SUDDEN CONFUSION – GO TO EMERGENCY ROOM

While it is easily seen when a person has a dramatic change in consciousness and they are in a stupor or coma, delirium is not that easy to identify. The emergency department is usually the point of entry into the hospital for the confused elder. The ER runs at a high speed and it is necessary for an accurate diagnosis for the patient’s family or friends to give a good history.

Patients in a deep sleep or stupor, who can only be aroused with extreme physical stimulation are in a medical emergency. The emergency room personnel assume that the person is not always so difficult to arouse, and they recognize the emergency. However identifying changes in a patient with delirium is much more difficult because the hospital staff do not know how the patient usually is. This puts the burden of communicating the emergency situation on the accompanying family member.

It is estimated that ER physicians miss the diagnosis of delirium in 57 to 83% of cases. This wastes valuable time for the patient, time that they need for early intervention. This missed diagnosis can be due to the fact that the elder themselves do not know why they have come to the hospital. Or if the elderly person is agitated they may even be admitted to the psychiatric ward, without a good assessment.

Giving a good mental history:

  • when did you first notice a change in mental function?
  • do these changes seem to come and go – get worse or better over time
  • does the person have problems paying attention – give an example of what is normal for this person and how they are now not acting normally – having difficulty carrying on a conversation – getting distracted and changing the subject
  • patients who are inattentive may actually fall asleep when they are not engaged in conversation, this change in sleep/awake patterns needs to be stated
  • the patient now has rambling thoughts and disorganized thinking
  • if the patient has had any recent falls, this is a very important piece of information and will help the physician in their physical examination – looking for possible head trauma
  • maintain an accurate list of all of the elder’s medications as well as any over the counter medications they are taking – maintaining this list will make it much easier in an emergency situation
  • share with the emergency staff if the elder has a history of alcohol abuse or use of sedatives
  • has the elder ever experienced an episode like this in the past?

Being prepared and ready with this pertinent information is impressive and will more likely get the attention of the emergency personnel than saying “He is just not acting right.”

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

SUDDEN CONFUSION – CAN THE PERSON WITH DEMENTIA GET DELIRIUM?

Many people, including those in healthcare use the terms dementia and delirium interchangeably. Even tho they are not the same, patients can have both conditions at the same time. A person with dementia can certainly develop delirium, they are even more inclined under certain circumstances, to develop delirium.

The person with several disease processes as well as dementia, will be the person at most risk for developing delirium. Research has shown that the person with dementia has a lower mental reserve and less ability to adjust to a physical assault. That assault can come in the form of an infection such as a urinary infection or upper respiratory infection. Because the person is more vulnerable due to their dementia, they can under these circumstances develop delirium.

Other factors creating an increased likely hood of developing delirium are advanced age, history of alcohol abuse, poor nutrition, poor physical function, poor vision, hearing loss, dehydration, congestive heart failure, extreme pain (such as that related to a fracture), and many medications especially narcotics. Many times the cause of the delirium will not be found.

When the person is admitted to the hospital they are at increased risk to develop delirium if they have dementia. Due to the nature of the running of a hospital, the confused person may have physical restraints to keep them safe if they are trying to get out of bed unassisted. The elderly who are incontinent may now have a catheter for the purpose of obtaining urine specimens as well as easier care considerations. These possibilities as well as the likelihood of the elder now having an increased number of medications can result in an increased risk of developing delirium.

In the United States, hospital emergency rooms are currently seeing approximately 18 million patients 65 years and older. As the population ages, the number of visits to the emergency room by the elderly will increase dramatically as well. The potential for large numbers of the elderly population going to the emergency room for sudden confusion and developing confusion when admitted to the hospital is increasing. All of this adds up to an expectation of  not only the increase in elderly persons with dementia but also the increase in cases of delirium.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

SUDDEN INCREASE IN CONFUSION IN ALZHEIMER’S PATIENT – IS THAT EVEN POSSIBLE?

Harold came into the skilled nursing facility, admitted from the local hospital. Harold lives at Pleasant Meadows, an assisted living community where he has been independent. The problem arises when the nurse from the skilled facility  calls the nurse from Pleasant Meadows. The Harold that the nurse now describes in not the man the Pleasant Meadows nurse has know for the last 6 month, before he went to the hospital. Harold?  Uncooperative, disoriented, unsteady on his feet, falling, with generalized weakness? No, no the nurse from Pleasant Meadows insists that they (the skilled facility) don’t know what they are doing and don’t know how to take care of Harold.

