The Confused Patient

Learning Objectives

• Differentiate between dementia and delirium.
• List the most common types of dementia.
• Describe common nurses' reactions to the confused patient.
• Describe effective nursing interventions for the confused patient with the following: memory deficits, unable to verbalize his or her needs, and at risk for falling.

Glossary

Agnosia– Loss of ability to recognize objects

Agraphia– Difficulty writing and drawing

Alzheimer's disease– Progressive deterioration of memory, and intellectual functioning, often leading to complete loss of functioning and personality. Autopsy reveals brain atrophy, senile plaques, and neurofibrillary tangles.

Apraxia– Inability to carry out motor activities despite intact motor function

Delirium – Rapid fluctuations in mental status, memory deficits, disorientation, and perceptual disturbances over a short period of time.

Dementia – Multiple cognitive deficits: aphasia, apraxia, agnosia, or disturbance in executive function such as organizing or abstracting.

Mild cognitive impairment– Subtle but measurable memory disorder when memory problems are greater than what are normally expected with aging but no other dementia symptoms.

Mixed dementia– Vascular dementia and Alzheimer's disease simultaneously.

Nocturnal delirium (sundowning syndrome) – Increased confusion and agitation at dusk.

Prompts – Staff actions used to help dementia patient initiate self-care or other desired behaviors after loss of verbal comprehension.

Pseudodementia– Depression in elderly people that appears similar to dementia.

Substance-induced persisting dementia– Dementia caused by intoxication or withdrawal from a substance such as alcohol or drugs.

Vascular dementia – Dementia caused by multiple strokes that have usually occurred at different times and involve the cortex and underlying white matter.

Confusion is not just a state of the mind seen in elderly people. It has many causes and can occur at any age. It significantly influences a patient's dignity, independence, personality, and support system, and can complicate the diagnosis and treatment of an illness. Confused patients are experiencing an alteration in higher level brain functioning such as comprehension or abstract thinking caused by delirium or dementia (Box 10-1 Factors that Contribute to Misdiagnosis in Dementia and Delirium and Box 10-2 Characteristics of Delirium and Dementia). These patients have difficulty remembering, learning, following directions, and communicating needs and pains. Nursing care must be modified to help these patients to retain and regain the mental abilities that can be recovered and to compensate for those that cannot.

Delirium is a reaction to underlying physiologic (illness, drug reaction, or exposure to a toxin) or psychologic stress. Nurses in the intensive care unit often see delirium induced by the disorienting and confusing environment, sensory deprivation, or sensory overload. It may also occur postoperatively related to anesthetic or electrolyte changes. It is also very common in advanced cancers and in the terminally ill (Kuebler, Heidrich, Vena, & English, 2006). Delirium is caused by a temporary malfunction of the brain. When the underlying causative condition is resolved, the delirium generally resolves. It is a medical emergency. If left untreated, it could progress to dementia, coma, or death depending on the underlying cause. It is often under-recognized until the symptoms become more flagrant. Delirium can take 3 forms: hyperalert-hyperactive, hypoalert-hypoactive, and mixed (Irving, Fick, & Foreman, 2006). See Table 10-1 Types of Delirium for Types of Delirium.

Dementia is generally a permanent condition caused by a variety of factors that lead to cellular brain changes or malformations. It is characterized by slow, insidious onset affecting memory (impaired ability to learn new information or to recall previously learned information), intellectual functioning, and the ability to problem solve. Types of dementia include Alzheimer's disease, vascular dementia, substance-induced dementia, and dementia caused by other medical conditions including HIV, Parkinson's disease, and Creutzfeldt-Jakob disease.

Alzheimer's disease is the most frequently seen type of dementia, affecting between 4 to 5 million Americans (Alzheimer's Association, 2006). The number affected has doubled since the 1980s because people are living longer. The current rate of dementia is expected to triple by 2050 (Davis, 2003; Hebert, Scherr, Bienias, Bennett, & Evans, 2003). It strikes at least 50% of people older than 85 years because the risk to develop it increases with age. Initial changes occur so slowly that they may not be recognized. The person may be regarded as absent minded. Changes in communication, personality, and social skills occur gradually. Because the decline is usually so slow, patients and families may deny its existence until a crisis occurs. The person with Alzheimer's disease loses the ability to relate to the environment and recognize loved ones. This contributes to families experiencing a prolonged grief process as they slowly lose who their loved one was. Because of the long trajectory, this disease has many financial impacts because the patient will require care for many years. In later stages, the individual may develop gait and motor disturbances and eventually become mute, bedridden, and incontinent. Death often occurs from severe debilitation, aspiration pneumonia, and recurrent infections. The average duration of the illness from onset of symptoms to death is 8 to 20 years.

