Journal of Gerontological Nursing

THE USE OF FUNCTIONAL CONSEQUENCES THEORY IN ACUTELY CONFUSED HOSPITALIZED ELDERLY

Cindy Kozak-Campbell, RN, MSN; Anna Marie Hughes, RN, EDD

Abstract

ABSTRACT

Acute confusion is a common complication of hospitalization in the elderly that impacts on both the use of health care resources and the functional status of individuals. Providing optimum nursing care for these patients depends on three factors: 1) the nurse's ability to differentiate acute confusion from other common conditions in the hospitalized elderly, chiefly dementia or depression, 2) the nurse's ability to identify factors contributing to this condition, and 3) the implementation of interventions to minimize the effects of these factors on the patient. This article differentiates the clinical features of acute confusion from those of depression and dementia, and discusses the use of the Functional Consequences Theory, developed by Miller (1990), as a framework for nursing assessment and management of care for elderly patients with this condition. The functional consequences theory framework assists the nurse to identify risk factors associated with the development of acute confusion in the hospitalized elderly. Further it guides the development of interventions to minimize the effects of this condition in this population. The use of this framework in the clinical setting is illustrated through a case study.

Abstract

ABSTRACT

Acute confusion is a common complication of hospitalization in the elderly that impacts on both the use of health care resources and the functional status of individuals. Providing optimum nursing care for these patients depends on three factors: 1) the nurse's ability to differentiate acute confusion from other common conditions in the hospitalized elderly, chiefly dementia or depression, 2) the nurse's ability to identify factors contributing to this condition, and 3) the implementation of interventions to minimize the effects of these factors on the patient. This article differentiates the clinical features of acute confusion from those of depression and dementia, and discusses the use of the Functional Consequences Theory, developed by Miller (1990), as a framework for nursing assessment and management of care for elderly patients with this condition. The functional consequences theory framework assists the nurse to identify risk factors associated with the development of acute confusion in the hospitalized elderly. Further it guides the development of interventions to minimize the effects of this condition in this population. The use of this framework in the clinical setting is illustrated through a case study.

As the population ages, the elderly comprise an ever increasing proportion of patients in the hospital. Acute confusion is a common complication of hospitalization for the elderly, with a documented incidence as high as 60% (Inouye, 1991). Acute confusion is associated with increased morbidity, increased mortality, increased length of hospitalization and increased intensity of nursing care. In addition, there is a higher rate of institutionalization for elderly patients who develop acute confusion while in the hospital (Inouye, 1991; Lipowski, 1983; Weddington, 1982; Williams, Ward, & Campbell, 1986). Therefore, acute confusion can be linked with higher cost and increased use of health care resources.

Acute confusion can also impact on the independence and quality of life of an elderly individual. The functional status of the individual may be permanently compromised. Although this is recognized by nurses, the current nursing care and management of patients with acute confusion often has little effect on improving patient outcomes for the acutely confused individual. Providing optimum care for these patients depends on three factors:

1) the nurse's ability to differentiate acute confusion from other common conditions in the hospitalized elderly, chiefly dementia and depression,

2) the ability of the nurse to identify factors contributing to the condition, and

3) the implementation of interventions to minimize the effects of acute confusion on the patient.

This article seeks to address these three factors by discussing how to differentiate acute confusion from depression and dementia, and offers the use of the Functional Consequences Theory, developed by Miller (1990), as a framework for the identification of factors contributing to acute confusion and for planning the nursing care and management of elderly patients with this condition.

DEFINING ACUTE CONFUSION

Acute confusion is a multidimensional condition. It is referred to in the literature by a variety of terms. These include dementia, delirium, acute brain syndrome, and acute transient cognitive disorder (Lipowski, 1983; Gillick, Seriell, & Gillick, 1982; Williams et al., 1979). A literature review reveals both a cognitive and a behavioral component to acute confusion. It is considered an abrupt, temporary change in central nervous system functioning accompanied by a range of inappropriate behaviors. Acute confusion is a dichotomous condition in that it is either present or not present. When present, it can be assessed on a continuum and has the qualities of duration and severity. Cognitive changes in acute confusion include changes in perception, thinking, orientation, and memory. Memory changes effect registration, retention, and recall (Lipowski, 1987). Behavioral changes are categorized as either hypo- or hyperactivity. They can be divided into the following categories: general behavior, alertness, motor activity and behavior indicative of perceptual changes (Williams et al., 1979; Vermeersch, 1990). Behaviors indicative of confusion are generally considered inappropriate, disruptive, and potentially endangering to the patient by the health care team. They can include such behaviors as pulling at lines and tubes, attempting to get up unassisted when it is unsafe, and a reversal of the sleep/wake cycle. Acute confusion is a reversible condition and, although multiple, its causes are often reversible physiologicallybased conditions. Prompt identification and treatment of the cause of acute confusion can resolve this condition. Undetected acute confusion can result in irreversible changes in cognition and behavior resulting in the decrease of the functional status of the individual.

