Course

Confusion, the mental state in which an individual is unable to think with complete clarity of mind, is characterized by a lack of awareness regarding the place, time or current circumstances. An individual who is afflicted with confusion is said to be confused. As an example, a confused person might not be able to recall that he is an inpatient resident at an extended care facility in New York, or that the current year is 2020.   

Confusion is very much linked with the concepts of cognition and orientation. Cognition entails the various mental functions by which knowledge is acquired, retained and utilized: perception, learning, memory and thinking (Kihlstrom, 2018). Some healthcare workers use the terms cognition and mentation interchangeably. Orientation refers to a person's awareness of four specific elements: 1) self, 2) place, 3) time and 4) situation. 

Clinicians such as physicians and nurses are trained to assess the orientation levels of their patients on a routine basis, normally as part of a mental status examination to determine cognition. When a person has full awareness of oneself, place, time and the current situation, she is described as "oriented times four" or "oriented x4," with the number four representing each of the four elements of orientation.

Orientation to self is the patient's ability to recall his or her own name, whereas orientation to place is the awareness or where he or she is. Orientation to time is the patient's ability to correctly recall the current time frame, including the day of the week, date, year and season. Finally, orientation to situation is the patient's ability to describe his or her current situation or circumstances in general terms.   

Orientation to self is typically the last measure of orientation to be lost; this tends to take place in only the most profound cases of dementia. So, if a confused elder can recall her name and nothing more, clinicians refer to her as "oriented times one" or "oriented x1." A confused elder who recalls his name and the place correctly is said to be "oriented x2," and a patient who accurately states his name, the place and the time is "oriented x3."

Dementia is a gradual impairment of mental function and decline in intellectual capacity that negatively impacts memory, behavior, personality, thinking and judgment. The World Health Organization [WHO] (2019) defines dementia as a progressive syndrome involving deterioration of cognition beyond what is expected from the normal aging process. Dementia is caused by a variety of health issues that result in harmful changes to the brain. Some types of dementia can be reversed with appropriate medical treatment while others are irreversible.

Dementia can be caused by a number of varied disease processes such as high blood pressure, acquired immunodeficiency syndrome (AIDS), Parkinson's disease, alcoholism, hypothyroidism, Huntington's disease, certain vitamin deficiencies, malnutrition, major head injuries, metal poisoning, Down's syndrome and other health problems. Alzheimer's disease is the most common cause of dementia worldwide and may account for between 60 and 70 percent of all cases of dementia (WHO, 2019).

Due to serious impediments in decision making and memory, persons who suffer from dementia commonly struggle to perform daily living tasks such as meal preparation, self-care, grooming, and managing households. For instance, someone who has dementia might not remember to bathe regularly or brush his teeth unless reminded and cued by a family member or caregiver. A person who has dementia is said to be demented.

Symptoms of dementia are often divided into two categories: cognition and behavioral. Symptoms of dementia related to cognition include poor problem solving, difficulty learning new skills and impaired decision making, whereas behavioral changes may include fear, insecurity, anger and depression-like symptoms (Alzheimer's Society, 2020). Dementia should never be considered a normal, expected life change associated with aging.

Alzheimer's disease, the most common kind of dementia and one of the most prevalent causes of death in the United States, is a progressive brain disease with no known cure at the time of this writing. Alzheimer's disease leads to shrinkage of parts of the brain due to an abnormal buildup of protein clusters called beta amyloid and tau that leave what are called plaques and tangles. The neurons (nerve cells) of the brain become infiltrated with these deposits of plaques and tangles before eventually dying off (Madick, 2016).

Alzheimer's disease affects males and females belonging to a cross-section of all racial-ethnic, economic and social groups in different societies. Even though the vast majority of persons afflicted with Alzheimer’s disease are elderly and over the age of 65, it can affect younger people too. Alzheimer’s dementia is a terminal disease; this means that the affected individual will die either due to it or with it.

In the beginning stages of Alzheimer's disease, the afflicted person might not have any noticeable signs or symptoms at first. For most affected individuals, the very first signs and symptoms of Alzheimer's disease are mild to moderate forgetfulness and an inability to store new information into one's memory. While the symptoms are tremendously varied, the ten most common ones include (Alzheimer's Association, 2019):

• Memory loss that interferes with daily living routines
• Difficulty planning or solving simple problems
• Difficulty finishing familiar tasks at home, at the workplace or at leisure
• Disorientation with time, place or situation
• Misunderstanding visual images and spatial relationships
• New-onset communication issues with words when speaking or writing
• Misplacing items and losing the ability to retrace one's steps
• Lessened or poor judgment
• Withdrawal from workplace, leisure and/or social activities
• Behavioral and personality changes 

Alzheimer's disease progresses gradually in a step-wise series of stages: early-stage, moderate stage and end-stage. Throughout the stages of Alzheimer's disease, the affected person progressively loses the ability to perform simple, routine tasks. A complete degradation of bodily function and communication skills eventually occurs in the context of the person becoming totally dependent on caregivers to deliver around-the-clock care during the final stages of the disease process.  