Vascular dementia, the second most common form, is caused by multiple strokes. Symptoms are variable depending on the extent, location, and timing of the strokes. Decline tends to occur in steps rather than a gradual decline. There is usually more fluctuation in functioning. Impairment is limited and distinct depending on the area of the brain affected. This contrasts with more global intellectual impairment in Alzheimer's disease. Evidence of strokes, such as one-sided weakness, sudden onset of loss of speech, and focal neurological signs, such as hyperactive deep tendon reflexes, occur with vascular dementia. Treatment of underlying hypertension and vascular disease may prevent further progression.

In 2001, guidelines for Mild Cognitive Impairment were developed by the American Academy of Neurology. This condition may be a predictor of dementia in about 50% of patients (Gauthier et al, 2006).

Delirium can have biological and psychological causes. Biological causes include a variety of medical conditions, exposure to toxins, and drugs. The onset of symptoms is related to exacerbation of a medical condition or introduction of a new medication for example, and contributes to the diagnosis. Psychological causes include sensory deprivation or overload, relocation or sudden changes, sleep deprivation, and immobilization.

Dementia can be caused by a variety of biological factors including the direct physiological effects of a medical condition, the persisting effects of a substance (drug of abuse, medication, or toxin), or multiple etiologies such as the combined effects of a stroke and Alzheimer's disease. Alzheimer's disease destroys brain cells and nerves leading to shrinkage as gaps develop in the temporal lobe and hippocampus where storing and retrieval of new information occurs. Diagnosis can now be made by magnetic resonance imaging (MRI) and positron emission tomography (PET) scan to document the brain atrophy.

The etiology of Alzheimer's disease remains the focus of much research. Current theories under investigation include decrease in the activity of the neurotransmitter acetylcholine and presence in the brain of the protein beta-amyloid. Thus far, theories of environmental toxins, poisons, or a slow-acting virus are unsupported. Genetic factors may also be present. There is a greater incidence of Alzheimer's disease in the family members of patients who acquire the disease before the age of 60 (Schutte, 2006).

Related Clinical Concerns

Delirium

Medical conditions that can generate delirium include systemic infections, hypoxia, hypercapnia, hypoglycemia, fluid or electrolyte imbalances, hepatic or renal disease, thiamine deficiency, sequelae of head trauma, postictal states, postoperative states, and complications of cancer. Some of the risk factors for delirium include vision impairment, cognitive impairment, restraints, malnutrition, and addition of more than three new medications (Samuels & Neugraschl, 2005). Elderly patients and cancer patients with pain are particularly vulnerable (Kuebler et al., 2006). Delirium is the most common cognitive disorder seen in palliative care and in as many as 80% of patients with advanced cancer (Elsayem, Driver, & Bruera, 2003). The presence of delirium increases the risk of complications associated with a medical illness and increases the risk of mortality.

Substance intoxication delirium can occur from ingestion of alcohol, amphetamines, cannabis, cocaine, hallucinogens, phencyclidine (PCP), opioids, hypnotics, and sedatives. Substance withdrawal delirium can occur from abruptly stopping significant abuse of alcohol (formerly called “delirium tremens”), hypnotics, antianxiety medications, and corticosteroids.

Many prescribed medications can contribute to delirium, including analgesics, anesthetics, anticonvulsants, antihistamines, antiparkinson drugs, corticosteroids, gastrointestinal medications, and psychotropic medications with anticholinergic side effects.

Dementia

Medical conditions that contribute to development of dementia include stroke, Parkinson's disease, Huntington's disease, AIDS, Creutzfeldt-Jakob disease, hypothyroidism, multiple sclerosis, traumatic brain injury, brain tumors, anoxia, lupus, and hepatic failure. Substance-induced persisting dementia can also occur with a long history of alcohol or substance abuse.