DIFFERENTIATION OF ACUTE CONFUSION FROM DEPRESSION AND DEMENTIA

The clinical features of acute confusion have many similarities to those of depression and dementia. In addition, these three conditions can occur simultaneously. When assessing an individual for acute confusion, it is important to be able to differentiate between acute confusion, dementia, and depression and to ensure that the diagnosis is accurate and nursing interventions are appropriate.

The clinical features of each of the three conditions, acute confusion, dementia and depression, are compared in Table 1.

Table

TABLE 1A Comparison of Mia Clinical Feature* of Acute Confusion, Dementia and Depression

TABLE 1

A Comparison of Mia Clinical Feature* of Acute Confusion, Dementia and Depression

Table

TABLE 1A Comparison of Mia Clinical Feature* of Acute Confusion, Dementia and Depression

TABLE 1

A Comparison of Mia Clinical Feature* of Acute Confusion, Dementia and Depression

Table

TABLE 2Definitions of Select Concepts In the Functional Consequence* Theory

TABLE 2

Definitions of Select Concepts In the Functional Consequence* Theory

Dementia

Dementia is defined as "an acquired decline in a range of cognitive abilities and intellectual skills accompanied by alterations in personality and behavior which impair daily functioning, social skills, and emotional control. These impairments appear in a clear consciousness" (Mclean, 1987, p. 149) Dementia is characterized by a slow permanent, progressive change ir cognitive abilities. Symptoms a« progressive but stable over time, and] of a long duration. Perceptual disturbances, psychomotor behavior^ and reversal of the sleep/wake cycle are uncommon (Foreman & Grabowski, 1992). Dementia has numerous causes, some of which may be reversible (Linderborn, 1988). Although dementia has no known cure, the cognitive declina associated with it can be slowed and! sometimes halted with appropriate treatment of underlying conditions (Organizing Committee, Canadian Consensus Conference on the Assessment of Dementia, 1991).

Depression

In general, depression is characterized by depressed mood, lethargy, indecisiveness, and diminished ability to think or concentrate. Onset can be abrupt or insidious. There is minimal change in alertness, attention, or orientation. Thinking is generally intact but with a theme of hopelessness. Behaviors rarely fluctuate, and agitation, hallucinations, and inappropriate conversation are rarely present. Sleep /wake cycle is often disturbed. Depression can have an abrupt onset that often coincides with life changes. The hallmarks ol depression are weight loss, earlw morning wakening, and diurnal variation in mood which is worse in the morning and improves during the day (American Psychiatric Association, 1987).

Note that the distinguishing features for acute confusion are:

1) the acute, rapid onset, abrupt progression, and short duration of the condition,

2) the presence of reduced awareness and fluctuating alertness,

3) disorganized thinking, and distorted perception, and

4) a reversal of the sleep/wake cycle.

The etiology of acute confusion is multifactorial, and encompasses physiological, psychological, and environmental factors. Use of the functional consequences theory framework (Miller, 1990) in assessment and care of the elderly person with acute confusion facilitates consideration of all these factors.

FUNCTIONAL CONSEQUENCES THEORY

Background

An assessment of functional ability is frequently used in gerontology to identify the effects of normal aging changes, illness, or injury on an individual; to assess well being; and to provide a framework to plan care (Sehy & Williams, 1991). It focuses on those acts an individual can and cannot do, and considers both physical and psychosocial functioning. It is a realistic framework to use with the elderly, as illness is frequently defined by this population as the restriction of activity, inability to do activities of daily living, or presence of discomfort rather than the presence or absence of pathology (Sehy & Williams, 1991). The functional consequences theory developed by Miuer (1990), builds on this commonly used functional assessment.

Components

Miller's functional consequences theory focuses on the needs that are unique to older individuals. It proposes that the ability of older adults to maintain maximal self care is affected by the interaction of normal age-related changes and additional risk factors the individual encounters. Age-related changes are defined as "inevitable, progressive, and irreversible changes that occur during later adulthood and are independent of extrinsic or pathological conditions" (Miller, 1990, p. 55). These changes are viewed as factors that increase the vulnerability of the older individual to the negative impact of risk factors. Risk factors are defined by Miller as those "conditions that increase the vulnerability of older people to negative functional consequences that interfere with the person's level of functioning or quality of life" (p. 55). She further characterizes risk factors to include the effects of disease, medications, and lifestyle; availability of support systems; psychosocial circumstances; environment; and attitudes, including attitudes of caregivers. A list of definitions of pertinent concepts from Miller's theory appear in Table 2.