Sadly this scenario is not unusual, for one healthcare facility to accuse another of not knowing what they are doing. Doesn’t the fact that because Harold already has the diagnosis of Alzheimer’s disease mean that it is understood that he is confused? Yes, Harold is always confused, but this new Harold is in an altered mental state. He was admitted to the hospital with pneumonia. Infections in the elderly many times can cause confusion. This infection caused Harold to experience a rapid decline in his mental functioning and an increase in his confusion.

Sudden increase in confusion can result in very vague symptoms. The family member might say he is “not acting right”, has different behavior, is either more sleepy or more agitated, is extremely distracted,  has recent inappropriate behavior. These sudden changes can come within days or even hours of onset. The great difficulty comes in diagnosing why the individual is suddenly more confused. As well as realizing that it is going to take much more time for the problem to resolve compared to the fast onset.

Harold will continue to have increased confusion even after he has recovered from his pneumonia. And Harold is likely not to return to his previous level of mental functioning.  This infection has tragically caused him to lose some mental clarity  and has resulted in progression of his dementia. Right now Harold needs one on one care, with people who explain the environment and what is going on, as well as protecting him from unsafe activities. All the while giving his mind the time to heal as well as his body.

Yes, it is not only possible for someone with Alzheimer’s disease to suddenly become more confused, it is more than likely when there is an infection involved. A sudden increase in confusion, or delirium continues to be misunderstood.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

IS DEMENTIA THE SAME AS MENTAL ILLNESS?

Mental illness is a broad term for disorders that affect thinking and behaviors. That, at first glance, can sound like dementia. However, there are known causes for many forms of mental illnesses. Also, strong effective treatment programs will include cognitive behavioral therapy, which is not used for persons with dementia.

Mental illnesses range from mood disorders; major depression, anxiety disorders, panic disorders, personality disorders, obsessive-compulsive disorder, to psychiatric disorders; anti-social, narcissistic, schizophrenic, and so many more.  These conditions are traceable to poor parenting practices, childhood trauma, bereavement, unemployment conditions, social stresses including cultural stresses, as well as abuses; drug abuse, cannabis, and alcohol abuse.

Cognitive behavioral therapy involves helping the individual in identifying their distressing thoughts, while seeing how realistic these thought patterns really are. This therapy, stresses working on distorted thinking, and coming up with positive problem solving techniques. Consistently focusing on how valid the person’s thoughts are, as well as examining how useful this thinking is to the individual. Cognitive behavioral therapy when successful will change troubling behaviors.

In order to be successful with this therapy the person has to possess the ability to reason. Loss of reason and judgement are early signs of dementia. As well as loss of the ability to focus, persons with dementia due to Alzheimer’s disease, are very easily distracted.  Persons with dementia, due to Alzheimer’s disease, will have short term and eventually long term memory loss.  Memory loss not a symptom of mental illness.

Above all, despite the changes seen in the individual with a dementing illness, he is not really distressed by his losses. For the most part his frustration is due to misunderstanding the environment and cooping with the loss of communication skills.  In contrast, persons with mental illness are very much distressed by their thoughts and behaviors.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

DEMENTIA 101 – DISEASES CAUSING DEMENTIA

Dementia is not a disease, but rather a combination of symptoms that may accompany a disease or physical condition.  These changes or symptoms, begin with memory loss, and slowly progress to the person having difficulty caring for themselves and eventually becoming totally dependent on others. The symptoms must include memory loss and at least one of the following to indicate dementia.

  • Loss of language skills, understanding words, spoken or written as well as the ability to speak coherently.
  • The loss of the ability to recognize objects and eventually people.
  • The loss of the ability to initiate and follow through with motor skills.
  • The loss of reason, judgement, planning and ability to follow through with a plan.

These changes have to be severe enough to interfere with the person’s ability to live independently, to be considered dementia. When the elder suffers only from occasional memory problems, that are not interfering with daily activities, they are considered to have mild cognitive impairment.

Alzheimer’s Disease: is the most common cause of dementia affecting between 50% – 70% of those diagnosed with dementia. By the time a person is 85 years old they will have about a 50% chance of developing Alzheimer’s Disease.

Vascular Dementia: The second leading cause of dementia is experiencing a stroke. This is not a slowly progressing dementia, it progresses as the elder continues to have small strokes causing more damage to the brain.