The dementia patient is at risk for many complications including unrelieved pain due to inability to express it. In addition this patient is at risk for skin breakdown, aspiration pneumonia, weight loss, and sepsis.

Children to Adolescents

Children may be more susceptible to delirium than adults, particularly in the presence of febrile episodes and in response to some medications such as anticholinergics. Assessment may be complicated by difficulty in eliciting the signs of problems in thinking, memory, and orientation. In fact, delirium can be mistaken for uncooperative behavior. One indication of delirium may be the inability of familiar figures to soothe the child. Children and teens may be at risk for delirium when they abuse club drugs, PCP, inhalants, or combinations of several illicit drugs.

Dementia is rare in children and adolescents but can occur as a result of medical conditions including AIDS, brain tumors, and head injury. As with delirium, dementia can be difficult to identify in young children. It may present as a deterioration in function, as in adults, or as a significant delay or deviation in normal development. Deterioration in school performance may be an early sign.

Older Adults

Delirium is extremely common in medically ill elderly people. It is a complex process that is caused by many age-related physiologic changes in the brain and other organs (Bond, Neelon, & Belyea, 2006). Ten percent to fifteen percent of hospitalized elderly persons exhibit delirium on admission (DSM-IV-TR, 2000); 15% to 30% of hospitalized medically ill older people may develop it at some time while they are in the hospital. Multiple medications, multiple chronic illnesses, use of over-the-counter medications, and impaired kidney and liver function contribute to the development of delirium. Specific conditions that put the elderly patient at greater risk include urinary tract infections, sepsis, stroke, bypass surgery, myocardial infarctions, and dehydration (Liptzen & Jacobson, 2006). A masked depression can appear as confusion (pseudodementia). Acutely confused elderly persons are often inappropriately labelled “demented,” when potentially reversible conditions go undiagnosed and untreated.

Dementia in general is most common after the age of 85 and is often seen in residents of nursing homes. It occurs with increasing frequency after the age of 65 but is not a normal or expected part of the aging process. Mixed dementias are also more common as people continue to live longer.

Possible Nurses' Reactions

• May have a more positive attitude and take more active measures in care of patients if they believe the confusion is reversible.
• May feel very frustrated and helpless because of lack of improvement, constant need to repeat instructions or break tasks down step by step, repetition of the same question, and time requirements for care of patients with irreversible dementia.
• To avoid feeling hopeless and helpless, may become emotionally detached and give only impersonal care.
• May find themselves bored, unfocused, or confused if patients have considerable problems in communicating verbally.
• May be angry with patient's pathology; may believe patient can control own behavior.
• May become impatient with negative, hostile, impulsive patients who are very slow to respond.
• May feel repulsed by poor hygiene, messy eating behaviors, incontinence, or inappropriate behaviors.

Behavior and Appearance

• Disheveled, inappropriate clothing; poor grooming
• Restless, agitated, impulsive, aggressive
• Wandering
• Perseveration (involuntary repetitive movements, speech [most common] or activity)
• Apraxia
• Agraphia
• Loss of coordination; stiff awkward movements; impairment of learned skilled movements
• Unsteady, shuffling gait; stooped, leaning posture
• Loss of ability to perform activities of daily living (ADLs)
• Types of aphasia including
• Echolalia (repetition of word, phrase, or syllable just said by someone else)
• Repetitive questions
• Palilalia (repeating sounds or words over and over)
• Anomia (difficulty finding wanted words) leading to paraphasia (using similar-sounding words) and circumlocution (using many words in place of the one word that is wanted)
• Slurred speech
• In late stages, may remember only a few key words used inappropriately in all situations (such as no)
• May become mute
• Hoarding
• Regression
• Hypersexual behavior such as obsessive masturbation
• Hyperoral symptoms including increased appetite
• Inappropriate eating and toileting behavior
• Sleep disturbance including nocturnal delirium (sundown syndrome)
• Overreaction to neutral stimuli (catastrophic reactions)
• Inability to tolerate stress and change