Figure. Select concepts in the functional consequences model of gerontological nursing. (Reprinted with permission from Miller, C.A. (1990). Nursing core of older adults: Theory ana practice (p. 53). Illinois: Scott, Foresman & Company. Copyright 1 990 by C.A. Miller.)

Figure. Select concepts in the functional consequences model of gerontological nursing. (Reprinted with permission from Miller, C.A. (1990). Nursing core of older adults: Theory ana practice (p. 53). Illinois: Scott, Foresman & Company. Copyright 1 990 by C.A. Miller.)

Miller states that the interrelationship of the concepts of age-related changes and risk factors is the crucial aspect that distinguishes care of the older adult from care of other populations. These concepts provide direction for nursing care so that interventions are planned to compensate for age-related changes, and/or modify or eliminate risk factors. The utility of this theory in providing care for the elderly individual with acute confusion is that it encompasses the multifactorial etiology of acute confusion, allows identification of factors contributing to the condition, and provides direction for nursing interventions thai address all factors.

Nurse's Role

The role of the nurse within th« functional consequences theory is twofold. It includes the identification and support of factors resulting in positive consequences, as well as the identification of factors thai result in negative consequences, with intervention to decrease 01 eliminate these factors. The ultimate goal of all interventions is to enable older individuals to function at theii highest level, despite the presence o] age-related changes and risk factors. These concepts are illustrated in the Figure on the previous page.

ETIOLOGY OF ACUTE CONFUSION

A brief discussion of the etiology of acute confusion and identification of factors contributing to the condition demonstrates the interrelationship of age-related changes and rislc factors.

Foreman (1986) and Lipowski (1983), in their classic articles, have presented comprehensive reviews of the multiple factors that can contribute to the development of acute confusion. These factors have been organized by this author within the functional consequences theory framework and are outlined in Table 3.

As reflected in Table 3, age-related changes in the elderly that place hospitalized individual at risk for acute confusion include:

1) a decreased ability of the brain to adapt to metabolic disturbances,

2) lowered resistance and ability of the body to cope with stress related to changes in the hypothalamus,

3) reduced ability to regulate body temperature,

Table

TABLE 3Etiologies at Acute Confusional States in the Hospitalized Elderly Organized within the Functional Consequences Theory

TABLE 3

Etiologies at Acute Confusional States in the Hospitalized Elderly Organized within the Functional Consequences Theory

Table

TABLE 3Etiologies at Acute Confusional States in the Hospitalized Elderly Organized within the Functional Consequences Theory

TABLE 3

Etiologies at Acute Confusional States in the Hospitalized Elderly Organized within the Functional Consequences Theory

4) a reduction in cardiac output, cerebral blood flow, and renal blood low and,

5) a reduction in hepatic and glucose metabolism (Blair, 1990).

Other age-related changes the elderly frequently have are sensory md perceptual deficits such as decreased vision and hearing Lipowski, 1983).

Using Miller's framework, risk actors for acute confusion can be considered in one of three categories, fhese are: 1) physiological functioning, 2) psychosocial functioning, and 3) factors influencing comfort and pleasure. A multitude of physiological actors have been identified as contributing to acute confusion. These nclude nutritional deficits, cardiovascular abnormalities, cerebral vasular disease, endocrine disturdisturbances, alterations in temperature gulation, pulmonary abnormalities, infective processes, metabolic disturbances, drug intoxications and mmobility (Foreman, 1986). Some of hese factors can also be categorized is age-related changes.

Psychosocial factors that can conribute to the development of acute confusion include emotional stress, lepression, anxiety, grief, dementia, social supports, and an unfamiliar environment. Also included with the psychosocial risk factors are the rharacteristics of the hospital environment, the method of care delivery in use on a nursing unit, and caregiver characteristics such as cnowledge of caring for the elderly ndividual in acute care and knowledge of acute confusion.

Comfort/Pleasure factors include jain, fatigue or sleep deprivation, iypo- or hyperthermia, sensory deprivation or environmental nonotony, sensory overload, and ack of meaningful routines.

