What We Know About Treating Confusion Stephanie J. Nagley and Annette Dever
The diagnosis confusion has lacked the clear conceptual or operational definition necessary for systematic study. In this article, the authors review the research literature that contributes to the current understanding of the phenomena of confusion. © 1988 by W.B. Saunders Company.
HE LABEL corrosion has been used by most T nurses at some time to describe patients with impairment in mental status. As with many clinical
From ttle Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH. StephanieJ. Nagley, Phl), RN: AssistantProfessor, Frances Payne Bolton School of Nursing, Case Western Reser~'e University; Annette Dever, MSN, RN: Instructor, Frances Payne Bolton School of Nursing, Case Western Rederve University, Cleveland, OH. Address reprint requests to Stephanie J. Nagley, PhD, RN, Frances Payne Bolton School of Nursing, Case Western Reserve University, 2121 A.bington Rd., Cleveland, OH 44106. © 1988 by W.B. Saunders Company. 0897-1897188/0102-0005505.(90/0
pairment (Nagley, 1986; Wolanin & Phillips, 1981). Wolanin's (1977) work on this subject adapted the categories of cognitive inaccessibility and social inaccessibility (Fisher & Pierce, 1967) to order the numerous behaviors identified by nurses as symptoms of confusion in elderly residents of a long-term care setting. Wolanin used a cognitive accessibility category for observations such as impairment of memory, disorientation, poor concentration and attention, misinterpretations of the environment, and inability to follow instructions. Social accessibility was evidenced by behaviors such as belligerence, combativeness, restlessness, wandering, and suspiciousness. In both categories, nurses identified behaviors that in some way affected their ability to interact with the individual and assure optimal care. This is in contrast to physicians' observations of mental status phenomena deemed important because of difficulty in obtaining a good medical history (Wolanin & Phillips, 1981). The need to understand confusion through the perceptions of nurses wa~ supported in a study of 60 hospitalized elderly patients by Nagley (1984). In this study, the Short Portable Mental Status Questionnaire (SPMSQ) (Pfeiffer, 1975) and an investigator-designed tool, the Clinical Assessment of Mental Status (CAMS), were used to identify the development of confusion over 4 days of hospitalization. Using the CAMS, nurse raters' attended to the patient's memory and orientation status but also included interactional behaviors such as eye contact, responsiveness, and body movement. This finding led to spectilation that nurses perceive confusion as a combination of cognitive and interactional behavior patterns that indicate mental clarity or impairment. Therefore, traditional measures such as the SPMSQ may not fully capture the phenomena of confusion as perceived by nurses.
Applied Nursing Research, Vol. 1, No. 2 (August), 1988: pp. 80-83
problems, our understanding of confusion and our interventions to ameliorate or alleviate the problem of confusion are based on clinical experience. Within the last few years a handful of researchers have sought to develop a scientific understanding of confusion and effective nursing interventions. While there may be a shared understanding of confusion among practitioners, a clear and concise definition of confusion necessary for scientific study is lacking. Some investigators have, in fact, advocated abandoning the term and in its place recommended the use of concepts such as delirium and,cognitive dysfunction. The 1984 accepted North American Nursing Diagnosis (NANDA) taxonomy does not recognize the term confusion. Instead two nursing diagnoses, alterations in thought processes and sensory-perceptual alterations, at least partially describe the clinical phenomena of confusion. Whatever label we decide to use, the task of developing a scientific understanding of this thing called confusion and the knowledge necessary to determine the most effective interventions remain the fundamental concerns of a clinician/researchep team. In general, there is agreement that confusion is a constellation of behaviors that indicate mental im-
Vermeersch (1986) asked nurses in the acute care setting to identify factors they perceived as important in determining the presence of confusion. She asked 228 medical-surgical nurses in three settings to rate 141 items drawn from research and which were descriptive of confusion and the defining characteristics of appropriate NANDA diagnoses. Five dimensions and the associated patient behaviors emerged, and these became the Clinical Assessment of Confusion (CAC) tool. Neelan and Champagne (1986) developed a tool to measure acute confusion in hospitalized adults. This tool also represents confusion as a clinical reality including items that are indicative of interactional as well as cognitive behavior.
