The assessment of confusion in the older adult


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Discussion around confusion and dementia by Philip Hall Dementia Nurse at Heart of England NHS Trust

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The assessment of confusion in the older adult

  1. 1. Phillip Hall – Senior Nurse DementiaPhillip.hall@heartofengland.nhs.ukExt - 44210
  2. 2.  a mental state characterized by disorientationregarding time, place, person, or situation. Itcauses bewilderment, perplexity, lack oforderly thought, and inability to choose or actdecisively and perform the activities of dailyliving
  3. 3. Confusion in the acute hospital
  4. 4.  Dementia – some causes treatable Delirium – usually treatable and often thefirst symptom of serious underlyingcondition Depression – often responds well totreatment All benefit from adaptations to care
  5. 5.  The development of multiple cognitive deficits manifested by: A. Two or more of the following cognitive disturbances: (a) aphasia (language disturbance) (b) apraxia (impaired ability to carry out motor activities depite intact motor function) (c) agnosia (failure to recognize or identify objects despite intact sensory function) (d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting) (e) memory impairment (impaired ability to learn new information or to recall previouslylearned information) B. The cognitive deficits in criteria A each cause significant impairment in social or occupational functioning andrepresent a significant decline from a previous level of functioning. C. The course is characterized by gradual onset and continuing cognitive decline
  6. 6.  Alzheimer’s Disease - 30% to 50% Vascular Dementia - 20% (but 50% of cases inhospital) Lewy Body Dementia – 10% to 30% Frontal Lobe Dementia – 5% Other causes - <5%
  7. 7.  Attention Concentration Orientation Short term memory Long term memory Praxis Language Executive function
  8. 8.  Delirium is a syndrome, or group ofsymptoms, caused by a disturbance in thenormal functioning of the brain. The deliriouspatient has a reduced awareness of andresponsiveness to the environment, whichmay be manifested as disorientation,incoherence, and memory disturbance.Delirium is often marked by hallucinations,delusions, and a dream-like state.
  9. 9. CONFUSION ASSESSMENT METHOD (CAM) SHORTENED VERSION WORKSHEET I. ACUTE ONSET AND FLUCTUATING COURSE BOX 1a) Is there evidence of an acute change in mental status from the patient’s baseline? No ____ Yes___b) Did the (abnormal) behaviour fluctuate during the day, that is tend to come and go or increase anddecrease in severity? No ____ Yes___ II. INATTENTIONDid the patient have difficulty focusing attention, for example, being easily distractible or having difficultykeeping track of what was being said? No ____ Yes___________________________________________________________________________ III. DISORGANIZED THINKING BOX 2Was the patient ‘s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclearor illogical flow of ideas, or unpredictable switching from subject to subject? No ____ Yes____ IV. ALTERED LEVEL OF CONSCIOUSNESSOverall, how would you rate the patient’s level of consciousness?Alert (normal) or___ Vigilant (hyperalert)___ Lethargic (drowsy, easily aroused)___ Stupor (difficult to arouse)___ Coma (unarousable)Do any checks appear? (any level of consciousness other than ‘normal’) No ____ Yes ___________________________________________________________________________If all ‘Yes’s’ in Box 1 are checked and at least one ‘Yes’ in Box 2 is checked a diagnosis of delirium is suggested.
  10. 10.  Deteriorating cognitive function: reducedconcentration, slow responses, confusion Perception: visual or auditory hallucinations Physical function: reduced mobility/movement, restlessness, agitation, change inappetite, sleep disturbances Social behaviour: lack of co-operation,withdrawal, altered communication, mood Emotional disturbance: mood swings
  11. 11. Three types of delirium;Hyperactive: Agitated, calling out, restless, wandering Least common, most frequently diagnosed Increased risk of falls and injuryHypoactive: Lethargic, slow to answer questions Most common, most dangerous, least recognised Increased pressure ulcer risk and aspirational pneumoniaMixed: combination of the above
  12. 12.  Increased morbidity Increased mortality Increased falls Higher length of stay Decreased likelihood of return home Eight fold increase of new diagnosis ofdementia Longer the delirium remains untreated thegreater all of the above risks
  13. 13. CHARACTERISTICSDEMENTIA DELIRIUM DEPRESSIONOnset Insidious, slow and oftenunrecognizedSudden, abrupt Recent, may correspondwith life changeCourse over 24hoursFairly stable, may seechanges due to stressesFluctuating, often withnighttime exacerbationsFairly stable, may beworse in the morningConsciousness Clear Reduced ClearAlertness Normal Increased, decreased orvariableNormalPsychomotoractivityNormal but may haveapraxiaIncreased, decreased,mixedVariable, agitation orretardationDuration Months to years Hours to weeks Variable (at least 6weeks) may be months toyearsAttention Generally normal Globally disordered,fluctuatesLittle impairment, verydistractibleOrientation Often impaired (answermay be close to right)Usually impaired,variable, fluctuatesUsually normal, mayanswer “don’t know”Speech Difficulty word finding,preseverationOften incoherent, slowor rapidMay be slow
  14. 14.  Right place, right time, right approach History is essential (recent and longer term) Confusion isn’t restricted to a single cause, atleast 5 out of 6 patients with delirium willalready have dementia Communication difficulties will need seriousconsideration Be aware of impact of identifying a problem Refer (RAID)
  15. 15.  Alzheimer’s Society – cognitive assessments; Addenbrooke’s Cognitive Assessment - 6 Item Cognitive Test – MMSE –
  16. 16.  Confusion Assessment Method training manual - European Delirium association –
  17. 17. Differential diagnosis – dementia and depression; in older adults (RCP); rating scales;Geriatric Depression Scale – Scale For Depression In Dementia –