Journal of Gerontological Nursing

Labeling of Confusion in the Elderly

Patriciann Furnari Brady, BS, MA, MS

Abstract

Elderly patients are frequently labeled confused as a result of behavior that is disturbing to nursing staff caring for them. Each patient deserves a careful medical and social evaluation before any diagnostic label is attached.

Abstract

Elderly patients are frequently labeled confused as a result of behavior that is disturbing to nursing staff caring for them. Each patient deserves a careful medical and social evaluation before any diagnostic label is attached.

The term confusion is often used as a nursing diagnosis. Interpretation of the meaning and subsequent communication of this term as a nursing diagnosis is often made on a subjective basis, rather than an objective basis from one health professional to another.1 There is a concern that this labeling contributes to sustained belief among the staff that the behavior is the norm for the labeled patient.2 The possible outcome from this labeling, be it self-fulfilling prophecy or self-sabotage, is often costly to the elderly individual's abilities and competencies.1

Various authors in the literature use a variety of characteristics to describe and define confusion. Williams et al3 and Forman4 describe confusion as a decline of mental functioning. Both of these authors list changes in the following mental functions as varying degrees of one or several disorders of consciousness: memory, attention, comprehension, judgment, mood, and interpretation of stimuli. Forman adds impairment of learning and calculation to the definition of confusion and notes these declines in mental functioning are often accompanied by emotional or behavioral disturbances.

Chisholm et al2 list behavioral disturbances in their definition of confusion as wandering behavior, talking incoherently, withdrawal, breaking off relationships, reduced perceptiveness, and inability to identify with all aspects of the immediate situation. It is worthy to note these behaviors are also symptoms of psychotic behavior and no method is presented to differentiate psychotic behavior from confusion or reversible brain impairment from irreversible brain impairment.

Wolanin and Phillips,5 who are frequently cited for their work in this area, define confusion as a condition characterized by the client's disorientation to time and place, incongruous conceptual boundaries, paranormal awareness, and seemingly inappropriate verbal statements that indicate deficit.

Method

The setting for this descriptive relationship study was a 113-bed, intermediate skill level of care nursing home adjacent to a teaching hospital. The sample for this study was 26 individual staff members of the nursing home including registered nurses, licensed practical nurses, medication aides, and nursing aides.

The tool developed by the investigator, based on nursing literature, was comprised of four sections and data were collected in the following manner:

1. Staff demographic information.

2. List of selected characteristics: Subjects were asked to indicate the degree to which they used listed characteristics in labeling confusion.

3. Video response: The subjects were asked to indicate the presence or absence of the selected characteristics as seen in a patient on videotape and to indicate if the patient was confused.

4. Definition of confusion.

The selected characteristics for this study were the defining characteristics of the nursing diagnosis Sensory Perceptual Alterations, related to factors associated with aging6 (Table). The subjects viewed a two-minute segment of the film Code Gray7 which included a discussion of the use of physical restraints between a nurse and an elderly female individual. All editorial comments not included as dialogue between the elderly individual and the nurse were deleted.

Results

The subjects of this study included four registered nurses, five licensed practical nurses, 11 nurses' aides and five medication aides. The most frequently cited educational level was high school (23%) and the remainder of the sample (77%) had education beyond high school. Eight subjects had worked with the elderly six to ten years and 12 subjects had worked with the elderly for one to five years.

Analysis of the Table shows that the characteristic cited most frequently in labeling confusion is time disorientation with seven subjects utilizing it 91% to 100% with an average of 61% to 70%. This was the highest average among the characteristics.

Table

TABLEUTILIZATION OF SELECTED CHARACTERISTICS AND PERCENT OF UTILIZATIONS

TABLE

UTILIZATION OF SELECTED CHARACTERISTICS AND PERCENT OF UTILIZATIONS

The mode of each characteristic is also indicated in the Table. A distinct pattern is identified. One characteristic, time disorientation, has a mode of 91% to 100%. Three characteristics are bimodal: disorientation to place and disorientation about people have the same bimodal pattern of five subjects each at 41% to 50% and 91% to 100%; the third bimodal characteristic is represented at both ends of the continuum with four subjects at 0% to 10% and at 91% to 100%. The mode of the remaining characteristics is 0% to 10%.

