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PubMed2000

Acute confusion assessment instruments: clinical versus research usability.

Acute confusion (AC), also referred to as delirium (AC/delirium), is a common problem seen by health professionals who work in a variety of care settings. This is an evaluative report on the clinical usability of instruments to assess AC/delirium as a part of nursing practice. Specifically, five instruments [the Confusion Assessment Method (CAM), Delirium Rating Scale (DRS), Delirium Symptom Inventory (DSI), Mini-Mental State Examination (MMSE), and Neelon/Champagne (NEECHAM) Confusion Scale] are discussed. The work demonstrates how the cooperation of nurses in practice, education, and research can improve both patient and staff outcomes.

Acute Disease↗
PubMed1999

Acute confusion and unreal experiences in intensive care patients in relation to the ICU syndrome. Part II.

The intensive care unit syndrome (ICU syndrome) is defined as an altered emotional state occurring in a highly stressful environment, which may manifest itself in various forms such as delirium, confusion, crazy dreams or unreal experiences. The purpose of this part of a study of patients' experiences is to describe and illuminate patients' experiences of acute confusion, disorientation, wakefulness, dreams and nightmares during and after their stay in the ICU. The data were obtained from 19 ventilated patients, who were interviewed twice and had stayed at least 36 hours in the ICU, the first interview being about one week after discharge from the ICU, and the second 4-8 weeks later. The hermeneutic approach used when interpreting and analysing the text from the interviews revealed that patients' experiences of unreal experiences were often associated with intense fear. Intense or continuous unbearable fear seems to result in frightening unreal experiences, which further increase the level of fear. Care actions or caring relationships with relatives or nurses can reduce this fear, which can help to prevent the occurrence and/or duration and intensity of the unreal experiences. Trust and confidence in nurses or significant others and feelings of self-control or trust in self-control seemed to reduce the risk of unreal experiences so that adverse stimuli might only trigger a mild confusion.

Acute Disease↗
PubMed1991

Confusing one person with another: what errors reveal about the elementary forms of social relations.

Seven studies investigated the cognitive structure of social relationships exhibited in the patterns of substitutions that occur when people confuse a person with another. The studies investigated natural errors in which people called a familiar person by the wrong name, misremembered with whom they had interacted, or mistakenly directed an action at an inappropriate person. These studies tested the relational-models theory of A. P. Fiske (1990b, 1991) that people use 4 basic models for social relationships. All 7 studies provide support for the theory; Ss tend to confuse people with whom they interact in the same basic relationship mode. In addition, Ss confuse people of the same gender. Other factors (age, race, role term, similarity of names) generally have smaller, less reliable effects, indicating that the 4 elementary modes of relationships are among the most salient schemata in everyday social cognition.

Adult↗
PubMed2002

Behaviors and outcomes of acute confusion in hospitalized patients.

The purpose of this study was to describe behaviors associated with acute confusion (AC) in hospitalized patients and to determine whether acutely confused patients experience more adverse outcomes compared with their nonconfused counterparts. Using a prospective design, 117 subjects were followed throughout hospital stay. Subjects who developed AC were more likely to fall, be incontinent, have a urinary catheter, and experience functional decline. Mortality was higher in subjects with AC. Contrary to popular belief, acutely confused patients exhibited decreased psychomotor activity. Nurses can be trained to recognize AC using a standardized protocol to improve outcomes for this vulnerable population.

Acute Disease↗
PubMed1996

The impact of a confusion technique on hypnotic responsivity in low-susceptible subjects.

The present study investigated the hypothesis that a confusion technique would produce greater hypnotic responsiveness for subjects who responded minimally to a standard hypnotic induction. Ten subjects who scored in the low range of hypnotic susceptibility on the HGSHS:A (scores of 0-4) participated in a confusion induction session. Hypnotic responsiveness was measured by several scales: the Harvard Group Scale of Hypnotic Susceptibility (HGSHS:A), a Depth Estimate (DE), and the Inventory Scale of Hypnotic Depth (ISHD). Qualitative data was collected via a follow-up interview. Collectively, the results did not support the hypothesis that a confusion technique is more effective than a standard induction for low-susceptible subjects. Implications for future research will be discussed.

Adolescent↗
PubMed2000

Non-convulsive status epilepticus: a treatable cause of confusion in pituitary apoplexy.

Confusion occurring in pituitary apoplexy is well described. We describe a case of pituitary apoplexy associated with confusion, occurring as a result of non-convulsive status epilepticus. Electroencephalography should be performed in pituitary apoplexy associated with confusion if this treatable and potentially serious complication is not to be missed.

Adenoma↗
PubMed1996

Development, implementation, and evaluation of a confusion protocol.