The development of acute confusion in the hospitalized elderly is rarely contributed to any one of the above factors alone. Rather, it is the interplay between age-related changes and the risk factors of physiological functioning, psychosocial functioning, and comfort/ pleasure factors that result in acute confusion in this patient population. This complex interplay makes it difficult for the nurse to predict which patients will develop this condition, and, therefore, to intervene to prevent the development of acute confusion.

DIRECTIONS FOR PRACTICE

Through the use of the functional consequences theory, a framework is provided to identify age-related changes and risk factors associated with the development of acute confusion in the hospitalized elderly and to guide the development of interventions to minirnize the effects of this condition in this population.

The following case study illustrates the application of the functional consequences theory in clinical practice.

CASE STUDY

Mrs. Wright is an 87-year-old woman who, prior to her admission, resided in a personal care home. She was described as an alert, oriented, and active individual, who assisted with organizing the weekly group outing for the facility. She was able to do all of her own daily personal care, and walked the length of a 60-foot hallway with the support of a cane to receive her meals in the facility dining room. Her laundry and housekeeping were done for her by the facility staff. Once a week she received assistance with a tub bath as it was difficult for her to get in and out of the tub. She is slightly hard of hearing, and wears glasses for both near and far vision. She has needed supervision for medication administration due to memory problems. She had been taking only a daily stool softener and acetaminophen morning, midday, and at bedtime for joint pain. Her only significant medical event to date had been an ankle fracture two years ago. She had an internal fixation with plate and screws inserted at the time of the fracture. Over the past week, she has had increasing ankle pain and swelling and has required acetaminophen every three to four hours to manage the discomfort. This pain limited her to a wheelchair during the last five days prior to her admission.

Four days ago, she was admitted to the orthopedic ward from emergency with an ankle infection. She is in a four-bed room with two roommates. The same day as admission, she was taken to surgery, and had the hardware removed from her ankle under a general anesthetic. Today is her fourth day following surgery. She is presently receiving intravenous antibiotics, and has ordered acetaminophen with 30 mg. of codeine on a "prn" basis for pain. In the last 24 hours she has received a total of two doses of analgesics, 10 hours apart. Over the past two days, she has become increasingly disoriented. She no longer recognizes where she is, repeatedly pulls out her intravenous lines and foley catheter, and picks at her wound dressings. She is refusing to eat or drink. She has not slept for the past two nights, and calls out for help frequently during both the day and night. She has one daughter who visits twice a day. The daughter is very upset with the sudden change in her mother's behavior.

Mrs. Wright displays many of the clinical features of acute confusion. These features also provide the diagnostic clues to differentiate her condition from dementia or depression. She has had an abrupt change in both her cognitive abilities and her behavior. Changes in her cognitive abilities that are readily identifiable include disorientation, decreased awareness of her surroundings, and disorganized thinking. Her behavior is hyperactive, inappropriate and disruptive to her care, and potentially dangerous. Her sleep/wake cycle is also disturbed. The development of acute confusion has a markedly negative impact on Mrs. Wrighfs functional abilities.

Using the functional consequences theory framework, contributing factors for Mrs. Wright's acute confusion can be identified. Age-related changes that are having an impact include the decreased ability of the brain to adapt to metabolic disturbances due to reduced blood flow, lowered resistance and ability to cope with stress related to changes in the hypothalamus, and perceptual problems as a result of decreased vision and hearing. Risk factors that are present are from all three categories. Risk factors under physiological functioning include a wound infection, refusal to eat or drink resulting in decreased food and fluid intake, and sleep deprivation. Othei factors that may be contributing to the acute confusion include potential electrolyte and hematological abnormalities. Risk factors under psychosocial functioning include a change from her usual routines and in her environment to depersonalizing routines and environment of the hospital. There may also be factors related to inadequate knowledge and 'traditional" attitudes toward the aged by the nurses caring for Mrs. Wright. Inadequate pain control following surgery and immobility impact her comfort and pleasure.

Identification of individual agerelated changes and risk factors that are contributing to acute confusion provides specific direction for nursing actions that focus on compensating for age-related changes and eliminating or minimizing the effects of risk factors. A number of specific actions could be implemented in the care of Mrs. Wright (Table 4). In addition, actions that are already present and should be continued include the administration of antibiotics to treat her wound infection, and the frequent visits by Mrs. Wright's daughter which provide a familiar person in her environment. These visits can be enhanced by an explanation of acute confusion and by teaching her daughter title value of bringing familiar items or pictures from home, and by conversing with her mother about normal home routines and family members. The effectiveness of the suggested nursing actions can be evaluated by assessing for improvements in Mrs. Wright's cognitive and functional abilities and for a decrease in her disruptive behaviors.