The association of the nursing home staffs six main demographic variables and frequency of selected characteristics was analyzed through the use of ANOVA. There was no significant relationship noted in the utilization of selected characteristics in labeling an elderly individual viewed on video as confused and the demographic characteristics of the nursing home staff. Of the 26 respondents, only one subject correctly listed the characteristics of the nursing home residents viewed on video as predetermined by the investigator. Interestingly, three of the 26 subjects incorrectly labeled the patient as confused.

Regardless of the position, education, age, employment length, or amount of time working with the elderly, there was no significant difference in the utilization of selected characteristics by nursing home staff in labeling elderly nursing home patients as confused. No selected characteristic was utilized primarily by nursing home staff in labeling an elderly nursing home individual as confused.

Discussion

Regardless of the position, education, age, employment length, or time working with the elderly, nursing home staff utilized a variety of characteristics in labeling elderly patients as confused. Selected characteristics of disorientation to time, place, about people and hallucinations were used more frequently by all staff in labeling elderly patients as confused, regardless of staff demographic characteristics. In a forced choice situation, there was a minimal ability in nursing home staffs ability to correctly assess characteristics presented by an elderly person on video and to identify confusion.

Regardless of the demographic variable, there was no significant difference in the utilization of selected characteristics by nursing home staff in labeling elderly nursing home residents as confused. Therefore, all nursing home staff utilize selected characteristics in the same manner. Thus, the findings support a proposed conceptual framework that attempts to differentiate the role of the individual nursing home staff in labeling an elderly nursing home patient as confused.

Conceptual Framework

Nursing assessment is dependent on gathering subjective and objective data about the patient. This process includes validation of the assessed data. A conceptual framework is proposed, adapted from Wolanin and Phillips5 which includes four levels of nursing diagnosis. This proposed framework (Figure) includes three levels of assessment and validation of assessment based on the analysis of the data from this study.

First Level of Assessment - The total nursing staff is involved with the assessment of the patient at this level. At this level, the total staff observe and collect data about the patient's behavior during their daily interactions.

Generated by the analysis of the data of this study, various characteristics are utilized to a different degree in labeling elderly patients as confused. Therefore, selected characteristics of the nursing diagnosis are listed as essential and related factors to be assessed. Change in the ability to problem solve, showing the most variability in utilization, is to be used in combination with either essentia] or related characteristics. Confusion at this level is a general symptom that calls attention to the need for further assessment.

Second Level of Assessment - Once the presence of essential and related characteristics are observed, the total staff should collaboratively assess the factors listed in the second level. Family and other healthcare professionals also can be included at this level of assessment. The validation methods of mental alertness screening, history and lifestyle are utilized to support the assessment data. Roslaniec and Fitzpatrick8 have reported that the Mental Status Examination is an effective tool for the assessment of confusion.

Table

FIGURECONCEPTUAL FRAMEWORK FOR LABEUNG ELDERLY NURSING HOME PAnENTS AS CONFUSED

FIGURE

CONCEPTUAL FRAMEWORK FOR LABEUNG ELDERLY NURSING HOME PAnENTS AS CONFUSED

Third Level of Assessment - This level of assessment requires the skill of a registered nurse. Through the utilization of the registered nurse's assessment skills, scientific knowledge, and technical skills, the remainder of the assessment of the elderly patient is to be completed.

Lincoln9 states in order to make an accurate assessment of confusion. knowledge of the sources of confusion is necessary. Only when this level of assessment is completed can a nursing diagnosis be identified. These three levels of assessment assist the nurse to identify a diagnosis that would then be used to plan appropriate nursing interventions. The registered nurse should then implement this patient's care through guidance and supervision of the total nursing home staff caring for an elderly, confused, nursing home patient.

The author recognizes the limitation of a small nonrandom sample and recommends a replication of this study using a large random sample in order to support generalization of the findings.