The beginning stage of Alzheimer's disease is also known by a range of other names including early-stage Alzheimer's dementia, stage 1 Alzheimer's disease or mild-stage Alzheimer's. The first stage of this progressive disease is characterized by symptoms such as "difficulty learning new material, decline in recent memory, difficulty performing tasks, deteriorating appearance, decreased concentration and judgment, disorientation to time, and difficulty finding words or naming objects" (Madick, 2016). Depending on age at the time of diagnosis, the first stage of Alzheimer's disease can last an average of two to four years.

An individual in the earliest stage is normally aware of the diagnosis or, at the very minimum, knows something is wrong with his or her memory. An individual in this stage of the disease process might still have enough judgment to make fully informed decisions affecting his/her future. Medications given to treat Alzheimer’s dementia tend to prolong the early stage of the disease process instead of cure it altogether. Recall that no cure for Alzheimer's exists at the time of this writing.

Individuals with early-stage Alzheimer's disease struggle to process new information, learn new things and pay attention to conversations. They routinely misplace important items such as car keys and wallets. In addition, these individuals have problems with orientation. Remember that orientation is defined as an individual's awareness of four specific elements: 1) self, 2) place, 3) time and 4) situation. It is common for individuals afflicted with early-stage Alzheimer's disease to be disoriented to time. Specifically, they forget the day of the week, the date and time unless reminded.

Communication difficulties are regularly noted in early-stage Alzheimer's, such as finding the correct words, using appropriate grammar and/or pronouncing words. Affected individuals in the early stage of Alzheimer's disease begin to have difficulties with verbal and written communication. They might "use a related word (e.g., 'book' for 'newspaper'), use substitutes for words (e.g., 'thing to sit on' instead of chair) or might not find any words at all" (Alzheimer's Society, 2020). A disinterest in grooming and an overreaction to stress are both noted in early-stage Alzheimer's disease.

A specific range of behaviors is often noted in the early stage of Alzheimer's such as forgetfulness of names, recent events and what has been recently said. As an example, the individual might forget a routine event that he usually remembers, such as a trip to the supermarket to buy two weeks of groceries. As a result, he thinks he must visit the supermarket even though he went grocery shopping last night. The individual completely forgot about the recent supermarket visit that occurred 18 hours ago. Reality orientation, the use of calendars, clocks, or signs to help memory, is helpful in the initial stages of Alzheimer's. A reality orientation aid is pictured directly below this paragraph.

The middle stage of Alzheimer's disease, also called moderate-stage Alzheimer's, is characterized by a repertoire of behaviors and symptoms. Cognitive impairment persists and progressively continues to worsen in this stage. "Cognitive impairment is when an individual has trouble remembering, learning new things, concentrating or making decisions that affect everyday life" (Centers for Disease Control and Prevention [CDC], 2011). At this point, the cognitive impairment is so pronounced that the affected individual requires help with daily living activities such as dressing, bathing and toileting.

The middle stage, which may last anywhere from two to ten years, is the time period in which most afflicted individuals exhibit symptoms of restlessness, continual pacing or constant wandering. Basic care becomes increasingly challenging for family caregivers during this stage. As a consequence, many family caregivers have extreme difficulty providing adequate care for the affected individual inside the personal residence and may actively seek alternate placement options. In general, these placements include long-term care nursing facilities and assisted living facilities that specialize in memory care.

Behaviors commonly associated with the middle stage of Alzheimer's disease include severe lapses in memory, forgetfulness regarding one's personal history, and decreased ability to recognize close friends and family. Personality changes are also common; as an example, a formerly mild-mannered elder might develop an angrily combative temperament during the middle stage of this disease process. Confusion, suspicion, anxiety, sadness, depression, aggression, and hostility are some of the traits that might be noted during the middle stage of Alzheimer's disease.

Therapies exist to reduce challenging behaviors in moderate stage Alzheimer's, including validation therapy, redirection, reminiscence therapy, activity therapy and music therapy. Validation therapy entails letting the person "live in the past or imaginary circumstances; to try to convince otherwise is often upsetting" (ISDH, 2015). Reminiscence therapy involves prompting the individual to reminisce about more pleasant times and to discuss the past. Activity therapy uses activities that the individual "enjoys to prevent boredom and frustration" (ISDH, 2015). Music therapy is the use of music to address the physical, mental and social needs of persons and can be especially beneficial in moderate-stage Alzheimer's. Hearing familiar songs can induce a response in clients that are unresponsive to other therapies (ISDH, 2015).