The researchers found that clinicians were more accurate in predicting confusion than the models. Although the meaning of confusion is not fully understood, a few studies have examined factors that may precipitate confusion. Williams et al. (1979) found that the best predictor for the development of confusion in the elderly patient hospitalized for repair of hip fracture was confusion on admission. The investigators also found that factors such as loss of mobility, problems with elimination, and use of narcotics and tranquilizers may increase the risk of the elderly person developing confusion during hospitalization. Williams, Campbell, Raynor, Mucholt, Mlynarczk, and Crane (1985) offer three models that shed light on the multidhnensional factors involved in the development of confusion in older adults hospitalized for hip fracture. Model 1, drawn from their study of 170 elderly patients, suggests that increased age, physical activity prior to injury, and increased errors on mental status admission scores were predictors for the development of confusion. This model predicts the probability of who may or may not become confused during hospitalization, but it cannot predict the intensity of confusion. Model 2 suggests that age, urine elimination problems, and mental status may be helpful in predictiqg confusion on d day-to-day basis. Model 3 points out the importance and interrelatedness of
mobility, pain, and narcotic use in the development of confusion. The investigation by Williams et al. (1985) also supports the view that confusion is a multidimensiofial variable that cannot be fully understood apart from the perceptions and inferences of the clinician. The researchers found that clinicians were more accurate in predicting confusion than the models, suggesting that clinicians may include factors in their assessments that were not a part of the modeling. Studies involving the predictors of confusion have a very practical importance for the clinician. From the investigations by Williams et al. (1979, 1985), the clinician can begin to draw inferences and design effective interventions for those thought to be at greatest risk. For example, there is evidence to support that urine elimination problems, prior physical activity, and the use of central nervous system depressants are additive factors. While the effects of narcotics on the development of confusion might be expected, the implication that prior activity levels and urine elimination problems are factors in the confusion scenario may not have been considered previously as significant variables. The interventions suggested are derived through inference of what actions may be effective given the probable cause of confusion. In general, nursing actions suggested in the literature are those that reestablish normal physiological status or assist patients in adequate interpretation of their environment (Geddes, 1968; Morris & Rhodes, 1972; Wahl, 1976; Weymouth, 1968; Williams et al., 1979; Wolanin & Holloway, 1980). When confusion stems from a physiological cause, the needed interventions are rather straightforward. Alterations in electrolyte balance or oxygenation can be managed through medical intervention and nursing support. Often, though, confusion may appear in the absence of obvious physiological deviation. This seems especially true in the older adult population in whom optimal mental clarity is maintained with a narrow tolerance for physiological or psychosocial deviation (Goldfarb, 1975; LaPorte, 1982). For example, a fluid imbalance that may have benign consequences in a younger adult may lead to confusion in the older adult. Seymour, Henschke, Cape, and Campbell (1980) reported that confusion was related to dehydration in elderly patients admitted to hospital through emergency services, and rehydra-
NAGLEY AND DEVER
tion was sufficient in several patients to correct the confusion. Wolanin and Phillips (1981) contend that in addition to fluid and electrolyte imbalance, alterations to body temperature in the older adult may lead to confusion. It is well documented that the elderly are more prone to hypothermia and experience confusion as a consequence (Krag & Kountz, 1950; Wolanin & Phillips, 1981). The nursing intervention would be to maintain optimal ambient temperature, recommended to range between 75 °F to 85 °F, and to provide other measures to increase the warmth of the individual (Wolanin & Phillips; 1981).
One way a person promotes self-identity is by having a variety of articles that have personal meaning immediately available. There are a number of physiological and psy• chosocial.risk factors associated with confusion. For psychosocial factors, such as loss of continuity with life history or sensory alterations, research has yet to demonstrate whether these are significant precipitating events or whether there are effective interventions. One of the psychosocial variables that has been theoretically identified as a factor in precipitating confusion is hospitalization. Wolanin and Holloway (1980) have coined the term "traumatic relocation" to emphasize the impact hospitalization may have on the older adult. Concomitant with hospitalization are loss of continuity with life hi~tory and disruption of daily activities, which are also identified as precipitating factors to the development of confusion in elderly persons (Wolanin & Holloway, 1980; Wolanin & Phillipg, 1981). T h e s a m e process of logical inference, in absence of empirical data, is drawn'upon by Hayter (1981) and Roberts (1980) to suggest nursing interventions for hospitalized elderly-persons. According to Roberts, the presence of personal possessions is important in the elderly patient's ability to maintain mental clarity. Hayter states that one way a person promotes self-identity is by having a variety of articles that have personal meaning im-
mediately available. Nursing actions that encourage the use of personal articles such as photographs, clothing, and religious symbols may be useful in preventing or easing confusion in the elderly patient. Disorientation and confusion usually go hand in hand. Reality orientation has been a long-standing intervention in response to disorientation (Moses, 1970; Porter, Rasmussen, & Burnside, 1981; Wahl, 1976). Hogstel (1979) examined the effectiveness of a reality-orientation program with 22 elderly nursing home residents and found no significant change in disorientation. Nodhturft and Sweeney (1982) found significant improvement in a group of nursing home residents using a realityorientation program. While clinical judgment would not support excluding the use of realityorientation measures, there is insufficient research to support its extensive and exclusive use. In fact, for those whose confusion and disorientation are due to moderate and severe dementia, reality orientation may be of little use (Hellenbrandt, 1978). Clinicians have observed that reality orientation may cause agitation in confused and disorientated elderly, possibly increasing stress by constantly questioning the patient in order to assess reality orientation. The costs and benefits of reality orientation should be weighed carefully. Alteration in sensory stimulation has been viewed as a cause of confusion. It can be inferred from the literature that alterations in sensory input may be a factor in the development of confusion (Roslaniec & Fitzpatrick, 1979). Therefore, it is reasonable to assume that the use of vision and heating aids and social interaction are effective interventions in preventing confusion. Another factor that can be seen as a psychosocial variable and which may be related to the development of confusion is mobility. The study by Williams et al. (1979) lends credence to the importance of interventions that encourage mobility as a means of preventing confusion. Again, there is no direct empirical support to suggest that interventions that improve mobility will prevent or ameliorate confusion. Confusion research is evolving and will eventually reveal those interventions that are most effective in reducing or preventing confusion. The nature of nursing practice does not allow us to pause and wait for empirical data to support our actions. Nurses in the clinical setting, however, can expe-
dite the development of our scientific understanding of confusion and appropriate interventions through their involvement in research. Researchers wilI draw on existing nursing interventions to understand and manipulate treatment variables. In order to verify this understanding and develop gen-
eralizations that are admissable to the body of nursing knowledge and useful for practice, it is necessary that research proceed with two questions: (a) "What is confusion?" and (b) "What nursing interventions are effective in preventing or ameliorating confusion?"
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