Because the phenomena of managing and therapeutically responding to confused elderly hospitalized patients is complex and difficult, a group of advanced practice nurses, supported by a pharmacist, nursing administration, and a School of Nursing professor, was commissioned to explore the research-based literature and provide practice recommendations for these patients. This article identifies one process undertaken for synthesizing and grounding an immense body of literature related to confused elderly patients. The literature review served to begin clarifying the differences between the diagnosis and required interventions for managing either acute or chronic confusion. These interventions were articulated within a protocol format (Marker model) familiar to staff members at our institution. The development, implementation, and evaluation of the protocol is presented, as well as suggestions for further research.

Acute Disease↗
PubMedDate not supplied

The NEECHAM Confusion Scale: construction, validation, and clinical testing.

This article reports the development of the NEECHAM Confusion Scale for rapid and unobtrusive assessment and monitoring of acute confusion. The scale was tested in two samples (N = 168 and 258, respectively) of elderly patients hospitalized for acute medical illness. Internal consistency and interrater reliability of the instrument were found to be high. The NEECHAM correlated well with the Mini-Mental State Examination and the sum of DSM-III-R positive items. Factor analyses identified and confirmed cognitive/behavioral and physiological domains. The NEECHAM provides a valid and reliable bedside assessment of acute confusion, particularly at its onset and in patients with "quiet" manifestations.

Confusion↗
PubMed1997

Management of acute confusion in the elderly.

Acute confusion in the elderly as a presenting symptom in an accident and emergency department requires just the same energy devoted to diagnosis as does, say for example, acute coma, epilepsy or haematemesis. Doctors in accident and emergency departments are reminded not to succumb to the pitfalls of assuming that acute confusion is merely part of a progressive dementia in an elderly person and therefore incapable of treatment. In this paper a number of clinical examples are given where treatment of the cause of the acute confusion has led to restoration of the patient's independent existence. In passing, the abbreviated mental test score is commended to accident and emergency doctors as being just as useful in a different context as the worldwide acceptance has been of the Glasgow Coma Score. Currently the standard abbreviated mental test score seems confined to the United Kingdom as part of the generally accepted practice.

Acute Disease↗
PubMedDate not supplied

Low serum albumin levels, confusion, and fecal incontinence: are these risk factors for pressure ulcers in mobility-impaired hospitalized adults?

BACKGROUND: Studies of risk factors for clinically significant pressure ulcers in the hospital have been limited by the small number of study subjects that develop pressure ulcers, resulting in contradictory findings regarding some risk factors. OBJECTIVE: To determine if three risk factors (low serum albumin level, fecal incontinence, and confusion) were significant risk factors when tested in a large data set. METHODS: The study design was a longitudinal cohort study using data collected as a component of a multi-site controlled clinical trial. The data were collected at 47 Veterans Affairs Hospitals. 2,771 subjects that required high levels of nursing care were identified to have mobility impairment. Their medical records were abstracted using a standard form to identify a large number of potential risk factors. The subsequent development of stage 2 or greater pressure ulcers was recorded for a maximum of 14 days after admission. RESULTS: 406 patients (14.7%) subsequently developed at least one stage 2 or greater pressure ulcer over a 2-week period. In a multivariate model, the presence of low albumin levels (odds ratio OR = 1.40) and confusion (OR = 1.45) were both found to be statistically significant risk factors, while fecal incontinence was not. Having a Do Not Resuscitate (DNR) order was also a significant risk factor (OR = 1.55). Two other known risk factors also entered the model: being malnourished (OR = 1.69) and requiring a urinary catheter (OR = 1.55). CONCLUSIONS: This study confirmed confusion and low albumin as pressure ulcer risk factors, but not fecal incontinence. A DNR order was found to be a new pressure ulcer risk factor not previously described in the literature.

Aged↗
PubMed2005

Can alcohol intoxication be excluded as the cause of confusion following head injury?

OBJECTIVE: To assess whether there is a breath alcohol level (BrAC) below which confusion in the head injured patient should not be attributed solely to the acute effects of alcohol. METHOD: Based in the Accident and Emergency Ward in Glasgow Royal Infirmary, a prospective observational study was carried out over a five month period. Patients admitted to the ward were recruited for the study if they had a primary diagnosis of head injury. The outcome measures recorded and analysed were sequential 2 hrly BrAC readings (mg/L) and Glasgow Coma Scale findings (Eye opening, motor and verbal responses). The relationship between these was investigated, which revealed additional relevant factors affecting level of consciousness. RESULTS: The breath alcohol analyser was found to be a useful non-invasive, quick and easy to use tool. The results obtained were consistent with the expected pattern of reducing BrAC levels over a 6 hour period. Within this group of patients, a poor correlation was found between each of the three responses of the Glasgow Coma Scale and BrAC readings. For those patients who remained confused, when their BrAC reading was less than 1 mg/L, other causes of a lowered level of consciousness were identified. CONCLUSION: Confusion in the head injured patient with a BrAC of less than 1 mg/L, should alert one to the likelihood of causes other than alcohol intoxication.

Adolescent↗
PubMed2000

Postoperative confusion preceded by decreased frontal lobe haemoglobin oxygen saturation.