Lewy Body Dementia:  Named for the round structures, or Lewy bodies found in the brain. This is frequently connected to the person who has, Parkinson’s disease with dementia.

Frontotemporal Dementia: This dementia doesn’t present with memory loss until much later in the disease process. The first signs are personality changes, and lack of empathy for others.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

WHEN DEMENTIA AND CONFUSION AREN’T PERMANENT – SUDDEN DELIRIUM

I receive emails from families who can’t understand what has happened to Mom, Dad, Uncle Charlie and so on. You see this person was just fine a couple of weeks age, driving, shopping, living alone, balancing their check book, and now the doctor says Mom has Alzheimer’s disease and needs to live in a nursing home. What usually happened is that Mom had an infection, an accident, change in medication or surgery and this put Mom into a state of delirium

Synonyms for delirium are; irrational, raving, deranged, and yes even demented. Once the stress is over, the elder returns to their previous state of cognition. But what if Mom is in the hospital when she becomes delirious? The hospital personnel don’t know Mom and  don’t recognize her delirium. Mom will be labelled a confused, demented elder and medicated to keep her under control and “safe.” This will only lead to increased confusion making Mom appear even more confused.

The presence of delirium can indicate that the elder’s brain has a decrease in capacity and may indicate an increased risk of developing dementia. The healthcare community sees delirium frequently with the elderly and infrequently with the young. The same person can have had no history of delirium, even though they have experienced several hospitalizations, yet when they are old, they become confused and disoriented every time they are admitted.

Whenever there is a sudden change in an elder’s ability to think, focus, reason, and remember, look back to whatever stress could have caused the change. The longer the person suffers from delirium, the more chance it will not be resolved.

Remember Alzheimer’s Disease is slow, delirium is fast and doesn’t have to be permanent.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

BUILDING BRAIN HEALTH PROTECTS AGAINST DEMENTIA – BY INCREASING OXYGEN – PART II

Blood is the transport system of oxygen to the brain. The brain uses three times the amount of oxygen as the muscles. An oxygen rich, blood supply, is very important to brain function. Known ways to improve in-door air quality and oxygen levels, are surprisingly simple.

Start with opening a window. Even sleeping with a window slightly cracked will increase the quality of the air in a bedroom. Bedroom are loaded with carpeting and fabrics know to have toxic chemicals. These chemicals can cause headaches, eye and nose irritation, as well as skin problems. Any allergic reaction will cause inflammation, possibly reducing quality air exchange, between heart, lungs and brain.

But more proven ways to improve air quality, come from straight from NASA. The NASA study tells us what plants produce the most oxygen and remove what chemicals. Opposite of us, plants take in carbon dioxide and give off oxygen. NASA recommends easily found houseplants, that are shown to be effective at removing toxic substances in the air, like formaldehyde, benzene and trichloethylene, while giving us increased levels of oxygen.

Especially sleeping in a room with increased levels of oxygen and reduction in toxic air quality, can help the person with dementia, avoid periods of agitation related to low oxygen levels. More than the general population, the person with dementia needs special brain support and increased oxygen provides that.

While searching for great oxygen producing, air cleaning plants be aware that many houseplants are toxic to children, pets and the elderly with dementia. The person with dementia will benefit greatly from increased oxygen to the brain, but needs to be protected from ingesting anything toxic. Even if the confused person has never attempted to ingest a non-food item, a person with dementia has that potential.

NASA recommended plants that are non-toxic include: dwarf date palm, areca palm, boston fern, kimberly queen fern, lily turf, spider plant, bamboo palm, broadleaf lady palm, barberton daisy, rubber plant and banana plant. While these plants are actually taking in carbon dioxide and producing oxygen, they are also adjusting the humidity in your home.

Due to the fact that houseplants are subtropical they do well inside with low light levels. The NASA study suggests one plant for every 100 square foot of living space. Some of these plants, (even with minimal attention) will grow to a very large, even ceiling height, providing even more improved air return.

When visiting a large greenhouse you will frequently hear comments about how much easier it is to breath in the greenhouse. There are also known psychological benefits for the person with dementia, when living in an environment with a large amount of plants.  The color green is known to be calming and also to help with memory. More oxygen to help the brain function, a pretty, calming color green and helping with memory. Plants, thank you NASA, what a good deal.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing 

5 REASONS THE PERSON WITH ALZHEIMER’S DISEASE CAN HAVE BAD BEHAVIORS

When life begins to be a mystery and the person with Alzheimer’s disease no longer understands what people say, the meaning of words, and he no longer understands the environment, he can react with anger. That anger can lead to his being restless or even combative. Sometimes striking out at caregivers, strangers and even those he loves.