The last stage of Alzheimer's disease has been referred to in the healthcare literature as end-stage Alzheimer's, late stage Alzheimer's or severe Alzheimer's dementia. In this final stage, the afflicted individual begins to lose all bodily functions in the context of eventually becoming bedridden, nonverbal, unable to feed oneself, and incontinent of bowel and bladder. During the last stage, the affected individual may be agitated or paranoid and only have the ability to say one word (Madick, 2016). This final stage can last anywhere from one to three years, inevitably ending with the individual's death.

Individuals with end-stage Alzheimer's disease become totally dependent upon caregivers to perform activities of daily living such as bathing, dressing, feeding, and toileting. It is approximately around this time frame that affected individuals begin to require around-the-clock care (Alzheimer's Association, 2019). Commonly noted attributes associated with the final stage include loss of ability to speak, incontinence of bowel and bladder, inability to swallow, inability to form new memories and process new information, and disorientation to people, places, time and current situations. 

Affected individuals may respond to music or touch during this stage, but most become unresponsive. The individual may not even be able to respond to the immediate  environment and might not recognize familiar faces or even oneself in the mirror (Madick, 2016). Immobility causes secondary problems in the later stages of Alzheimer's dementia. Being bedridden results in heightened vulnerability to health issues such as blood clots, skin infections and sepsis, which triggers inflammation that can cause organ failure (Alzheimer's Association, 2019). All of these health issues can result in death.

In the very last stage of Alzheimer’s, the afflicted individual may lose the ability to swallow food and fluids since this disease process causes deterioration to the part of the brain that controls swallowing functions. Damage to areas of the brain that control swallowing makes it difficult to for the individual to eat and drink, leading to ingesting fluids and food particles into the trachea (windpipe) rather than the esophagus (food pipe) (Alzheimer's Association, 2019). This leads to a medical condition called aspiration pneumonia, a common cause of death for many persons in the latter stage of Alzheimer's.

Family caregivers and healthcare workers who deliver direct care to clients with Alzheimer's dementia must be knowledgeable about the vast range of problematic behaviors associated with this progressive disease process. The key behaviors of clients afflicted with Alzheimer's include agitation, wandering, elopement, delusions and hallucinations (Indiana State Department of Health [ISDH], 2015). In addition, other behavioral issues such as sundowning, violence, catastrophic reactions, inappropriate sexual acts, hoarding and rummaging are frequently noted in clients with Alzheimer's.

Agitation, a term that describes excessive physical movement and verbal activity, often arises due to one or more unmet needs that the demented client might not be able to communicate such as hunger, pain, boredom, tiredness or loneliness (Heerema, 2019). Caregivers can address agitation by staying calm, removing any environmental triggers such as noise, and meeting unmet needs through offering snacks, companionship, or activities to relieve prolonged boredom. Two types of wandering exist. Active wandering includes pacing, searching for something or trying to stay busy, while passive wandering happens when the client paces aimlessly and distractedly (Alzheimer Society of Canada, 2017). 

Elopement takes place when a client leaves a safe place such as the home setting or the healthcare facility without caregivers' or staff members' knowledge of the exit. Clients with Alzheimer's disease tend to exhibit exit-seeking behaviors during the middle stages of their disease process and are at a heightened risk of elopement. Caregivers can reduce the chances of an elopement incident by assigning nursing facility residents with Alzheimer's to rooms located far away from exit doors. Also, door alarms and hourly rounding are other interventions that can help prevent elopements from happening.

Hallucinations and delusions are two symptoms of Alzheimer's disease that cause clients "to not experience things as they really are" (Alzheimer Society of Canada, 2017). Delusions are false beliefs, while hallucinations are sensory perceptions of things that are not there. As an example, Mr. Tompkins has the delusion that he is President of the United States, and he is having visual hallucinations of snakes in his bed when there are none. Caregivers can manage delusions and hallucinations with pleasant distractions such as games, activities or music. It is best to not get angry and avoid arguing because a caregiver "will not win an argument with a person who is having a hallucination or delusion" (Alzheimer Society of Canada, 2017). To the client, delusions and hallucinations are real.  

Sundowning, also called sundowner's syndrome, is the term used to describe a notable Increase in behavioral problems as the sun sets in the evening. This phenomenon takes place because the client with Alzheimer's dementia is tired and agitated at the end of the day and/or becoming frightened of the lack of daylight. Caregivers can prevent sundowning by being proactive. This involves planning to complete most of the client's activities of daily living during the early part of the day to avoid aggravating her in the evening. Other helpful actions include maintaining a calm environment, reducing caffeine intake from the evening diet if possible, and redirecting the client by offering activities or favorite foods (ISDH, 2015).