CONCLUSION

The importance of nursing in the recognition and treatment of acute confusion cannot be minimized. Nurses' initial and constant contact with the patient allows them to detect subtle changes in behavior and cognitive abilities in the individual mat allow for early detection of acute confusion. The ability to recognize acute confusion as a reversible condition, and differentiate it from dementia and depression is essential for optimal management of patients with this condition. The functional consequences theory provides a framework to maximize the use of health caie resources and improve the outcomes of elderly patients in the hospital.

Table

TABLE 4Nursing Actions fo Minimizo the Effects of Acute Confusion for Mrs. WrIgM

TABLE 4

Nursing Actions fo Minimizo the Effects of Acute Confusion for Mrs. WrIgM

REFERENCES

  • American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders. 3rd ed. rev. Washington, DC: American Psychiatric Association, 1987, 100-103.
  • Blair, K.A. (1990). Aging: Physiological aspects and clinical implications. Nurse Practitioner, 15(2), 14-28.

Foreman, M.D. (1986). Acute confusional states in hospitalized elderly: A research dilemma. Nursing Research, 35(1), 34-38.

  • Foreman, M.D., & Grabowski, R. (1992). Diagnostic dilemma: Cognitive impairment in the elderly. Journal of Gerontological Nursing, 18(9), 5-12.
  • GilUck, MR., Serrell, N.A., & Gillick, L.S. (1982). Adverse consequences of hospitalization in the elderly. Social Science and Medicine, 16, 1033-1038.
  • Inouye, S.K. (1991, April 30). The recognition of delirium. Hospital Practice, 61-62.
  • Lipowski, Z.J. (1983). Transient cognitive disorders (delirium, acute confusional states) in the elderly. American Journal of Psychiatry, 240(11), 1426-1436
  • Linderborn, K.M. (1988). The need to assess dementia. Journal of Gerontological Nursing, 14(1), 35-39.
  • Lipowski, ZJ. (1983). Transient cognitive disorders (delirium, acute confusional states) in the elderly. American Journal of Psychiatry, 140(11), 1426-1436.
  • Lipowski, ZJ. (1987). Delirium (acute confusional states). Journal of the American Medical Association, 258(13), 1789-1792.
  • Mdean, S. (1987). Assessing dementia. Part 1: Difficulties, definitions and differential diagnosis. Australian and New Zealand Journal of Psychiatry, 21, 142-174.
  • Miller, C.A. (1990). Nursing care of older adults: Theory and practice pp. 49-62). Illinois: Scott, Foresman and Company.
  • Organizing Committee, Canadian Consensus Conference on the Assessment o: Dementia. (1991) Assessing dementia: ttw Canadian consensus. Canadian Medica Association Journal, 144(7), 851-853.
  • Sehy, Y. & Williams, M. (1991). Functiona assessment. In W.C. Chenitz, J.T Stone, & S Salisbury, Clinical gerontological nursing: / guide to advanced practice. Philadelphia: W.B Saunders.
  • Vermeersch, P.E. (1990). The clínica assessment of confusion - A. Applied Nursing Research, 3(3), 128-133.
  • Weddington, W. W. (1982). The mortality oi delirium: An underappreciated problem? Psychosomatics, 23(12), 1232-1235.
  • Williams, M.A., Holloway, J.R., Winn M.C., Wolanin, M.O., Lawler, M.L., Westwick C.R., & Chin, M.H. (1979). Nursing activity and acute confusional states in elderly hip fractured patients. Nursing Research, 28(1), 25 35.
  • Williams, M.A., Ward, S.E., Campbell, E-B (1986). Issues in studying confusion in oldet hospitalized patients. In S. Stinson, J. Kerr, I Giovannetti, P. Field & J. MacPhail (Eds.), International Nursing Research Conferenct Proceedings: New Frontiers in Nursing Research (pp. 390-391). Edmonton, Alberta.

TABLE 1

A Comparison of Mia Clinical Feature* of Acute Confusion, Dementia and Depression

TABLE 1

A Comparison of Mia Clinical Feature* of Acute Confusion, Dementia and Depression

TABLE 2

Definitions of Select Concepts In the Functional Consequence* Theory

TABLE 3

Etiologies at Acute Confusional States in the Hospitalized Elderly Organized within the Functional Consequences Theory

TABLE 3

Etiologies at Acute Confusional States in the Hospitalized Elderly Organized within the Functional Consequences Theory

TABLE 4

Nursing Actions fo Minimizo the Effects of Acute Confusion for Mrs. WrIgM

10.3928/0098-9134-19960101-06

Sign up to receive

Journal E-contents