We describe a 58-year-old male patient with confusion and prolonged recovery after liver transplantation. A cause was not apparent for the confusion, but during surgery, monitoring of the frontal lobe cerebral haemoglobin oxygen saturation by near-infrared spectrophotometry showed cerebral hypo-oxygenation despite optimization of conventional cardiovascular parameters. It is possible that intraoperative cerebral ischaemia is the cause of postsurgical confusion and with near-infrared spectrophotometry this hypothesis may be tested clinically.

Anesthesia Recovery Period↗
PubMed2002

Risk for acute confusion on hospital admission.

Elderly individuals are at risk for acute confusion (AC) during hospitalization. Using a prospective design, this study assessed the relationship between admission risk factors and subsequent development of AC in 117 elderly hospitalized patients. AC was ascertained using the NEECHAM Confusion Scale. Other measures included demographic data, cognitive status, physical function, laboratory data, medications, infections, activity, pain, and nursing acuity. The cumulative incidence estimate was 14%. Patients who developed AC were more likely to be admitted to the hospital from somewhere other than home, to have lower admission NEECHAM and MMSE scores, and to have restricted activity levels, an infection, and abnormal lab values. These patients were more cognitively and physically frail and may have been chronically undernourished and dehydrated on admission to the hospital. Nurses can be trained to routinely assess for acute confusion using easily implemented instruments incorporated into a research-based protocol.

Acute Disease↗
PubMed2000

Recovery from spontaneous confabulations parallels recovery of temporal confusion in memory.

BACKGROUND: In previous studies, the authors found that patients with spontaneous confabulation differ from those with nonconfabulating amnesia by 1) temporal context confusion (TCC) in memory based on an inability to suppress intrusions of currently irrelevant memory traces into ongoing thinking; and 2) lesions involving the orbitofrontal cortex, basal forebrain, or amygdala and perirhinal cortex. OBJECTIVES: To study the long-term clinical course of spontaneous confabulations, determine whether TCC in memory also parallels the clinical course of spontaneous confabulations, and study the impact of lesion site on clinical course. METHODS: Eight patients with spontaneous confabulation were re-examined 18 months after onset. Tests of memory and executive functioning and measurement of TCC in memory were again applied. MRI according to a standard protocol was performed to determine areas of permanent damage. RESULTS: Seven patients eventually stopped confabulating. TCC, but not common memory or executive tests, precisely paralleled the course of spontaneous confabulations. Patients with isolated, less extensive, orbitofrontal lesions stopped confabulating first and had the best neuropsychological outcome. Patients with basal forebrain lesions continued to confabulate for several months and remained amnesic. One patient with extensive orbitofrontal damage and perirhinal cortex damage continues to confabulate after more than 3 years, continuing to confuse memory traces. CONCLUSIONS: Temporal context confusion in memory is not only the sole feature reliably separating patients with spontaneous confabulation from those with nonconfabulating amnesia in the acute stage, it is also the only feature that precisely parallels the clinical course of spontaneous confabulations. Most patients eventually stop confabulating but duration of confabulations depends on the lesion site.

Adult↗
PubMed2003

Fusion or confusion in obsessive compulsive disorder.

Inferential confusion occurs when a person mistakes an imagined possibility for a real probability and might account for some types of thought-action and other fusions reported in obsessive-compulsive disorder. Inferential confusion could account for the ego-dystonic nature of obsessions and their recurrent nature, since the person acts "as if" an imagined aversive inference is probable and tries unsuccessfully to modify this imaginary probability in reality. The clinical implications of the inferential confusion model focus primarily on the role of the imagination in obsessive-compulsive disorder rather than on cognitive beliefs.

Cognition↗
PubMed2000

The many faces of confusion. Timing and collateral history often hold the key to diagnosis.

Recognition of a patient's state of confusion is only the beginning of a clinical odyssey that can implicate a huge spectrum of diagnostic possibilities. Among these are delirium, depression, dementia, and sensory deprivation. However, with appropriate physical examination and laboratory studies, collateral history, and clarification of time course for the symptom complex, the cause of confusion need not remain confusing.

Aged↗
PubMed1989

Fear of senility: the nurse's role in managing reversible confusion.

1. Acute illnesses in the elderly often cause reversible confusion. 2. Agitated and unsafe behavior is an attempt by the confused elderly to maintain self-image and physical and psychological integrity. 3. Ebersole and Hess' humanistic framework can guide the nurse to prioritize and meet the needs of the confused elderly.

Aged↗
PubMed1990

Do drugs affect social behavior in the confused elderly?

Mental confusion in the elderly can be manifested by impairments in the areas of memory, orientation, concentration, and judgment. The number and classification of drugs prescribed for elderly residents of nursing care facilities can contribute to the development of mental confusion. As the number of drugs prescribed for confused elderly increases, the potential for these persons to engage in group social behavior decreases.

Aged↗