Mood and Emotions

• Emotional lability
• Depression
• Suspicion, paranoia, hostility
• Anxiety

Thoughts, Beliefs, and Perceptions

• Loss of recent or remote memory or both
• Disorientation, first to time, then place, then person
• Impaired concentration
• Loss of abstract thinking ability
• Loss of ability to calculate
• Inability to learn and use new information
• Loss of ability to plan, initiate, sequence, monitor, and stop complex behavior
• Agnosia
• Ability to read words without knowing what they mean
• Loss of ability to read
• Confabulation
• Loss of awareness of spatial relationships; loss of awareness of own body parts and how they are organized in relation to each other
• Illusions
• Delusions, hallucinations
• Impaired insight and judgment

Relationships and Interactions

• Personality changes: accentuation or alteration of premorbid traits that affects previous relationships (e.g., caretaker role reversals); family unsure how to interact with patient
• Loss of social skills; social withdrawal
• Clinging, demanding
• Inability to sustain real relationships as memory gaps eliminate continuity; in later phases, may not recognize family or friends
• Negative, belligerent, briefly combative at times; hostility caused by brain damage or by misinterpreting events; not necessarily by the behavior of others

Physical Responses

• The patient may not verbalize or demonstrate common physical signs of pain or other symptoms such as bladder distention, constipation, dehydration, injuries, or urinary tract infections.
• Laboratory data, medication history, and possibly drug screening should be performed to evaluate patient at the onset of confusion.

Pertinent History

• Complex medical history
• Chronic illness
• Substance abuse
• Head trauma

Collaborative Management

Pharmacological

A great many medications cause confusion. Confused patients who are taking multiple medications may need to have the medications withdrawn one at a time to determine their impact on the symptoms and the underlying illness. Any medications used to treat confusion should be started at lower dosages. Drugs that commonly cause delirium include anticholinergics, benzodiazepines, steroids, antiemetics, and opioids.

Confused patients often become disruptive and may need to be controlled to protect the patient and environment. Haloperidol (Haldol) is frequently used to treat agitation and aggression. Atypical antipsychotics like resperidone are also useful. Side effects such as orthostatic hypotension must be closely monitored because the patient may not be able to verbalize how he or she is feeling. Other medications used with this population include short acting benzodiazepines like lorazepam and selective serotonin reuptake inhibitors (SSRIs).

Buspirone (Buspar) has been used successfully in patient's with Alzheimer's disease, although it may take several weeks to take effect fully. Hypnotics, antidepressants (particularly SSRIs used for irritability), and anticonvulsants (used for rage) are also useful. However, using medications to control agitation should not replace other interventions. There can be a tendency to use medications to sedate the patient rather than pursue behavioral techniques.

Medications to slow down the decline of Alzheimer's disease include cholinesterase inhibitors such as donepezil hydrochloride (Aricept), rivastignine (Exelon) and Galantamine (Rozadyne) have been used to temporarily improve cognitive function. Memantine (Namenda) is used to treat moderate to advanced Alzheimer's disease. It is a NMDA antagonist that protects brain cells against the influx of calcium into the nerve cells. It does not stop the disease but may help increase independence in activities of daily living and slow the progression.

Rehabilitation

A multidisciplinary approach for the patient with dementia is essential. Physical and occupational therapy, nutritional support, speech therapy, psychiatry, social work, nursing, and medicine all need to be part of the long-term management of this patient. It is important that families use all available resources to reduce their isolation and stress. A variety of nonpharmacological approaches have been helpful to reduce agitation. Some include pet therapy, massage, therapeutic touch, and aromatherapy.

Impaired Verbal Communication

IMPAIRED VERBAL COMMUNICATION evidenced by inability to name objects or sensations such as pain; inability to comprehend verbal instructions; inability to communicate needs; inappropriate, dramatic reactions or accusations, catastrophic reactions related to confusion, disorientation, memory loss.