Implication for Practice

Elderly patients are frequently labeled confused as a result of behavior that is disturbing to nursing staff caring for them. Each patient deserves a careful medical and social evaluation before any diagnostic label is attached.

The proposed conceptual framework suggests the following format be used by nursing clinicians and nursing educators for providing care for the elderly. Nursing educators can utilize this format to explore with students the various causes of confusion in the elderly. Once students are familiar with the various causes of confusion in the elderly, it will become more evident that responding to a symptom of disorientation is not adequate nursing intervention. If the diagnosis is confusion secondary to compromised brain support, various medical and nursing interventions must be used to facilitate the patient's orientation. Lincoln9 stated that various levels of nursing staff have high percentages of incorrect response in the area of irreversible sources of confusion. Additional educational information about confusion is necessary since a lack of clarity about causes of confusion affects nursing diagnosis and intervention.

The proposed conceptual framework provides for nursing clinicians specific recommendations when caring for the elderly. The total nursing home staff should observe essential and related characteristics in an elderly patient. It is the nursing staff who care for the patient on a daily basis and observe change. These staff members should be familiar with the potential causes of confusion and, therefore, can alert the remainder of the staff to potential problems. A dry bed at night for an elderly patient who is generally incontinent could indicate a potential signal of dehydration which may not be noted until a confused state is evident.

The registered nurse, with her physical assessment skills and mental status examination skills, can complete a comprehensive assessment of the elderly patient. Nursing interventions, to be effective, cannot be initiated until a complete assessment is accomplished. Interactional factors and the physiological status of the patient must be completed.

The nursing clinician must determine adequate nursing intervention for each patient on an individual basis and guide and monitor the total team's care for this patient. In general, the nursing activities stressed as being helpful in preventing or ameliorating confusion states are: measures to prevent diminished oxygenation of the brain; measures to maintain hydration; measures to avoid extremes to sensory input; provisions of a safe, ordered, and orienting environment with familiar objects; making certain circumstances are clear, noncomplicated, heard, and understood; and judicious administration of drugs.3

Wolanin and Phillips5 have stated: nursing focus is not on a disease and its treatment, but rather on an elderly person who has a life to live, a death to die and a need to be sustained at his highest level of functioning during both processes.

References

  • 1 . Rameizl P: A case for assessment technology in long term care: The nursing perspective. Rehabilitation Nursing 1984; 9(6):29-3l.
  • 2. Chisholm SE, Deniston OL, lgreson RM, et al: Prevalence of confusion in the elderly hospitalized patient. J Gerontol Nurs 1982; 8(2):87-%.
  • 3. Williams MA, Holloway JR, Winn MC, et al: Nursing activities and acute confusional states in elderly hip-fractured patients. Nursing Research 1979; 28(l):25-35.
  • 4. Forman MD: Acute confusional states in the elderly: An algorithm. Dimensions cf Critical Care 1984; 3(4):207-2l5.
  • 5. Wolanin MO. Phillips LRF: Confusion Prevention and Care, St Louis, Mo: C.V. Mosby. 1981. pp 1-77.
  • 6. Carpenito U: Nursing Diagnosis: Application to Clinical Practice, Philadelphia, J.B. Lippincott, 1983, pp 400-404.
  • 7. Mitchell C, Achtenberg B (producers): Code Gray Ethical Dilemmas in Nursing. Boston, Fanlight Productions, 1983.
  • 8. Roslaniec A, Fitzpatrick JJ: Changes in mental status in older adults with four days of hospitalization. Research in Nursing and Health 1979; 2:177-187.
  • 9. Lincoln R: What do nurses know about confusion in the aged? J Gerontol Nurs 1984; IO(8):26-32.

TABLE

UTILIZATION OF SELECTED CHARACTERISTICS AND PERCENT OF UTILIZATIONS

FIGURE

CONCEPTUAL FRAMEWORK FOR LABEUNG ELDERLY NURSING HOME PAnENTS AS CONFUSED

10.3928/0098-9134-19870601-07

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