Introduction

Declines in cognitive functioning, such as delayed response time, difficulty with complex tasks, and loss of recent memory, are hallmark signs of aging.1 When a patient presents with confusion, the interprofessional health care team needs to determine the root cause of symptoms and treat accordingly. Pathological conditions of cognitive impairment highly associated with aging include delirium, dementia, and depression.1 Assessment of cognitive function is integral in identifying these conditions, guiding choice of treatments, and determining their effectiveness.1 Chronic confusion associated with progressive cognitive decline is known as dementia. Over 24 million individuals worldwide have a diagnosis of dementia. Prevalence rises with age, affecting nearly 50% of individuals over age 85.2 Dementia is defined as a clinical syndrome of cognitive deficits that involves memory impairment, behavioral disturbances, and functional decline.2,3 Risk factors of dementia include advanced age, mild cognitive impairment, cardiovascular disease, and family history of dementia.2 Mild cognitive impairment (MCI) is often considered a precursor of dementia. It is present in approximately 15% of adults over age 65 with more than half progressing to dementia within five years.2,3 Common forms of progressive dementia include Alzheimer’s disease, vascular dementia, and dementia with Lewy bodies. Less common types include dementia secondary to Parkinson’s disease, dementia secondary to HIV, frontotemporal dementia, and Creutzfeld-Jakob disease.2

Interprofessional Assessment and Collaborative Interventions

When approaching care for a patient who is showing signs of confusion, the interprofessional team will aim to identify and resolve potentially reversible conditions such as delirium (see Abrupt change in mental status), recognize and control comorbid diseases like depression (see Depressed), promote early diagnosis and management of dementia, and offer support to caregivers.2 Altered cognitive functioning may be erroneously perceived by health care professionals as a normal consequence of aging, which leads to missed opportunity for intervention. Regular cognitive screening is essential for early detection to halt, reverse, or slow progression of confusion, memory loss, impaired decision-making, and other cognitive impairments.1 Naturally-occurring observations and conversations during nursing care activities may first alert staff to patient’s confusion if he or she is inattentive and responding unusually or inappropriately. Further assessment can be done using validated and commonly used tools such as the Mini-Mental State Examination (MMSE), the Mini-Cog, and the Montreal Cognitive Assessment (MoCA).1,2,3 Current guidelines recommend completing these assessments on admission and discharge from an institutional care setting, on transfer from one setting to another, every 8-12 hours during hospitalization, in the outpatient setting within six weeks of discharge, with any major changes in medication regimen, and with onset of unusual behavior.1

While screening assessments can aid in detecting presence or absence of cognitive impairment, no assessment is currently capable of confirming whether the change is due to delirium, dementia, or depression.1 It may be difficult for clinicians to differentiate between these conditions, as they often coexist and are similarly expressed.2 Nurses and providers must collect an accurate health history from patients, with clarification and validation from family members and caregivers as needed.2 Acute and primary care providers will conduct a comprehensive physical assessment, with a focus on the neurological and cardiovascular system to identify risk factors of dementia. Providers can make referrals to neurologists and neuropsychologists for further evaluation of dementia pathology using non-contrast computed tomography (CT), magnetic resonance imaging (MRI), and extensive cognitive testing.2,3

The team will also need to assess the patient across functional, behavioral, and environmental domains. As patients with dementia experience decline in activities of daily living and instrumental activities of daily living, staff members including physical therapists, occupational therapists, and registered nurses, can utilize the Katz ADL and Lawton IADL scales to assess patients’ function at baseline and over time.2,3 Dementia is frequently associated with behavioral disturbances that warrant intervention. Nurses, providers, and geriatric psychiatrists should assess patients with validated tools such as the Geriatric Depression Scale (GDS) to help determine whether patients require non-pharmacological or pharmacological treatment.2 Pharmacists with experience treating older adults should be consulted when selecting medications to treat functional decline and behavioral disturbances in patients with dementia. While non-pharmacological interventions are preferred, supplementation with psychotropic medications may be administered in the lowest effective dose for the shortest amount of time.Patients with dementia are also likely to be prescribed acetylcholinesterase inhibitors (donepezil hydrochloride, or Aricept) or N-methyl-D-aspartate receptor antagonists (Memantine, or Namenda) to slow the progressive decline of neurological function.2,3 Nurses will assist prescribers in closely monitoring patients for medication effectiveness and adverse side effects.2

Caregiver assessment is also vital for families of patients with dementia, as caregivers are often burdened psychologically, physically, and financially, and at increased risk for depression, physical illness, and anxiety. A helpful screening tool for nurses and prescribers to identify families with caregiving concerns is the Modified Caregiver Strain Index (MCSI). The interprofessional team can provide education surrounding dementia care and support to families while including hospital and community social workers in the conversation to connect families to local resources.2 In taking the holistic view of the confused patient with dementia, nurses will work to engage the patient socially, stimulate his or her cognition, provide patient with adequate rest, hydration, and nutrition, advocate for avoidance of physical and pharmacological restraints, encourage mobility and independence in completing ADLs and iADLs, address behavioral issues, and ensure a safe and therapeutic environment for treatment.2

Interprofessional contacts for this topic:

Acute care providers

Geriatric psychiatrists

Neurologists

Neuropsychologists

Primary care providers

Pharmacists

Registered nurses

Physical therapists

Occupational therapists

Social workers

Link to the following evidence-based protocols:

Age-related changes

Assessing cognition

Atypical presentation

Delirium

Dementia

Depression

References

1Milisen, K., Braes, T., & Foreman, M. D. (2012). Assessing cognitive function. In M. Boltz, E. Capezuti, T. Fulmer, & D. Zwicker (Eds.), Evidence-based geriatric nursing protocols for best practice (4th ed., pp. 122-134). New York, NY: Springer Publishing Company.

2Fletcher, K. (2012). Dementia. In M. Boltz, E. Capezuti, T. Fulmer, & D. Zwicker (Eds.), Evidence-based geriatric nursing protocols for best practice (4th ed., pp. 163-185). New York, NY: Springer Publishing Company.

3Gauthier, S., Reisberg, B., Zaudig, M., Petersen, R. C., Ritchie, K., Broich, K., ... & Winblad, B. (2006). Mild cognitive impairment. The Lancet, 367(9518), 1262-1270.