What causes bad behaviors in Alzheimer’s disease:

  1. His short term memory is affected, so no he doesn’t remember what he just had for lunch. And furthermore all of those questions, about things he can’t remember are getting on his nerves.
  2. He has poor judgement, so even though he has always been a cautious person he now is very impulsive. Even possibly having inappropriate social behavior, because he no longer exercises good judgement in actions or what he says.
  3.  He now is making poor decisions, due to Alzheimer’s disease and no longer understanding the environment. Spontaneously walking outside alone, to take a walk in winter without coat, hat gloves, etc.
  4. He now has an obvious short attention span, becoming impatient, fidgeting, having difficulty sitting still, becoming easily distracted or easily bored.
  5. He is losing verbal skills and having difficulty expressing wants and needs. So becomes angry when people do not meet those needs because of poor communication.

It turns out not to be such a mystery as to why the person with Alzheimer’s disease can have bad behaviors. The person with with Alzheimer’s disease is living in on ongoing mystery.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

WHY YOU DON’T ARGUE WITH A PERSON WITH DEMENTIA OR DELUSIONS

The elderly person with dementia, who has a persistent fixed incorrect idea or delusion, is literally unable to change their mind. The idea might be harmless, as in the case of the elderly woman who insisted she was always on a train. Or it might be dangerous as the person who is insisting he has to leave and go to work, when he hasn’t worked for many years. Harmless or not, these ideas frighten the family or caregiver because it demonstrates irrational thinking.  Using rational explanations or arguing doesn’t work when the person is unable to change their mind.

5 ways to address delusions without arguing:

  1. Let it go if at all possible. If the idea is not dangerous, doesn’t bother the person or others, let it go.
  2. If the idea or delusion is frightening, such as the woman who thought people were living on her patio, give reassuring , comforting words. “I am here and will stay with you,” while you use a distracting activity.
  3. A delusion might be an expression of some fear. Look to the environment. Are there shadows, do you need more light, are curtain or shades open at night creating reflections on a window?
  4. Support the feelings the person expresses, not the delusion.
  5. Ask the person to show you what they see. The shadow on a wall, when reality is distorted, may become a ghost to the confused.

Many delusions are just plain hurtful, as with the spouse who is no longer recognized and is accused of being an impostor. Some delusions are very embarrassing for the family, and require understanding and the education of others.  Well meaning friends and acquaintances may intercede and begin arguing the irrational  idea or delusion. Look at this as an opportunity to educate other people, so that they may support you, in creating your plan of care for this person.

When caring for the individual with irrational ideas, you never argue these thoughts away.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

DEMENTIA CARE – DECORATING FOR DEMENTIA – CREATING A SMART ENVIRONMENT

Lets face it we cannot get away from environment.  We are always in some kind of environment, but is it a healthy environment or troublesome environment? And for the person with dementia many things we take for granted in the environment are unhealthy as well as troublesome. These are environmental stressers that the person with dementia either hears, sees, or think they see.

Hearing stressors, are anything that is too loud. This can be the rattle and clink of utensils in a restaurant or even the voices when several people are talking at the same time, at the next table.  Anything that causes constant noise, like the TV or radio.  It will also be things that cause sporadic loud noises like a vacuum or landscapers.

A hearing stressor can also be when the person, who is trying to communicate with the confused person, just talks too fast. If the person is trying to understand, and can’t even catch the words, trying so hard will be stressful. And creates an environmental stress, where the person just seems to want to get away.

Things you commonly see in an environment can be very stressful for the confused person. When a person with advanced dementia looks at a shiny floor, it can appear as if there is water on the floor. Or even worse, that there is ice on the floor. A dark area of a carpet or tile can look like there is a big hole in the floor. Another frequent problem with flooring is small patterns. A carpet with obvious patterns will look like there is something on the floor. Many an elderly person has fallen trying to pick up something that wasn’t there.

The demented person does need contrast in color to be able to see the difference in surfaces. In a bathroom, if the tile floor is solid white and the toilet white, the person will have difficulty locating the toilet. He just doesn’t see white on white. In the same way when eating, a white plate on a white table, needs a colored place mat under the plate for the person to see it.

Keep this in mind, when walking around the house, think of contrast in doorways and furniture compared to wall color as well as floor color. Using the environment for great dementia care.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing