensed personnel in the 21 to 30 age group; while highest scores for nonlicensed staff were in the 31-40 age group. Lowest mean knowledge scores were found in the over 50 age group in both subsamples.
Level of education showed a linear trend with mean knowledge scores, both for licensed and nonlicensed personnel. Those subjects with a greater amount of formal education had higher mean scores than the other subjects. Mean knowledge scores tended to decrease slightly with years of nursing experience in the licensed group, but not in the nonlicensed subjects. No relationship was seen between knowledge scores and years of nursing experience in a nursing home.
Study question three was: How do licensed and nonlicensed staff differ in opinions about the reversibility or irreversibility of sources of confusion?
For each source of confusion listed on the opinionnaire, frequencies were tabulated for each response code: "No"; "Yes, Temporary"; and "Yes, Permanent." Calculations were made for licensed, nonlicensed and total numbers of subjects.
Fifteen items were indicated reversible by a majority of licensed personnel, and 13 were indicated by nonlicensed personnel. None of the opinion items were selected by nonlicensed staff as irreversible, whereas three opinion items were selected by licensed staff. Some of the conditions (two) listed on the opinionnaire were not thought by staff to lead to confusion; while on some items there was no clear majority. In general, the licensed group more closely matched the original intent of the instrument in that they chose 15 out of 16 conditions as reversible and three out of four as irreversible.
Eight of the conditions were selected by 75% or more of the licensed staff as reversible sources of confusion. The highest percentages were demonstrated for 1) "being tied in a chair" (86%), 2) "Tranquilizer drugs" (85%), 3) "Lack of choices" (80%), and 4) Sleep problems" (80%), and 5) "No visitors to talk to" (80%). Nonlicensed staff chose slightly differently. Their top selections were: I) Tranquilizers" (74%), 2) "Small strokes" (73%), 3) "Being tied in a chair (72%) and 4) "Sleep problems (69%) and 5) "Lack of choices" (63%). None of the conditions were marked by 75% or more of nonlicensed personnel; indicating less certainty on their part as to the reversibility of the conditions.
In analyzing the responses by category, it can be noted that "Compromised Brain Support" received the highest percentage of "reversible" responses, with an average response rate of 68% for the four reversible conditions drawn from that category. The other categories in order were: "Disruption in Pattern and Meaning" with an average 62% response rate; "Sensoriperceptual problems" (60%); "Altered Physiologic States" (56%). The lowest was the "True Dementias" with an average 44% response rate indicating irreversibility.
Each of the conditions on the opinionnaire had one or more subjects who did not attempt to answer that specific item. The highest percentage of "no response" was found on the item "Alzheimer's disease", (25% of nonlicensed personnel did not answer this item).
First, the findings of this study have direct application for education. The subjects were found to have a considerable knowledge of reversible and irreversible sources of confusion in elderly nursing home residents. There were gaps in this knowledge however. This was evident in the findings that nursing assistants generally had lower scores than the licensed staff; that nursing personnel who were older and had less education tended to have lower knowledge scores; and that the total sample had high percentages of incorrect responses in the area of irreversible sources of confusion.
From these findings, educational programs could be developed for nursing home personnel . Since subjects had more difficulty with items regarding the true dementias and altered physiologic states, these content areas should be emphasized in educational offerings. In addition, the multiplicity of reversible sources of confusion should be addressed with the appropriate management of each underscored.
It was beyond the scope of this study to examine the relationship between nurses' knowledge of confusion and their application of this knowledge in actual practice. However, the findings of this study could be used to focus both knowledge and practice. Although this sample performed well on items related to caregiver's effects on confused behavior, inservice programs could be developed Avhich would creatively demonstrate how the caregiver's approach to the elderly person can aggravate or minimize his confusion.
A further finding from this study was that knowledge scores were lower for nurses with less education. This finding has implications for nursing education. Development of gerontological content for nursing curricula at all levels is sorely needed to give nurses the theoretical bases for care of the elderly. As the elderly population expands, more and more nurses have contact with the aged in a multitude of health care settings. Without this gerontological knowledge base, nurses and supporting health care personnel have difficulty managing the problems of the elderly. This often leads to poor health care, or at the worst, neglect. Confusion is a common problem among elderly, often associated with physical illness and stress. With the knowledge gained from this study and further study of confusion, a better understanding of confusion could be promoted at all educational levels.
Secondly, the study instrument warrants continued development and use with multiple samples. The instrument detected both adequacy of knowledge and gaps in knowledge in the study sample. As part of the analysis of the validity of the instrument, an item analysis was conducted of the knowledge questionnaire. This item analysis demonstrated that as a whole, the instrument differentiated between levels of educational preparation. Fifteen of the items discriminated between licensed and nonlicensed personnel in their knowledge of categories of confusion.
Further, the item analysis assisted in determining revisions of the instrument. For instance, items needing revision were: "Being alone without family and friends", "Being fed all the time" and "Problems with blood vessels." These three did not discriminate between licensed and nonlicensed staff and proved to have many incorrect responses. The items related to "hypotension" and "dehydration" discriminated well between licensed and nonlicensed staff and were of moderate difficulty; thus should be retained.
To test for internal consistency of the instrument and reliability, a Cronbach's alpha was determined. Part II had a reliability coefficient of .692 and Part III demonstrated a .644. These coefficients indicate a moderately high reliability. On the basis of outcomes of use of the instrument in this study, an initial effort in instrument construction should be to establish better validity of instrument items through use of a panel of experts on confusion. Testing the instrument with a variety of nursing personnel in nursing homes, hospitals and community settings, would help determine test-retest reliability of the tool. Further development of the instrument would prove useful not only for nursing, but for the field of gerontology in general.
Third, further theoretical development of the framework proposed by Wolanin and Phillips and its continued use in research is indicated. This study provided a beginning operationalization of the framework. The five categories proposed by Wolanin and Phillips proved to be meaningful for development of items to test knowledge of study subjects, as demonstrated by the consistency of the findings. Continued theorizing about behaviors representative of the five categories is paramount for understanding confused elderly in a variety of health care settings.
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