Patient Outcomes

• Demonstrates understanding of nurses and communication
• Able to communicate thoughts and needs
• Responds appropriately

Interventions

• Look directly at patient when speaking. Call patient by name frequently. Identify yourself by name before each conversation and refer to others by their names rather than “he” or “she.”
• Keep interactions simple. Use short words and simple sentences that express one thought or question at a time.
• Ask specific questions such as “Does your stomach hurt?” rather than general ones like “How are you?”
• Reinforce speech with nonverbal techniques. For example, point, touch, or demonstrate an action while talking about it. For instance, if the patient is trying to tell you about his or her body, point as well as ask “Is this where it hurts?”
• Note in the chart or on the care plan the phrases, key words, and techniques that the patient responds to so that others can use them as well.
• If patient keeps repeating a question, try distraction and give reassurance that he or she will be cared for. Repetitive questions may indicate anxiety, and you want to be reassuring.
• If patient is searching for a particular word or trying to communicate something, guess at what it is, and ask if your guess is correct. If you are unable to determine what he or she is trying to say, focus on the feelings possibly being communicated. Always ask patient to confirm whether your determination is correct.
• If patient is reacting inappropriately, remain calm and reassure him or her that you are there to help. Avoid arguing or trying to convince patient that he or she is overreacting. Clarify any information or instructions. Assist patient with the next step of a task that is the source of frustration. Try to distract patient by removing him or her from disturbing situation.
• If patient makes inappropriate accusations, such as accusing the staff of stealing his or her glasses, help look for the missing item. Remember that the patient may accuse you of stealing because of memory loss. Also, routinely check wastebaskets for missing items.
• Family/caregiver support to deal with difficult behaviors. Resources for support should be provided to avoid reactions to behavior with frustration and aggression.

Impaired Memory

IMPAIRED MEMORY evidenced by confusion, decreased ability to perform activities of daily living (ADLs), or inability to follow therapeutic regimen; inappropriate emotional or behavioral responses related to delirium, dementia, or other cognitive deficits.

Patient Outcomes

• Demonstrates improved orientation to person, place, and time
• Demonstrates improved ability to perform ADLs
• Displays less emotional or behavioral agitation

Interventions

• Establish a baseline assessment of patient's mental status and functioning:
• Observe ability to perform ADLs.
• Use a standardized method of mental status assessment such as that found in Table 3-1 Mental Status Examination and Related Definitions.
• Ask the patient orientation questions. For example, ask patient personal questions such as names of his or her children or home address. Make sure that you can verify the answers from the chart or family.
• Assess if patient is willing to discuss memory lapses. Determine emotional responses to these lapses. Do not push the discussion if the patient becomes agitated or defensive.
• Be aware that patient may try to disguise memory loss by confabulation, avoiding responding, or by speaking in a rambling style to hide the fact that no thought or information is being expressed.
• Be aware that when social skills and personality are still intact, patient may mistakenly appear stubborn and resistant rather than unable to remember.
• Do not argue with patient about what he or she remembers. Rather, focus on immediate and specific tasks to be completed. Give patient step-by-step instructions on what needs to be done. Be directive without being domineering.
• Do not make demands that the patient cannot handle or focus on topics that clearly cause distress. Such demands will only add to the confusion and/or agitation.
• Break down complex tasks into individual steps. The seemingly simple act of brushing one's teeth can take over 10 steps. Be aware of the steps the patient can handle himself or herself and those requiring assistance. Use prompts to cue each step of the task.
• Establish a regular and predictable routine. Try to do things at the same time and in the same order each day, such as shave, bathe, and then eat breakfast. Communicate routines to the staff to coordinate patient's care and ensure that the same techniques are used. Obtain input from the family on patient's usual routine. Use prompts such as consistent cue words or signs to remind patient of the routine.
• Attempt to arrange for consistent staff to care for patient.
• Keep surroundings simple. Reduce clutter. Do not leave equipment in the patient's room if possible.
• Personalize the patient's room. Have the family bring in photos and favorite objects. Encourage the family to create a memory box with meaningful items from the patient's past (wedding photos, special momentos).
• Place a large, visible clock and calendar in the patient's room. Cross each day off the calendar daily. Place large signs on the wall noting where patient is and special events such as when the family is coming and the next upcoming holiday.
• Write lists of daily activities or tasks patient needs to do if still able to read and comprehend. Put labels on possessions and patient's name on his or her door in large letters.
• Avoid an overstimulating environment. In the hospital, the patient's room should be close enough to nurses' station to monitor safety yet far enough away to avoid noise. Restrict the number of people visiting at one time.
• If the patient tends to wander, make sure all staff are aware of this problem and can bring him or her back to the unit. Consider using alarms, if available, for a patient at high risk of leaving the area. Monitor all exits. Draw a large red octagon-shaped stop sign and hang it by the exit. At home, make sure exits are monitored. Have the family notify neighbors of the problem and elicit their assistance to monitor for wandering. Make sure the patient always has some form of identification stating that he or she is confused, such as an identification bracelet. Maintain photos of the patient to be shown if he or she is missing.
• Provide some form of night light. If the bathroom is connected to patient's room, leave the bathroom light on. Otherwise, use reflective tape in the shape of arrows to direct the patient to the bathroom door. Encourage the use of a bedside commode.