Behavioral issues such as violence, catastrophic reactions, inappropriate sexual behavior, hoarding and rummaging are sometimes seen in clients with Alzheimer's dementia. These behaviors can present uniquely stressful challenges to family caregivers and professionally trained members of staff. Hence, it is essential that anyone who provides care to clients with Alzheimer's become familiar with methods to manage these aforementioned behaviors.

Violence, defined as the use of physical force, and aggressive behaviors are often exhibited by the elder due to unmet physical needs, social needs or psychological needs (Alzheimer's Society, 2020). Caregivers should address a violent client with Alzheimer's by offering distractions to redirect attention, communicating, providing reassurance, and remaining mindful of one's own body language. Sitting is recommended since it makes the caregiver appear less threatening. Do not suddenly touch the client without consent because this may startle him and escalate the situation. If the situation appears to be escalating and becoming more violent, leave and return later if it is safe to do so.

A catastrophic reaction occurs when a demented client overreacts to a routine situation by becoming overly agitated, angry or emotional. For instance, Mrs. Connors screams and overreacts angrily when a dietary aide removes an empty plate from her room for dish-washing. Catastrophic reactions occur due to fatigue or over-stimulation (ISDH, 2015). Prevention is best; in other words, caregivers should keep the client from having a catastrophic reaction if possible. Prevention is possible by keeping the environment non-stimulating, doing tasks in small steps, and eliminating potential triggers. If a catastrophic reaction does occur, the caregiver should stay calm and attempt to redirect the client to another activity.

Inappropriate sexual behavior encompasses a broad range of behaviors involving sexual disinhibition on the part of the affected client. Individuals with moderate-stage Alzheimer's dementia might engage in acts such as groping other persons, masturbating in public, demanding sex, displaying genitalia and/or breasts, and appearing naked. All of these actions fall into the wide realm of inappropriate sexual behavior. First and foremost, the caregiver should remain calm and avoid overreacting. If possible, try to redirect or relocate the client to a private area (ISDH, 2015). If the inappropriate sexual behaviors are occurring in a communal setting such as a nursing facility, notify the nurse and keep other residents safe.

Hoarding, the habit of accumulating items, is a common behavior for those afflicted with Alzheimer's dementia. Hoarding for a demented person stems from trying to have control in their lives; also, memory loss contributes to this behavior, so it tends to occur in the early and middle stages of dementia (Alzheimer Society, 2013). Rummaging, the act of haphazardly searching through items, often accompanies hoarding. Caregivers should note that the client does not mean to steal when hoarding and rummaging; rather, both activities arise due to the behavioral changes of dementia. It helps to label personal belongings to avoid losing them. If working in a facility with other residents, routinely check rooms for items which may belong to others, redirect the demented client to his own room, and mark other rooms with symbols or labels to keep him from entering them (ISDH, 2015).

Alzheimer's Association. (2019). 2019 Alzheimer's disease facts and figures. Alzheimer's & Dementia, 15(3), 321-387. 

Alzheimer Society of Canada. (2017). Wandering. Retrieved April 12, 2020 from https://alzheimer.ca/en/on/We-can-help/Resources/Shifting-Focus/Examples-of-responsive-behaviour/Wandering

Alzheimer Society of Ottawa and Renfrew County. (2013). Hoarding. Retrieved April 14, 2020 from https://alzheimer.ca/sites/default/files/files/chapters-on/cornwall/info/fact%20sheets%20en/hoarding%20ascd%20may%2030%202013.pdf

Alzheimer's Society. (2020). Dementia and language. Retrieved April 12, 2020 from https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/symptoms/dementia-and-language

Centers for Disease Control and Prevention. (2011). Cognitive Impairment: a Call for Action Now! Retrieved April 12, 2020 from https://www.cdc.gov/aging/pdf/cognitive_impairment/cogimp_poilicy_final.pdf

Heerema, E. (2019). Responding to Agitation in Dementia. VeryWell Health. Retrieved April 12, 2020 from https://www.verywellhealth.com/tips-on-responding-to-agitation-in-dementia-97642

Indiana State Department of Health. (2015). Nurse Aide Curriculum. Retrieved April 12, 2020 from https://www.in.gov/isdh/files/Indiana_Nurse_Aide_Curriculum.pdf

Kihlstrom, J.F. (2018). Unconscious Cognition. Retrieved April 12, 2020 from https://www.sciencedirect.com/topics/medicine-and-dentistry/cognition

Madick, K. (2016). Care of the Patient with Alzheimer's. CEUfast Inc. Retrieved April 12, 2020 from https://ceufast.com/course/care-of-the-alzheimers-patient-for-the-cna

World Health Organization. (2019). Dementia. Retrieved April 12, 2020 from https://www.who.int/news-room/fact-sheets/detail/dementia