Risk for Injury

RISK FOR INJURY evidenced by falls and bumping into objects. related to problems in gait, vision, hearing, lack of coordination, confusion, or lack of understanding of environmental hazards.

Patient Outcomes

• Remains free of injury
• Demonstrates appropriate actions to avoid injury
• Reduce use of restraints

Interventions

• Be aware of factors that increase risk for falls (Box 10-3 Causes of Increased Risk of Falls and Injury).
• If patient is a fall risk, keep side rails up and bed in lowest position. At home consider taking the mattress off the bed frame and putting it on the floor to avoid injuries from falls. In the inpatient setting, bed alarms and hip protectors can be used to prevent injury.
• Even with side rails up, be aware that patient may get out of bed. Keep area around bed free from clutter. Make sure that there is always a clear path to the bathroom because that is the place where the patient will most often attempt to go. Make sure that patient uses the bathroom before going to bed at night. Plan administration of medications such as laxatives and diuretics so that they are not given in the evening. Recognize that the patient with dementia may have sleep pattern disturbances and become more confused at night.
• Make rounds frequently for patients at high risk for falling. Keep the patient's door open, and make sure all staff members know that this patient is at risk.
• Use restraints only after all other methods are ineffective. In some instances, restraints can increase confusion in elderly patients.
• If the patient has an unsteady gait, have him or her take your arm instead of the reverse while walking. Make sure the patient has access to any needed equipment such as walkers or wheelchairs. Provide instruction as appropriate within the patient's ability to understand. Ensure that any furniture or objects the patient leans on for support are sturdy and well balanced. Railings in hallways and bathrooms are very helpful. The patient may need prompts to perform simple actions, such as walking.
• Make sure the patient receives adequate exercise within the limitations of his or her abilities and condition.
• If the patient wears glasses or a hearing aid, make sure that these are in place before any activity. Be sure to check that the hearing aid battery is good.
• Ensure that the room is adequately lighted for any activity and that the call light is within reach when patient is in bed, in bathroom, or sitting in chair.
• Check the patient routinely for bruises, cuts, or burns.
• Use colored waterproof tape along the area of the bathtub where patient is to stop filling with water. Decorative markers that stick to the bottom of the shower or tub can compensate for spatial disorientation.
• Use brightly colored materials in the room, if possible.
• Be aware that the patient may try to pull out catheters or intravenous tubing. Try to reduce risk of the patient's pulling out the tubes by reducing the discomfort associated with tubes. For instance, use the smallest-size nasogastric tube or cover the IV site with a large bandage to avoid the patient's pulling on the tubes. Wrist restraints, freedom splints, or monitoring by a family member may be required to avoid injury.
• Be aware of medication interactions that could add to confusion and the risk for falls.

Nutrition, Imbalanced: Less Than Body Requirements, and Fluid Volume Deficit

NUTRITION, IMBALANCED: LESS THAN BODY REQUIREMENTS, AND FLUID VOLUME DEFICIT evidenced by weight loss, electrolyte imbalance, increased confusion, or other signs of dehydration, related to impaired recognition of hunger and thirst, memory loss, impaired movements.

Patient Outcomes

• Receives adequate nutritional and fluid intake
• Displays ability to recognize signs of hunger and thirst
• Demonstrates ability to feed self

Interventions

• Assess the patient's ability to feed and care for self (Fig. 10-1 Self-care Checklist).
• Provide assistance, as needed, for dressing, personal hygiene, and eating.
• Determine how much patient can safely do independently. Perhaps just opening containers or cutting meat is all that is needed to promote independence. Provide verbal cues to keep patient on track.
• Determine patient's food preferences and provide these foods, if possible. Encourage the family to bring familiar foods from home if appropriate.
• Make sure that dentures are in place and that they fit correctly before serving a meal.
• Allow hot foods to cool to prevent burn injury.
• Simplify the meal routine. The patient may be able to cope with only one food or one utensil at a time. Provide finger foods if utensils are difficult to use.
• Reduce distraction during mealtimes. For instance, turn off the television or radio.
• Assess regularly for signs of dehydration and aspiration (coughing after eating/drinking). Use thickened liquids or pureed diet.
• Make sure that patient can see his or her food and hear your instructions.
• Consider liquid supplements if eating solid food is too difficult.
• Assess for constipation.
• For patient with end-stage dementia, family may face decision on whether to pursue aggressive nutrition intervention if patient refuses to eat or is unable to swallow. Provide support for the family in attempting to weigh these difficult options. Consider offering ethics consultation or palliative care/hospice assistance, if appropriate.

Alternate Nursing Diagnoses

• Confusion, Acute
• Confusion, Chronic
• Family Processes, Interrupted
• Sensory Perception, Disturbed
• Sleep Pattern, Disturbed
• Therapeutic Regimen Management: Ineffective
• Thought Processes, Disturbed

Patient & Family Education

• Provide simple instructions based on patient's current ability to comprehend.
• Teach the family techniques to control uncooperative and aggressive behavior.
• Give the family information about the disease so that they can better understand that the patient has no control over his or her behavior.
• Teach the family or caregivers about the need to avoid stress and fatigue for the patient because this can increase behavior problems.
• Encourage family to obtain material and newsletters from the Alzheimer's Association (alzheimers.org). Also encourage them to obtain a copy of The 36-Hour Day by Mace and Rabins.
• Alert family to signs of caregiver abuse.
• Teach the family or caregivers to build support systems to maintain a balance in their lives. Give information on obtaining caregivers.
• Encourage family to consider options for the future such as nursing homes, in-patient dementia programs.
• If the patient is in the early stages of dementia, encourage discussion of wishes for resuscitation and feeding tubes when the disease advances. Encourage completion of an advance directive.
• Review realistic expectations from Alzheimer's drugs and symptom management medications.
• For patients with delirium, help the patient/family identify possible sources of the delirium so the risk can be minimized in the future.
• Teach the family about the emotional strain created by caring for the confused patient. Educate them that, with Alzheimer's disease in particular, the family may go through a mourning process for the person who their loved one used to be. This process is complicated because the patient looks the same but no longer has the same personality. Adult children must be prepared to reverse roles and become caretakers.

• Document any changes in levels of confusion, memory, behavioral routines, or consciousness.
• Document which activities the patient cannot do.
• Document if patient is able to start an activity but requires a prompt to continue. Document words or physical directions that work as a prompt.
• Document stimulus that causes the patient to have catastrophic reactions, such as too much noise or too many demands at the same time.
• Document the patient's response to medications.
• Document any techniques that have been effective in calming patient.

When to Call for Help

• Sudden onset of confusion
• Episodes of patient’s becoming physically combative
• Patient who becomes a danger to self or others because of poor judgment (driving, cooking, etc.)
• Severe agitation unresponsive to medication or other interventions
• Delirium that does not remit or gets worse

Who to Call for Help

• Social Worker
• Security
• Psychiatric Team
• Geriatrician

Community-Based Care

• Be sure that the family has the needed information on financial resources and legal information for power of attorney.
• Report all indications of caregiver abuse.
• Assist the family or caregivers to set a plan to provide them with needed rest and recreation. Encourage family and caregivers to seek out support of friends or clergy. Encourage attendance at local support groups.
• If the care demands become too great, families need to consider placing the patient in a nursing home, specialized Alzheimer's program, or day care. Provide information on any specialized programs in the community and suggestions for what to look for in a facility. Provide families with support to make this difficult decision.
• Give specific information on this patient's management to home health agencies and skilled nursing facilities.
• Give information from local Alzheimer's Association chapters on treatment programs, research, and facilities.
• Patients with end-stage dementia may be appropriate for referral for palliative care or hospice care when they are bedbound, experiencing repeated infections, and are having difficulty with eating and drinking.
• Refer to home health agency if patient to be discharged home with a feeding tube or needs further instructions on prevention of aspiration, skin breakdown.